Surgeons’ skills that saved Asteria’s life

After enduring several months of a painful and complicated pregnancy, it was now time for Asteria Mtiro (20) to face a surgical knife in theatre for the first time in her life —not the familiar Caesarian-Section(C/S) surgery though.

Asteria had an abdominal pregnancy. Her unborn baby was developing outside the womb. This prompted doctors at Bunda Designated District Hospital in Mara region to open her abdomen surgically to remove the unborn baby. Sadly, it was already dead.

“My pregnancy lasted 12 months. I was in pain throughout. At one point, my tummy shrunk. I didn’t know why. The pain became intense. Then, I could sense a bad smell. I think my problem was not noticed early at the clinics I attended,’’ she recalls.

Asteria, who previously worked as a waitress in Dar es Salaam, speaks to Your Health while at her home in Bweri village, Musoma District where she is now recovering from the surgery she underwent in May this year.

Yet, as she now recounts her story of tribulations, a big smile is written on her face. She believes that her life was saved only after Dr Chacha Phillipo, a surgeon who operated on her, decided to go the extra mile.

Dr Phillipo is one of the surgeons in Mara region who recently acquired skills to perform safe surgery as part of an on-going initiative in the Lake Zone, dubbed Safe Surgery (SS2020), funded by GE Foundation, a philanthropic organisation.

In ideal situations, a patient with an abdominal pregnancy such as the case with Asteria, should be handled by a team that has medical personnel from multiple specialties— surgeons, obstetricians and anesthesiologists.

However, in Tanzania, few people have access to such specialised care. It is estimated that density of specialist surgical workforce is 0.31 physician surgeons, obstetricians and anesthesiologists per 100,000 population, says the Lancet Commission on Global Surgery.

At least 20-40 surgical specialists are needed per 100,000 population, suggests the commission. Yet, world health bodies, ministries of health and surgical society organisations say much is still desired in ensuring safe surgery.

The World Health Organisation (WHO) has warned in previous reports that unsafe surgical care can cause substantial harm.

“Mortality from general anesthesia alone is reported to be as high as one in 150 in some parts of Sub-Saharan Africa,” says WHO in its report: Safe Surgery, published in www.who.int.

In the Lake Zone, Tanzania, the Safe Surgery 2020 initiative is seen as a major attempt to reduce preventable deaths through emphasising on best practices in surgical care at lower level hospitals.

The initiative came after public health stakeholders established that when surgical teams have the power to learn, innovate and work better together, they can perform more surgeries with fewer complications.

“Quite often, patients with surgical problems may die simply because certain principles have not been adhered to,” says the SS2020 project Director, Dr Augustino Hellar.

“Asteria’s case serves an example of how team work, coupled with clinical skills can save a life,’’ points out Dr Hellar.

“In trying to empower the surgeons, general doctors and other clinical staff, we use what we call the low-dose-high frequency technique. We gradually expose them to the management of procedures, starting with simpler ones, to more complicated ones and we do this repeatedly,’’ says the director.

“It doesn’t just end up with training. We assign mentors in their work places who have to keep monitoring their skills and providing guidance where necessary,’’ he explains further.

No backing down

Doctors who work at Bunda District Hospital, have been trained to understand that they are not supposed to back down in saving lives even in situations of major resource constraints.

Asteria didn’t plan to undergo surgery at Bunda District Hospital where Dr Phillipo works. She was taken to the facility in a desperate attempt by her family to save life.

“When nurses and doctors realised that my pregnancy was complicated, they referred me for an operation at Bugando Referral Hospital in Mwanza,’’ Asteria says. Bugando hospital is located 222 km from Musoma.

“My family could not afford the cost. We were asked to pay about Sh800,000 for medical tests and the operation. So, my family decided to take me back to Musoma. We were almost giving up. This was so hurting. I think I was at the point of dying,” says Asteria .

This is a common phenomenon in Tanzania. Lack of affordable, quality healthcare traps families into poverty. Often, households have to borrow money or sell assets to pay for healthcare. That was the case with Asteria’s family.

Her father, Mr John Masasi, says the family had to sell off some property, including what Asteria owned, in the efforts to raise money for treatment and transport to hospitals.

The unexpected happens

When Asteria’s family failed to access healthcare at Bugando in Mwanza, the next option was to board a bus back to Musoma, over 220km away, with the patient.

While on their way back to Musoma, Asteria’s mother Pili Nyamuhanga, says, “Passengers on the bus saw that my daughter was in pain. They advised that we don’t go past Bunda Hospital. I had little faith in it. Most district hospital has failed to treat her. But that’s where her life was saved.”

What’s missing at local hospitals?

In most local hospitals in African countries, including Tanzania, the demand for safer and affordable surgical interventions still remains high, says a Lancet study, titled: Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

Published January this year, the study revealed that surgery patients are twice likely to die in Africa compared to the global average because of lack of resources.

But, at times, it’s not necessarily due to lack of resources, says Ms Takae Lisso, a representative of Mara’s Regional Medical Officer. She spoke on Tuesday last week during the opening of the Safe Surgery 2020 training sessions for health workers on safe surgery in Tarime District.

“You see, things such as adhering to a checklist during surgery or sharing patients’ information among the surgical team requires just a reminder and mentorship. That’s why we need to keep updating our medical staff with new knowledge and nurturing their attitude,’’ she said.

According to Dr Phillipo, the case with Asteria is one of the rare pregnancies that could have risked her life if urgent action was not taken.

But, he insists, it took just leadership skills, confidence, clinical acumen and the team which was demonstrated by the surgeons, obstetricians and anesthesiologists at the hospital to ensure that Asteria survived.

“When I examined Asteria that day and got to know her family’s financial challenges, it dawned on me that I had no other option but to intervene, lest she could die. I mobilised the team,’’ he tells Your Health.

He continues, “Before being trained on safe surgery, I think I couldn’t have had the guts to intervene. I think I could have made the decision to refer her back to Bugando Referral.”

“I mean! Look here, what do I do when a referral hospital just sends a patient back to a district hospital?,’’ he queries and laughs. “Anyway, I had to intervene.”

“Besides, we made a close follow-up of her surgical wound and carried out all the post-operative procedures keenly,” he explains.

“In the past, there have been cases where such patients were operated on but given little attention. The wounds would turn septic in the due course because of neglect and at times could cause death,’’ says Dr Phillipo.

Almost 20 percent of deaths in Tanzania result from diseases that can be treated by surgical care, government data show. Asteria has survived to tell her story. Not many in the country make it like her.