A pulse oximeter for every operating theatre in IndiaBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f676 (Published 04 February 2013) Cite this as: BMJ 2013;346:f676
A machine no bigger than a mobile phone has become one of the most important medical devices in safe surgical care, making anaesthesia safer. The machine is the pulse oximeter. It checks a patient’s blood oxygen concentration and sounds an alarm if it changes by as little as 1%. Without oximeters clinicians may not notice signs of hypoxia until patients become cyanosed, when oxygen saturation is already damagingly low.
Introduced in 1985, pulse oximeters were rapidly adopted by anaesthetists as a universal standard of care in operating theatres; emergency, recovery, and neonatal units; and (especially paediatric) wards. But even now, more than 77 000 operating rooms worldwide lack them. The proportion of theatres working without a pulse oximeter ranges from 41% in Latin America, to 49% in South Asia, to 70% in sub-Saharan Africa.1 Lack of adequate monitoring means that tens of thousands of lives are lost every year.
The World Health Organization says that 234 million operations take place every year globally.2 And the number is on the rise. About seven million people around the globe have preventable surgical injuries every year, and a million of them die during or immediately after surgery.2
This inspired Atul Gawande, born in New York to Indian doctor-parents and now a professor at Harvard Medical School and Harvard School of Public Health, to start the not for profit organisation Lifebox in 2010, with the World Federation of Societies of Anaesthesiologists and the Association of Anaesthetists of Great Britain and Ireland. The aim is to equip every operating theatre in low resource countries with an oximeter. Gawande says that pulse oximeters will greatly improve the safety and quality of surgical care in poorer countries such as India.
“But a single machine can cost thousands of dollars. We at Lifebox have now started to make it available for just $250 [13 300 rupees; £160; €185]. Hospitals that are very poor are getting it for free, thanks to the funds we are raising,” Gawande says.
Gawande’s father, from Maharashtra, and mother, from Gujarat, who later settled in Ohio, were among the first donors to Lifebox.
“We shipped over 140 such machines to India last year, many of them funded by Smile Train, the cleft lip/palate charity. Till now we have raised $600 000. We aim to raise one million dollars this year. The BMJ made it a Christmas plea to donate to Lifebox last year while the societies of anaesthesia from UK and Ireland to South Africa have adopted it as their primary charity,” Gawande says.
Lifebox has recently launched a global campaign “to close the global pulse oximetry gap, to ‘Make it 0,’” beginning with a two year, $1.25m initiative to provide 5000 pulse oximeters to anaesthesia providers in need across Africa, Asia, Eastern Europe, and Latin America.
Children benefit most
Rebecca Jacob, an anaesthetist who was associated with the Christian Medical College in Vellore, Tamil Nadu, for 38 years before she retired as the head of the department of anaesthesia, says, “Pulse oximeters have made the big difference between life and death for my patients. I wouldn’t think of doing anaesthesia now without one. It has saved mainly children, who get hypoxic faster than adults.”
Jacob has been involved with the global oximetry project of the World Federation of Societies of Anaesthesiologists since 2002. She says that the pulse oximeter provided by Lifebox is “really cheap but a very advanced machine.” Hospitals that lack a pulse oximeter in their operating theatre or recovery setting can easily contact Lifebox online, complete a needs assessment form, and apply to receive a donated unit. Lifebox meets as many of these requests as its funds allow.
“I have seen how care has improved in small and mid-sized hospitals in India, Cambodia, and Vietnam, thanks to pulse oximeters provided by Lifebox. Pulse oximeters help us anticipate an emergency. Having a pulse oximeter is more important than even having an electrocardiograph. It helps not just children, but adults, pregnant women suffering from post partum haemorrhage, or old patients with lung and respiratory diseases. Once hypoxia sets in, the brain can undergo irreversible damage. A pulse oximeter is therefore an early warning device and a diagnostic tool,” Jacob adds.
She says that hospitals in the large states of Madhya Pradesh, Bihar, Uttar Pradesh, and north eastern India face a severe shortage of pulse oximeters.
Gawande says, “In most high-income countries where pulse oximetry is universal across the perioperative process, anaesthesia has become very safe: rates of mortality directly attributable to anaesthesia are typically less than 1 in 100 000 procedures. In low income countries the rate is often at least ten times higher than this, and can be up to 1000 times higher.”
Safe surgery checklist
The oximeter is a key component of WHO’s 19 point Surgical Safety Checklist, which substantially lowers deaths and complications from surgery. The checklist prompts the surgical team at crucial moments to mark the correct site for surgery, give an antibiotic within 60 minutes of making an incision, check the patient for allergies, and count sponges and needles to ensure that none are left in a patient. It has reduced complications by more than 30%.3
Surgical teams in eight hospitals around the globe, including India, who followed the checklist while conducting 7500 operations, found that the rate of major complications after surgery fell from 11% to 7%, a reduction of 36%. Deaths after major operations fell by more than 40% (from 1.5% to 0.8%).3
“The oximeter is the only thing on the checklist that must be paid for. So far, we have sent over 4000 such machines to colleagues in need,” Gawande says. More than 70 countries have benefited from Lifebox, including Azerbaijan, Bangladesh, Bolivia, Cambodia, Cameroon, China, Ethiopia, Georgia, Ghana, India, Kazakhstan, Pakistan, Paraguay, Sri Lanka, Tajikistan, Tanzania, Thailand, Uganda, and Zambia.
WHO recently concluded that patient safety during surgery had emerged as a substantial public health concern.1 It found that China conducted most surgical procedures, followed by Russia and India. The study found that 3-16% of all inpatient surgical procedures in developed countries resulted in unnecessary complications, with death rates nearly 8%.
In developing countries, the death rate was nearly 10% for major surgery. Mortality from general anaesthesia affected one in 150 patients while infections were reported in 3% of surgeries, with a death rate of 0.5%. Almost half of the adverse effects of surgery were preventable.
Gawande, who is also a general and endocrine surgeon at Brigham and Women’s Hospital, says, “As each oximeter is used on 25-30 patients a week, in 2012 alone we have helped improve the safety of surgery and anaesthesia for around two million patients.”
Cite this as: BMJ 2013;346:f676
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare
To donate to Lifebox go to www.lifebox.org/donations.
Provenance and peer review: Commissioned; not externally peer reviewed.