How I came to be involved in Clean Cut
I arrived on the ground in Ethiopia with Lifebox last summer to a program that was clicking and running in full force. The Clean Cut program, with support from the Federal and Regional Ministries of Health in Ethiopia and our initial partners from the GE Foundation and Assist International as part of Safe Surgery 2020, is improving the quality of surgery delivered in several hospitals in Ethiopia and seeking to reduce surgical infections. The design of our program is simple but requires the collaboration and buy-in of our local colleagues to be effective.
This was more of a homecoming than a new adventure for me, as I’ve been living in Ethiopia on and off for the past 11 years. Starting off as a Peace Corps Volunteer in a Health and HIV/AIDS project in 2007, the experience I had in Ethiopia shaped my perspective of health care and my worldview. Since that time I have been compelled to return again and again, not only because I find the work here so profound, but also to grow the relationships I have formed in this incredible country; those that started as friends, co-workers and hosts have become like family. Needless to say, when the opportunity arose to work with Lifebox on a project that built the capacity of local surgeons to improve their own healthcare delivery model, I jumped at the chance.
Clean Cut, briefly, is aimed at improving basic operating room practices that can prevent surgical infections – infections that can be deadly to patients, particularly in a setting such as Ethiopia. Many predisposing factors are difficult to change – patients may present late to care, be malnourished, elderly, have other complicating disease processes. But by ensuring patients receive antibiotics at the right time, instruments are clean and sterile, and there are no breaks in surgical linens or gauze packs left behind, we can reduce the number of surgical infections that occur.
Our project has been implemented in five Ethiopian hospitals so far, and today I’m visiting one of the more remote sites. The surgeon here is held in high regard by everyone I meet. His former teacher describes him as a flawless resident. His team admires and respects him because he treats them with equal respect and listens to their concerns. On our first day together at a previous visit in the hospital, we made rounds in the surgical ward, a barracks-style building with four rooms off a single hallway with eight patients to a room, with only one surgeon and one gynecologist on staff here.
He remarked on the resources available at this hospital – we talked about the trauma cases that present to the hospital on a regular basis, owing to the road traffic accidents that are so common along the major highways. “I should be able to reduce femur fractures, perform a burr hole, at least, for those patients with long bone fractures or head trauma.” He has the training for these procedures, but the hospital has no traction equipment or neurosurgical drill set.
Today we visit the hospital to hold a regularly scheduled meeting and review data from the Clean Cut program. But we have an ace up our sleeve today: a biomedical engineer from the mentor hospital in Addis, and, as it turned out, a rather industrious taxi driver.
We arrive on site, birds chirping after a morning rain, sheep and goats grazing in the hospital shrubbery. Today, everyone is dressed in business casual attire because there are no OR cases scheduled.
Three dry heat and two steam autoclaves – the machines used to sterilize surgical instruments – are all broken.
Using cobbled-together sets from the Emergency Department dry autoclave, they are still able to perform emergency Cesarean sections, but all other cases have been referred to Addis Ababa for the past several weeks. At our last visit they had been using small dry-heat autoclaves to sterilize sets, which had been working at variable quality, but have finally given out. The hospital has two massive steam autoclaves; but like so much other biomedical equipment in the developing world, they have been sitting in disuse for as long as anyone can remember. They are used as overflow storage containers for linens and instrument packs in the instrument processing room.
The engineer, who much to my delight is a young woman about my age, gets to work straightaway, dismantling the circuit board and taking stock of the various pressure and temperature gauges. The problems uncovered are numerous. The electrical wiring configuration is all wrong, and some functional pieces from one autoclave are cannibalized to repair the other. Our driver from Addis has followed us into the instrument processing room,curiously observing at first, he then offers to get a circuit tester from the car. Soon, he and the engineer are huddled together around the autoclave, brows touching and conspiring about next steps, with the hospital staff gathered around.
Several small victories are made – the wiring is reconfigured and the machine actually turns on – fan whirring at a furious speed and a dull roar filling the room. The tank filled with water and steam begins to pour out the side. The dials and settings are re-adjusted to yield an appropriate sterilization cycle.
After about four hours of finagling, the whole room is thick with steam and the temperature is rising. We start a sterilization cycle thinking it may work, and then a dramatic gush of steam from the bottom of the machine reveals a leak. I think to myself for some reason this feels like being in an old battleship or submarine – the steam escaping from gaskets, clanking and clunking of metal equipment, tools strewn about. Our driver is fully in his element, hammering away to reshape a copper pipe like some sort of medieval blacksmith.
After some further adjustments, refastening the copper piping, loosening and tightening this and that connection, we try again. This time, the seal holds. The behemoth steam autoclave periodically belches a cloud of steam out the release valve. We watch the temperature on the digital display climb and climb, until finally it reaches 121C and holds steady. The whole team is transfixed on this process, staring at the dials as though we can collectively will the machine to work. Finally, the cycle is finished. The steam is released in a dramatic gasp and the giant door cranked open. We cross fingers and toes in anticipation – the test pack is pulled out of the autoclave and beautiful black stripes illuminate the sterile indicator tape – indicating the cycle was successful.
The room erupts in cheering and high fives all around. The local electrician, our pediatric surgeon lead, the engineer, our taxi driver, visiting physician consultants and the staff nurses all united by this victory. In that moment our realized goal is singular and clear – surgery can be resumed. The autoclave is working. Patients can again receive the timely care they need.
The machine is loaded with laparotomy and cesarean sets, and minor trays – the instrument sets that have been packed and waiting in the corner for the past few weeks. The heavy door is closed and the first of many sterilization cycles begins.
Teamwork saved the day
Something we take for granted so often in the resource-rich settings of hospitals in the US is the everyday functioning of operating room processes. Surgery becomes focused on the finer points of ensuring the needle is loaded perfectly when handed to the surgeon, on maximizing efficiency and room turnover. Not that these things aren’t important. But we have oxygen tanks (that are full of oxygen). We have sterile instruments. In fact, if we do not like the tips of these forceps or the way this clamp grabs tissue, we can have our pick of ten others at a moments notice. They will come in individually sterilized disposable packs. There are so many unseen processes that go into providing a safe operation that rarely concern the surgeon in such a discrete way.
Resource-poor settings such as Ethiopia do not have that luxury. We must rely even more on teamwork and communication to ensure safe surgery, even regarding processes that happen outside the operating rooms. The basics, such as making sure surgical drapes aren’t ripped, gauze are counted fastidiously, and surgical instruments are appropriately sterilized, rely much more on teamwork here than in resource-rich settings where there are many backup systems to ensure mistakes aren’t made. The government and Ministry of Health in Ethiopia have put a huge priority on improving surgical capacity and quality, pioneering the SaLTS program, one of the first national surgical plans in the world. Their efforts have, and continue to, improve surgical care in this country. However, the climb uphill is long, and at the local level providers must think in innovative ways, and work as a team to overcome many challenges.
Sometimes all it takes is to make a tangible impact in the care of surgical patients is a little dedication and teamwork. And it doesn’t hurt to have a renaissance man for a taxi driver.