Propelling Safe Surgery with Sustainable Technology

This is a guest blog post written in collaboration with Arbutus Medical, a member of the G4 Alliance's member network. Arbutus works to develop innovative devices for use in developing countries, disaster relief, and other low-resource environments. 

Dr. Danwald Mwayafu knows what it’s like to start from scratch. As a recent graduate and the lone orthopaedic surgeon at Mbale Regional Referral Hospital in Eastern Uganda, Dr. Dan is building his practice from the ground up. Budgets are limited, and Dr. Dan doesn’t have access to all the tools he needs.

“I deal with broken equipment on a daily basis,” laments Dr. Dan. “It ranges from small equipment to major tools. I don't have access to the most basic tools for orthopaedic surgery - large fragment sets, Schanz pins and clamps for basic external fixation of open fractures, intramedullary nailing sets for closed femur fractures, small fragment sets, LCDCP, recon plates and buttress condylar and plateau plates."

“This [lack of equipment] affects my patients,” he continues. “Increased or prolonged hospital stay, malunions and nonunions of fractures.” There is a raw frustration in Dr. Dan’s words. His orthopaedic ward is overflowing with trauma patients requiring urgent surgery. If he doesn’t treat them, they will end up with lifelong disabilities.

 

At Mulago Hospital, the ‘Medical Device Graveyard’ is where old medical equipment goes to die. Many broken devices have been out of service for many years, but remain (sardonically) affixed with prominent notes that read ‘NEEDS FIXING’. Photo by Arbutus Medical

At Mulago Hospital, the ‘Medical Device Graveyard’ is where old medical equipment goes to die. Many broken devices have been out of service for many years, but remain (sardonically) affixed with prominent notes that read ‘NEEDS FIXING’.

Photo by Arbutus Medical

Dan’s situation is not unique. It has been estimated that 11% of the global burden of disease can be treated with surgery, yet surgeons of all specialties worldwide face barriers when it comes to safe and affordable equipment. Five billion people worldwide still do not have access to safe surgery.

General surgeons in low- and middle-income countries regularly face barriers such as a lack of personnel and equipment when trying to implement modern techniques. For example, laparoscopic surgery involves using tiny keyhole incisions and small instruments to perform many procedures such as gallbladder removal. It causes patients less pain after surgery, allows faster recovery, and is the standard of care in developed countries. Yet many surgeons don’t have access to even the simplest instruments required for basic procedures, let alone the equipment required for laparoscopic surgery.

Spine and neurosurgeons are often hindered by lack of adequate support services such as radiology. For example, MRI machines required to diagnose and plan surgeries are few and far between.

Other specialists often reuse devices that otherwise should be disposable, simply for lack of another option.

And at the most basic level, electricity and running water are not always readily available. One survey among surgeons in Uganda reported sudden losses of electricity during operations, which not only delayed surgery, but also prevented hospitals from appropriately sterilizing their surgical equipment.

Even when equipment is available to surgeons, a shortfall in user training, supporting infrastructure, and technology management programs mean that devices regularly end up in disrepair. Robert Malkin of Duke University explored this problem in one study where his group catalogued over 120,000 pieces of medical equipment in over 21 countries. What they found: 38% of the devices were out of service, sitting idle. In another study, his group found that over 70% of donated medical devices fail after just one year of use.

I’d like to see hospitals purchase more equipment like the DrillCover. Affordable and reliable equipment designed specifically for our environment. If I had all the equipment I need, I could deliver quality work, and improve the quality of life for the local people.”
— Dr. Danwald Mwayafu

There isn’t one silver bullet that will make surgical equipment available worldwide, but the first step is to acknowledge the immense scope of the problem and the variety of ways we can address it as the global surgery community. First, we can invest in programs to train more biomedical technicians so they can maintain and service equipment. Second, we can support hospitals who are developing technology management programs so they can better plan and manage their entire inventory of equipment. For humanitarian groups, initiatives can be as simple as providing device donations with instruction manuals in the correct language, ensuring electrical equipment is compatible with the country’s power supply, and informing the receiving technology management department of a new device at the time of donation so they are aware that the device is in use.

Another way to help is through design and development of technology specifically for users in low-resource settings. Innovations to basic technology such as a pulse oximeter, a simple device which when placed on the finger can measure the patient’s oxygen levels, have provided tremendous benefit. Groups like Lifebox, Gradian Health Systems, D-Rev, and our team at Arbutus Medical design equipment from scratch for users in low-resource settings. This leads to technology that is affordable, requires minimal ongoing maintenance, is easy to repair, easy to operate, functions well under a fluctuating power supply, and requires few consumables.

Equally important, we can help low- and middle-income countries develop their medical device supply chains to ensure that when replacement parts are needed, surgeons can get access to those components in a timely fashion.

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Our team at Arbutus Medical first connected with Dan when he was training as a resident at Makerere University in Kampala, Uganda. When Dan was posted in Mbale Regional Referral Hospital, Dan let us know that he didn’t have a surgical power drill. For an orthopaedic surgeon, a drill is vital for almost every procedure requiring insertion of plates, screws and other hardware. Dan only had access to a manual hand-crank drill to make holes in bone. With the operating theatre over 30° many days, and only dull drill bits at his disposal, it’s easy to imagine the sweaty challenge Dan would face each day when trying to drill holes in bone by hand. Dan’s only other alternative was to improvise and use a nonsterile hardware drill, a major infection risk.

With help from the University of British Columbia’s Uganda Sustainable Trauma Orthopaedic Program, we were able to set Dan up with a kit of DrillCovers - a set of safe, surgical-grade linen covers for a nonsterile power drill. With the DrillCover, Dan doesn’t have to compromise the sterility of the procedure and his surgeries are a little more efficient. “I’d like to see hospitals purchase more equipment like the DrillCover,” he says. “Affordable and reliable equipment designed specifically for our environment. If I had all the equipment I need, I could deliver quality work... and improve quality of life for the local people.”

As a community, we are slowly improving access to safe surgical equipment for surgeons like Dan across the world. Let’s keep at it so surgeons like Dan can provide safe surgery for all.