The entrepreneurship bug

So i caught the entrepreneurship bug!

It was the start of May 2014, I'd over the preceding weeks had a family member in Abuja, Nigeria who had some health issues. The travails we experienced in attempting to get quality care was distressing. Particularly as finances were not the limiting factor but rather systemic issues that conspired to provide mediocre care.

As  i pondered on this problem i suddenly got the bright spark of an idea that would improve the quality of the health system. The idea filled me with such excitement that i wanted to quit my job right away and jump on a plane to get started on my idea.

Unfortunately reality soon set in, I  had bills to pay, a family to raise etc. I was convinced however that i was on to something. In my mind's eye i had this vision of the wonderful change my innovation could bring. The next logical thing for me to do was to put it down in writing, my business plan was born! I spent hours and days without sleep working on it. I've subsequently gone on to find out the traditional business plan has fallen out of favour particular in tech ventures - my bright idea is a tech venture that aims to improves the quality of healthcare.

So while i had the momentum i bought a domain and webhosting on the 11th of may. Money had been spent i was committed!

Now this may not apply for others but for me, writing down a business plan was useful as it helped solidify my thoughts and forced me to do more research and gain more knowledge. The more work i did the more of a knowledge gap i realised i had. Next step thus was to hit my local library. I browsed the business and IT sections and picked up 2 books - 'the lean startup' by Eric ries and 'how to start a tech business' by Alex cowan. I went on to find out that the former book was a huge bible for tech startups.

...And so my study began.

Key performance indicators

Browsing the intranet of my hospital, I came across the quarterly hospital health target report.

The report consisted of parameters the ministry of health requires all hospitals to report. These parameters are in areas the ministry feel are important goals - so called 'health priorities'-  that are to be met in order to fulfill the need of the population accessing healthcare.

This is not a new phenomenon, the idea of key performance indicators (KPIs) is wide spread in business and is used to judge performance as well as highlight areas for improvement.

It is also a useful goal setting strategy that helps keep the goal always in focus. While it can be detrimental in that focus may start to shift to numbers than perhaps what the numbers are trying to achieve, it is felt to be generally a good thing that most organizations and governments imbibe.

A look at the KPIs for this particular health ministry, summarized in a webpage that houses the results reveal targets in:

- Shorter stays in emergency department - 95 percent of patients will be admitted, discharged, or transferred from an emergency department within six hours.

- Improved access to elective surgery - volume to increase by 4000 discharges per year

- Increased immunization - 90 percent of 8 month olds will have their primary course of immunization on time

- Shorter waits for cancer treatment - all patients ready for treatment wait less than 4 weeks

- Better help for smokers to quit - 95 percent of hospitalized patients who smoke and are seen by a health practitioner in public hospitals and 90 percent of enrolled patients who smoke and are seen by a health practitioner in general practice are offered brief advice and support to quit smoking.

- More heart and diabetes checks - 90 percent of the eligible population will have had their cardiovascular risk assessed in the last five years.

The data from different regions are collated and a quarterly reported published. One is then able to compare data across different areas and times for the whole country. The public are aware of it and have certain expectations when they access health care. Staff also have defined targets to work towards in their everyday roles

Over time it is easy to see where one needs to appropriately target interventions or employ different management strategies to ensure improvement. 

These indicators are obviously well thought out, with specific numeric targets. It shows homework has been done and the government has chosen priority areas to invest time and effort to improve the well being of the population. It is also safe to conclude that systems exist to gather this information.

Seeing this, i did a google search for any similarity in the Nigerian health system. To my surprise i came across a national health plan. The plan was laudable in that it was quite a detailed document that had reasonably specific targets and KPIs. The more i read the more obvious it became to me that quite a lot of work had been put into it. But as often is the case with Nigeria, many a great reports are left to rot on government shelves while the status quo carries on.

Where the plan was further let down was the lack of data. Several indicators couldn't be measured as the data just wasn't available. Furthermore the number of KPIs were large, this in my opinion defeats the purpose.

What is needed is something like the much maligned 7 point plan of former president Yar'adua (God rest his soul).

7 indicators with achievable goals, monitored quarterly, easily measurable and impactful in the day to day health of the average individual. This should then be easily accessible to the general public who can compare, contrast and put pressure on the right people when needs be to make sure things get done.

Of course more systems for data collection needs to be put in place to facilitate this and people and healthcare workers need to be educated and carried along. All in all it's not that difficult, all that's needed is the will and we know that when there's a will there's a way!

Emergency medical service - As simple as ABC

I'm currently doing a stint in the Emergency department in a country in the Pacific working alongside great doctors and nurses. They all do a great job saving lives and providing good service to the local community. It made me think of what options exist in my beloved homeland Nigeria for people in need of emergency medical attention.

A Google search of 'emergency medicine nigeria' doesn't yield much evidence of a structured approach to the delivery of emergency care. Several websites allude to the non-existence of a working state ambulance service or a national emergency telephone number such as a '111', '911' or '999' (depending on where in the world  you are).

Thankfully some private groups have attempted to fill the gap but their attempts sadly fall short of what is needed. Their services while laudable are either not skilled enough or not well publicized. What's more deterring is the phone numbers they encourage people dial in case of an emergency. The numbers are often longer than the numbers on a lottery ticket! tough enough to remember on a good day, much worse when in the panic stricken state of an emergency. Reminds me of an episode of 'IT crowd' where '999' is changed to '011 899 988 199...' (See video here)  Perhaps they should try a similarly catchy song!

The poor state of  the existing situation is seen here in a Nigerian paper on Pubmed (read here). The authors tracked over four years how victims of rood traffic accidents presented to an emergency department in Ilorin. A whooping 52% of victims were brought in by relatives and 40% by police or FRSC. In the majority of these instances no intervention was given during transport, furthermore none of the transporters were trained in any type of life support, not even the police or FRSC officers! This paper makes dire reading!

So now one has somehow made their way - against many odds- to the emergency room, what service do they expect to receive? Stories abound on how patients are required to deposit large amounts of money before they are attended to (follow my friends blog http://amahzeeing.blogspot.co.nz/ who writes from the front line on some of the problems plaguing our hospitals)

When money is finally deposited, one obstacle after another surfaces. an instance of a fatal obstacle i read recently is that of a vibrant young girl (read here) who was having an acute asthma attack. She arrived at a hospital that had no supply of oxygen thus had to seek attention elsewhere but sadly passed away before she could be treated. Tell me please how can an emergency room not have oxygen! It's simple ABC - Airway, breathing, circulation. If an emergency room can't manage ABC it has no business taking emergencies or calling itself an emergency room.

A similarly sad story was told  to me during my medical elective in Nigeria. It goes as follows: a patient had come in severely distressed and was in danger of losing his airway. A call was made to secure the airway  through the placement of a tube that goes directly into the windpipe, to do this one needs a laryngoscope. Okay so people run around frantically searching for the scope and finally find it! yay, a life will be saved, not quite. The scope has no batteries to power it. Another frantic search for batteries ensues, yay! a drawer full of batteries found, a life will be saved. Not quite. The drawer is locked and the key holder is nowhere to be found. A life slips away.

The system (used here in the most liberal sense of the word) is broken from top to bottom, nothing works. Nil to few people really care. More must be done, life cannot be as trivial as it currently is. Other than the obvious setting up of an emergency number and a good ambulance service the following suggestions in my opinion can improve emergency care as it currently is:
 - All secondary school students should be taught the rudiments of life support,
 - Police and road safety officers should be required to learn basic life support and
 - Emergency departments need to be tightly regulated to ensure they possess a bare minimum of materials and services or be shut down.

I believe if the above are implemented a big difference will be observed in our emergency care in Nigeria. They are not too difficult to do and is not to much to ask, all that's needed is the will. It's really as simple as ABC

I recently came across a website that aims to build up the blood donor database in Nigeria. It's by a group called the one percent project who want to create a 10,000 strong army of volunteers who regularly donate blood.

This is a laudable project that i support fully. Read here my post on blood.

It's not everyday you get a chance to 'Be a hero, it's in your blood'.

Of medical errors

Here's a great anecdote lifted from the blog of Dr Kavanagh a rheumatologist:

In my first few months working as a rheumatologist a referral letter arrived from a local doctor about a lady with rheumatoid arthritis. She had recently moved to the West of Ireland from the UK, where her original diagnosis had been made. Her GP had originally referred her to a general physician in a small local hospital who had struggled with her care and she was looking for second opinion.


After assessing her, it quickly became apparent that original diagnosis had been incorrect. The patient had numerous explanations for her pain other than rheumatoid arthritis and the investigation that was likely to have prompted her original diagnosis (a positive rheumatoid factor test) as due to the fact that she had Sjogren’s syndrome (a condition which causes dryness of the eyes and mouth).


My specialist pride congratulated itself on making such a clever diagnosis and for being smarter than either the physician who had cared for her of late or the rheumatologist who had made the original diagnosis. Gosh I’m good, I thought.


‘That’s wonderful news Doctor. You mean I don’t have rheumatoid arthritis after all?’


‘Not in my opinion you don’t.’


‘Its great to see someone who knows what he’s talking about. Do you mind me asking where you did your training?’


‘In the UK. In Cambridge mainly.’


‘Really Doctor? In Addenbrooke’s?’


‘I was there for 4 years.’


‘That’s amazing. That’s where I was told I had rheumatoid.’


With that she thanked me, stood up to leave, and just before she left the room, turned to me and said;


‘I knew you looked familiar.’


It’s never a bad idea to get a second opinion. Even if it’s from your self.

Blood

Blood courses through the vasculature of mammals bringing vital nutrients to every cell and ferrying waste substances away to be excreted. Blood flowing is synonymous with life, a lack of or stagnation of blood similarly signifying death or at least its proximity. Blood is central to all that the body does. A simple biopsy of it with appropriate testing can reveal the onset of disease, its severity, rate of progression and whether or not disease will respond to treatment. When lost it must be swiftly replaced with a suitable type.

Pro reason

The recent death of a pregnant woman in Ireland has caused huge furore in the polity of the republic. While the exact details of the case are yet unknown many have been up in arms over the claim that the pregnant woman's life was lost as a direct result of the prohibition of abortion in Ireland. Many pro life and pro choice groups have clashed repeatedly and the debate rages on. This series of events resurrected in my mind the thoughts I've had regarding abortion. 

Abortion is always a difficult topic and with most difficult topics there usually isn't one right answer. In my mind's eye i can see situations where i will be in favor of abortion. One such instance is that of rape where contrary to Sen. Todd Akin, pregnancy can and does result. Conversely i would be against situations where a pregnancy is unplanned and abortion is used as a form of contraception. Grey areas exist in my mind regarding abortions for fetal abnormalities and severe congenital/ genetic conditions. I can understand why a parent may want an abortion in these cases but I can also see how permitting that would begin a descent down a slippery slope towards eugenics, a practice many will agree is less than desirable. 

I believe that a baby has a right to life. The real issue is determining when that life actually begins. Is it when the sperm fertilizes the egg, when the morula is formed, when the fetal heart begins beating or when... i could go on. The bottom line is we don't know and we probably never will. What i do know though is the immense joy children bring into the world often regardless of the circumstances surrounding their conception or the state of their health at birth. Children bring hope and joy, the possibility of change and a new beginning. They also bring lots of poo and tears but we'll gloss over those! Abortion on the other hand in my experience brings adverse emotional and psychological  effects to not a few women. Some psychiatrists argue that research hasn't revealed measurable difference in the mental well being of women who have undergone abortion. I however still have my doubts probably due to the anecdotes i have come across that suggest otherwise. 

Finally you ask, so what should we do? legislate for or against it? What i have thought up is an independent panel that consists of legal and medical experts that women can apply to and have their case for an abortion to be heard swiftly. They'll always be available, take into consideration all the potential issues and ramifications and give a decision accordingly. I know this will give rise to many new issues but that's my little stab at the problem. The real answer: I don't know. I spare a thought often for women who have to consider this difficult option.