Possible, but difficult, revisited

We have been able to operate on the two patients that we delayed last week due to a lack of blood, plus one more Wednesday.  The blood bank went out and had a very successful blood drive in the surrounding villages on Sunday.  There is another patient (17 years old) awaiting surgery who has been acutely ill and requires further evaluation prior to mitral valve surgery.

Many of the readers of this blog (if there are many readers of this blog) know for the last 8 years I have been the director of the Quality Improvement and Patient Safety program in my department at the University of Rochester.  This was challenging and often frustrating, and along the way I learned many lessons and developed an interest in errors and their prevention.  Although when I arrived here, I was relieved to be able to work and “not have to fix everything,” I guess I should not be surprised that I cannot just turn off the constant thinking about how to make things better.  The cardiac center does many things well, especially for a place that has only been open for four years.  Like every place, though, there are opportunities to improve communication, reduce the risk of error, and provide more patient-centered care.  There are many challenges for me in this environment.  These include but are not limited to: an incomplete understanding of the medical-legal environment of Cameroon, an incomplete understanding of the culture as it pertains to working on improvement, significant language barriers at many levels, a different education process for the nurses and staff, and significantly more limited resources than we had at Strong.  Even in the U.S. it is always challenging to identify the resources to implement our ideas for improved safety; here it is even more difficult to improve infrastructure to make care safer.

In the news I saw that Great Britain appears to have taken a step backwards in safety by criminalizing certain failings.  I am hoping that they will be very clear about what behavior is criminal and not include errors in these prosecutions as many places have done.  I have been reading Sydney Dekker's The Field Guide to Understanding Human Error.  It will be interesting to think about how to apply his ideas to medicine in Cameroon.

Possible, but difficult

On the last night of the Italian Mission, Drs. Giamberti and Cirri shared the story of the beginning of the mission.  They were always cognizant to try to speak English if Falan or I were present, even if they were primarily speaking to their own Italian-speaking group.  Early in the relationship between San Donato and St. Elizabeth’s, patients would be transferred for Italy for surgery.  There was a desire to perform surgery on these pediatric patients here in Cameroon.  The first year they decided to operate on 3 patients with patent ductus arteriosus.  For my non-medical readers, this is a condition in which a structure that is necessary for fetal life fails to transition to life in which oxygen is provided by the lungs instead of by the placenta, creating too much blood flow to the lungs, and too much work for the heart.  If it does not close spontaneously shortly after birth, it can be closed surgically.  The reason that this procedure was chosen to begin heart surgery in Shisong is that it can be done without the use of the heart-lung machine.  Dr. Giamberti said that they wanted to show that it would be possible to perform cardiac surgery here in Shisong, but that it would be difficult.  They then proceeded to share the adventures that occurred during this first mission.  Although we laughed at how silly the problems seemed and marveled at the genius of some of the problem-solving that occurs here in Cameroon (this is not so different than occurs when we look at the history of medical advances in the U.S.), the fact of the matter is that many barriers remain to high level care here in Africa.  It remains true that it is possible, but it is difficult.  The Italian mission organizations have built a beautiful, modern facility for the delivery of high-level cardiac care.  We do not have to worry about having to cancel an operation because the operating room is full of butterflies, as happened during that first year.  There are automatic generators to provide constant electricity so that the perfusionist (the specialist who runs the heart-lung machine) does not have to choose between keeping the patient alive and providing the surgeon with suction, as happened during that first mission because the person whose job it was to start the generator was not immediately available.  There is water, and commercial scrub solutions, and sterile instrument pans for each case.  What is keeping patients from accessing necessary heart surgery today?  Today the problem was a lack of blood availability for a patient with A+ type blood.  There is a volunteer donor program, but it is still in its infancy.  The patients must bring family members with them to donate blood.  This blood might not be appropriate for the patient having surgery, but it is expected that they will contribute to the blood bank.  The blood bank will go out on Sunday to the surrounding villages to encourage blood donation and have what we would call “blood drives.”  The blood bank is also establishing a component program.  Currently only whole blood is available.  The component program will allow us to be more selective with the way that we use blood, and reduce exposure to antibodies in patients who only need red cells, as well as treat coagulopathy (bleeding) more effectively.   I have already described the financial problems that many patients face in preparing for surgery.  Soon I will describe another organization that is raising funds specifically for these patients.  I am hoping that they will soon have 501c3 status in the US, as well as a US donation website.  In the meantime, I would like to encourage my readers who pray to continue to pray about these issues and particularly if there is a way to support these needs.  For my readers who don’t pray, you can still think about whether there is a way to support these needs, and if you are thinking about giving prayer a try again, here is a place to start.

In the pictures, you see Mr. Thomas who is the director for the blood bank, and the chairs for the volunteer blood donors.  There is also a small lounge where they can have snacks and drinks after donating.