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

Nicaragua day 2

Today Dra. Espinoza and I are visiting La Mascota, Aleman, the main social security hospital, and a specialty regional hospital that serves as the national referral center for opthalmic surgery.

Mascota is a busy pediatric hospital with a large caseload. The 5 oximeters here are used in 3 ORs, with the remaining 2 used in the PACU. On the way towards the operating room, we noticed a 2d old child being transported to the neonatal ICU after a congenital diaphragmatic hernia repair with the aid of a Lifebox pulse oximeter! Before the introduction of the project this additional level of safety would not have been possible, which is especially important for this type of patient as their respiratory function is at times severely compromised. In the operating room, we were able to observe the use of an oximeter during an orthopedic procedure. Today´s caseload includes a craniotomy, thoracotomy, and tracheostomy to mention a few, so the anesthesiologists and nurses here are especially grateful for the additional level of safety provided by the checklist and oximeters.

Aleman Managua is a busy general hospital that also serves as the national referral center for colonoscopy. Here the oximeters are used in the remote colonoscopy suite and for each of the nearly 30 patients that recover in the PACU every day. Before the project the dozen or so anesthetics performed there would take place without the use of any continuous monitoring. The nearby specialty opthalmic hospital is a national referral center with over 30 cases a day. Here the unilateral nature of their cases and rapidity of turnover make for a potential recipe for mistakes, and both the anesthesia and nursing staff were grateful for the introduction of the GHO safety checklist. In addition, recognition of the very common oculocardiac reflex during opthalmic surgery has dramatically improved with the new pulse oximeters.

Seguro Social Managua is a hospital for patients who have government supported health insurance. Because of this, it is slightly better equipped than the public hospitals, which rely only on donations and limited government funding for their resources. Here the two Lifeboxes are used in the PACU, a place that before had no available monitoring.

Brian O’Gara MD

Nicaragua four months on

Day 1 Fonseca, Velez País, Berthe Calderon 

After waking up at 4am and the lovely surprise of a first class seat on Copa airlines, I arrive on the tarmac in Managua around 830am.

There is an immediately noticeable change in climate here, with temperaturas roughly 20dF higher than Guate city.  No time to gripe about the weather, especially with heavy snow set to hit Boston today, as I am picked up by Dra. Espinoza and whisked away to visit 3 local Managuan hospitals.

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Fonseca is a large public hospital that cares for a large number of patients, averaging in between 30-50 OR cases a day.  Before the donation of Lifeboxes, their PACU had no means of continuous monitoring.  In addition, before the Project started a surgical safety checklist was sporadically used, whereas as of today it is an absolute requirement before beginning any elective case.  The recovery área here houses up to 10 patients at a time, and it is hard to think about what caring for that many post surgical patients was like here before the use of our oximeters.  In front of my very eyes a pediatric patient was brought into recovery and an oximeter was immediately placed.  The anesthesia resident recognized that the patient was becoming hypoxic, made a correction in the patient’s head position and applied supplemental 02.  In addition, we discovered that the anesthesiologists here had come up with a great way to secure and protect their oximeters from misuse and theft, by placing them in locked plexiglass boxes. 

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Suffice to say this trip has gotten off to a good start.

Velez País and Berthe Calderon are two public hospitals that specialize in pediatric and maternity care respectively.  Here we came across different types of challenges to providing safer perioperative care. 

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In Velez they have all the equipment they could possibly need, including neonatal probes, but they don’t have the staff to run the ORs and recovery áreas past 2pm! 

In Berthe we met with Dr. Amador who like those in Fonseca uses the oximeters mainly in the PACU and wisely locked them up high on the wall, but as seen in the picture below there was only one available oxygen flowmeter for as many as 12 post-operative patients. 

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Clearly there exist many barriers to improving the quality of perioperative care that go far beyond having pulse oximeters, because what good are they when you can’t give your patients oxygen?

Brian O’Gara MD

My last day in Guatemala

After a great stay at the Eco Hotel Uxlabil in San Pedro de la Laguna, a stop on the way back to catch a little bit of El Clasico and perhaps  a little too much sunshine, it was time to get back to work on Monday. 

Dra. de Izquierdo and her medical student Cori brought me to the General Hospital in Guatemala City where we again met up with Dr. Salazar.  I was treated to a tour of the facilities, including the main ORs, ICUs, and Maternity.  There I had a chance to share experiences with their anesthesia chief resident, who turns out wants to be an intensivist as well!  It’s amazing how much they accomplish there.

After our tour it was time for the AGARTE society meeting, where I was lucky enough to meet with representatives from many of the remaining Lifebox sites. 

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Dras. Navas and de Izquierdo gave the introductory talks regarding the Lifebox efforts and we interviewed the remaining representatives as to their progress.  Many shared stories of gratitude for our involvement, and many brought their logbooks with them, detailing accounts of excellent patient care.

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After the brief Q&A, it was my turn to present my findings, and I managed to get them across in 100% Spanish.  Briefly, I was very happy to report that every device donated was fully functional and being used in locations where the need was greatest.  It was thrilling to hear their stories of gratitude and to see examples of improved perioperative patient care both with the initiation of the checklist and donated oximeters.  My main concerns that arose on the visit were regarding the ongoing need to educate those who were caring for patients with oximeters, in particular the nurses and techs, and the need for more thorough use of the logbooks.  I stressed that the ultimate goal of the Project is to improve peroperative patient safety, and although the anecdotal evidence is overwhelming, without proper documentation we will never be able to prove that this is taking place.

After the meeting Dra de Izquierdo surprised me with an afternoon trip to walk the gorgeous streets of Antigua.  Overall the trip was a huge success, and I can’t wait to see what the future holds for Lifebox and Guatemala.

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Brian O’Gara MD

Guatemala revisited - Days 1 to 3

Day 1: After three separate 2.5 hour flights begining at 5am in Boston, I arrive on the tarmac at Guatemala city airport. Much to my relief my luggage arrives with me, and I am greeted by two very friendly Guatemalan medical students, Corinne and Irene. They whisk me away for lunch and a well deserved rest. Tomorrow we start fresh with a visit to 3 hospitals!

Day 2: Dr. Juan Esteban Salazar arrives bright and early to start our trip. The Holiday Inn Guatemala City where I´m staying is in a neighbourhood that might as well be called “Little America.” Our local breakfast hotspot is none other than an Applebees!

We start our trip west which will include visits to the National Hospitals in Cuilapa, Jutiapa, and Jalapa. These hospitals, like the nearly 40 others that received Lifeboxes in Guatemala, are government-funded hospitals with very limited resources. Many of the physicians who work here do so either on a pro bono basis with time also spent working for a private hospital, or work for much less salary than their private colleagues.

Dr. Salazar was the perfect escort for today´s trip, as he had previous working relationships with many of the anesthesiologists we encountered. We had a great chance at Cuilapa to see our Lifeboxes at work both in the recovery area and in the operating room!

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Next it was on to Jutiapa, where we met Dra. Caradona. She was incredibly grateful for our donation, as the Lifeboxes were the ONLY functioning monitors at her disposal in BOTH the operating rooms and the recovery areas! Today she was taking care of a young boy who needed a general anesthetic for an intraocular operation. Without our oximeters, Dra. Caradona and the other anesthesia staff here would be flying blind for over 10 OR cases a day.

As it would turn out to be the case with most sites we would visit over the course of the next two days, the ventilator and monitor seen below are both almost completely broken. The ventilator only serves the purposes of an oxygen and anesthetic vapor delivery system, the bellows have long since been in a state beyond repair and therefore Dra. Caradona needs to hand-ventilate all her patients.

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Now on to the final stop in Jalapa, where hospital director Dra. Munoz proudly displayed our latest donations.

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Here in Jalapa they have functional monitors for the ORs that also have the ability to measure NIBP and EKG. Unlike Jutiapa, the Lifeboxes here are used mainly for pre and post operative care and patient transport.

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She did say, however, that the Lifeboxes have been incredibly useful in the care of decompensating patients on medical floors and critical care. In addition, without the pediatric probe donated by Lifebox, the staff here would not be able to monitor their pediatric OR patients, as the equipment they have is too large.

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That concludes day 1. On to our reward after 4.5 hours of driving of some nachos and refreshments at the Hard Rock Cafe Guate City!

Day 2: I´m picked up bright and early by the president of the Guatemalan Anesthesia Society, Dra. Karla Navas. We have a big task ahead of us today as we are visiting 4 local hospitals in Atitlan, Esquintla, Antigua, Chimaltenango.

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Our first stop is the national hospital in Atitlan. Again here the oximeters are mainly used for post anesthesia care and patient transport, with the one important exception of the intensive care units. The ICU here in Atitlan houses 12 patient beds, and the 2 Lifeboxes there serve as their only continous monitoring system! For ventilated patients, a ventilator has to be rented out from a nearby private hospital, and occasionally they will throw in a monitoring system. Safe to say all the doctors and nurses we met in the ICU were very grateful.

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In Escuintla, we encountered a busy public hospital with nearly 25 OR cases a day. The 2 Lifeboxes are used mainly in the PACU and in patient transport to the ICU. In interviews with both MD and nursing staff, the response was overwhelming grateful for the donation of the oximeters and for the introduction of the safety checklist. Everyone here feels that patient safety has been dramatically improved.

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Antigua is a beautiful city that has maintained it´s roots as a Spanish colony. Antiguans are very proud of their cobblestone streets and esquisitely designed churches. It´s place as a main tourist attraction makes for some additional resources for the local public hospital. They even have Desflurane vaporizers!

During our visit here we had a chance to inspect their Lifebox logbooks, which were filled with accounts of patient care in the recovery room. Especially powerful were the desciptions of hypoxic events recognized early due to the presence of the oximeter, which included cases of endobronchial intubation and excessive uterine manipulation. 

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We took the opportunity to stop in Antigua for lunch at a local coffee plantation where we dined on a traditional local dish, Pepian.

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Chimaltenango was our final stop for the day. Here they used the 4 oximeters for post OR and obstetric care. Again inspection of the logbooks yielded some classic clinical pearls, here we learned of a case of laryngospasm aided in detection by their Lifebox. They use their Lifebox oximeters here creatively and logically, as tomorrow they are planning to use in the total care of a pre-ecclamptic mother.

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Day 3: Solola and Lake Atitlan

Today I am accompanied by my gracious and fabulous host here in Guatemala, Dra. Sandra de Izquierdo.

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We head out to visit the national hospital in Solola. Here they use the oximeters for intraoperative care of pediatric patients, as well as PACU care and transport for all patients. Dra. de Izquierdo´s daughter Gladys, a medical student, helped to model our donated oximeters.

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On our way out we visited the neonatal intensive care unit, where the staff pediatrician as well as the hospital director underscored a common need for our Lifebox sites: neonatal oximeter sensors.

Now it´s off for a little R&R at Lake Atitlan for the next 36 hours. Now Dr. Brian can turn into vacation Brian for a moment!

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Brian O’Gara, MD