The inverse Swiss cheese model of Success!

I have been shown the Swiss cheese model for error or disaster many times in my career. But I wonder if there is a Swiss cheese model for success? So instead of the multiple holes lining up to allow an environment for disaster, all the right holes line up allowing you to sail through against all the odds and come out the other side with a truly excellent result. If there is not such a model, I would like to propose it now and give you an example that happened just the other day.

I have written little about the staff and expertise that goes on behind the scenes allowing AMREF FD to do its job. They made those first layers of Swiss cheese line up, just in time.

Coming from a first world country and working at AMREF you become very acutely aware of the different medical capabilities in the third world and how incredibly remote (geographically and logistically) some of these places are. And that’s coming from someone who has worked in Antarctica! If taken ill in one of these places you had better cross your fingers and hope your own body can sort it out. While out here I have often thought about one of my medical school colleagues, who tragically succumbed to a severe illness in the bush of Africa on her elective. I wonder if she would still be with us if AMREF FD had been there and able to pick her up in time.

The landscape of northern Ethiopia

We received word of a young man travelling in a remote area of Ethiopia who had become extremely sick. They thought it was probably malaria but could not confirm. He had had a pretty classic malarial course with a few days of very high fevers, rigors and then started to develop dark urine and jaundiced skin. He seemed to improve on a dose of artemether (administered by another member of the group he was with) and then during the night became drowsy, confused and convulsed. He had not regained consciousness since. The doctors in the small clinic there had neither the supply of medication, nor the facilities to treat such a severe illness. Their experience of severe malaria like that in their local population is that it is invariably fatal. They just expect to watch people pass away.

When a distress emergency call like this comes into AMREF a number of things need to happen before we can get going. One of the first things is getting confirmation from the insurance that they will pay and the patient is covered for what we propose to do. Then we need to get the guys at Phoenix to work out how to get us there. That requires knowledge of the airspace, the airstrips in the region and, crucially in this case, their opening hours. Our operations team need to get immigration to agree to let the patient into the country and get clearance for our aircraft to enter the countries airspace and land.

From Wiki - a monolithic rock-hewn church in Lalibela

In this particular case, the challenge was that the call came through about lunchtime and the airstrip we were flying to could not support night flights. Lalibela is a site of considerable beauty and cultural heritage in Ethiopia attracting a large amount of pilgrims and tourists alike, so the runway is tarmac and well maintained, allowing us to get there is a jet. But immigration dictates we cannot go straight there; we use first stop in the capital Addis Ababa to process the paperwork. Only in extremely rare circumstances is that wavered in any country, not just Ethiopia. (For example, because of a prior agreement, we can fly straight to any airstrip in Tanzania without going to Dar Es Salaam). So given that it’s two hours from Nairobi to Addis Ababa, then about 30 mins until we can set off to Lalibela which takes 45minutes and shuts at 18:00, we were looking at a cut-off time of 14:30. If we missed it we would have to wait until morning. The medical report strongly suggested that the patient would not survive such a delay.

As our Operations staff battled with Ethiopian immigration and badgered to gain clearance for the flight, our radio room in desperation tried to charter a flight in Ethiopia to go get the patient and bring him to Addis (which is open 24 hrs) then we could pick him up there, but we couldn’t get a doctor or nurse to do the escort. At 13:45 it was looking like this young man’s life was slipping through our fingers. All we could do as the medical team was sit with our equipment, ready to go and hoping the operations team could pull it off in time. It just seemed crazy to me that this red tape can’t be sorted out while we are on our way or even once we had picked him up, but that just isn’t the way it works.

The carcass of a DC3 plane at Addis Ababa Airport

At 14:10 we got the call the clearance had been granted, the insurance had confirmed they were happy, the patient’s travel documents had been found and we started up the jet. It was still going to be tight. It was entirely dependent on the immigration officials at Addis Ababa. Airport officials here seem to behave a little like ‘Rheopectic liquids’ i.e. they become 'slower and thicker over time when shaken, agitated, or otherwise stressed'. Utter deference to their lofty status and prostrated begging normally works better for the fluid dynamics of the situation.

A deep canyon under the clouds

In Addis we were able to speak to the doctor treating this chap. He was worried. Really worried. He said his respiratory pattern was changing indicating he was not long for this world. This news came as the pilot did his calculations and worked out we would have about 30 minutes on ground. We told the doctor to him to get him to the airstrip, we couldn’t come to him. He was reluctant but it was the only way.

The flight into Lalibela was about 45 minutes. As Clement the flight nurse and I drew up drugs and set up the ventilator I caught glimpses out the window of an incredible landscape. If the only pictures of Ethiopia you have ever seen have been from Oxfam adverts, the country has been rather misrepresented. This particular region is breath-taking, with vast undulating valleys, deep canyons and lush green cultivated fields. From that elevation I missed any of the famous temples carved out of the ground and canyon walls but I could see the scattered village buildings resembling little mushroom plantations. Soon we were banking hard around a valley rim and on finals into Lalibela.

The patient had been brought to the airstrip and he looked worse than I imagined. His travelling companions were obviously incredibly worried and glad to see us. Like any of these situations a little crowd of locals had gathered to watch. It’s annoying and intrusive but you get used to it. There simply is no point telling them it isn’t a spectator sport. Because it is really. You just have to get on with it and they can be useful on occasions as another pair of hands to help lift things.

Clement and I set to our resuscitation (being given our absolute max time of 45 minutes) and the pilots were incredibly helpful and just became members of the medical team. When rushed in a situation like this where there is no one to bail you out like in hospital, it is even more critical you keep your head, calm down and go through your checklists. Communication is key and despite not having worked with Clement for long (he is one of our newest flight nurses) we gelled and did a bloody good job if I do say so myself. Within our allotted 45 minutes we had more IV lines in him with improving oxygenation, a blood pressure, and had established him on the ventilator without any complications. We settled him into the plane with all our pumps, drips and machines and were taking off from the beautiful Lalibela just as the light was fading.

With all our kit we were able to invasively monitor his progress as we treated and correct his various issues. As he improved he started to require more sedation to help him cope with the ventilator which is a promising sign that his brain was coming back on line. By the time we arrived in the hospital in Nairobi we performed a blood gas test which showed he had massively improved and was even breathing for himself. I am told he is now stable and improving in intensive care and the doctors are very positive about his prognosis. Discussing the case, we all agree that had it not been for the actions of our dedicated operations team busting through that red-tape and our pilots 'pushing the envelope', the story would have been very different. But for this lucky young man, all the holes in the Swiss cheese lined up just in time.