Do you floss your teeth?

It is one thing to know what you should do, yet quite another thing to actually do it.

I know I should floss my teeth regularly ……but do I do it?

I know I should exercise regularly, eat healthily and have 5 portions of fruit and veg per day – but do I do it ALL the time…..or just SOME of the time…..or NEVER !!

For the last 18 months I have been attempting to create the strategy, then design and implement a new Mercy Ships Healthcare Education Program in the Republic of Congo, and I have learnt a lot. One thing I keep coming back to is the idea that education and training is fundamentally about behaviour change. An education program can increase knowledge and skills, but if we don’t apply those skills through a sustainable change in our behaviour then there will be little long term change. We all know we should eat healthily, take regular exercise, floss our teeth etc, but how many of us actually do it all the time? It is hard to change / modify our behaviour. It isn’t enough to simply know what is best.

The World Health Organisation (WHO) 2nd Global Patients Safety Challenge is called Safe Surgery Saves Lives. They have designed a Safe Surgery Checklist to make surgery safer. The checklist is based around 6 key steps to check:
1. you have the right patient for the right procedure
2. the anesthetist has done a risk assessment for placement of the breathing tube
3. the anesthetist is using a monitor to keep an eye on the oxygen levels in your body
4. the team have evaluated the risk of major blood loss
5. antibiotics are given on time
6. that swabs and instruments are counted at the end of the surgery to make sure nothing is left inside the patient.

These are pretty basic things that most people think they do all the time. But when this was studied in 8 countries (England, US, Canada, NZ, India, Philippines, Jordan, and Tanzania) they realised these key steps only happened 1/3 of the time….and that wasn’t just in the low-income countries! A simple checklist helped improve behaviour so that these 6 steps were done 2/3 of the time. Still not ALL the time. But even doing it 2/3 of the time led to a reduction in mortality and infection rates of almost 50%. Wow! Unbelievable. Not new drugs or equipment, but simple behaviour change can improve health! And that is good news for where I work in West and Central Africa because it doesn’t cost much, and it is something everyone can do! BUT behaviour change is difficult.

Using a locally adapted version of the WHO safe surgery checklist has been mandatory in UK hospitals for several years, but still doctors and nurses are resistant to it. Studies of hand washing in hospitals are the same. Everyone knows they must wash their hands, but time and time again, studies show health care professionals do not do what they are supposed to do.
Why is that?
Perhaps it is the same reason you and I do not ALWAYS, ALL THE TIME take regular exercise, eat healthily and floss our teeth. Behaviour change is hard. I think we need a significant event or relationship to motivate us. Rather like if I suffered a heart attack and nearly died I would be more likely be motivated to modify my diet and exercise regime. Or if my spouse was a dental hygienist, out of love and respect, then perhaps I would probably be more likely to floss my teeth regularly? Relationship and personal relevance are, I think, some of the biggest motivators for behaviour change. So, these are some of the foundation stones of the Mercy Ships Healthcare Education strategy. Relationship and Relevance. Our training program aims to train the whole surgical ecosystem – surgeons, anesthesia, OR nurses, ward nurses, sterile processing technicians etc.

I am immensely proud of what we have done and still continue to do in the Republic of Congo. Recently we took a team to Dolisie Hospital (check out the pictures above). This was a partnership with Lifebox www.lifebox.org and SPECT www.spedc.org We aimed to provide individual education for the anesthetists, OR nurses and Sterile Processing technicians and help them create their own version of the WHO safe surgery checklist. We built relationships, showed the relevance to them of how something simple can save lives, and tried to impart knowledge, skills and professional attitude. We all worked hard and by the end of 4 days we were proud to help them present their own checklist to the Hospital Director. We will return in 6 weeks to encourage them and see how things are going. Behaviour change is hard. We all need encouragement.

Since we returned from Dolisie, I have eaten healthily but I haven’t been running, nor have I flossed my teeth. (oh dear – my uncle is my dentist so there’s a confession!) I have only done 1 out of 3 things I know are important. My prayer for those at Dolisie is that they might do better than me. I hope they will have been able to do more than one of the 6 checklist steps that are important. I do not expect them to achieve everything. Behaviour change is hard. But we will go back to encourage them and continue to build relationships and share our hearts desire – that we all become better doctors and nurses so that we can serve our patients better and make health care safer.

Footnote: This last month we also ran an anesthesia course called SAFE Obstetric Anesthesia in association with AAGBI. Some good photos can be found on a friends blog www.stephcongo.blogspot.com She is a French lady who lives in Ottawa and came all the way to help translate for us and serve the people of Pointe Noire, by helping to train anesthetists.

Ditto

Ditto. Or…… I could say ‘same again’. This month has been a repeat of last month. One where I felt God’s hand on absolutely everything, and I am not quite sure how I got through all I did. A healthcare education assessment visit to Guinea, a Program’s Conference (reviewing lessons learned and making future plans), a visit to Ghana for the West African College of Surgeons Meeting, and an International Maxillo-facial Surgery Conference here in Pointe Noire. I have given several talks and written several reports. I am tired but satisfied. When I started with Mercy Ships over two years ago, many of these things were mere ideas. It is amazing how far we have come, and I am grateful to so many people who have made it happen (over 100 crew members alone have helped with our one-on-one mentoring education projects). And that is just the tip of the ice-berg. I am also in awe of how ‘things or coincidences have just happened’, such as conversations occurring in the right order, chance meetings, being in the right place at the right time……it is the upward spiral of synergy. Or you could look at it another way and call it the reverse phenomena of the ‘swiss cheese model’ of medical errors (for those familiar with Medical Risk Analysis) I could go into more details but I thought I’d share something else I have been musing on. I remember what used to happen when I needed repairs or building work done around my house back home. I didn’t want to get ‘ripped off’ and always wanted a good deal on the price, but at the same time I always wanted the builder to earn a good wage. I wanted him to make good money, enough to feed his family and still have enough to be generous to others. I never felt these two aims were mutually exclusive. I have always believed it was possible because it is God’s heart for everyone to ‘prosper them and not to harm them’. That means me AND the builder. Stephen Covey would call this a win / win situations. Stephen Covey is the author of the best-selling book called ‘The 7 habits of highly effective people’. It was suggested a few years ago that I read this book as part of my Personal Development Plan for my NHS Appraisal (essential for my medical license). I highly recommend the book and I re-read it in preparation for some of the things on my plate this month. As I this last month unfolded, I found myself watching and using many things I had learnt from the book! The book also gave a terminology to things I had always intrinsically believed but never articulated so eloquently, such as win/win scenarios with my builders. ‘The 7 habits of highly effective people’ literally describes 7 principles or habits by which to live your life. The first 3 habits centre on Private Victories, based around being proactive, having vision and purpose and being disciplined in achieving these things. The next 3 habits relate to Public Victories and involve win/win scenarios, synergising and most important of all, seeking first to be understand before being understood. And finally, the 7th habit is an all encompassing habit which is about taking care of yourself. Not in a selfish way, but in a kind of biblical ‘love your neighbour as yourself’ type way, ie if you cannot love yourself and take care of yourself how can you do it for others. We must learn to value ourselves and our time. The book was first published in 1989 and has remained a best-seller for over 20 years. The principles and habits described have remained successful across a generation, and that is an achievement in itself as culture and work ethic changes. At the end of the book, Stephen Covey writes a personal note which says: ‘As I conclude this book, I would like to share my own personal conviction concerning what I believe to be the source of correct principles. I believe that correct principles are natural laws, and that God, the Creator and Father of us all, is the source of our conscience. I believe that to the degree people live by this inspired conscience, they will grow to fulfil their natures; to the degree that they do not, they will not rise above the animal plane. I believe that there are parts to human nature that cannot be reached by either legislation or education, but require the power of God to deal with. I believe that as human beings, we cannot perfect ourselves. To the degree to which we align ourselves with correct principles, divine endowments will be released within our nature in enabling us to fulfil the measure of our creation.’ I share these beliefs. I need the power of God to help change the darker aspects of my human nature. I cannot perfect myself. And I need divine endowments to help me do what I do, and to fulfil my nature and my destiny. The word of God stands forever and the principles in the Bible are true and useful for all aspects of our lives. Physical, mental, emotional and spiritual. As we align ourselves with these principles, we begin to fulfil our destiny and live as we were originally designed to live. Success is released in our own lives and the lives of those around us. I saw that this month. Just like last month. And what about next month…..something tells me I will be saying ‘Ditto’ …… all over again.

Explaining the inexplicable

Unexpected champagne.....warm crusty bread, Camembert, Gruyere cheese, red wine, chocolate mousse, coffee, more chocolates.....and unlimited free Internet access courtesy of the african airline, Air de Côte d'Ivoire. In the west we use words such as 'luck' or 'chance' or 'fate' to explain the inexplicable. Many people are uncomfortable with something being inexplicable. We want answers, we want to understand. Nothing wrong with that. But why, in a rather bizzare way, when we cant explain something, do we make up another inexplicable concept and call it luck or fate. What is luck and who gets it? What is fate and how do you get good fate not bad fate? Where I work in Africa, people don't believe in abstract concepts such as 'luck' or 'fate'. It is more personal. It is all in the hands of the God or gods, so the fundamental question when things happen is, 'who did this to you?' When bad things happen the mindset is often 'who cursed you?' And when one encounters a series of 'lucky events' the response is 'wow what favour you/I have!' What do you think? I ask because I am interested in how you might interpret the week I just had? Good luck or bad luck? Fate? Miracles? Blessings or curses? You probably know what I believe, but I will tell you at the end! I am writing this on a plane to Conakry, Guinea having travelled from Pointe Noire, Congo via Gabon, Ivory Coast, and Mali. Five flights and I am sitting in Business Class, seat 1A, having just been served champagne, European cheese, wine and chocolate truffles. My chair is so big and deep that my feet barely touch the floor and if I sit back in this giant seat my thighs are not long enough to reach the edge of the seat so my knees can bend properly! I was finally on route to Guinea three days later than planned. On Monday evening we had an emergency in the Operating Room (OR), which consumed my whole week and delayed my trip to Guinea. Simon was a young man with a severe abscess in his jaw which needed surgical intervention. When the team woke him up and removed the breathing tube from his mouth he suddenly and unexpectedly could not breath. A crisis call to the OR came over the ships loudspeaker. None of the 4 anesthetists including me were unable to reintubate the young man (put the breathing tube back in). It was also very difficult to assist his breathing using a mask or other airway device. So two maxillo facial surgeons performed an emergency tracheostomy (cutting a hole in his windpipe to place a breathing tube) just in time, to save his life. Simon had a lot of blood and pus in his lungs and we tried as best we could to wash this out and then supported his breathing using a ventilator (breathing machine) and kept him asleep with sedation and pain killers. We had great difficulty keeping him alive even with all our equipment. Even in England it would have been a struggle as his lungs were so damaged they could not absorb the oxygen well enough. I really thought Simon might die. So we cancelled my flights to Guinea, the team would have to go without me. Patients come first. Now was not the time to be planning future healthcare education when someone's life hung in the balance. Many people were praying for a miracle. By Thursday morning Simon had made a miraculous recovery, his airways pressures were lower, oxygen requirement halved, drains no longer bubbling and saturations the best for the last 3 days. At 5pm Friday (4 days after the emergency) he was sitting in a chair, without any of our machines and communicating with sign language. A miraculous recovery and I have not seen one so fast and neither had Alan, another consultant anaesthetist and intensivist from England. We all think we witnessed a miraculous recovery. From my perspective it was a busy and stressful week. Responsibility and worry on weighing on my shoulders. And then there was the visit to Guinea. Three of us were going to re-establish relationships with the Guinean government, port and logistics, and make a more formal healthcare education assessment (my role). The other two had left early on friday without me and my ticket was now booked for Sunday evening with teh remaining connections on Monday. That felt like good luck....or could it be miraculous provision on a more personal level? Simon was better, and I now had time to catch up on some much needed sleep. Fate or favour? And the story continued with the provision of free Internet at the guest house on Sunday evening after I flew to Brazzaville. Monday morning, free unlimited Internet at Brazzaville airport ( better than the with 45 minute time limit at Heathrow). Then my flight from Abidjan was cancelled so I was put on a later one, given a VIP pass to the airport lounge and upgraded to Business Class. Hence the champagne.....warm crusty bread, Camembert, Gruyere cheese, red wine, chocolate mousse, coffee, more chocolates ! All the free Internet access and flight delays meant I managed to catch up with all my backlog of emails and design some more training plans. Was this my lucky travel day....was the patients recovery just fate.....maybe? Or maybe there is a God who knew what I needed? God doesn't make people sick, that is the work of the evil one. But God does work all things together for good for those who love him. God worked a miracle to save Simon's life, I got a weekend I didn't deserve but did need, and even played a game of tennis and went swimming. Gods favour was on my travels, redeeming my time. I took 5 flights and ate 4 croissants (courtesy of the French influence on African airlines). I believe that God worked it to save Simon's life ( we don't normally do his type of emergency surgery on the ship), and so that I could still travel to Guinea and not be totally exhausted. We are building relationships in Guinea and asking them what would they like us to do to help, not just with surgical services but also with training. The saying 'give a man a fish and feed him for a day, teach a man to fish and feed him for a lifetime' has never been more true. One of our objectives in Guinea is to seek to understand what the training needs are as perceived by the ministry of health, the hospital directors, and individual doctors/nurses/other departments. Then we can try and match their needs to our training resources. Training is about change, not just of systems but of ourselves. And that is part of our vision, to 'transform individuals and serve nations one at a time'. That's why we are here. That's why I am here. And even though it is actually incredibly difficult to make a difference, to see the application of the things we teach effect lasting change, it is worth the effort. I believe in a God who really can do 'more than all I ask or imagine according to his power at work in me'. I am very grateful for the miracles I have seen this week in Simons's life and in my life - in real, tangible and personal ones that God gives me because he loves me. You see, I believe God is still performing miracles today. He hasn't stopped and he never will. What would it take, I wonder, for you to believe the same? To believe His love for you and his desire to bless you in the same intimate and personal way.