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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.

Rajiv