Improvisation vs. Standard Operating Procedures

June 23, 2015
One of several equipment graveyards at one of the hospitals

By Brittany Zick, MSc-GH '16

I’m a bit late on this week’s post because on June 13th, I left Uganda to travel to Tanzania, where I will be until the middle of July. And since I arrived here, I have been so busy organizing and preparing for my new group of engineering students from Engineering World Health!

I love this organization, and they in fact gave me my start in global health in 2008 … and basically changed all of my career aspirations after that. But I’ll talk more about EWH and my awesome students later – I’ll be spending a month with them every day and they will surely be sick of me by the end!

Before I transition all the way out of research mode, I just wanted to reflect back over the time I spent in Uganda and the research that I was conducting. You may remember, I went to three different public hospitals in Uganda to assess their neurosurgical capacity, especially their ability to handle the increasing burden of road traffic injury, which consistently produce fatal traumatic brain injuries.

During this time, I spoke to nearly 40 different members of medical staff at the hospitals and asked them about the challenges they face in providing care to surgical patients. As my research focused a lot on equipment and infrastructure, I would frequently ask surgeons and nurses about times when their equipment or support systems had failed them. One answer I received in almost every single interview:

“We improvise.”

This of course seems like the logical answer – if you are operating on a patient and something goes wrong with the procedure as planned, you must of course come up with another way to finish the surgery. But considering the context … how much improvisation are you comfortable with when someone is performing brain surgery on you? In many of the places I visited, there is simply no other option.

Imagine performing an abdominal surgery and needing a suction machine to drain an abscess or remove blood around the area of the incision. About 10 minutes into the surgery, the suction machine is no longer working. So you call your administrator saying you need another one. Then of course, there is no back up suction machine. So you are stuck in your surgery with a patient open on the table and must continue to a point where you can safely end the surgery. So what did one of my research participants do in this scenario?

“We had to improvise. I had to use my hands to scoop out the pus into the trash can and try not to get sick myself. I couldn’t leave them there on the table like that …”

Now imagine being an orthopedic surgeon and needing to perform any orthopedic surgery. Most likely you will need a bone drill with a relatively new bit so that it will actually penetrate the bone. Well … the drills might be there, but the bits never come with replacements and eventually the nice drills are discarded because the replacement parts are too expensive to be procured by the hospital. So one of my research participants explained his solution:

“We now use a regular power drill, like you would use for your own hardware projects at home. We sterilize it between patients, but we can get new bits when we need them and it’s available. Other than this, we had nothing. We had to improvise.”

With my experience in engineering, the idea of improvisation is comfortable and necessary as a part of my job. Engineers are known to be more effective and talented if they can tap into their creative MacGyver instincts. But doctors are supposed to memorize procedures from books and follow rules. That’s why they are in school for so many years and pass stringent tests to be sure they know exactly how to handle each medical emergency according to the standard procedure. But before you judge the Ugandan doctors for breaking the rules, realize that the standard procedures are not feasible. They had to take the same exams and are aware of the ideal way to perform surgery XYZ, but don’t have the equipment, staff personnel, infrastructure, or administrative support necessary to follow SOPs.

So do you want the MacGyver doctor that refuses to let you pass away without trying something anything – to save your life? Or the Standard Operating Procedure doctor that insists on quality standards that are unfeasible in a low resource environment and therefore you are likely to have no surgical intervention whatsoever?

If you ask me, I wish no one had to make this decision. The doctors of Uganda and other developing countries have difficult decisions to make daily that might be traumatizing to the rest of us. And they do it every day and keep going back to work with long hours and low pay. At least I can hope that the research of myself and my colleagues at Duke’s Global Neurosurgery and Neuroscience (DGNN) Division will add to the existing momentum for the low resource medical technology and global surgery movements. The work of DGNN and EWH actually go hand in hand in application to global surgery; and one research study at a time, one new device at a time, we hope to get closer to equitable healthcare access in global health.

Things I learned this week:

  1. Tanzania has really progressed since I left it seven years ago, but the people are just as welcoming and polite as ever.
  2. A doctor or nurse who is not willing to improvise in Uganda will have a very difficult time.
  3. After nine weeks away from home, it is Father’s Day! And being away from home makes me realize just how much I still need and miss my dad, who even sent me  the 28-year-old me at summer camp in Africa – a little care package this week.