The value of the Strategic Plan

As part of the Cost Effectiveness study that Geoff and I are doing, we need to break down the cost of running the hospital to an operation by operation level. This hasn’t been done before in published literature to the degree that we would like to do it and I believe it’s because most surgeons aren’t married to management consultants. However, we are here to break new ground.

When I try to explain to most people here what we are trying to achieve a glazed expression comes over their eyes and they start to tell me all the difficult calculations that have to be made, if they even know where to begin. I’m not fazed from a theoretical standpoint – I’ve worked out the cost of production of plastic sheet in North America to enough detail to prove to the owner of the business that he was undercharging on some product lines. I am confident I can tackle a hospital.

What I haven’t been confident about is getting the information needed to do it. Hence I am writing about this element rather late in our trip. I know from home that most organisations aren’t entirely keen on having outsiders go through their books and here, where both me personally and my career are unknown, I expected it to be even more tricky.

So I played the long game and waited until we had the Acting Medical Superintendent on board and then explained to him the numbers that I would need. At his request I made a document explaining all of these and he signed it and sent me to the chap in accounts.

First it went to the Acting Accountant who seemed eager and told me he could do all the numbers in two weeks. Personally, I thought it would take a month to fill in what I’d asked for but I’m a sucker for enthusiasm. After 6 weeks I still had nothing and he’d lost the form. No problem, I put a soft copy on his desktop – you can’t lose that…

Then the Accountant came back. He wanted to see my request so I was positioned on a chair outside his office (but not in view of the door) whilst his Deputy took in a paper copy. I was there for half an hour. I was not surprised and nor (because I’ve been here long enough) was I bored, annoyed by the waste of my time or anything else. I occupied myself watching people coming to pay bills or pick up their pay. Partly my relaxed approach is because I’ve been here a long time but partly it was because I knew what the problem was…

The problem was that the 10 page document that I had written was a wish list. At home over 75% of Financial Directors or CFOs would have looked at it and sucked their teeth. Not because the information didn’t exist, per se, but because I wanted it cut a particular way – and normally that’s not how the business is separated, most commonly for legacy reasons. In this instance I wanted costs allocated by department down to Repair and Maintenance. I was pretty sure they wouldn’t have it! But it’s always better to ask.

Presently, I was called in to the office and the difficulty of my document was explained to me. After a few moments the Accountant asked me my background and, finding that I was both an Engineer and worked for an Accountancy firm, promptly relaxed and advised his Deputy that they could speak freely. I took this to mean that they could speak in Accounting jargon and assume that I was keeping up ;)

A compromise was reached swiftly. There was just one problem. Salaries. The Medical Superintendent told me these would be a problem because most staff are paid directly by the Government and not the hospital, so he believed their salaries would be unknown [We need them anyway because we have to do the total cost]. This was not the problem – there is a large yellow book with all the salaries in sat in Accounts. The problem was that they didn’t know how many staff of each grade were in each department… So I set off to find that out for them.

This was a little before Christmas and we have hit the dreaded Year End so progress has been slightly hampered. In the interim, I have been asking the Project Manager to work out how much it would cost to build the hospital again from scratch. He mentioned that it would help if we had the Strategic Plan.

There is a Strategic Plan?? This is gold dust to me. On every project the acquisition of the Strategic Plan is the key first step. It will solve all problems – everything will become clear, there will be no confusion. In reality it’s often a bit of a let down but, you know, hope springs eternal and all that.

The second it’s on my USB stick I feel invincible. It’s 102 pages long I discover, surely it contains everything I could possibly need and more?! I begin to read, OK, so it’s not quite what I was expecting but there are some snippets in here. Anyway, not to worry, the numbers in the back will explain everything, I just need to get a quick idea of the big changes and then open my Excel.

Copy pasting tables sat in the sunshine is not a chore – my colleagues should work outside more in summer, honest. I have data from 2009-2011. I have data from 2013-2015 and I have data for the current year, 2012. This is perfect. I am sorted.

Except that they don’t match. The same sinking feeling I get at home happens. Someone has changed the descriptions of some of the lines. All of a sudden £40k has disappeared from one place and cropped up in another, but I can’t see why. There are bizarre trends that I’m not sure about – is it real or did something else change? Drugs funding is split out in some places but not in others, my attempts to pro rata it don’t seem to make much sense. Capital projects includes RMI, RMI includes new equipment purchase, somewhere there’s a massive double count on new items.

Perhaps the Strategic Plan isn’t going to be the Holy Grail this time either. Maybe it never is. I’ve decided to wait for the Accountant – it might be taking a while but at least he’s telling me that the problem is he didn’t believe his first set of numbers! And at home, that’s almost invariably a good sign (in the end).

The meeting of European and Zambian medicine 2

Looking back, I have already discussed the difficulties I faced dealing with the wide difference between my training in burns care in Chelmsford, textbook care and the reality on the ground here. In fact, we have made big strides, with most patients now being resuscitated better, much faster turnaround and decision making for conservative versus surgical treatment and the consequent reduction in bed time and blood usage. We have however started the more difficult task of modernising the care of patients following major abdominal surgery.

There is now good evidence that feeding people immediately after major surgery reduces the catabolic physiological response to trauma and improves their recovery. The evidence also supports early feeding even when there is a bowel anastomosis, with some exceptions (generally when the patient is critically ill or has been obstructed for a prolonged time). British practice, and my training, has moved away from the previous theory that a patient should not be fed until they open their bowels post-op, to reflect this new evidence. Indeed, I was at a national conference last year where someone suggested it would be negligent not to adhere to enhanced recovery protocols following colorectal surgery, a large part of which centres around early post-op feeding. To this it can be added that the patient population here is already malnourished pre-presentation, and a further week of starvation is a huge physiological challenge on top of a laparotomy.

The current practice at SFH, which has been the international norm for a very long time, is to keep a nasogastric tube in situ and the patient nil by mouth until they open their bowels. This is irrespective of whether they have had an open and shut exploratory laparotomy, a major bowel resection or surgery to another abdominal organ. Three examples from this week best illustrate things:

1. 18 year old boy with traumatic bladder rupture, repaired and catheter left in. Bowel not injured. Should be fed immediately post-op.

2. 56 year old man, HIV positive, small bowel intususseption reduced but not resected at laparotomy (CD4 count unavailable so we were unsure how an anastomosis would fare). Patient had been obstructed for over a week and was left with a bowel full of fluid, so best left with a NG tube, but would rapidly recover and feed on day 1 or 2.

3. 30 year old lady with recurrent sigmoid volvulus, underwent a semi-elective sigmoid colectomy once volvulus reduced. Should be fed immediately post-op.

On each of these patients, we have clearly indicated the feeding instructions on the post-op plan. For each of them, the recovery nurse has (sometimes aggressively) questioned us and told us we were wrong, and the ward nurse has ignored the instructions. I am not being critical - the staff are adhering to the standard of care that is the norm here, and are being true to their training. I also appreciate the need to be sensitive to the fact that we are new faces and are transient members of staff, and so people need time to adjust to us and our ideas. It is however challenging to reconcile that with our desire to provide care that we know to be first rate.

At the moment we are working hard, on a case-by-case basis, to convert nurses and licentiates to our way of thinking. We remove the NG tubes ourselves and directly communicate to the patients and relatives about feeding. We also, every day, discuss the reasons for our approach with the nurses on duty. It is feeling a little easier than with the burns changes, and I suspect that is because I have been around longer, and that the nurses have seen the benefits of my burns changes. We shall have to wait and see how long it takes to make these changes stick!

Our Christmas day activities...

[I've put photos at the bottom because I'm too frustrated with the Blogger software to try and weave them in today]
Geoff has already written about the impact of Christmas on the busyness of the hospital and I was tasked with writing about what we did on the day. I was going to do it a few days ago but my present from Geoff this year was a hideous case of man flu - I could have died.

Thankfully I pulled through, with some assistance from Dr Rory who informed me last night "This is the first time I've ever had to prescribe someone drugs for a cold...". Probably so and it's the first time I've not been able to go to the Chemist to buy them myself :p

Anyway, on Christmas morning Geoff got up as usual and headed into the hospital to do his ward round. That done, he and Gemma came back for a short while to get all Christmassed up. This involved putting on the hats that Geoff's parents had sent over and collecting the gifts for the children. I was in charge of photography.

We started on Mukasa - the female and child surgical ward - things did not begin as expected. Gemma approached the first child who promptly burst into tears and grabbed onto its mum to hide its face. This was repeated a lot. Tigger is very scary, apparently, and colouring books are confusing. Not a single child smiled on receipt of the gift, although the parents invariably looked pleased!

However, after a time, when they thought we weren't looking anymore, we could see them starting to play with the toys, even Tigger. The ones that went down best were the small cuddly toys for the two toddlers in traction (see the photo). They were busy throwing their toys around and generally having as much fun as you can when you are suspended by your legs :)

The older children on Kizito (so, boys) were a little more responsive but it struck me that perhaps colouring books and crayons aren't common around here and many weren't sure why they were being given what they were. The little toy cars with internal mechanisms were easier to understand.

Once all the surgical children had been seen to, we moved to the Paediatrics ward with the remainder of the presents. It was a similar experience with the mums and children eyeing us with some suspicion. I made a little crown out of pipe cleaners, which I put on the head of the first child that came within reach  - his face was a picture "What on earth has the silly woman done to me?"

We soon returned to Kizito to serve the lunch of chicken and rice. Each patient was also given a bar of soap, some salt and some sugar. I asked the Social Worker about the salt and sugar and she just said it had been like that when she took over. Our best guess is that these are things the patients will actually use and therefore they make good presents - the African equivalent of socks!!!

That done we headed home for a break to grab a small snack and chat to people on Skype. All hands were needed on deck from about 4pm to prepare the Christmas meal in the Mess. When I told one of the current students that we were cooking in the Mess her only response was "You know that it's filthy, right?". Yes, I did - see previous posts on the subject.

Many hands make light work and things were well on their way in under an hour. This gave me a chance to boil all the cloths available (which we'd had to pin down with knives given their propensity to move of their own accord) and spray the entire place with fly spray (it felt like genocide). I regretted the decision to Dettol the metal counter top when I saw how black the previously white cloth became! After the meal the game switched to trying to kill the massive cockroaches that were now crawling over everything.

We did our best to make the meal as traditional as possible - there were crackers and hats, mulled wine (even though it was a hot night) and enough leftovers to feed the students for lunch the next day. Everyone seemed to have a really good time.

That said, I'm already looking forward to the Christmas lunch that my Mum is going to prepare for us when we get back....... mmmmmmm yummy and no food hygiene concerns either!

The surgical team on Kizito

Geoff gives a present to a toddler in traction

Geoff and Kalynda serve lunch under supervision

Picture of me just to prove that I haven't changed :) You must be so glad!!

Christmas in the hospital

Charlotte is the better person to talk about the fun and games on Christmas Eve and Christmas Day, so I will talk about our working week instead!

Unsurprisingly, Christmas in Katete is not the commercial extravaganza that it is at home. At most, people spend more time in Church (there was a service that lasted at least 4 hours on Christmas Eve and another similar length one on Christmas day) and government employees get the day off. As it is planting season, the workload has already significantly diminished, and a lot of our planned cases are now not coming for their operations, I assume because they are in the fields.

The week has however been a busy week for emergencies. Last week we did a string of laparotomies for advanced bowel obstruction or severe abdominal sepsis. By far the worst was the young man on whom we had brought out a stoma because he was critically ill with a typhoid perforation. We had to take him back to theatre, just at the point he was getting better, because his relative had pushed the stoma back inside the abdomen because he did not like the look of it. The week has been another week of multiple laparotomies. On Monday, it was a semi-elective cholecystectomy and a colectomy for an intusussepting polyp. Tuesday was pleasantly quiet, although come Wednesday I had booked four laparotomies. One internal hernia with extensive small bowel necrosis needing a right hemicolectomy, one sigmoid colectomy for volvulus and one quick small bowel intususseption for reduction. The fourth was just too ill to anaesthetise and was managed non-operatively (she had been unwell for two months prior to their referral and showed it).

Friday was a bit quieter, although we still did 5 skin grafts and a string of fracture manipulations. Perhaps the most rewarding op (provided it works) was on a 4 year old boy who had lost a chunk of skin and muscle from his forehead falling over. One of the rural clinics had tried to suture it, but it had fallen to bits. We sought some advice from home, emailing a photo to a plastic surgeon, and did our best to close the defect primarily. In the end though the only way we could cover the bone was with a little rhomboid flap, which currently looks pretty good considering everything.

Next week, I'm looking forward to the division of the groin flap on Wednesday!

Referral

I was once told by a tutor in Cambridge that the only question a doctor really needed to be able to answer was "can I deal with this?" and if not, "who can?" This is a perfectly reasonable approach where there are multiple specialist centres, well staffed with a range of experts, all linked by excellent, affordable transport links. Unsurprisingly, that is not the case in Zambia. The concept of referral is therefore very different from at home.

St Francis' receives a huge number of referrals, most from the Katete district health centres, but a sizeable number from other district hospitals (particularly Nyimba, Petauke and Lundazi) and a lot even from our regional referral centre in Chipata. As I have hinted at in previous posts, we have the only surgeons in the province and so it makes sense that all complicated cases come to us. The other hospitals will however provide some basic surgical services, including Caesarean sections, hernia repairs and fracture management. Referrals, particularly of sick inpatients, arrive in a hospital car, which is often sent only when full. This means we often only see the very sick and unmanageable, or inadequately managed patients from the referring centres, giving us a somewhat distorted view of their work!

The patients we receive generally come for a specialist opinion, which is quite often a disappointing (to the patient) "do nothing". Common examples of this are fractured clavicles, acromeo-clavicular and sterno-clavicular joint dislocations or terribly advanced cancers. Nyimba quite often sends a car on a Thursday evening, which means we occasionally get someone who has had conservative management of an abdominal catastrophe for several days who then needs an emergency laparotomy at night, which can be somewhat frustrating! [Particularly for the Surgeon's wife! - Ed] Others include complications that are related to treatment at the other hospital. Our gynaecologists always have at least one C section complication from elsewhere (normally a ureteric or bladder injury). We most commonly receive problematic open fractures or closed fractures that can't be reduced without performing an internal fixation. This week's disaster was a young man with a degloving injury of his leg and a Gustilo 3 open ankle fracture which had been sutured at another centre one week earlier. We had to debride a huge amount of dead tissue and apply an external fixator, and now it is looking like he will keep his leg.

We also receive a lot of self-referrals, some who are convinced we can do something they have been denied in the main hospital in Lusaka (some are right, like the chap who travelled 8 hours to have a lipoma removed this week, some are wrong, mostly those with complicated urological problems) and others who just want treatment at what is perceived to be the best hospital available.

Perhaps the oddest referral yet came from a wildlife charity worker, who arranged to send a young boy whose chronic osteomyelitis and exposed tibia had been mostly ignored by his local hospital.

Our access to referral is a little more tricky. Most patients have neither the will nor the money to travel to Lusaka. When they get there, I understand they have to wait for treatment, further adding to the cost. Most will ask us to do everything at St Francis', and I'm sure a significant number of those we do refer on actually just go home instead. So, we try and offer as much as is safely possible.

The question of "can I deal with this?" became somewhat more complicated last week, as due to a clash of annual leave, I was less supported than usual. There is no such thing as a critical care transfer, so if someone is profoundly unwell and needs emergency surgery they either die or have surgery here, by whoever is available.

I am working on the principle that if I do nothing and the result would be worse than if I do something, even if things go wrong, then I should do the most straightforward operation possible. So, while I am still sending off our complicated urology cases (we get a lot of advanced bladder cancers and difficult gonorrhoeal strictures), I have taken on a bit of orthopaedic work beyond my usual UK experience (open reductions of supra condylar fractures and external fixators mainly) and had to take on one complicated laparotomy (a relative decided he did not like the look of the ileostomy we had brought out for a typhoid perforation, so forced it back inside the abdomen). We also (despite not being plastic surgeons) performed a pedicled groin flap to resurface someone's hand. He would not have gone to Lusaka and just gone home with a terrible wound if we had tried to refer him. The flap looks great, and if it had failed we could have done a skin graft, which was our worst case scenario if we didn't do the flap. So even a failed operation would have been no worse than no operation.

Gemma is now back from her interviews, so I have a consultant around all the time again. Last week did however provide an interesting insight into learning my limits and the often complicated decision making around taking patients to theatre.

I have been looking at some interview skills websites for when I get back, and was amused to see a discussion of the question "a patient needs an emergency operation that you have no experience of, and the consultant is unreachable - what do you do?" The answer listed a whole range of options, through calling other consultants, calling other hospitals, calling the MDU and only then considering doing the operation if all else fails. I am somewhat looking forward to the reassurance of having such a wealth of opportunities for help when I get back!

Next in the frog series

On the night of the fire, Will was supposed to be helping Geoff and Jamie with it but was instead scouring our garden for creatures.

He found a frog, which from the markings and secretion on its back we decided was probably poisonous. See! I was right to wonder about the last one. He asked for a cup to take it home in to photograph - I've told him he can keep the cup!

After a while Nat rang to see if he was still alive. He claimed that the poison was neurotoxic and he couldn't move - we just laughed, which made him huff down the phone.

The next day, when I checked my email I discovered this:

Subject: banded rubber frog says...

BITE ME.

I laughed a lot. Particularly because the frog does appear to be taunting you to bite him and it's relevant because I'd been threatening to say that to some people here that had annoyed me!!

We start exploring...

As many of you are finishing work today for the holidays, I thought I'd do an easy post. There's a message from us at the bottom if you are pressed for time!!!

After 4 months here we thought it was about time we did some exploring. Geoff hasn't had the chance yet just to wander about so we planned a walk yesterday from the hospital to Katete. Instead of taking the direct route we chose to go through the villages and live up to our name of Muzungu ("aimless wanderer").

We met many people that would like our 'assistance' and quite a few children that just wanted their photos taken and then to be shown the outcome. It's funny that even the most scared children (many associate white people with pain - they are the doctors after all!) know what a camera is and what they want. We didn't tell any of the children in the photos below how to pose for us - this is their choice :) It seems that you must look stern or angry in photos here.

I have played around with the photos - and yes, some of them would have benefited from a bit less touching up, I'm still learning. Didn't want to put Will out of a job immediately...

Earlier in the week Gemma and I went for a slightly more adventurous stroll - that involved climbing over a tree over a stream to get back to the hospital. Some of the photos are from that.

The sky really was almost this colour!

There is a man in this mango tree - towards the top right

This is a house

MERRY CHRISTMAS!!!!

We keep hearing of new people that are reading this blog, which is always pleasing. We hope that you are enjoying what you read and that you have a wonderful Christmas and New Year.

If you have a few moments to email either of us then we would love to hear from you!

Below is a photo of us making a fire to roast chestnuts on the other night. Apologies to Julie and Gemma, whose faces have become less distinct in my tweaking :) but you can see me better now!

Will, Geoff, Jamie, Julie, Gemma, Nat, Charlotte