Tag: Anesthesia

7 Must-Read New Yorker Articles on Global Health

I made this short list for Gradian’s blog and figured it was worth reposting here. Seriously: read these articles.

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The New Yorker opened its archives this week as part of a website redesign. If you’re a regular reader – or, let’s be honest, like most of us you just try to keep up with it – you know how fantastic its articles are.

If you’re not a subscriber, we’ve got you covered. Here are a few of our favorite global health/surgery/anesthesia pieces; check them out and let us know yours!

M0000173 First demonstration of surgical anaesthesia, 16th Oct 1846.

The first demonstration of surgical anesthesia, in 1846 (via)

Slow Ideas, by Atul Gawande (July 2013) – “Why do some innovations spread so swiftly and others so slowly? Consider the very different trajectories of surgical anesthesia and antiseptics, both of which were discovered in the nineteenth century”

HIV

HIV virus particle (via)

 

The Doomsday Strain, by Michael Specter (December 2010) – can scientists and researchers catch the next spillover disease before it spread? (I also wrote about Oxitec here)

A (non-genetically-modified) mosquito (via)

A (non-genetically-modified) mosquito (via)

 

The Mosquito Solution, by Michael Specter (July 2012) – can we eradicate a deadly disease by genetically modifying mosquitoes? Should we?

In 1944, a U.S. Army serviceman sprays an Italian woman with DDT (via)

In 1944, a U.S. Army serviceman sprays an Italian woman with DDT (via)

The Mosquito Killer, by Malcolm Gladwell (July 2001) – DDT was an integral component of the American effort to eradicate malaria in the states. The story of Fred Soper, the inventor of DDT

Turkeys - a vector for avian flu (via)

Turkeys – a vector for avian flu (via)

Nature’s Bioterrorist, by Michael Specter (February 2005) – on avian flu

 

A poster warning of Tuberculosis and influenza (via)

A poster warning of Tuberculosis and influenza (via)

A Deadly Misdiagnosis, by Michael Specter (November 2010) – tuberculosis is a really, really hard disease to kill. Why?

A vial of smallpox vaccine (via)

A vial of smallpox vaccine (via)

The Demon in the Freezer, by Richard Preston (July 1999) – the story behind the eradication of smallpox

Designing Medical Devices for Predictably Unpredictable Environments

An operating theater at Connaught Hospital in Freetown, Sierra Leone (photo: Steve Rudy)

An operating theater at Connaught Hospital in Freetown, Sierra Leone (photo: Steve Rudy)

Via The Lancet Global Health Blog

(Full Disclosure: I work here, so am obviously an interested party)

Many remote hospitals in sub-Saharan Africa lack basic medical devices, like infant incubators, radiant warmers, and anaesthesia machines. Recognizing this, well-meaning individuals and organizations from high-income countries donate medical equipment – sometimes new, but mostly used – to these hospitals. Despite the best of intentions, this equipment often fails. Fortunately, social entrepreneurs and engineers are re-thinking medical device development in ways that could lead to real, sustainable improvements in health systems around the world.

There is no question that donated, used medical equipment has a role to play in strengthening low-resource health systems; it can better allow clinicians to provide life-altering, life-saving care to their communities. But, as Jane Cockerell, Chief Executive of the Tropical Health and Education Trust (THET), pointed out recently on this blog, the system must do better. (Her organization also helpfully produced a how-to guide for medical device donations). Roughly halfof medical equipment in developing countries – much of it donated – is inoperable or otherwise out of service. This is simply not good enough.

Medical device donations fail for a lot of reasons, but the main one is that medical equipment functions most effectively when it is designed for the environments it will be used in, and most medical devices used in sub-Saharan Africa don’t meet this modest bar. So they break – and often stay broken. Even when used medical device donations are thoughtfully executed, there’s a limit to how effective they can be. A MRI machine designed for an American hospital simply isn’t fit to adapt to the most common difficulties faced by remote, under-resourced hospitals in Malawi or Nepal. A power outage in America is a national newsworthy event; in much of Malawi, it’s a daily occurrence. An American hospital running out of compressed oxygen would be vilified, scandalized, and sued; a low-resource Nepali hospital running out of compressed oxygen is the status quo. When an X-ray machine needs maintenance or a spare part in America, a trained expert with a spare part is readily available; in remote, under-supported Malawian hospitals it’s difficult to find either.

And so, as painful as it is to see life-saving medical equipment sit broken, idle, or otherwise inoperable in hospitals’ “medical device graveyards,” it isn’t remarkable or even all that surprising. It’s actually kind of obvious: the equipment isn’t designed for that environment, so why would we expect it to work there?

Designing devices to meet the needs in which they’ll be used – call it “context-aware design” – isn’t new. It’s perhaps the central tenet of medical device design: Know Thy Hospital. In hospitals and health systems in low-resource settings, the customer needs flexible technology fit for predictable unpredictability. Sometimes the electricity is available; sometimes it’s not. The shipment of oxygen canisters may have arrived on time; it may be 2 months late.

My organization, Gradian Health Systems, manufactures and sells the Universal Anaesthesia Machine (UAM), a device designed to function continuously in any environment. It’s made to thrive in predictably unpredictable environments. When electricity is available, the UAM’s in-built oxygen concentrator supplies ample oxygen to the patient. When the electricity cuts out, the system uses cylinder/tank or pipeline oxygen; if that isn’t available, it seamlessly converts to room air (known as draw-over anaesthesia). The oxygen monitor will last up to 10 hours on rechargeable battery backup, providing integrated safety in a potentially unsafe environment.

Training on the Universal Anaesthesia Machine at Connaught Hospital in Freetown, Sierra Leone (photo: Steve Rudy)

Training on the Universal Anaesthesia Machine at Connaught Hospital in Freetown, Sierra Leone (photo: Steve Rudy)

Crucially, the UAM is built for easy maintenance and repair, because that’s what the customer needs. With nothing more than a hex wrench, a screwdriver, and basic training provided during installation, the hospital’s in-house technician is able to diagnose most issues with the machine and locally source the necessary spare part. If he or she is unable to fix it, there will always be an in-country biomedical engineer who knows the UAM well – because we trained him or her.

My organization is only one of many to focus on context-aware design for difficult environments; to name just two others:

  • D-Rev created the Brilliance phototherapy unit, which uses LED bulbs that can last 25 times as long as a typical compact fluorescent bulb
  • Daktari designed a rugged, ultra-portable CD4 counter that can be used just about anywhere, allowing physicians to safely bring it to remote areas

Universities are helping to develop the context-aware design mindset in students, too.Rice University and Stanford University both have well-regarded programmes that have spun off a number of highly disruptive technologies that were designed with the end user in mind, including:

It is crucial to design medical equipment that meets stringent safety and regulatory standards set by national and international bodies, like FDA and CE-mark approval. Without adhering to these high standards, device designers run the risk of creating technologies that are “good enough for them” but not “good enough for us.”

Organizations like THET have done an invaluable service by documenting how to appropriately donate used medical equipment. But we must recognize that used equipment is, at best, a partial solution. It isn’t designed for use in predictably unpredictable environments, and for that reason it often fails. Proper design focuses on the needs of the customer – not the needs of the donor.

Saturday Links

*”Is it possible?” is really three separate questions: 1) Is it theoretically possible? (the answer is probably yes); 2) Is it feasible? (the answer is much less clear); 3) Is it the right way to expend limited global health resources? (again, even less clear)

A Hospital Transitions Away From Ether

(Via Gradian Health Systems, a case study I wrote on how one hospital in Uganda began using the Universal Anaesthesia Machine that Gradian manufactures and distributes)

Mbale is a sleepy town of 100,000 people tucked into the verdant Mount Elgon region of eastern Uganda. Its major hospital, Mbale Regional Referral Hospital (MRRH), caters to an estimated one million people, and most days you’ll find caretakers and family members sitting on the grass outside, as patients receive care in the many wards and multiple operating theaters inside.

Women travel from all around the region to visit the Obstetrics and Gynecology Operating Theater at the hospital, often braving uneven, muddy roads that are next-to-impossible to use during the rainy season. Theater staff handle up to 10 operations each day, sometimes under trying – even dangerous – conditions.

Mbale Regional Referral Hospital,  Uganda

Mbale Regional Referral Hospital, Mbale, Uganda

Like too many operating theaters in Sub-Saharan Africa, the electricity is intermittent and the generator unreliable, which leads to surgeons and nurses operating by the dull glow of mobile phone flashlights at night.

Proper equipment is often inoperable or missing. Some maternity cases can be safely and successfully completed under spinal anesthesia, but there is often a shortage of spinal needles, so anesthetic officers are forced to use larger, non-spinal needles, which come with an increased risk of postdural puncture headache and nerve damage.

Many patients require general anesthesia, which until recently was performed at MRRH with an old Epstein Macintosh Oxford (EMO) draw-over vaporizer – a device widely relied upon in Uganda. It uses ether, one of the first anesthetic agents to be used in operating theaters in the mid-19th century, and one of the last anesthetic agents you’ll see used in most of the world’s surgeries today (it was taken off the World Health Organization’s list of essential medicines in 2005).

Opponents of ether’s use claim that it is dangerous compared to agents like halothane, isoflurane, and sevoflurane, as it is flammable and explosive in confined spaces. Further, there is concern that it takes a long time to exit the body, so patients have extended recovery times, a drawback exacerbated by inadequate monitoring equipment and low staff levels.

An EMO (Epstein and Macintosh of Oxford) System

An EMO (Epstein and Macintosh of Oxford) System

 

Proponents hold that it is relatively easy to administer and is safer in obstetric cases with an elevated risk of hemorrhage. Recognizing its usefulness, some global health expertshave lobbied the WHO to re-include ether on its list of essential medicines.

Dr. Jodie Smythe, a British anesthetic trainee working in the Obstetrics and Gynecology Operating Theater as part of a partnership with the Uganda Maternal and Newborn HUB, saw surgeries performed with the EMO draw-over vaporizer, and thought that both patients and staff would benefit from a more modern anesthetic device.

After seeing the TEDx Talk on the Universal Anaesthesia Machine (UAM), Dr. Smythe reached out to Gradian, and over the next few months a coalition of organizations, including MRRH itself, contributed funds to purchase a UAM for use in the Obstetrics and Gynecology theater.

Soon after, the UAM was shipped to Mbale. As with all installations, Gradian ensured that proper technical and clinical trainers came to the hospital to train staff on the use and maintenance of the UAM. A physician consultant anesthetist at Mulago National Referral Hospital and two biomedical engineers traveled to Mbale, where they trained over 30 surgeons, nurses, and technicians during two days of classroom and theater-based learning.

Dr. Ayebale conducts classroom training at Mbale

 

BMET, Robert Dickinson, workes with the BMET team at Mbale Hospital

 

Transitioning from ether to more modern anesthetic agents is challenging. For years – in some cases, decades – the anesthetic officers had used an EMO draw-over vaporizer with ether, and switching to a hybrid continuous-flow/drawover device with halothane or isoflurane is a significant change clinically and operationally. But because the anesthetic officers had high-touch, in-person tutelage during an operation, they quickly learned by doing, and were soon manipulating the bellows and the vaporizer with ease.

In a clear sign that the UAM found a satisfied customer, during training multiple anesthetic officers asked how the hospital could procure another UAM for their hospital. Months later, the UAM is used every day.

There still aren’t enough spinal needles, and the operating theater loses power regularly. But, with the UAM to provide anesthesia, it is undoubtedly a better place for patients to undergo life-saving operations than it was before. The transition away from ether wasn’t easy, but it was smooth, and now patients receive safe, reliable general anesthesia monitored by professionals trained specifically on the use of the UAM.

Surgery with the UAM at Mbale Regional Referral Hospital

 

Tuesday Links

  • This is an encouraging sign and should be repeated in a number of different contexts to see what works best. True public health often has little to do with the health care system
  • All of the recent coverage on the AMA’s control of Medicare pricing, including this article in the Washington Post, may help change the system – hopefully
  • Atul Gawande’s latest at the New Yorker is, predictably, excellent. He writes about behavior change and norm shifting, focusing on anesthesia and infant warming (which are topics I’ve been writing about, actually)
  • Jon Chait with an excellent, quick read on Detroit’s harmful mix of race, politics, and poverty
  • Trivia: what percent of radiologists missed a gorilla on a CT scan?
  • Beautiful writing: “I learned smells from books, which made me think they were fictional. When real people said That stinks, or I can smell the sea from here, I thought they were faking, that they were willing to pretend those smells existed beyond the page.”