Before I get started, let me introduce myself. I’m Nick (on the right) the Lifebox Fellow: AKA an ST6 Anaesthetic Trainee in The Central London School of Anaesthesia (TCLSA) undertaking an Out of Programme Experience (OOPE) in the delivery of clinical teaching and Quality Improvement (QI) Projects in a developing world healthcare system.
(Translated for those of you fortunate enough not to have to know the intricacies and terminology of the UK medical training pathway – I’m a doctor, specialising in anaesthesia and I recently left the UK to work in an Ethiopian hospital for six months.)
I, perhaps naively, felt moderately prepared for practicing medicine in a low-resource setting. By moderately, I mean I had the privilege of visiting Jimma University Hospital, Oromia, Ethiopia for a week in April 2015. I joined the faculty for the eSAFE Paediatrics course, teaching a cohort of anaesthetic nurse practitioners and anaesthesiology residents. Although clinical contact was minimal, I experienced a flavour of just how different a hospital in this cultural and economic environment could feel. Unsurprisingly this proved a significant under-preparation for the experiences that have followed.
Lifebox offers two Fellowships for senior UK-based anaesthetic trainees (or anaesthesiology residents if you reside west of the Atlantic) to undertake educational and QI projects in Ethiopia and Uganda. Having previously worked in East Africa before medicine and done my fair share of travelling it seemed like the proverbial no brainer. I applied.
Six months later I found myself on a dusty, cobbled street in an Ethiopian University town called Jimma with two (highly strategically packed) 23kg cases and an illegally-heavy piece of hand luggage. Somehow I had managed to secure a life (six-hour potholed undertaking) from Addis Ababa to Jimma with a German GIZ (equivalent to DFID in the UK) employee who I met back in April. Even more fortunately I managed to sublet a house off an American biomedical engineer (you might be a getting a flavour of the ex pat community out here – and I haven’t even mentioned the Peace Corps Volunteers) with electricity and (sporadically) running water. Quite a result really.
This proved essential as it enable me to hit the ground (close to) running when I stepped into the Intensive Care Unit the next day to commence clinical duties. I (re)met the three anaesthesiology residents (American nomenclature predominates here) and the head of Anaesthesiology Department. After my scrubs envy (one of the residents was sporting a Winnie the Poo matching set – as with almost all equipment here, donated by a foreign NGO or travelling medic) had subsided, I set about clarifying exactly what was expected of me during my six months here.
After one month I think I finally have a clearer idea of what that remit is. I supervise the residents anaesthetising for cases in theatre, teach theory / simulation with the residents and teach the ITU nurses. In addition, I am trying to “improve” things; much easier said than done as I hope my blog entries will convey to you over the coming months. If you ask me my role in a month, I dare say I may write something entirely different.
Assuming most of those reading are residing in so-called ‘developed’ world nations, with a particular experience of care provision, you may be in need of a brief explanation of exactly how things work out here. Or at least as much as I have gathered in a month. It is certainly very different to the completely state-funded system we are fortunate to have in the UK.
In a nutshell, and to paraphrase most of the issues highlighted in the eye-opening Lancet Commission on Global Surgery released this year, the majority of Ethiopians cannot afford health care. There is huge unmet surgical need, poor infrastructure resulting in often inadequate power and water supplies, and unreliable procurement and supply pathways resulting in suboptimal availability and maintenance of equipment and medical supplies. Add to this the particular poor transport and road networks, combined with financial, cultural and religious barriers to attending medical professionals, and you begin to see how patients present late and with serious complications – conditions that would usually get diagnosed and treated in their infancy back home.
The maternal mortality rate (MMR) in Ethiopia is the 6th worst in the world, although World Bank figures show some improvement has been made in recent years, from 500 per 100,000 live births in 2010 to around 420 per 100,000 in 2013.
For comparison the MMR in the UK is 8 per 100,000.
The global improvement in MMRs is perhaps in part a reflection of the successful application of the UN’s Millennium Development Goals, (MDGs), specifically 4 and 5 whose aims were to reduce child mortality and improve maternal health. As of this year all MDGs will give way to the SDGs: Sustainable Development Goals. These will map out the ambitious aims of the international community until 2030 including, – hopefully following on from the Lancet Commission and the World Health Assembly resolution – an increased emphasis on global surgery.
For all the above, there are genuinely impressive components to the healthcare delivery here. Ingenious improvisation is born out of necessity and the very same problems that create such diverse and advanced pathology also cultivate incredibly skilled medical physicians who diagnose purely on clinical examination and surgeons who resect any lesion, anywhere on the body. Put another way; there are no “exclude-a-gram” CT scans (in fact any CT or MRI scans for that matter) or dedicated hand surgeons here!
Let me summarise a patient’s surgical journey to try and illustrate a few things for you.
You arrive for your operation. As previously stated there is a huge unmet surgical need, so most elective surgery here is, quite rightly, trumped by emergency work – or simply elective work that has become semi-elective or emergency by virtue of the fact it presented late in the first place.
You arrive for your now semi-elective operation. You have been consented and seen by the surgical team, and in a desperate attempt to begin to clear the backlog of surgical cases you are put onto a hugely oversubscribed list for the day. The sort of list you might turn up to in the UK amid much head scratching, consternation and mutterings of “exactly who booked this list” or “this is totally unrealistic”. Invariably your case is cancelled and you are rescheduled for another day.
On a subsequent day you are still on a hugely oversubscribed list – but this time fortunate enough to be near the top of it, and on a relatively quiet HBB day – “hit by bajaj” (a popular form of transport and frequent cause of trauma). You arrive in the OR. Prior to this you’ve been seen by the surgical resident and the anaesthetic nurse/doctor/level 5 graduate (I will explain the exact nature of anaesthesia delivery in Ethiopia in due course).
Between the two teams a list of required medications, fluids, IV drips, antibiotics, analgesia (pain relief), urinary catheters etc. has been constructed. You have duly been required to pay for all these items and arrive in OR sheepishly clutching your box. If you haven’t got quite enough money, your pain relief is usually the first thing to be struck off the shopping list. Not insignificant for any operation, let alone if you’re having, for example, a laparotomy (opening of your abdomen).
Once you’re off to sleep the difficulties may continue, although as part of the global community of gratefully unconscious patients, you’re unable to appreciate them. For reasons of limited finance and difficulty of procurement, the disposable culture of high-resource setting healthcare does not materialise here. What this means in reality is that all the ideally disposable equipment like facemasks, breathing tubes, suction tubes, etc, are cleaned after use and reused the following day, retrieved from the red bowl in the anaesthetic store room. The only exception to this rule is if the patient is a known to be HIV positive, in which case the equipment is disposed of.
Limited biomedical engineering means that both surgical and anaesthetic equipment here is tricky to maintain and prone to malfunctioning – potentially at highly inopportune times. As most of these are provided ad hoc by well meaning Non Governmental Organisations (NGOs) or other charities, there is no uniformity or consistency – which makes maintenance and understanding their operation even more challenging. As previously mentioned the flip side of this situation is the creation of ingenuity and opportunism that manifests in many unexpected ways.
Once finished you are woken up and after passing through recovery you are returned to your busy ward, often overflowing onto a corridor to recuperate.
It may seem confusing but there are four different grades of anaesthetists practicing in Ethiopia. It’s especially confusing for any anaesthetist from the UK, where only medically qualified doctors practice anaesthesia. Indeed, prior to 1974 no Ethiopian anaesthetists of any qualification existed; anaesthesia was undertaken solely by foreign practitioners.
Currently, according to the Ministry of Health, Ethiopia has around 1000 BSc graduates, 30 Anaesthesiologists (i.e. medically qualified anaesthetists), 70 MSc. graduates and 211 Anaesthesia “level 5” graduates (a fast track anaesthesia qualification introduced in 2012 to rapidly increase anaesthesia practitioner numbers). There is currently a national government drive to increase recruitment from the Medical Interns (recent medical school graduates, similar to Foundation Year Doctors in the UK) to Anaesthesiology Residency Training Programmes (akin to Core/Specialty Training Programmes in the UK). Prior to last year these rare creatures only existed in Addis, and barely amounted to double figures in number. But as of this year, 3 have started in Jimma and the current recruitment for Jimma’s second cohort is underway.
Consequently it is an exciting time to be here to help nurture the first crop and oversea the start of the new intake. This resident teaching component of the Lifebox Fellowship is arguably the most important aspect my time here, and I will describe these sessions in more detail in upcoming blog entries.
One of my key focuses from a QI perspective will be in the matter most dear to Lifebox: safer surgery promotion. Having already performed wonders with the introduction of pulse oximeters across some areas of Ethiopia as well as more than 100 low-resource setting countries, Lifebox is taking its next programmatic step in wider application of the WHO Surgical Safety Checklist in challenging environments. This means a particular emphasis on reducing surgical site infections (rates are more than double that of high-resource settings) via a systematic review of current practice, and the introduction of new processes.
My arrival here corresponds very fortuitously with a large grant from the GE Foundation to Lifebox to pilot this work in Ethiopia, led byTom Weiser – Lifebox trustee, and trauma surgeon in Stanford, USA and one of the original creators of the WHO Surgical Safety Checklist. Having had the privilege of pre departure Skype sessions with Tom, one of the original team behind the landmark WHO Checklist paper, I feel very optimistic about the prospects of this exciting venture. Tom arrived for a whistle-stop tour of Ethiopia recently, so, watch this space…
One of the most exciting projects that I will be pursuing during my time in Jimma is the (re)introduction of the WHO Surgical Safety Checklist in the three operating theatres here (two in maternity, one in ophthalmology).
The ambitious aim is to try and achieve sustainable implementation of this highly evidence based communication and team-working tool. I was well aware before my arrival this was going to be a key part of my time here, and have to admit to being a bit apprehensive about the project. Implementing the checklist into a low-resource setting (or a high-resource setting for that matter) is, in my opinion, the poisoned chalice of Quality Improvement (QI) – it has a notoriously high failure rate on the sustainability front.
Thankfully I was joined for a few days in September by someone who knows a thing or two about the checklist: Tom Weiser, Lifebox trustee, surgeon and one of the original authors behind the landmark WHO Surgical Safety Checklist NEJM paper. This, I suspect, can only help matters.
It was a highly insightful and interesting experience prearranging all the meetings in anticipation of Tom’s arrival and attending them post his arrival. Having somehow convinced him to stay in the spare room of my house, which boasts mostly continuous power and mostly absent running water, I had plenty of opportunity to pick his brain over a St George (a beer named after the patron saint of England – or Giyorgis, also significant in Ethiopia) or Tej (honey wine). He has impressive exploits behind him, and plans for this new venture – and I hope I can continue the project’s momentum now that he has left.
I will try and give you a whistle stop tour of the meetings we attended to try and get the Checklist implementation off to a running start.
You never can be quite sure how scheduled meetings will pan out here. Striking the balance between frequently reminding the attendees of the time and venue whilst at least pretending to retain an air of local laid-backness can be tricky…
This first meeting was meant to kick start the whole week, so I was particularly keen not to deliver Tom to an empty room on his first day. I had enlisted Dr Yemane, previous head of the anaesthesiology department at Jimma, to head whip up support – as well as bombarding the various heads of departments with text/emails/phone calls/good old-fashioned door knocking. I wouldn’t go as far as to say I needn’t have worried but by hook or by crook the numbers gradually swelled into a sizeable and, importantly, mixed professional audience.
As expected, Tom delivered a slick presentation, and the audience slowly found their voices. By the end a thorough discussion of the issues of checklist implementation in Jimma was underway. It was at this point I did breathe a slight sigh of relief. Perhaps this venture does actually have legs.
It didn’t stop there though. Next came the second key meeting of Tom’s visit; with senior management. Attendees included Mr Kora, VP of Administration, Jimma University, Dr Fekadu, CEO, Dr Diriba, Medical Director, Dr Seifu, General Surgeon, Tom and myself. It was in the same venue that I had previously sat down with Mr Kora and members from the GE Foundation and Dalberg who were here to begin to map part of the Safe Surgery 2020 initiative that was launched in September.
This was a different kind of meeting, with a complicated sell: Tom outlining the concept of the checklist he was ‘bringing’ whilst explicitly stating that it’s something Jimma has to take ownership of and not rely completely on foreign implementation. I quite agree this message needs to be repeatedly stressed. There is no hope whatsoever of sustainability with any forenji (Amharic word for foreign person) intervention here, let alone the checklist, without local buy in and locally appointed leaders who, put simply, get it.
The potentially hard sell to senior management in the case of the checklist is the fact that this isn’t a foreign intervention that comes, as they so often do, with bundles of cash or donations of equipment. This is a team working and communication template that will reap both short and long term benefits in patient outcome and system efficiency. These both, of course, will ultimately result in financial gain – but perhaps not with the immediacy that low-resource setting world institutions have come to hope for, and dare I say expect, from foreign/NGO aid.
Probably the most impressive thing to come out of the meeting was the feeling that the management did begin to appreciate that specific financial donations were not immediately forthcoming but that, regardless of this, the Checklist was still something Jimma should be striving to introduce. This was surely the number one objective our meeting. Job done, we retired for evening entertainment in the form of St Georges, injeera, and the company of several Peace Corps volunteers. There really are quite a lot of Americans out here.
The following day kicked off with arguably the most constructive meeting of Tom’s brief visit. We had managed to get together a good representation of the professional bodies that will all ultimately have to find value in the checklist for it to actually achieve universal uptake. Present: surgery, anaesthesiology, anaesthetics, nursing staff, theatre scrub, the theatre matron as well as Tom, myself and Dr Fekadu chairing.
It was good to hear lots of people speaking up on what they thought the important issues were and what should and shouldn’t be included on the personalised Jimma checklist. Not all disagreements reached a comprehensive resolution but what took shape from that meeting was the first draft of the Jimma checklist. Realistic as a workable version or not, the important thing is that it wasn’t our checklist – it’s theirs to run with and modify if difficulties arise during implementation. It is after all, draft 1.
After an enlightening impromptu extended lunchtime conversation with Tom, Mr Gugsa (head of nursing) and Dr Seifu about potential training programmes they are keen to get off the ground, we set out to a more low key presentation for the theatre nurses. I say low key because it turned out to be mostly nursing students, some of whom hadn’t spent time in the operating theatre. Still, catch them early I suppose!
When it comes to locally engaged clinicians who get it and are driven to improve things amidst the adversity that exists here, Mr Gugsa and Dr Seifu are squarely in that bracket; both very inspirational people. Unfortunately Mr Gugsa is off abroad to undertake his PhD in January, but such is the nature of the beast I suppose. If you are successful and strive for success out here, foreign doors are bound to open – and who can judge anyone for taking the opportunity to better himself educationally and financially, even if it is to the detriment of the institution they vacate?I’m not really sure what the answer to this problem is, but it does appear to be a recurring theme.
I pretty much left Tom to his own devices after day 2 as I felt like I had neglected my clinical duties a bit. That said, I bumped into Tom again in theatre later where a pretty successful stab at the checklist was undertaken – without any foranjee involvement! (Apart from to introduce ourselves of course).
Tom went on his way a day later for a meeting at another potential pilot site and then on to Addis.It was pleasure and a privilege at my humble stage to meet such an established international global surgery player like him. I hope to do justice to his vision and maintain the collaboration with future Lifebox Fellows and Research Fellows from Stanford, who will hopefully come out to Jimma to the near future to carry on this and other projects on. It is potentially the beginning of some very exciting times here – but only if we press on with the initiative that’s been created and, as I say, we get locally engaged leaders from within Jimma. Time will tell.
One of the most difficult things about this placement was always going to be adjusting to the significant cultural differences that exist between Ethiopia and the UK. Ethiopia is an extremely religious country, both Ethiopian Orthodox Christianity (slight national majority) and Islam (the majority in Jimma). Despite being a committed atheist I find religion fascinating, and discussions with the anaesthesiology residents have frequently turned to religion.
Hearing their views as devout Orthodox Christians whilst simultaneously medics and scientists who are taught to question everything and seek out evidence, seems conflicting to me, but not to them. (Though we’re down the road from what is generally believed to be the birthplace of humanity and the home of Lucy in Addis!). I admire such devout resolution to one’s beliefs, even if I personally cannot understand it.
An interesting societal quirk of having two predominating religions in Ethiopia is that both religions’ holidays are given national holiday status. This does seem to manifest in frequent days off for all, regardless of denomination! (Not that I can talk mind; I am quite partial to Christmas.)
Last week we had Eid al-Adha following soon after by Meskel. Eid al-Adha is the Islamic festival celebrating Abraham’s near sacrifice of his son to God, and Meskel is the Ethiopian Orthodox Christian celebration of part of the Cross (the right arm of it, I’ve been told by one of my residents) being found on Ethiopian soil by Queen Helena. They celebrate with a huge gathering in to light the Demera, a large bonfire engulfing a representation of the True Cross. I was tempted to cram into the crowded arena but having read about the recent tragic events at the Haj, I thought better of it and admired from a distance.
As night fell, I couldn’t help thinking of Bonfire Night back in the UK – albeit with a slightly different rationale and no human effigy set ablaze. As the crowds dispersed, they did so with much good-natured singing, dancing and general merriment. Considering this whole escapade started with myself and Sonja, a Swiss orthopaedic surgeon out here doing amazing work with GoStar, spontaneously jumping into a bajaj and asking in pigeon Amharic (or rather very slow English with much gesticulation) take us to Meskel, I think this had to go down as a success.
And, dare I say it, this whole experience.