Decompensation

Today I ‘decompensated’ in theatre. Today it was one time too many, and I found my frustration bubble over. I did not shout, but perhaps raised my voice a touch. I vocalised the words “this is completely unacceptable” and was very blunt with my other comments. I even said that I was cross. I am not a shouty person (and hope I never will be). For me, this was a big deal. And clearly it had an impact. Whether this episode will ultimately be a good thing, or not, only time will tell. It will either be a catalyst to help drive improvement, or it will damage my relationships with the team. I really hope it is the former. I am only human after all.

My frustration was simply that we are better than this. The team here is better than this. But why are we making the same mistakes? I found myself watching an adult patient having an unnecessarily long period of hypoxia (time without oxygen). Once again, the same issues emerge. A lack of situational awareness perhaps. A lack of communication. A lack of preparedness (the CO₂ monitor was not connected, the new suction catheters I had had sent over from the UK were not ready, the bougie was in the store room). When things go well, they are very slick. But when things are tricky, the situation seems to escalate. Problems will always emerge in healthcare, but rather than the brakes going on and returning to a place of safety, somehow things seem to spiral and become unnecessarily hazardous. I seem to have been the brakes more often than I would have liked.

Today the patient was a difficult intubation (this means it is difficult to get the breathing tube into the right place) and we did not have our lead anaesthetist present. Things were taking longer than ‘normal’. Equipment was not ready. The clock ticked on. All this time the patient was without oxygen. The pressure to secure the airway increased. But it was not forthcoming. At this point, the team should have stopped. Reset. Reoxygenated the patient and tried again. Up until this point, whilst not ideal, everything was safe. And such things happen in theatres across the world. Not uncommonly even. However here, things ploughed on. In what looked like a last ditched effort, the tube was sited. Unfortunately, it transpired, this was in the oesophagus (food pipe, the wrong place). But it would take time to establish this fact (longer because the CO₂ monitoring wasn’t attached). It was around this time that I spoke up. The operating room was noisy, and I asked for quiet. The saturations were unrecordable. We needed to try and rescue what was rapidly heading towards a disastrous situation. I just hoped it would be in time. The tube was taken out. Thankfully, a bag and mask (a technique used in resuscitation) was very effective and the saturations climbed. Soon we had returned to a place of safety. Hopefully there would be no long-term damage.

I was encouraged to take over. But this time I refused. I knew the team was better than the last few minutes. Having vocalised my frustration, I now voiced an air of calm (far from how I was feeling, but the team didn’t need to know that). “Take a deep breath. The patient is safe. Now what do you need to do this properly?”. I stood behind the nurse anaesthetist and took on the role of their ODP (a crucial person in the UK who helps make sure everything is ready, acts as an extra pair of hands, a second pair of eyes and is a supporting role not be underestimated). I attached the CO₂ monitor. We got the boogie. We set up the suction properly. We were ready. The patient had been well re-preoxygenated. I said “You do this. You can do this. You have plenty of time now. Relax”. I could see that he did. I could tell it was not easy, but he was calm. He used the boogie and intubated the patient. Fantastic. “Well done” I said.

I washed my hands and did his surgery.

There was definitely an air of ‘walking on eggshells’ in theatre for a short time after that. But this slowly dissipated, and we returned to our normal happy place. At the end of the case I said thank you and well done to the whole team as I usually do, but this time apologised for ‘getting cross’. “I was frustrated. You are better than that”, I said. They smiled and nodded. I went to write the operation note. I was distracted though. What am I missing? Why do these things happen? What don’t I understand? Clearly things here are very different to the UK. Clearly a consultant anaesthetist in the UK has substantially more experience and training than the staff here. But I genuinely rate the staff that I work with in Muheza. For what they are, for what they have, they are excellent. But it occurred to me that I did not understand the whole picture. They were not me, and I was not them. And so I walked to the coffee room. It was a jovial place and I was reluctant to drag us back to a less happy place. But I did. I asked my Tanzanian colleague (the senior surgeon); “Do you want to talk about what happened? Ask the team. If you do, come and get me.”

What happened next, was fantastic. I was both humbled and delighted. He came to get me and when I walked back, the whole team were lined up on chairs sitting in front of the whiteboard I had bought. We had not used it yet. What a way to start. We spent the next 30 minutes unpicking what had happened. A classical ‘simulation debrief’ if you like. Except of course it wasn’t a simulation. No punches pulled and no stones left unturned. It was incredibly honest and incredibly insightful. Together we identified the problems, why they were an issue and, perhaps most importantly, what we could do to change our practice.

Perhaps today was a good day.

When I visited the ward later, the patient was awake and talking. Another close shave, but I think we got away with it.