Feature BMJ Christmas Appeal 2012

Lifebox: the difference a donation makes

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8407 (Published 12 December 2012) Cite this as: BMJ 2012;345:e8407
  1. Jane Feinmann, freelance journalist
  1. 1London, UK
  1. jane{at}janefeinmann.com

Atul Gawande, writer, and surgeon at Brigham and Women’s Hospital in Boston, US, is also chair of Lifebox, chosen as the BMJ’s Christmas charity. Jane Feinmann asked him just what a BMJ reader donation means

There are 20 national and international anaesthesia societies and associations backing the Lifebox campaign. Why are anaesthetists so passionate about these devices?

Pulse oximetry has enormous symbolic as well as practical value for anaesthetists in the West. The technology is a key component in the revolution in anaesthesia care over the last generation that has brought down the death rate from anaesthesia by over 95%. Anaesthetists were pioneers in bringing concepts of patient safety into medicine, and the oximeter is emblematic of these improvements. These advances, not just in technology but also in ideas, have not made their way into low income countries or even, in many cases, into middle income countries, where most anaesthetists are not doctors but medical officers with more limited training and much lower professional status and do not have the voice to make changes. The enthusiasm for Lifebox is because it is working to bring about the technological and cultural advances in safety that have not so far occurred in over 70 000 operating theatres in the world today.

Can you recall the first time you witnessed a pulse oximeter being used?

In the 1970s, my father, a surgeon in rural Ohio, complained bitterly about the common practice of anaesthestists leaving the room to smoke a cigarette while the patient was asleep. The anaesthetist would say to my dad: “Call me if you have any trouble.” When the first guidelines on monitoring the patient during anaesthesia were published, my dad was almost waving them in the air. He insisted the hospital spend the money on a pulse oximeter and also that the anaesthetist stay in the room during the operation. It provoked a bitter battle. One of the angry colleagues put open needles in his operating shoes one morning. The same struggle—for safety, professionalism, and mutual respect—is currently taking place in low income countries. That change can be difficult, but its outcome is critical for patients.

What was the effect of the introduction of pulse oximetry in high income countries?

The biggest trial of pulse oximetry involved some 20 000 patients, and as such was too small to pick up changes in mortality. But there are good reasons why every anaesthesia organisation in the world includes oximetry in their minimum guidelines. Before pulse oximeters were introduced, 1 in 5000 general anaesthetics resulted in the patient dying, with hundreds of deaths, often of perfectly healthy people, every year. Surgeons commonly told the patient: “Don’t worry about the surgery; it is the anaesthesia that is the risky part of the operation”—starting that well worn tradition of the surgeon blaming the anaesthestist. That was no longer true by the late ’80s. By then, the anaesthesia related death rate had fallen below 1 in 100 000 operations. That fall came with the introduction of the pulse oximeter together with a bundle of changes in safety practice including monitoring temperature, blood pressure, and other parameters at determined intervals.

Will the effect of Lifebox be as dramatic in low income countries?

It is already happening. If all we were doing was parachuting in a bunch of pulse oximeters, we wouldn’t have such a tremendous impact, but we work with local anaesthesia societies and ministries of health to identify the need for pulse oximeters and then help deliver these where they will be appropriately used. As part of the distribution of equipment we organise training in the use of pulse oximetry, safe surgery, and emergency obstetrics. This is carried out both by experienced people within the country and by outsiders brought in to run training workshops that have a sustainable impact.

In Uganda, where an estimated 70% of operating theatres did not have a pulse oximeter before Lifebox began its work, we were able to provide a pulse oximeter, along with training, so that nearly every hospital in the country that offered surgery was brought up to standard. Six months later, we circled back to see whether the devices were still in use and whether those who had received training had retained their knowledge, and the answer was yes on both counts. Only one pulse oximeter was missing, and that was because an anaesthesia provider had taken it with her to South Sudan to do refugee surgery. That was fine by us.

Poor countries struggle to afford basic healthcare. Shouldn’t BMJ readers be funding immunisation rather than a luxury such as pulse oximetry?

Several studies show that the cost effectiveness of emergency surgery, notably after road traffic incidents or in obstetrics, is as high or higher than that of vaccines in low income countries. Bear in mind that road traffic incidents are now one of the top five killers in the developing world, with cardiac disease replacing respiratory disease and malnutrition as the number one cause of death in Asia and Latin America. Prevention of maternal death is also directly related to the provision of surgical care with emergency obstetrics accounting for half of surgery in sub-Saharan African countries. That’s hundreds of thousands of people facing huge risks in undergoing life saving surgery. With a Lifebox device costing about 10% of the normal price of a theatre monitor, it ends up costing pennies for each patient at an incredibly high risk moment in their lives.

How many operations can be carried out with a single pulse oximeter?

A typical operating theatre in these low income environments will carry out more than 1000 operations a year. So a single pulse oximeter that lasts for two years will bring safer surgery to over 2000 people. And in many cases, with a replacement £16 probe, the Lifebox oximeter can last for several years.

Yet at £160, the Lifebox pulse oximeter is considerably more expensive than the FDA approved and CE marked “high quality” devices that sell online for £20 or so. Why is this?

Those inexpensive devices are “spot” pulse oximeters. They’re not designed for continuous monitoring; nor do they have a pulse tone or an audible alarm that sounds when the heart rate or oxygen levels deteriorate. Without this alarm, you lose the critical moment of knowing right away that you have a patient in trouble. I have been in operating theatres using spot pulse oximeters and when I looked under the drapes, I’ve seen a reading of 70%. As well as meeting the minimum specifications for the provision of safe oximetry in the operating theatre, Lifebox oximeters can withstand extreme heat and cold, the battery is functional for at least 12 hours, and they can be dropped from table height without breaking. There is a serious problem with medical equipment in low resource countries that breaks down soon after arrival—the Lifebox oximeter is optimally designed for the needs of that environment.

What would a pulse oximeter in every theatre mean for low income countries?

It’s a device that stands for nothing more than safety. When you introduce the device and safety training into the riskiest part of the hospital system you begin to build confidence that there are professional values at work, aimed at generating better, safer care—and that turning to hospitals when you are in trouble is safe, that these are places you want to go. We have shown that this is the case. In Moldova, we monitored the effect of introducing pulse oximetry and the WHO safe surgery checklist to units that didn’t have them previously. We found that in the three months after getting a device, there was a significant reduction in major complication rates of more than 25%. At a larger level, these values and imperatives start to flow into the system as practitioners understand that someone not breathing well is something the clinician can be responsible for and do something about. The monitoring starts to leak beyond the operating room—to a baby that is having difficulty breathing, for instance. I see all that as absolutely terrific.

What was the effect of last year’s BMJ donation?

It was a really extraordinary injection of funds—more than £33 000, allowing us to distribute oximeters in Cameroon, Cambodia, Sierra Leone, Nicaragua, Papua New Guinea, Bangladesh, Nepal, and Uganda. It funded 210 pulse oximeters directly and put training into these places. In 2012, we went from providing training and oximeters in one country, Uganda, to doing the same in 10 countries by the close of this year. There was an indirect result that the BMJ campaign bought us credibility with other non-governmental organisations. We have partnered with several groups that have allowed us to take the programme to multiple other places, ranging from Honduras and El Salvador to Eritrea and Ethiopia. Our whole organisation could not be more grateful.


Cite this as: BMJ 2012;345:e8407