I was feeling tired and nervous. I had just spent three hours in the operating room with a woman who had serious bleeding after delivering her baby. She received seven units of blood and had developed a complication called pulmonary oedema (where fluid goes into your lungs) and renal failure as a result of the massive haemorrhage. For now, she was stable and I had to shift my mind towards the 15 staff members from maternity and the emergency room (ER) who were coming to the Learning & Development Room for our first obstetric simulation training session.
I had been planning this training session for about two months. Here in the MSF Mother and Child hospital we see so many women here who are only able to reach us well after they have developed serious pregnancy complications. These include issues like eclampsia (seizures relating to blood pressure), life-threatening bleeding, and problems in labour.
The staff here are experts in managing these complications, but they typically rely on external trainers to do obstetric emergency drills to keep these skills fresh, and these sessions had all been cancelled for the past 18 months due to COVID-19.
Alongside practising the technical skills needed to manage complications, I realised we could also take the opportunity to review non-technical skills such as leadership, communication, and team-working. These skills are difficult to teach using lectures or out of textbooks, but in my role as a consultant back home we’ve had great success using a combination of simulation training and 'human factors' training. I pitched it to the team here and they were on board to give it a try.
I wasn’t sure whether the language barrier would be an issue. I don’t speak Arabic apart from the basic greetings I have picked up, and while the doctors here speak English, many midwives and nurses don’t. Luckily, we have two very skilled and experienced full-time hospital translators who would help with this.
The 'patient' perspective
Next we’d need some volunteer staff members to act as the 'patients'. Fortunately, our wonderful midwife from France and clinical team leader from the Philippines took two scenarios each and gave great performances.
There is a huge amount of research evidence that shows that having a positive workplace culture that encourages learning rather than blame is associated with improved patient safety outcomes
Not only did this aspect make the training day fun and engaging, the 'patients' were also able to give feedback to the team from their perspective. It is so important to remember to reassure our patients and their accompanying relatives through what can be traumatic and scary experiences.
We did four simulated scenarios: a ruptured ectopic pregnancy that needed rapid triage, resuscitation in the ER and transfer to maternity for surgery; a pregnant woman who has a cardiac arrest whilst in labour; a cord prolapse requiring an emergency Caesarean; and a uterine inversion, which is a rare complication that can occur after the baby is born and lead to life-threatening haemorrhage.
Simulation training has been shown to tease out issues surrounding team dynamics and communication. The aim is to make staff members more confident to speak up when they have concerns in real life.
These things may sound boring and mundane, but will actually save lives...
With each scenario, the team got more comfortable with the role-play. Each debrief after the scenario raised numerous issues around the importance of having a team leader when things get stressful, how to communicate effectively in the chaos of an emergency (use eye-contact, name your colleague and ask them to come back to you confirming the task has been done), and how simple tools like a check-list can make emergency surgery safer.
Support and trust
One of the most moving conversations we had during a scenario debrief was about how important it is to support and trust each other during challenging situations.
One doctor told me that she was afraid of doing a peri-mortem Caesarean section, where a Caesarean is performed even under non-sterile conditions in order to increase the chance of CPR working where a pregnant woman’s heart has stopped.
This is a terrifying scenario for any doctor, no matter how experienced. She was afraid that without the trust and support of her team, the family would blame her subsequently if the woman died, even though she knows that medically the correct thing would be to do the Caesarean to increase the chance of saving the woman’s life.
One of the most moving conversations was about how important it is to support and trust each other during challenging situations...
This stood out to me because I have the exact same conversations when I am teaching human factors to colleagues in the UK. Especially through the COVID-19 pandemic, when the UK variant was raging through the intensive care units in London, and I could see my colleagues burning out all around me, people were telling me that their capacity for empathy was reduced, and that sometimes they felt blamed by the people around them when faced with outcomes like a patient dying.
The importance of culture
There is a huge amount of research evidence that shows that having a positive workplace culture that encourages learning rather than blame is associated with improved patient safety outcomes.
Essentially, regardless of geography or resources, a hospital where staff are praised when they do well, and are encouraged to share incidents and near misses, is also a hospital that has better safety outcomes because everybody is encouraged to discuss cases openly and learn from mistakes.
The science of human factors in healthcare encourages all staff to expect errors to occur because we are all human, and teaches them how to protect each other from error through the use of check-lists, “thinking loudly” (directly translated from Arabic, to mean "speak out loud your concern that is in your head”), and supportive team working.
Human factors encourages managers to look for systems-based solutions to make error less likely. Examples of such things I have worked hard with the departmental supervisors to do here in Yemen include re-designing the prescription chart, staff rostering that provides enough rest days after night shifts, and organising drug storage rooms so that expired drugs are easily identified and disposed of. These things may sound boring and mundane, but will actually save lives.
MSF has been explicit about it’s commitment to “cultivate and model a culture of patient safety, openness, transparency and accountability” (this quote is from the 2020-2023 strategic plan). During our simulation debrief we discussed how it is only through having frank and open conversations about how we feel that our colleagues can “walk in our shoes” and support us through often challenging clinical environments.
At the end of the day, our training team sat together and debriefed. We had learnt a lot from running the simulations and had lots of ideas for improvements for the next time. Two of the Yemeni staff (an anaesthetist and a midwife) enjoyed the day so much that they are going to join the training team on our next simulation day. We hope that by running these drills every month more of the team will feel confident in helping to deliver them, creating a sustainable in-house education programme.
In this way, the team will be supporting each other to communicate effectively, to speak up when there is any concern, and to substitute blame for learning if challenging scenarios ever arise.
Thirst for knowledge
My colleagues in the UK talk daily about burning out due to COVID. My colleagues in Yemen have been working not only through the pandemic, but through many other challenges.
On a daily basis for the past six years, many have been separated from their families due to living on either side of the frontline. They have had severe restrictions to overseas travel. They have had their educational opportunities and career development paused. And yet, they show an immense thirst for knowledge, often coming in on their off days for training sessions, and they continue to work so hard to do their best for the mums and babies who come through our doors.
Top image shows the mother and child hospital in Taiz Houban, Yemen.