Starting with a new generation

Heading back to Rwanda last week saw my third visit with Lifebox, only this time I was not alone. Somehow, an aspirational idea to combine my Lifebox checklist and pulse oximeter work with a surgical skills workshop had gained traction since my last visit. So, with additional support from the Association of Surgeons in Training, Royal College of Surgeons of England and the Royal College of Physicians and Surgeons of Glasgow, five colleagues were also flying out from various corners of the UK to join me during my trip.

I flew out ahead in order to fit in some follow-up time at CHUK prior to the course, and stayed on afterwards to visit Kibagabaga hospital too. The hustle and bustle of CHUK, the central University teaching hospital in Kigali, has always provided both a challenge and an inspiration during my visits. With so much going on, this busy hospital has much to gain from checklist implementation. Yet that busyness also makes the implementation all the more difficult, and there remains much work ahead to ensure everything is done to reduce avoidable patient errors.

Thankfully the conversation around my checklist work there has been facilitated by the relationship we have built supplying them with Lifebox pulse oximeters. On that front I’m certainly being recognised now, and on this visit no sooner had I arrived in the theatre block then staff started bringing me oximeters to check. Repairs were made, batteries swapped, probes replaced and several new pulse oximeters donated. The machines at CHUK are looking pretty beaten up now, but it is pleasing to see they are clearly being well used.

Kibagabaga always provides a contrast to CHUK, and it was great to see some familiar faces and hear how their work with the checklist is progressing. I was particularly pleased to be able to spend a morning observing surgery and see them putting the checklist into action. The original adapted checklist they developed with Lifebox is still on the wall, and the staff were clearly comfortable with using it.

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In addition, I was pleased to donate a further pulse oximeter following their request on my last visit.

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The weekend training course focussed on students just starting their final attachments before clinical practice. In Rwanda, newly qualified doctors are usually sent to district general hospitals where they will be performing c-sections and emergency surgery with little supervision from the outset. This is despite minimal practical training in basic surgical skills and related topics – including patient safety.

During the weekend we trained over 50 final year students in basic surgical skills, with a special session dedicated to Lifebox’s work around the surgical safety checklist and pulse oximetry. My colleagues, previously unfamiliar with surgical practice in such settings, noted the response when I asked who had experience of preventable patient safety problems. A retained swab had been witnessed by the majority of participants.

Although overall awareness of the checklist was high, an understanding of the individual items and particularly the rational for these was very variable. Having an opportunity to talk them through the checks was certainly valuable and I was impressed by the student’s appreciation of the issues and their general enthusiasm.

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Overall, given the complexities of this particular trip, we were pleased at how successful and well received it was – certainly promising for running another joint training session in future. In the longer term, expanding this for those just finishing training and starting practice is perhaps the right point for such training to be given. Changing the practice of established healthcare practitioners is difficult work. Catching them before or as they are starting their careers raises the hope of embedding safe surgical practice right from the very beginning.

The separate surgical skills blog featuring daily contributions from all the visiting team focusses on the backdrop to current healthcare provision, including the lack of basic surgical skills training and the impact of this. For those interested in that aspect, the training weekend blog is available here: http://www.asit.org/news/FSS_Rwanda_2014.

Tour de Yorkshire

Forget about the yellow jersey - this month we’ve only got eyes for red polka dots!  Find out what happened when 15 intrepid amateur cyclists set off to give the professionals a run for their money - and their money to Lifebox…

Nick Burr reports.

On the 5th of July, 15 of us set off on a gruelling bike ride through the Yorkshire Hills.

Our aim: Stage 2 of ‘le Tour de Yorkshire' (the hard one!)

Our goal: to raise funds for Lifebox Foundation, the only charity  dedicated to making surgery safer in low-resource countries.  

The meticulous plans failed immediately as the two groups arrived at different start points in York. After some frantic phone calls we eventually got on our way and cycled several miles in the wrong direction before finding the route. Fortunately there was a break in the rain and after a change in navigator we were off.

90 minutes behind schedule.

 

This meant that we were now likely to cross North Leeds just as the pro-cyclists headed out on Stage 1 towards Harrogate. Sure enough as we got to the crossing point we found ourselves pedalling furiously up the road, with huge crowds and a procession of motorbikes, cars, floats and officials all cheering us (to get out of the way).

The day got hotter and hotter, the hills longer and steeper as we slogged over Crag Vale, Holme Moss and onwards towards Sheffield. There were increasingly desperate questions as the day went on, mostly: “how many hills are left?” and “are we nearly there yet?

Every time though, just on cue, the trusty support team turned up with food, drink and painkillers. Thankfully there were no pulse oximeters on board as there could have been some medically enforced retirements.

After 12 hours in the saddle, 127 miles and countless spectacular views we eventually reached Sheffield. It was a fantastic day and a great effort by all. 

We’ve raised more than £2600 so far.  This will make an immediate difference to colleagues and patients around the world, in hospitals where the risk of dying from anaesthesia alone is as high as 1:133.

We would like to thank everybody who sponsored us for this truly worthwhile cause. It really helped us push on when our legs were burning.

Dominican Republic Diary

With more than 50,000 members, the American Society of Anesthesiologists (ASA) is one of the largest independent anesthesia organisations in the world.  Lifebox is thrilled to be working with their Global Humanitarian Outreach (GHO) committee to make anaesthesia and surgery safer for everyone.

We’ve got a five-year challenge to deliver oximeters and training to hospitals in Latin America, working with local communities for long-term change.  Click to read updates from the first projects in Nicaragua and Guatemala – and read on for more Lifebox Journeys from ASA past president and Lifebox USA trustee Dr Alexander Hannenberg, who joined the latest project in the Dominican Republic…

Date: Thursday, May 29th 2014

Re: LATIN LEADERSHIP

Just spent some time with the CLASA executive board – about 10-12 member countries represented and outstanding participation from our friends from Guatemala and Nicaragua, who showed up in force! 

Their presence, is proof of concept that Latin leadership is ready to take on the Lifebox mission.  Sandra de Izquierdo (Guatemala) has begun laying the groundwork for a future generation of globally conscious Guatemalan physicians by bringing along two medical students to observe and assist.  Lots of interest, lots of questions from the CLASA delegates and we’re getting ready for the workshop tomorrow. 

I emphasised the role of local societies in both delivering and funding the programme, and spent a bit of time with Miguel Mercado, President of the Bolivian Society.  He believes that the oximeter need there may be substantially higher than was first estimated, and we discussed how to ensure the oximeters go to hospitals in real need.   

Tomorrow, an unknown number of professionals from the Eastern D.R. provinces are expected for the Lifebox workshop.  But we’ve got lots of instructors and I’m optimistic that we can handle whatever comes…

Date: Friday, May 30th 2014

Re: SAFE SURGERY FUNDAMENTALS

Today, a combination of slight frustration and immense gratification (a good balance on the whole!).  A bit of chaos with scheduling some conflicting sessions meant we lost a few of our 18 participants at the coffee break, but the faculty was stellar.  

Guatemalan and Nicaraguan friends from our November visit were doing most of the teaching, and I had the pleasure of a Guatemalan senior medical student bailing me out when I ran into linguistic trouble. 

Most exciting – the amazing evidence of ongoing engagement around the programmes in both Guatemala and Nicaragua.  In Guatemala, the minister of health, who attended the workshop last year, commissioned an expanded oximetry needs assessment, and based on this study, the Asociacion de Anestesiologia, Reanimacion y Tratamiento del Dolor (AGARTD) is applying for a grant to extend the oximeter distribution beyond ORs throughout public hospitals.

In Nicaragua some of our local sponsors (Serge Amador and ANARE President Maria de Espinoza ) have launched a study project on the quality of Checklist use, trying to distinguish between a “tick the box” approach and genuine multi-disciplinary engagement – a safe surgery fundamental. 

 

Date: Saturday, May 31st 

Re: LOOKING TO THE FUTURE

A small program this morning with about six participants – we ran the workshop as a single group.  Once again, our visiting faculty distinguished itself in the conduct of the program.  Karla Navas (AGARTD President) led a discussion of 5-6 scenarios with the group masterfully and Serge Amador presented on the WHO Surgical Safety Checklist with clearly evident passion.  

Nearly all of the people who came to support our program from Guatemala and Nicaragua had the opportunity to personally lead components of the training, and I have great confidence in their ability to deliver a robust program.

The impact of the training and the oximeter distribution is immediate – but a lot of our most important conversations are about the future of the project.  Following the morning session, I spoke with Carlos Guzman (President SDA) about future steps in the DR – ensuring trainers have the right experience, keeping up with the needs assessment  and planning a national session that will bring end-users for training - especially recovery nurses, who are so vital for a safe perioperative process.   There is a lot of enthusiasm among the Dominican anesthesiologists not only for extending the scope of Lifebox in their country, but joining in the broader Latin American effort.

Thinking about the success of projects like Kenya – Kenyan funding, as well as faculty – we spoke about internal fund raising.

Of course there are some practical issues – 20 oximeters still in customs, but delighted to report that the Health Ministry is going to assist. 

I am also pleased to report that I survived a beach volleyball game with the Guatemalan medical students, though a final report on the consequences is most probably best reserved for another day…

Hasta luego!

Alex

Kibagabaga Hospital: A Checklist Capable Culture

So the Lifebox journey story continues today, albeit in a slightly hungry mood having failed to locate a suitable alternative to our favourite lunchtime burger bar in Kigali, now sadly closed. 

Resting our feet at the downtown Bourbon Cafe following our return from Kibagabaga hospital, my colleague, Charles “Beau” Bush, the Paul Farmer Global Surgery Research Associate here, and I had some time to reflect on the current situation over some potent volcano-strength local coffee. A perfect place for conversation, sat on the café’s pleasantly warm balcony amongst the casual chatter of locals and a myriad of overseas workers. There can’t be so many places in the world where such a mix of people come together in one coffee house, in one small city, with the snippets of caught conversations covering every accent from Canada to Cape Town. Interestingly, talk of healthcare work is frequently overheard here. 

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Kibagabaga Hospital has been the primary test bed for Lifebox’s WHO Surgical Safety Checklist adaptation and implementation program, initially led by my predecessor Sophie Reshamwalla. Since the start of last year, this small district general hospital has been leading the way in Rwanda, where use of the WHO Surgical Safety Checklist has been mandated by the Health Ministry. 

A modern hospital built in the 1990’s, it is set around green quadrangles full of beautifully tended box hedges and palm trees. This sets up a different atmosphere, far from the busy hustle and bustle of the hospitals in central Kigali. Perhaps this friendly and calm atmosphere holds some key to the success of checklist implementation here. 

The hospital carries out approximately 8 caesarean sections per day, mainly under spinal anaesthetic. Not much other surgery is performed now as no general surgeon is currently available, so cases are referred on to the city centre hospitals. Life here continues at a steady pace, save for visits from overseas surgical teams every 3 months or so, bringing with them their expertise in cleft lip and fistula surgery. 

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Talking with the nursing and anaesthetic staff, their enthusiasm for the checklist was clear, and they spoke freely about its use. Interestingly, the first benefit volunteered related to the introduction of swab counting. Retained swabs were a frequent problem in the past, whereas now staff struggled to remember the last time this had occurred in a patient. 

For all the differences between the local healthcare setting here and at home in London, the problems reported surrounding checklist use sounded familiar. When it comes to implementing change, we are all human. Difficulty getting doctors engaged was a frequently cited problem, mainly due to time pressures resulting in a rush to push cases through without delay. 

Looking at the hard figures, monitored checklist compliance has not dropped below 50% here, which compares favourably with many hospitals closer to home. But this talk of numbers masks some of the true benefits of the considerable time spent here investing in this hospital and the staff. This checklist compliance is the visible marker of something else deeper under the surface. For them, a safety culture has become a part of their daily work; to omit the checklist would be departing from normal practice. That is a heart-warming change to witness. 

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But the other frequently cited problem really surprised me: the lack of comparators to other hospitals makes it difficult for them to assess how they compare, and whether they are getting better. This one comment told me something very important about the whole ethos of this hospital – that these staff have an underlying desire to improve themselves and what they do. 

That desire is something difficult to teach, if it can be taught at all. Such a culture is an essential foundation for implementing change and starting quality improvement. Without that desire, sustainability is a distant hope. But with it, we can work with the staff to build and facilitate a better, safer future. 

On that positive note, it’s time to find lunch.

 

Back at Kibagabaga

Travelling back to Rwanda with Lifebox for refresher training on the checklist and pulse oximeters, I have to confess that I was looking forwarding to revisiting one place more than any other. Sadly that wasn’t the wonderful Lil’ Vegas burger bar in downtown Kigali. Although without doubt the best place near the University Hospital to grab a working lunch while devising world-conquering checklist implementation strategies, reports of its sad demise had even reached as far afield as London.

No, the one place I was really looking forward to visiting was Kibagabaga district hospital on the outskirts of Kigali. A warm and friendly healthcare centre set amongst immaculately coiffured gardens, this small hospital occupies a special place in the heart of Lifebox. As the centre where our checklist implementation was first trialled in Rwanda, and where it has been most successfully embedded, I wanted to see with my own eyes how the team were getting on. 

What my own eyes were not ready for was the taxi moto ride to the hospital. For those not familiar with the taxi moto concept, imagine taking your scariest theme park roller coaster ride, mounting it on a 2-wheel motorbike, and calling it a taxi. So most of this ride was completed with my own eyes tightly shut, only opening occasionally when either 1) another vehicle, pedestrian, animal or vegetable brushed against me while I was sat clinging white-knuckles on to the back of the bike, or 2) each time the taxi moto driver stopped to ask others for directions (having reassured me before we set off that, yes of course, he knew where Kibagabaga hospital was).

Note to self: when next talking to a taxi moto driver, speak more slowly so that the difference between instructing them to drive “slowly” versus “quickly” is more clearly understood prior to setting off.

My predecessor, Sophie Reshamwalla, had originally introduced the checklist here at Kibagabaga at the start of 2013, with a follow-up visit from myself at the end of last year, and more regular teaching from Charles “Beau” Bush, the current Paul Farmer Global Surgery Research Associate in Rwanda, who accompanied me on today’s visit. Would our confidence in this hospital’s work be justified?

Needless to say, it was well worth the harrowing journey to get here.

Not only did the long, motor bike ride with so many wrong turns and cross-country shortcuts eventually help abate my abject fear of untimely death by taxi moto, but the enthusiasm from the local hospital staff was something special.

We took time to chat with the theatre team, nurses and anaesthesia technicians. As a more ‘mature’ checklist hospital, with over a year’s post-implementation experience, I was keen to hear about their experiences. What had worked, what hadn’t, and what could Lifebox do to help?

 But it’s lunchtime here now, so I will look forward to filing that report just as soon as we’ve found a new burger bar for our lunch!

Day 5 : Last day in Nicaragua

My last official day of work in Nicaragua was spent as a gracious guest of Dra. Espinoza at her society’s first annual meeting on quality improvement and excellence in anesthesia care.  The meeting was a perfect opportunity to share our findings on the Lifebox project and to discuss plans for improvement in the future.  Dra. Espinoza is an excellent, compassionate physician who has strived in her many years of practice to provide both excellent individual care for her patients as well as in the administrative aspects of running an anesthesia department at a public maternity hospital for over 20 years.  With both her and her invited speakers lectures the main message was clear; in spite of the lack of resources and support from various public entities, the responsibility for quality anesthetic care is each of our responsibility.  The speakers today presented many tools to aid in making this happen, even at a very basic level.  Once again my turn at the lecturn was entirely in Spanish, so I kept it brief.  I expressed the joy at seeing the benefits of our project’s work first hand in the hospitals I was lucky enough to visit, but also in accordance with the theme of the meeting stressed the importance of organization and unity in communication and principle as the means to provide the best possible care for our patients.

I am incredibly pleased to have been a part of this amazing Lifebox journey that has now spanned 2 countries in twelve days.  In the days to come I plan on sharing the great stories and the many lessons I have learned in the process with our international colleagues so that we can not only revel in our successes, but also better understand the myriad of challenges that we face going forward.  

Brian O’Gara MD

Nicaragua day 4

Espana Chinandega, Abdulla Chinandega, and Leon.

On my last day of site visits in Latin America, our day started with two examples of gaps in organization and communication that at times make the completion of any charitable mission hard to accomplish. For sites such as the two in Chinandega, the long distance from the mother organizations in Managua and the extreme lack of resources make the distribution and use of new donated equipment very complicated and coveted by those in the hospital who were fortunate to have received aid.

In Hospital Espana we encountered a situation where the local chief anesthesiologist had kept the oximeters under extremely close guard, to the point that when he was not physically present in the hospital the staff were not able to access the equipment. Fear of loss, missuse, or theft of the oximeters had led to a continued lapse in the safety of the surgical care of the patients in Espana. Unfortunately for many of the staff at Espana that day was was the first time they had laid their hands on the new equipment. Our discussions with them as well as the chief stressed the importance of the proper and liberal use of the new monitors as well as the safety checklist, as without them patients in their region will be at risk for avoidable perioperative complications. The staff were very appreciative of our desire to aid their patients, and were excited to start off down the path to safer care.

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Abdulla Chinandega is a general hospital with extremely limited resources and little contact with the national anesthesia society. Due to this unfamiliarity with the Lifebox representatives and their mission, the 3 donated oximeters were sent to Abdulla by the ministry of health and were given to the hospital’s intensive care units without first passing through hands of the local anesthesiologists. Unfortunately they were unaware of the devices presence in their hospital. We were able to meet with the intensivists, nurses, and anesthesiologists in an amicable and collaborative fashion. Our conversation focused on the understanding that the patients in those areas were of course in need of proper monitoring, but the use and dispersement of the oximeters should be at the discretion of the anesthesiologist, with the primary objective for our mission being safer perioperative care. In the end everyone understood that the project will lead to better safe care of all their patients, which ultimately is the most important.

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In my last stop on our whirlwind tour of public hospitals in Nicaragua, we visited the large general hospital in Leon.  This busy referral center was a teaching hospital for the nation’s resident anesthesiologists, and had 8 operating rooms and multiple remote locations.  The 10 oximeters donated were in almost constant and complete use in all locations.  On my tour through the operating room, I got a glimpse of a Lifebox in use during a urologic procedure.  The oximeter was placed on the anesthesia machine behind the head of the patient in the usual fashion, but there was something else that was very noticeable.  The Lifebox oximeter had come to rest in between 2 other pulse oximeters in that operating room that had long since been functional.  The image below is a testament to both the success of the project and the challenges it faces in the future, as we aim to build a successful foundation for continued and durable safe perioperative care throughout the world.  With our combined efforts with the local societies to provide continued education and through the provision and maintenance of vital equipment, we will ensure that in the years to come the Lifebox oximeter does not become another symbol of a well-intentioned donation that doesn’t stand the test of time.  

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Brian O’Gara MD

Day 3: Jinotepe, Masaya, Japon Amistad Granada

Jinotepe is a busy general hospital that handles both adult and pediatric operative cases. Here we met Dra. Monterrey, the anesthetist-in-chief, who expressed her gratitude for the new oximeters and the additional level of safety both they and the checklist provide.

Her gratitude was tempered by concern however, over the condition of the other monitors in her operating rooms, many with limited functionality, including EKG cables with frayed cords. In other critical areas of the hospital such as the labor and delivery floor and the neonatal nursery, there are no continuous monitors. The do however keep one Lifebox with a neonatal probe handy for immediate post cesarian delivery care, as seen below.

Clearly the needs of the this hospital are many, and the battle to provide safer care for all patients extends far beyond safer care in the operating room.

Relieved by our help in the continuous struggle for resources, a nurse in the recovery area shared the following (translated from Spanish):

"Thank you very much to everyone in the Lifebox project. You have helped us take better care of our patients, who are now much safer because of your work."

In Masaya, a general hospital close to one of the largest active volcanoes in Nicaragua, we encountered possibly the best example of organization and use of the Lifeboxes that I have seen on my trip to Nicaragua. Here Dr. Ortega and his team are using the 5 oximeters they have for the care of their PACU patients and in one of their operating rooms. They showed me a log of nearly 200 patients, many with incredible stories of the early recognition of hypoxia and arrhythmias aided by the Lifebox oximeter. One particular case involved a new mother who had delivered via cesarian section. In the recovery room nearly an hour after the completion of the case, the nurse was alerted by the tachycardia alarm on the monitor. As she assessed the patient, who was comfortable and resting, she removed the overlying blankets to find a large amount of post partum hemorrhage. The patient was immediately taken back to the operating room where a potentially life saving hysterectomy was performed for profound uterine atony. The quick action by the nurse and attending anesthesiologist perhaps would have been delayed until the patient was in critical condition had she not been continuously monitored, as she otherwise did not show any obvious signs of discomfort or distress, with her hemorrage hidden by the blankets on her recovery bed.

The Nicaraguans have a close diplomatic relationship with the Japanese, and the next hospital we visited was erected with the help of the local Japanese Embassy in Granada. Here there are 6 oximeters in use, with 4 in the PACU. The remaining two are currently on loan to the pediatric and adult intensive care units due to a high alert for Dengue fever in the region and potential for large numbers of patients with cardiorespiratory derangements. This was a great example of interservice collaboration and sharing resources in times of need. It was here at Amistad Japon, however, that I was reminded of one of the biggest challenges for our project going forward. Our host brought us to an unoccupied operating room which served as a graveyard for broken, nonfunctioning, or otherwise useless equipment that had been donated from various charitable surgical and anesthesia groups such as ours. We must take steps to ensure proper maintenance and follow up of our equipment so that the local staff doesn’t have to add them to this growing pile of well intentioned medical garbage.

After a long day of visits, it was time to relax and spend some time enjoying the traditional local dish Vigoron and viewing the architecture in Granada, a previous Spanish colony with much of its infrastructure from that time beautifully preserved.

Brian O’Gara MD