Category Archives: Medical Equipment

FreePulse: Testing In Nepal

Editorial note: this post is post-dated to December 28th. Poor internet connectivity prevented me from posting this until now!

FreePulse is a low-cost patient monitor designed for use in resource-constrained hospitals. I’ve been developing this monitor for about three years now, and I’ve been working closely with Access Health Care to design our first on-the-ground test in Nepal. I’m very excited to see where we’ll go and the lessons we’ll learn!

What We’ve Done So Far

The GoFundMe for FreePulse received a humbling and overwhelming response this summer, raising $1000 more than the projected goal. This generosity allowed me to push forward prototyping the fully functional model of FreePulse, which led to steady improvements in the design as well as a steady increase in the amount of wires sprawled out across my desk.

Messy Wires

There were four major areas of improvement that version 1 of FreePulse entailed, so I’ll give a quick overview of the work that was done over the latter part of 2016. Each of these topics could be a blog post in their own right, and I aim to expand on them in more detail in the future.

Improvements to the Software

The software of FreePulse was completely revamped during the summer to use a new modular, sandbox-like approach to displaying graphical elements like signal traces and buttons. You can check out much of the progress on that front in this PR (and on that note, you can always be up-to-date on the latest software progress by checking out the FreePulse GitHub page!). More work is still to be done here, but these modifications have laid the groundwork for expanding FreePulse’s capabilities to display many different kinds of modules and signals.

Addition of Pulse Oximetery

Using a sophisticated and efficient analog front-end chip from TI, a low-cost and hardware-efficient pulse oximeter module was added to FreePulse. This module accepts a standard DB-9 port probe, meaning it is compatible with a wide array of existing pulse oximeter clips.

Pulse Ox

The software algorithms for calculating percent oxygen content are all available on the GitHub page. These algorithms were determined empirically by testing against gold-standard reference pulse oximeters and fine-tuning calibration parameters.

Addition of Semi-Automatic Blood Pressure Measurement

Using a standard connection hose that will fit virtually any existing blood pressure cuff, the non-invasive blood pressure (NIBP) unit was built to provide simple blood pressure measurements at minimal cost and complexity. I added a DC control valve and pressure sensor to control the release and detection of pressure fluctuations in the cuff, and the extraction of pulse rate and blood pressure were performed in software. What this means for the user is that in order to take someone’s blood pressure, you simply have to hit “Start” and pump the cuff up to 200 mmHg with a hand pump. After the cuff is inflated, the deflation and pressure detection is completely automated, making it a very hands-off procedure.

NIBP System

Development of a Printed Circuit Board

After spending so much time with this mess of wires on my desk, it was time to translate that into a clean printed circuit board (PCB) that would be used in the prototype devices. Working with Mrs. Barbara Burcham, an incredibly talented (and patient!) PCB layout professional, we designed and revised a circuit board that saved as much space as possible while retaining full hardware functionality. I’m thrilled with the result, and the biggest testament to Mrs. Burcham’s talent is that the fully assembled board was able to be programmed on the first print! That doesn’t happen very often.

PCB Flashable

Preparing for the First Hospital Test

While improving the technical aspects of FreePulse, I also began working with contacts in Nepal to organize on-the-ground tests of FreePulse’s capabilities. Two organizations played critical roles in supporting this effort: Access Health Care and Innolitics, LLC. In addition to this, an incredibly generous donation from Yujan and Mekha Shrestha was the final gift that covered the rest of the budget for the proposed test trip. With the support of these donors, the testing and evaluation was set for this coming winter.

In preparation for this opportunity, a copious amount of background research and testing was performed to ensure safety compliance and hospital readiness. I began reaching out to doctors in Nepal and gauging community interest in the project, and eventually I determined what hospitals would be optimal fits for FreePulse’s first on-the-ground test. After determining the hospitals, the full weight of effort became preparing a prototype that would be functional both in its operation as well as its form factor. I needed a PCB, and I needed a case!

PCB Flashable

PCB Flashable

For the former, I used the PCB design that Mrs. Burcham and I were developing and fabricated it using OshPark, a community-driven PCB manufacturing site. I then modeled a case for the monitor in Solidworks and fabricated it using an ABS 3D printer. Although the schedule was tight, two functional FreePulse prototypes are now on the ground in Nepal!

What We’re Up To Now

Videographer and media guru Madeleine Dunaway and I are on the ground beginning our visitation of the three hospitals from which we will be testing FreePulse: Amppipal Hospital, Okhaldhunga Community Hospital, and the Annapurna Neurological Institute. Our goal is to demonstrate FreePulse’s efficacy and receive user feedback from doctors and nurses that will guide the development of the next iteration of FreePulse. We are thrilled at the opportunity to work with the doctors and nurses at these hospitals! We hope to build relationships that will help us to better understand what needs are experienced by medical professionals in the developing world and how we can design better medical equipment to satisfy those needs.

I will be blogging about our experience here and sharing the lessons we are learning, as well as sharing some footage of FreePulse in action in the field. Stay tuned here or at my blog to get the latest updates as we begin our adventure in Nepal!

Open Road Nepal

Mount Meru Hospital, Tanzania

Each Friday for the next three weeks, the Tanzania EWH team will  work at Mount Meru Hospital just outside the heart of Arusha.

The Tanzanian health care system consists of larger referral/consultant hospitals such as Kilimanjaro Christian Medical Center, regional referral centers covering several districts, and smaller hospitals covering one district each such as Karatu Hospital.

Mount Meru is a regional hospital with departments for obstetrics and gynecology, pediatrics, surgery, out-patients, and units for ophthalmology and dentistry. The hospital also has a laboratory and an intensive care unit. The hospital typically sees 500 patients per day on an outpatient basis and admits approximately 250-290 patients every day.

Generally there is a fee to be seen by a doctor at Mount Meru; however, as a public hospital, they are obliged to serve all people, and will provide free health care to those who cannot afford  it.

The typical population served by the hospital consists of farmers, pastoralists or industry workers. These are families that earn a low to middle-class income. Some of those who work in the outskirts of the districts covered by Mount Meru Hospital (for example people coming from Ngorongoro or Longido district) have nine hours travelling time to the hospital. Others simply can’t afford the cost of transportation. As a result, acute patients, especially pregnant women and children, often reach the hospital too late for doctors to do anything.

According to hospital staff, the largest barriers to provide health care services in Tanzania are lack of capacity to handle all, but especially acute patients, lack of funding and lack of accessibility to medicines, supplies and health care technologies. These issues are more or less apparent in all across governmental Tanzanian hospitals from the district level up to referral/consultant levels. Handling acute cases is a particularly large problem at district hospitals, which is why regional hospitals like Mount Meru experience a very high occupancy rate and a high number of patients, that do not reach the hospital in time for an ideal outcome of their treatment.

At Mount Meru Hospital, one challenge in meeting the demand is the large amount of donated equipment of which only about half is currently functioning. The entire region has just one biomedical engineering technician (BMET), Mr. Sharif Rajabu Kishakali. As of early 2015, he is the first ever BMET at Mt. Meru Hospital. He is currently working on a preventative maintenance program for the hospital’s equipment. The attached pictures are a collection from the projects he is currently working on.

How Our Team Helped Roosevelt Hospital Achieve a 79x Value for Money in Guatemala — and More!

As described extensively on this blog, working in a developing country hospital is not always easy.

In effect, it always results in a great sensation of success, when one suddenly finds a hidden stash of valuable – yes – cables. Exactly that happened when our group found the ECG’s cables and power supplies shown in the pictures below.

In a storage room at the emergency department of the hospital we found 7 vital signs monitors, 7 Power supplies, 2 pulse-oximeters and 3 ECG cables in woking condition. Unfortunately, all remaining cables for the seven machines were broken, an example of which (an SPO2 sensor/pulse-oximeter) is shown here.

From all the parts we had an fixed we managed partially assemble 5 working Vital Signs Monitors: Two of them were put back in to service with pulse-oximetry and ECG working, 3 of them with ECG only. Unfortunately the department didn’t have any compatible blood pressure cuffs, so we would have to buy new ones, just as we wouls need additional pulseoximeters and ECG cables.

Vital signs monitors are fairly simple pieces of medical equipment, however the cheapest completely refurbished set found on eBay that is corresponding to these machines is $3.503.

Thus having these pieces in working condition would have an extremely high value to Roosevelt Hospital. Meanwhile the cheapest prices on eBay for replacement parts, that we need to put all of these vital signs monitors back into service, are found for $24 (SPO2) + $54.50 (ECG) + $12.5 (Blood pressure cuffs).

In “How to repair shielding on ECG cables and leads”  I described how we we repaired three sets of cables. The fixes were good, but not perfect in that we did make the cables work, but the signal was still somewhat noisy, for which reason the machines couldn’t have been used in surgery and detailed diagnosetics – rather they were useful for general “simple” monitoring.

Considereing the fixed cables as being in working condition (a somewhat noisy signal is, after all, better than no signal at all), we now just needed 2 ECG cables, 5 SPO2 censors and 7 blood pressure cuffs to make all of these machines work.

The total cost of this according to the prices on eBay would be just $321, although with used parts.

Considering that a completely new refurbished set on eBay costs 3.503, the value of these equipments reach $24521 in order to buy seven of these machines.

By repairing these machines our team achieved 79x value for money (even though the fix wasn’t perfect).

Now, I thought this story would end here, when, out of the blue, I received an email from Mr. Juan Fernández at Spacelabs Healthcare in Latin America,  who wrote that they would be able to send the broken parts to us —  free of charge! We could now make all the machines work perfectly (with no noise on the line). My collegue in Guatemala, biomedical engineer and expert technician Mr. Joe Leier will receive and bring this donation to Roosevelt Hospital as soon as possible.

I want to thank the people, that have been a part of saving these machines: my collegues Ms. Rebecca Avena and Mr. Joe Leir and Mr. Juan Fernandez at Spacelabs. We at EWH and Roosevelt hospital we are extremely thankful for this donation, which now means that Roosevelt hospital has 7 fully refurbished, high quality patient monitors working in their emergency department.

Challenges Working in a Hospital in a Low Income Country

By Michael Kosteljanetz

Originally Published: April 10th 2014

 Editors Note: Michael Kosteljanetz is Senior Consultant, Dr. Med. Sci. at the Department of Neurosurgery at Rigshospitalet University Hospital in Copenhagen. On several occasions, Michael has been working and teaching in Rwanda and Ethiopia, where his expertise in his profession is an urgent needed. Michael here describes his experiences with the challenges of working at a hospital in a ressource-poor setting. This article was originally written for students at the Engineering World Health Chapter at the Technical University of Denmark to prepare them for working in developing country hospitals, however it is highly interesting material for anyone with just a slight interest in developing countries!

 

It would not be fair to judge the entire developing world based on personal experience which stems from a brief stay in Addis Abeba, Ethiopia, where I worked at a private Christian hospital and a large public university hospital and three stays in Kigali, Rwanda, where I have worked for a total of 6 months in a public, teaching hospital as participant in a large American-Rwandan project. My daily work takes place in the hospital’s surgical department.

Rwanda’s situation may be different from the situation in other African countries, because the shortage of health personnel here largely is a consequence of the genocide in 1994, where approximately one million people were killed, and among them a great number of health workers. Besides, a great number of people fled to the neighbouring countries and Europe or America.

In many ways Rwanda is a well organized country, partly because of its small size, approximately 2/3 of Denmark. It is very densely populated, almost 11 million people live there. There is a network of roads, the main roads are paved and there is a well developed network of buses that takes you almost anywhere in the country. Mobile phone penetration is around 50% (in 2012), internet approximately 10%.

In my specialty, neurosurgery, there are two neurosurgeons that serve the population, both work in the capital Kigali, where one million people lives. One works at a private hospital, the other at the university hospital. The two departments are affiliated and patients can be transferred from one hospital to the other under certain circumstances.

The hospital where I worked is one of 3 or 4 greater referral hospitals. The country has a great number of health centres, more than 40 district hospitals, most of them run by nurses and general practitioners, who can perform a limited number of operations, e.g. caesarian section. In a few district hospitals there are surgeons who can perform ”neurosurgical” operations e.g. shunts for hydrocephalus.

Although the economy is growing, the country is still poor, the average income being 1/30 of that in Denmark, which of course has major influence on the quality of healthcare delivered. More than 90% of the population has a health insurance, which is very uncommon for an African country. In most cases the patients have to pay 10% of the expenses, which in a poor country like Rwanda may be more than they can afford, even though it amounts to what we would consider a minor expense, say 50 or 100$.

The University Hospital of Kigali, Rwanda was originally built almost 100 years ago and almost all buildings which are pavilions are more than 70 years old, which means that facilities and logistics are far from satisfactory. Most rooms have 8 or more beds. Washing and toilet facilities are of course very scarce.

There is one CT scanner at the university hospital, however, it may not always work. X-ray films are not always available, so most often it is not possible to get print-outs of the scan. Even if one gets one it will only depict a fraction of the entire examination; as a consequence not all aspects and angles of the disease are depicted, sometimes making it very difficult for the surgeon to make a professional decision based on the CT, just as surgical and treatment planning may be challenging. X-rays and scans cannot be transmitted electronically, so in order to discuss a case with a colleague, say when a transfer is considered, one has to take a photo of the scan on one’s smart-phone and send it and again, for which reason the image quality is a challenge. If the patient needs a MR scan they have to go to the private hospital where the only MR in the country is, but the same remarks that apply for CT goes for the MR as well.

The Operation Theater was built in 2009, but in spite of that it is already worn down, most likely because it was built with the poor materials. Many of the tiles in the floor are broken, so that water can collect in the small cavities that have been formed, the humidity has penetrated the ceiling in the theatres so that there is visible mould in most operating rooms. Because of the humidity, but probably also because of poor quality, whatever that can rust has become rusty; the wheels on most tables, where surgical instruments are placed during surgery are broken so hardly any table can roll. Legs of tables and stools are broken or at least most times broken so that they stand askew. The Danish ”Arbejdstilsyn” (Danish Working Enviroment Au- thority, red.) would immediately close the operating theaters due to the electrical installations. Electric lines and sockets runs across the floor even though it is regularly wet from the cleaning and sockets in the walls are faulty. Many of the lights and the operation lamps do not work properly and 1 or 2 out of 4 bulbs often do not work. The doors to all operating theatres are broken, so that they can neither open or close, meaning that they are more or less open most of the time, also during operations, which is practical because the personnel tends to come in and out of the room. Since the sun shines most of the time the room gets hot, and the ventilator switch cannot be reached by most people of average height. The windows have no shadow so the sun shines and sometimes blinds the surgeon.

Operating tables cannot be adjusted electronically as they could when they were new and even to adjust them manually is difficult. Suction equipment which you need to suction away blood during an operation is faulty. The main reason being that the disposable suction tubes, like many other disposable consumables are used not one but several times leading to a change in the stiffness of the tubes, so that they collapse, when suction is activated.

Since the surgical instruments themselves often are robust, made by steel, they are usually working but even simple instruments may not be available.

Now, while you can perform a great number of abdominal operations with a very limited number of instruments, neurosurgery is for the most part a hightech area. Scissors and scalpels almost always work, especially when they are sharpened. Most surgeons use suction, which I have described and a bipolar, which is a kind of electrical tweezers that can burn tissue in a very limited area and thereby induce coagulation of vessels and stop bleeding. Contrary to other surgical fields, bleeding in neurosurgery cannot be stopped by ligature of the bleeding vessel. Our bipolar has been repaired with adhesive tape, so that it works most of the time, which it did not the year before.

Essentially problems related to the operating theaters can be divided into:

  1. Lack of equipment. This can be divided into large, high-tech equipment, which is very expensive to purchase (operating tables, surgical microscope, special aspirators etc) and lesser like normal surgical instruments, hooks etc.
  2. Lack of maintenance.
  3. Lack of sufficient knowledge about the function of the equipment, leading to faulty usage and maintenance.
  4. Lack of renewal/exchange.
  5. Lack of daily consumables that is sutures, gauze, patties (small cotton pieces to protect the tissue, e.g. the brain during surgery).
  6. Lack of special consumables needed for certain operation (e.g. shunts, ventricular drains).
  7. Logistic problems, including storage facilities.
  8. Buildings.
  9. Irregularities in water and electrical supply (rare).
  10. Lack of skilled personel (scrub nurses and anaesthetists).
  11. Lack of facilities for postoperative care and observation (that includes the rooms as well as the personel).

Logistic problems include poor planning and surveillance of the daily surgical plans. If one wanted to be sure that the cases one had planned would be brought to the OR, it was mandatory to be present in the OR, meaning that one could not leave the OR for rounds or seeing patients in the out–patient–clinic while waiting for the preparations for the operation. Because of the long and awkward routes from the wards to the OR (among other things), waiting time before and between operations were often 2-3 hours. Part of the waiting time could sometimes be explained by shortage of a consumable that had to be procured or instruments that were not sterilised.

Roughly the above mentioned can be divided in a) shortage of fundings for buildings, including repair and maintenance b) shortage of skilled personel c) lack of resources for training and education of personel e) logistic problems.

To which extent one or more of these issues are more important than others cannot be concluded from my non-scientific observations, neither can I conclude which means are most appropriate to solve the problems. This will demand further analysis. Considering that Rwanda is a country where the economy is steadily growing there is a chance that some of these problems can be solved because of improved funding but other problems could be dealt with in the meantime.

Note: Neurosurgery is the specialty that deals with the surgical treatment of diseases and congenital conditions and injuries in the central–nervous–system, that is the brain, the nerves, the spinal cord and the surround- ing tissue (meninges and skull and verter- bal bodies). The neurosurgeon removes e.g. tumours, haemorrhages, aneurysms. Some neurosurgeons mainly operate on the spine.

Authored by Michael Kosteljanetz, edited by David Kovacs. Published by the Engineering World Health chapter at the Technical University of Denmark.

Find PDF Version at: challenges-working-hospital.

How Broken Medical Equipment Ends Up in the Worlds Poorest Hospitals

Global Medical Aid (GMA), an aid organization from the Capitol Region of Denmark, was given broken medical equipment and therefore forced to spend their resources separating life-saving medical equipment from useless machines. Unfortunately, not all organisations perform this vital quality control: many donations end up as nothing more than piles of junk at the world’s poorest hospitals.

Medical equipment is extremely valuable and has the potential to significantly improve health care in developing countries. In an effort to aid the world’s poorest health care systems, western hospitals often donate used medical equipment when updating their inventory.

Unfortunately, donations often don’t have the intended positive impact. An example of how donations can end up causing more harm than good was featured on the main Danish news channel DR1:

Aid Organization was Given Broken Medical Equipment: We are Being Used as Landfill

The news story was on national Danish television and radio.

It is described how regional politicians of the Capitol Region of Denmark did not set aside resources for testing of equipment donations before the machines were given to Global Medical Aid (GMA). GMA had to spend a large amount of financial and human resources on separating useful pieces from broken ones —  resources that should have been spent on the transportation of equipment to developing countries. (See translation of the full story at the end of this post).

Not all aid organisations pay third parties to test the quality of their donations as GMA does. Many aid organizations simply ship malfunctioning equipment directly to developing countries without any quality assurance whatsoever.

An example of this is illustrated in the pictures below from Roosevelt Hospital in Guatemala City, taken on the the 30th of December 2014. I am currently working at the hospital with Engineering World Health as part of a six person team of students and professionals from Rochester Institute of Technology, George Mason University, Marquette University and the Technical University of Denmark. We are based at Roosevelt Hospital in Guatemala City with the aim of placing broken donated equipment back into service.

Broken equipment in the equipment "junk yard" #2
How donations can end up once they reach the target hospital: Broken equipment in the equipment “junk yard” and Hospital Roosevelt in Guatemala City. This photo was taken on the 30th of December 2014.

Already during our first day at the hospital we found vital medical equipment out of use: 14 haemodyalisis machines, 7 vital signs monitors, 4 anaesthesia machines and an incubator. The well-meaning donations are left as junk in the “equipment graveyard” in the back of the hospital.

Another example of failure to target donations properly is shown in the following picture from the same hospital, featuring the pictured dental chair, which is still partly contained in the original wrapping, indicating that the chair has most probably never been used.

This dental chair was donated to Roosevelt Hospital in Guatemala and as seen on the picture, it has never been used: Part of the original wrapping is still on there.
This dental chair was donated to Roosevelt National Hospital in Guatemala and as seen on the picture, it has never been used: Part of the original wrapping is still on the chair.

Unfortunately, the problem we are facing at Roosevelt Hospital is not unique. It is seen in developing countries around the world. Leslie Calman, CEO at Engineering World Health, summarises the issue as follows:

“The donation of medical equipment is a generous and well-meaning outpouring of aid, intended to strengthen health care systems, reduce human suffering and extend life-saving remedies to millions. But if not done with care and attendtion to local conditions — including the capacity of local hospitals to install and maintain the equipment —  the generosity may not live up to its donors’ good intentions. The Secretary General of the United Nations has stated that as much as 70% of essential medical equipment is not functioning in the developing world.  Coupled with equipment donations should be an investment in training a local workforce to maintain and service the equipment. This would create local jobs, build skills, improve the environment, and create the conditions in which healthcare can be safely delivered.”

The magnitude of harm caused by faulty equipment donations goes largely unnoticed. To illustrate this, consider the following: According to World Bank, the Danish health care expenditure in 2012 was 11.2% of Danish GDP, accumulating to $6,304 per capita (the corresponding number in the United States is 17.9%). This means that $6304 is spent on health care for every single one of Denmark’s 5.6 million citizens.

$34.65 billion is spent on health care in Denmark every year. Contrary to popular belief, this money is not spent on the high salaries of doctors. Based on the average yearly physician’s salary in Denmark of $85,000 and nurse’s salary set at $54,000, only 18% of the Danish health care expenditure is spent on salaries. The major part of the remaining $28.14 billion is spent on hospital infrastructure and the extremely valuable medical equipment.

My point is not that poor hospitals don’t need equipment donations. Rather, the important aspect to realise is that the donation of advanced technologies is extremely complicated.  Resource-poor health care systems are in need of expertise from professionals who understand advanced health care technologies and the logistical complexity behind donations.

The fact that a vast amount of broken equipment is sent off to fill up the words poorest hospitals without ever being used is ethically irresponsible and indefensible. It is essential that local health care workers, departments, and hospitals ensure that well-meaing donations actually end up fulfilling their life-saving purpose.

Translation of the original story: 

Danish hospitals donate used medical equipment to alleviate poor countries. However, aid organisation warns that the equipment may be dangerous to use.
In a corner of Global Medical Aid's storage halls in Birkerød you'll find more than 30 infusion pumps. They are donated from hospitals in the Capitol Region and should have been sent to poor countries in Africa, but as it turns out, this equipment is completely defective.
The relief organisation Global Medical Aid sends hospital equipment to poor countries around the world. They are now accusing the Capitol Region for using them as a landfill. 
The reason is that the organisation has been given an abundance of used medical equipment that does not work at all. Everything from anaesthesia machines to infusion pumps and defibrillators have turned out to be broken.
"We have obviously been treated as if we were a landfill site, where hospitals could get rid of the equipment they have been storing in basements for years" says Hans Frederik Dydensborg, the president of Global Medical Aid (GMA).The politicians of the region have now decided that medical equipment is to be donated in an ethically responsible way. According to GMA, it is directly unethical when hospitals donate equipment that doesn't work. GMA has incurred large expenses in separating working pieces from broken ones -- money that should have been spent on bringing the equipment to the world’s poorest countries."We have had large amounts of unnecessary expenses, with the consequence being that we haven't been able to send off the containers as expected" says Hans Frederik Dydensborg.In the Capitol Region, the chairman of the IT and debureaucratisation committee, who is responsible for recycling medical equipment, is concerned about the fact some donations have proven to be useless."Of course the equipment must have a certain standard, and of course it to be in a condition such that it can be used" says Lise Müller (Socialist People's Party).To avoid faulty donations in the future, the Capitol Region is now creating a storage hall in order to collect used equipment from hospitals and check it up for errors and deficiencies before they are sent on to aid organisations.In the region of Mid-Jutland, they have good experiences with a corresponding scheme."I am sure that we can find people who could find use of the equipment. If they don't, we will have to throw it out. But of course we have to learn from this, that the equipment we donate is of the right quality" says Lise Müller. The new storage halls will cost about DKK 2 million (USD 330.000) a year to maintain and the money will be found in the 2016 budget of the capitol region.

How to Repair Broken Shielding on ECG Cables

The work done by engineers in a developing country includes a range of smart repairs that help hospitals save significant expenses.

Equipment cables are common examples of broken parts found in developing countries. Just a week ago I described how our group found seven vital signs monitors out of use at Roosevelt National Hospital in Guatemala. This last week, our group found the cables for the monitors, however the shielding on them was broken. The picture on the left shows the cable with broken shielding, while the picture on the right depicts the noisy — and clinically useless — ECG signal.

Buying one new ECG   cable for a patient monitor would cost $51 if purchased on eBay.  However, it is feasible to fix the ECG cables and avoid the cost of purchasing new parts.  In order to do this, we performed three simple steps:

1) Wrap foil carefully around the ECG cables.

2)  Ensure that the foil is electrically connected to the ends of the original ECG cable shielding.

3)  Wrap the foil tightly in electrical tape

The photo on the right shows the resulting ECG signal. The ‘p-q-r-s-t” sequence of a normal ECG signal can be seen on the screen.

The result is still not optimal, as there is residual noise interfering with the signal. Our group is currently investigating ways to make the shielding more effective so that the foil is optimally electrically connected along the entire length of the cables.

The EWH Guatemala Winter Institute 2014/15 Roosevelt Group considering the resulting signal and if it can be further improved.
The EWH Guatemala Winter Institute 2014/15 Roosevelt Group considering the resulting signal and if it can be further improved. Left: Caty Lin – George Mason University, Middle behind: Shanyce Stewart, Rochester Institute of Technology, Middle in front: Becca Avena – Marquette University and Co-op at GE Healthcare, Right: Mohammad Ali – George Mason University.

 

What’s it Like to Work in a Developing Country Hospital?

It is now a little more than a week ago that I returned from and unforgettable journey to Africa. It’s been such a journey that expands horizons, gives new perspectives, creates new visions and changes beliefs and values. During my stay I worked for a month at local hospitals, an experience that was different in so many ways from what I had expected.

Prior to our placements at local hospitals the students of the 2014 EWH summer institute (myself included) took part in a month-long educational course on “Engineering in the Developing World” and an introductory Swahili course – a program which proved to be of considerable advantage as we were soon to develop a trusting relationship with the departments we would come to work for.
After this first month of education I was moved to my placement along with my group, which besides myself consisted of a student from Duke and one from Harvard. We were to work in two hospitals: Kilimanjaro Christianity Medical Centre (KCMC) and Mawenzi Hospital, both situated in the town of Moshi, Kilimanjaro region.
The KCMC is one of the largest and most prestigious institutions in Tanzania and has a biomedical engineering department consisting of 30 engineers and technicians. Despite good will and hard work from the department, it was obvious that we could do much in both hospitals, just as we could learn a lot from them. Our group alone repaired more than 60 pieces of equipment during our stay. Overall, this year’s EWH summer program returned 4,200 pieces of equipment amounting to 8.6 milion according to the latest figures from EWH.
If I was to draw one conclusion about medical equipment in developing countries today, I would say that it simply should not be allowed to donate without informing properly about that specific piece of equipment in the local language (or in English, at the least):
In so many places we found rooms and whole warehouses filled with piles of medical devices. To our surprise, very often these devices could be put back into service by simple mechanical repairs. We even found completely new operating theatres that could not be used because they were packed full of unused equipment. I was left behind wondering if donations do any good at all – or if they do more harm than good. During our month at the hospital we slowly started to learn the reasons why these equipments weren’t in use: How were people supposed know how to use a piece equipment, if they had no manual for it? Or how could they use a machine, if the user interface was in Dutch or in German? When a repair was to be done after all, many reported difficulties and bureaucratic systems when having to acquire replacement parts, such as a lightbulb for a microscope.
The type of problem that could arise when departments were not provided information about new technologies became clear to me one day at the KCMC, when our group was asked to repair an Infant Warmer from GE. We were told the following: The department had received a completely new machine and put it into a small room where they normally observed newborns in the early hours after a birth. But when the staff began to use it, the machine heated the room up to a temperature so high, that it was unbearable to stay in there.
The solution turned out to be immensely simple: the skin-temperature sensor had mistakenly been placed under the bedside, and had to be moved to the skin of the newborn – otherwise the device would constantly work to achieve a temperature of 35.5 degrees under the bed instead of on the baby’s skin. Thus the machine was heating on and on (and on…).
After having cleared out this first misunderstanding, we explained that the machine could not, as some thought, be used to take X-rays images, but that it merely contained a tray for a detector plate so that you weren’t forced to move the baby around unnecessarily,  and that the machine could not calculate an APGAR-score, but that it contains a stopwatch simply to help you with the task. The problem wasn’t lack of education or ability to understand how a machine works. It was simply the fact that people were not provided the necessary information. Even if some information was provided, it was not done properly: How is a nurse going to read a 500 page manual, while working in a ward full of women in labour? Seeing this and other similar cases, one of our main focuses became developing quick start guides in order to provide departments with a fast and simple way of knowing how to use a device.
Another typical issue that we encountered was how departments virtually never took advantage of vital signs monitors and ECG’s because they had run out of the necessary electrically conductive gel. There are a number of alternatives to conductive gel – in principle anything that contains electrolytes, for example aloe vera or ketchup, can be used. It should have been obvious however (as I did not first think of), that most doctors and patients do not want to use these methods, as they are uncomfortable and inconvenient. I remember explaining to a doctor how he could make his own electrically conductive gel using water, flour and salt. His response: “Is that really recommended?”. Imagine his reaction, had I recommended him to use ketchup. In addition, many Africans are proud people to whom one can and should not just offer anything (just as one would probably not do anyone at home). Therefore, developing a gel that is more likely to be used clinically, and in addition could be produced cheaply using local materials, would be an example of a simple and small, but valuable project for developing world hospitals (while you can find alternatives to conductive gels, I still haven’t seen one that actually looks like the gel that is used in clinics). Notably the KCMC already had the means to produce their own ultrasound gel (which is acoustically and not electrically conductive) so they shouldn’t be too far away from being able to produce their own conductive gel too.
This and many other projects are still to be carried out to make the daily life at a these hospitals run smoothly. Here I have given just two examples of what it can be like to work in the developing world. So many ways remain in which one can help this  parallel world of ours, in which resources are so scarce that we are constantly forced to think in new and innovative ways to provide the best possible health care for the all people.

Fixes in Moshi, KCMC and Mawenzi

ewhdtu:

The last couple of weeks have been stuffed with interesting fixes and great experiences in Moshi, KCMC and Mawenzi, Here are some of my favourite photos.

Charging batteries

Goodmorning-battery charge for a paediatric pulse-oximeter:

9 volts / 250 ohm resistor , charging with approximately 40-50 miliamps, yielding charging rate of about 1/20.

Educating, teaching and building parts

Some pictures from a great day in Moshi: We fixed an infant warmer, taught nurses how to use the manual suction pump and made new parts for infant incubator with assistance from the orthopedics/prothsis department.

1: KJ is teaching a nurse at the female medical ward how to use the manual suction pump – which was suprisingly challenging, not just for the locals, but also for us (had to read the manual…)

2: Samson from the orthopaedic department at KCMC is preparing a new piece for an infant incubator that we have been working on.

3: The KCMC has a whole department for creating prothesis – the department is actually a Danida donation from the 70, where approx. 70 danes came to Moshi to do development work.

4: We were (here KJ) teaching one nurse from each department of Mawenzi how to use the manual suctionpumpt. The main points are to put water around the lid to close it tightly and fold the tube for vacuum.

5: Nurse is bringing back the suction pump to the department – now working – this pump is useful whenever there’s a powercut or when the electrical ones breake (which happens quite often..)

6: This guy spent approx. 1.5 hrs showing me around Moshi as we were lookig for a diode that we needed to fix an infant incubator. People in Moshi are reallyreallyreally helpful