Tag Archives: equipment

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.

Guatemala: Vital Signs Monitors and Dialysis Machines

Guatemala log #2

During our first day at the hospital we’ve been working on two projects:

The Vital signs monitors. 

The emergency department of Roosevelt hospital has received seven vital signs monitors as donations. They suspect the machines should be working fine, however the cables for measuring oxygen saturation, ECG and oxygen saturation are broken. Unfortunately we cannot test these machines as the power supplies are missing.

Furthermore only managed to collect one set of cables in condition good enough for them to be reapaired and unfortunately buying new ones would cost hundreds of dollars per machine.

For now the strategy will be to get a DC power supply for the machine as quickly as possible (18 V, 2,7A) and then we will try to get just one machine up and running.

The 13-17 dialysis machines

I have seen thirteen machines with my own eyes, some say however that the hospital has 17 Dexter 1550 type dyalisis machines. We started out trouble shooting two of the machines that looked as if they were in a proper condition.

The machines are quite old old but some of them are in a surprisingly good condition. Currently the haemodialysis department is renting machines from an external company, which is expensive, so it is our hope that we can help the hospital by getting their own machines working and thereby save some expenses.

Chancy with one of the dialysis machine.
Shanyce and Mohammed with one of the dialysis machine.

Unfortunately we are currently in doubt whether or not the consumable products are necessary to use the machine are available.

For now however, we are still testing the machine!

Stay tuned for the coming updates for the continuation of these projects and the initiation on the baby-bottle project!

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