“People send things with the best of intentions, but they’re not thinking about where these things are going to be used,” explained Dr Eva Manciles-Robert, when she visited the Lifebox office yesterday to confirm plans for the workshop she’ll be running in April at the Connaught Hospital in Freetown, Sierra Leone.

Dr Eva Manciles-Robert visits London and demonstrates the pulse oximeter (in colour-coordinated style)

In Sierra Leone, where Dr Manciles-Robert returned to practice in 2007, you need equipment that is fit for purpose.  Like the Lifebox oximeter.

It’s high quality but it does a very specific job, for a very specific environment.

For instance – in a low-resource setting, the operating room will likely have a concrete floor, and no engineer to fix broken equipment.  So the Lifebox oximeter is robust enough that you can drop it from a metre’s height off the table without immediate consignment to the equipment graveyard.

The electricity supply will almost certainly be fickle, so it runs off a rechargeable battery that can be powered up when mains power is available, and will keep a patient safely monitored throughout an operation even when the power inevitably fails.

The majority of anaesthesia providers will have between six months and two years of training before heading out to rural facilities where they will be the only person qualified to deliver anaesthesia for miles around.  So the Lifebox oximeter is intuitive, with a basic interface and large screen.  And the education materials come in six different languages.

There are only two medical anaesthetists in the entire country of Sierra Leone, as well as 60 nurse anaesthetists.  (“Sixty more than there were just after the war,” Dr Manciels-Robert reminded us.)  They are responsible for the anaesthesia care of 6 million people.  And they handle everything.

So the Lifebox workshop that Dr Manciles-Robert is leading will make an enormous difference.  Over two days, nurse anaesthetists will learn about pulse oximetry and the WHO Surgical Safety Checklist.

Thanks to our donors Dr Manciles-Robert will be able to distribute 36 oximeters, ensuring that every operating room in the country is equipped.  Surgeons and anaesthesia providers in the provinces will be able to do more complex cases, safely, rather than sending patients hundreds of miles to over-crowded, under-resourced main hospitals.

“When I went back I was in awe of my colleagues,” said Dr Manciles-Robert, who trained in Ireland.  “In Sierra Leone, you go back to medicine as medicine once was.  You depend on your finger, eyes, nose.  But it could be so much more.”

We’ll keep you updated on how it goes.

That’s in addition to the 37 diploma nurses who have spent between 6 months and 2 years training in anaesthesia to meet the needs of 5 million people.

“As you can see,” the Ludwigsburg, Germany native wrote last year, “anaesthesia is in agony in Eritrea and changes have to come rather quickly.”

Dr Tradl Elsholz (right) watches Dr Berhane Debru, director of medical services at the Eritrea Ministry of Health, formally open the workshop

The one positive thing to be said about these terrifying numbers is that, boy, you can really see what difference a small group of people can make.

 “First of all I would like to thank you, because mostly there is not any workshop done for anaesthetists for the last three or four years.”

“I really appreciate the Checklist, that [taught] me to create a good working atmosphere for the future.”

“About 80% of my knowledge is improved from the sessions of pulse oximetry.”

Just a peek at the incredible feedback we received last week from participants in a Lifebox workshop that Dr Elsholz ran in Asmara on February 3^rd.  Alongside her full time responsibilities as head of the department of anaesthesia at the College of Health Sciences in Asmara, she has taken up the Lifebox mission, and you can see that the impact is immediate – and that the yearning for education and training is immense.

Ready, set, pre-test

35 nurse anaesthetists attended from across the country.  One stayed overnight in Asmara; eight stayed two nights, as they had traveled more than six hours to reach the workshop; two traveled more than 10 hours, to learn about pulse oximetry and the WHO Surgical Safety Checklist.

They left full-headed and full-handed – Lifebox donated 78 pulse oximeters to the Eritrea Ministry of Health, and Dr Elsholz distributed them to ensure that all operating theatres would have access to a device.

"What can happen during anaesthesia that might cause problems with oxygen delivery to the tissues?" (Note oximeter on the table!)

A multiple-choice quiz given before and after the workshop showed that training had an instant effect: comparing pre-and post-workshop results was like comparing the football scores of matches played in the dark, and then played again in the light.  Goal!

Of course sustainable change needs reinforcement, and we’ll be following up with Dr Elsholz and the participants in the next few months to make sure that their oximeters are working, and that the training has stuck.

And Dr Elsholz will continue her indomitable work, developing basic nationwide standards of anaesthesia, and securing education opportunities for her colleagues.

“If you are interested, you might some day visit Eritrea to see [for] yourself,” she wrote warmly.  But “if ever you come, be prepared for some CME [continuing medical education] courses for the anaesthetists and some nice lectures for our students.”

He seems quite healthy, but look at the Lifebox pulse oximeter (and the knowing smile) he’s wearing: 92% oxygen saturation.

Anything higher than 80 out of 100 on a test is a pretty high pass, but when it comes to oxygen saturation, anything lower than than 95% is a concern and 80% is a crisis situation. If Dr Rastogi wasn’t wearing a pulse oximeter you’d have no way of knowing that his oxygen saturation is not at the level it should be.

This is the blindfolded reality that anaesthesia providers in more than 77,000 operating theatres worldwide face every day.  The only way they can tell if a patient is becoming dangerously hypoxic (starved of oxygen) is by close observation for signs of cyanosis – when the patient’s skin starts turning blue.

Action stations!

When we’re training anaesthesia providers in pulse oximetry and the WHO Surgical Safety Checklist, we focus on the fact that the Sp02 (oxygen saturation) for patients of all ages should be 95% and above.  When the Sp02 falls below 90%, the patient is becoming dangerously deprived of oxygen.

In low-income countries, oxygen cylinders can sit empty for months; many of the critical therapies that we take for granted just aren’t an option.  Early identification of a problem makes successful intervention, with the limited resources available, much more likely – pulse oximetry monitoring, quite obviously, saves lives.

Breathing easy

And please don’t worry about Dr Rastogi – Cotacachi Hospital is at 8000 feet above sea level, and he’s just acclimatizing to the altitude!

That’s an incredible opportunity to save lives! And it’s one of the reasons why we need to do something about the fact that the poorest third of the world’s population receives only 3.5% of the world’s major surgical procedures (the richest third receives 73.6%). {1}

At Lifebox we’re regularly shocked by these statistics – but we also see how many people and organizations there are committed to making a difference.  Last Friday we were lucky enough to meet some of them, at the Global Surgical Frontiers Day , hosted by the Royal College of Surgeons.

It was like walking into a party where you want to talk to every single person in the room!

Professor Chris Lavy, who worked as an orthopaedic surgeon for a decade in Malawi, brought together more than twenty organizations of all different sizes to present their initiatives and talk about opportunities for working together.

Some groups, like Aid to Hospitals Worldwide, redress the balance shipping container by shipping container – they send recycled NHS equipment  to ill-equipped facilities in low-resource countries.  Others, like Out To Africa, nurture direct links, pairing colleagues between the Mid Essex Hospital in Chelmsford and the University Teaching Hospital in Zambia to support professional development.

Some, like the College of Surgeons of East, Central and Southern Africa (COSECSA) cross a continent, helping to develop national surgical policy, running training and exams. Others, like Mercy Ships cross waves and oceans, in liners refitted with operating rooms, surgeons and family on board, to perform crucial procedures docked along the coast of Africa.

Like we said, the statistics made our eyes water, and the personal stories – two-year old twins who received cataract operations through Mercy Ships and woke up to see their mother – and each other – for the first time; a gentleman from the Congo eating by himself for the first time in eleven years after receiving prosthetics from Willing and Abel - made our throats catch.

Lord Ribeiro wants YOU to Make it Zero

But we straightened our ties and talked to Lord Ribeiro, a leading figure in international surgery, who spoke about his hometown of Achimota in Ghana, and asked attendees to create an organizational structure that could benefit those who really needed it.

During his speech on the surgical and education work done by Mercy Ships Lord McColl told that old story of the child on the shore throwing marooned starfish, one by one, back into the water – what difference will it possibly make? asks the cynic, with so many of them hopelessly beached ?

Well of course it makes all the difference in the world to the ones that get thrown back, reminded His Lordship.  But he also acknowledged what was special about this conference – figuring out how we can work together in training and education, making a sustainable change, so that people in low-resource countries get the surgical opportunities they deserve – and lives aren’t beached prematurely.

{1} Weiser TG, Regenbogen SE, Thompson KD et al (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139–144

You can read more about anaesthesia at Juba, and medicine across South Sudan on her blog here: www.southsudanmedicaljournal.wordpress.com 

“South Sudan is a brand new country, adjusting to its newfound independence.  The infrastructure and the finances are not yet fully developed, and Juba Teaching Hospital frequently has no electricity or running water.  However, when there is emergency surgery to be done, we have to work in spite of this. It is not uncommon to start a procedure with electricity and finish without.

Another power outage - medical staff work by torch light to finish an operation

The anaesthetic medical assistants make the best of working within an extremely resource poor setting. Their ability to “make do and mend” is inspiring.  However, I soon realised it was not possible to mend everything and there are some things that you’d really prefer not to do without, pulse oximeters included.  The theatre building comprises of three theatres and only one had access to a functional oximeter  – and that was mains electricity dependent, lasting only a few minutes on battery power when the electricity cut.

The day that I took the Lifebox oximeters to work, we had a patient who required an emergency laparotomy for bowel obstruction.  Soon after the rapid sequence induction and intubation the electricity cut. One of the other anaesthetists immediately went to get an oximeter and we all breathed a sigh of relief when the display demonstrated a good waveform and healthy oxygen saturations.

Emergency laparotomy the day the Lifebox pulse oximeter arrives

Pulse-oximetry saves lives.  Being able to monitor the saturations of all of our patients undergoing procedures in any of our theatres will make our working life less stressful and our practice safer.  Having to choose which patient to monitor and delaying surgery because of a lack of basic monitoring are problems that myself and the other anaesthetists at Juba Teaching Hosptial will no longer have to worry about.

Thank you Lifebox!  Now on to trying to solve those 101 other issues…”

ASA held their annual meeting in Chicago last week, and invited Lifebox along to meet some of their members and introduce the project.  They were expecting around 15,000 members and exhibitors – that’s called a party to dress up for.

So we flew away early Thursday morning from Oximetry HQ in London with brochures, articles, badges and our beautiful campaign video to a temporary new home in the McCormick Place convention centre.

The ASA works through its committee on Global Humanitarian Outreach to address the global crisis in anaesthesia.  They recognize that Lifebox is a tangible opportunity to support colleagues and patients ravaged by it every day.

We were thrilled to hear immediate past president Dr Alexander Hanneberg announce that “this is a very important initiative, and the ASA is committed wholeheartedly to seeing this gap closed.”

‘This gap,’ of course, is the life-threatening absence of pulse oximeters in more than 77,000 operating rooms in low-resource countries worldwide.  Every day, operations take place in circumstances that threaten the very lives of patients providers are working to save.

Another highlight: recently the entire department of anaesthesia at the University of Florida pitched together to raise money for Lifebox, and on the first day of the conference, head of department Dr Jerry Cohen presented Lifebox trustee (and ASA keynote speaker – check it out here) Dr Atul Gawande with a cheque for $33,700.  That’s enough to buy more than 130 oximeters!

We’ll have updates in the coming weeks – be sure to check back to hear more about When Lifebox Went West.

So at Lifebox it’s a privilege to hear first hand accounts from providers who meet this number, faces first, every day.

Benson Nfon Tanjong is an anaesthesia provider in the Northwest Region of Cameroon.   He’s president of the Cameroon North Westerner’s Association of Anesthetics, and a driving force for safer anaesthesia in his country.

That’s him above, with some old monitoring machines at his hospital – they haven’t worked in some time.

We wanted to share some extracts from a letter he sent us recently:

“Health care delivery in the developing world is still overwhelmed with so much poverty.  Patients come to the hospital almost at the terminal stage of their illness, after visiting many traditional healers.  Still, on a yearly basis we operate about 1200 cases.

We have two operating theatres with four beds, and a very simple Boyles anaesthetic machine with no ventilator attached.  We have one pulse oximeter, which we agree to use on the most serious patient of the day.  We have one functioning monitor that constantly goes off, following regular power shortages.

In my practice I have experienced serious negative effects from the absence of a pulse oximeter.

Four months ago I was called for an emergency cesarean hysterectomy for a 31-year-old woman whose placenta had ruptured overnight.  We realized that the baby had died in utero – probably of severe hypoxia.  The maternity ward in our hospital is a pretty busy one, but with no equipment to help in resuscitation of either babies or the mothers.  After the hysterectomy, the lady was not recovering from the anaesthesia.  I ordered a blood gas analysis, and the results were more or les those of a living corpse.  In about an hour the patient arrested and died.

This is life experience.  This woman needed a pulse oximeter early on, so that changes in saturation could be diagnosed earlier, and proper measures taken.

Amidst all the drawbacks we still do our best, and still succeed in carrying out very complicated surgeries.  We have patients traveling distances of over 1000 km to come for treatments.”

 ”Last week a mother came to my facility,” the 40-year old clinical anaesthetic officer explained, as we wandered around the Mbarara University of Science and Technology campus, looking for a quiet place to talk.

The afternoon training session was starting soon and most of the participants were sat on the balcony overlooking the main road into Mbarara – talking over the mechanical gutturals of passing motorbikes and digesting stacked plates of matooke (steamed bananas), ugali (maize), goat stew and groundnut sauce.

Leaning against the ground floor wall, she told us about the mother, who’d had a caesarean section at a district hospital three months ago.  She’d reported back three times since with severe abdominal pain and discharge from the wound.

A scan showed a mass, which was dismissed as scar tissue following the surgery.

“She came to us and our gynaecologist said, let’s see what this mass is,” said Christine.  “Let’s do an exploratory laparoscopy.”

“We found a big mop left in her abdomen from the c-section.”

A mop is a large swab, about 12 inches in diameter, often used instead of suction in low-resource hospitals during operations – they can be washed and reused repeatedly. The mop had become completely embedded in the woman’s small gut and colon.

Christine and the surgical team tried to separate the mop, but it was a complex procedure.

“Afterwards she was very sick – wasted, pathetic-looking, like a kid of five years.  After eight hours, she died.”

One of the last steps on the Surgical Safety Checklist, to be carried out before the patient leaves the operating room is:

Completion of Instrument, sponge and needle counts.

“If they had done the Checklist…” said Christine, quietly, shaking her head.

Away for just four days during the Lifebox training and annual meeting of the Uganda Society of Anaesthesia, she eats lunch with her left hand and fields phone calls about her recovering patients with her right.

In between, she tells stories of patients she has saved, and lost – and how a pulse oximeter would help.

“It’s very necessary – especially with caesarean section mothers, who bleed a lot – most of our c-sections are emergencies, with the mothers already in a bad state.”

Pauline’s hospital was designed to fit 100 beds, but today it holds more than 200: rows of patients line the floor, bringing their own blankets or buying mats from the stalls that spore in front of the building.  With so few other resources, the early warning provided by a pulse oximeter is a powerful one: it can pre-empt a life-threatening loss of blood or oxygen in the operating room.  And so often, as we heard again and again during our stay, there is no blood, there is no oxygen to give.

Pauline went home with one of the Lifebox pulse oximeters.  For us who had gotten to know her a little, it was a small personal relief as well as professional satisfaction: when we met her in July she was 28 weeks pregnant.  “I will deliver in the very hospital I am working in,” she explained, smiling.  “For us in Africa, you work till you deliver!”

Ask him about that moment and the anaesthetic officer, who has worked at a district hospital in Western Uganda for six years, remembers every detail with agitated clarity.

“[The mother] had had eight pregnancies and five miscarriages – she needed this baby,” he said.

Unaffordable cost, dangerous transport and a tradition of home births mean that women in Uganda are largely reluctant to plan for delivery in a hospital.  Often when they do arrive, their condition has long since deteriorated from ‘at risk’ to ‘critical’.

“She came late – the transport was a problem for her – and by the time she arrived, she had a ruptured uterus.  But fortunately when we opened her up, we found the baby was alive.”

While the surgeon prepared to operate, Philip put the pulse oximeter on the woman’s finger, and waited for a reading.  Nothing picked up.

“I thought, maybe it was fitting – or her cold hands had interfered with it.  At first I didn’t know it was a complete breakdown.  I thought, maybe her heart has stopped.”

“I tried to detach it from the main system, and tried it on myself.  It was the same.  Then I called my assistant.”

“I thought, my God, this is a machine that made my work easier and safer for my patient – what am I going to do?

Now my work will be difficult.  Now it will really suffer.”

Thanks to your support, Lifebox was able to give Philip a brand new pulse oximetry package.  Sensitive to changes in blood oxygen levels of just 1%, the Lifebox oximeter will allow him to focus on his patients without the dreadful anxiety of knowing they could desaturate at any moment without warning.  Non-invasive and portable, the oximeter will be used on hundreds of patients over the next few years, and it will, without question, save lives.