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Jun 21st 2016

A Half Cancelled surgical list leads to a Patient Safety Initiative

A Half Cancelled surgical list leads to a Patient Safety Initiative


I started the day at 730 on ward rounds. Generally these serve as a sort of triage and recount which patients came in overnight across various surgical domains. The Clinical Officers (CO) run the show as they do most of healthcare in Malawi. I will write about the Malawi healthcare system structure on another day.  The COs work hard and are very happy to learn from any insight one may have. Following a sort of larger grand rounds, where I revisited the obstetrical ailment of molar pregnancy for the first time since medical school in the 1980s, I headed for the OR.  A small, not ambitiously booked list of four transurethral cases turned into one. Even the fact that we have access to that basic equipment is a testament to my old colleague Bob Macmillan, who with his own personal generosity brought that equipment a few months ago.  The serendipitous event of Bob ending up in the same place where I have a role with Dignitas laid down the groundwork for my trip.  My plan has been to pick up on this, do some cases and train the surgery COs to eventually do some of this work. To date the only option is an open prostatectomy, still occasionally done in the west for massive prostate glands. My anaesthetist, a clinical officer, did not show up today. I then went and spoke to another CO who was reluctant to take on too much as he would be on call tonight, to find the time to at least do one case with me. The very likebable Macmillan Lingo Manje (no relation to Bob!) obliged me.  Our first patient had to be aborted as he had uncontrolled blood pressure of 230/135.  This finding alone illustrates a gap in basic longitudinal primary care. We sent for the second patient after some further delay.  Once started and without getting into any medical detail things went well enough although not without some unexpected turns.  It was now 1:15 and Mr Lingo Manje needed to leave.  My anaesthesia access was finished. Inadequate healthcare in Malawi and elsewhere in Africa is about the many gaps.  Gaps in access to equipment, coherent administrative planning and leadership and most importantly human expertise.  Anaesthesia is at a particular premium from what I can see.  There are five trained MD anaesthetists in all of Malawi.  The service is overwhelmingly provided by clinical officers.  The same is true in virtually all aspects of this healthcare system. 



Mr Macmillan Lingo Manje


We will try for another operative list on Thursday and again twice next week. Tomorrow I will spend the day fully on Dignitas activities

On further reflection though there are many simple things that we can do to help influence real change. The clinicians here, while not having access to much resource are motivated by the same things we all are; to help relieve suffering, restore health and try and maintain human dignity.  As I wandered around waiting (seemingly forever) in the OR today I came across the surgery checklist. Of course all of my medical and nursing colleagues will instantly recognize this. Taken from the airline industry it is a way to try and ensure that medical error at the time of surgery is reduced.   A World Health Organization initiative, it has been shown to save many lives. The hyperlink is worth further reading.  When I asked what happens at ZCH no one has been doing the checklist. Some had an idea of what it was.  It turns out that someone had just gone a few weeks earlier to learn about the checklist and had gone as far as putting it on the wall. No planning beyond that had occurred. No one had looked at the wall.  I used the opportunity even with our one patient to do a formal checklist with my CO anaesthetist. Perhaps that sort of low hanging fruit, simple and yet of potentially major impact is where we can more immediately improve care. It was a worthwhile effort and I am now giving formal rounds to the surgery department on the checklist Thursday to hopefully champion this and effect a culture change.  My strong sense is the magnitude of benefit with implementing a checklist in the developing world is likely far greater than what its adoption has done in the west where many safety inititiatives had already been deeply embedded over many years.  

Half my surgery list cancelled and yet it seemed like a day well spent in the OR.  My Garron Hospital colleagues know very well how I would take to that back home!  Krista I may need to retire the gong.  





Surgery Safety Checklist: A Familiar OR Scene in a Canada



Dignitas tomorrow (although I know there will be some patients to see in the overflowing surgery clinic) and then back to the OR to try again Thursday.





Posted: June 21, 2016

By: Ed Collis

Rajiv, my friend,
You are doing wonderful things.
I hate to say it, but, you are a better man than I.

Your friend,

Posted: June 21, 2016

By: Patricia Campbell

Hi Rajiv,
Great job at trailblazing such an initiative as the surgical checklist..
You are truly a champion for patient safety! Hope your day
will be better on Thursday.

Posted: June 21, 2016

By: Patricia Campbell

Great job Rajiv. You are truly a champion for patient safety.
Hope the checklist initiative will get off to a great start!
and your OR list on Thursday will be more fruitful!

Posted: June 22, 2016

By: Carmine Simone

Fascinating stuff Rajiv! Looking forward to reading more. Can't wait till your return to review and reflect on your learnings.

Posted: June 22, 2016

By: Terry Maloney

R........... most interesting reads so far. Almost hard to imagine the local conditions on the ground there. Congrats on taking this on !! I know you will relish the experience.

Posted: June 22, 2016

By: John Keenan

Great stuff! Keep it coming.

Posted: July 05, 2016

By: Penny

Hello Rajiv

You have to take your opportunities for improvement as they come. Things we take for granted and even consider superfluous can be the height of innovation in other circumstances.
I was shocked by that BP reading. Hypertension has been and continues to be a very significant cause of sudden premature death in African countries. One factor is the use of salt and smoke as a preservative for meats. Electricity is a luxury still. This is a public health area I would like to work on when I retire because early death in males is very likely to condemn the family to destitution.
Thank you for your good work

Posted: July 10, 2016

By: Peter Levitt

FASCINATING reading - I feel like I am back in Africa!

Posted: July 10, 2016

By: Heather Johnston

Rajiv, I am so enjoying these blogs. Some time I will tell you about an
anaesthetist friend (Canadian) who came out to do some work when I was in
West Africa. He lasted about three hours


Posted: July 10, 2016

By: John Lloyd

Hi Doctor Singal:

Delighted to hear you're involved with Dignitas, our Rotary Club of Toronto has been involved with and supportive of Medicine sans frontier for some time and the head of Dignitas has spoken to our club. Well done, take care of yourself.

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