Tag Archives: health

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

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.

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.

 

AHCN #9 – 14 hours Incredible Walk

After reaching Rukum on impossible roads, meeting with the Local Development Officer, visiting the Salle Bajjar/Musikot District Hospital where we experienced the harsh reality for the patients of Rukum, buying medication and receiving donations at the Chitwan Medical College Teaching Hospital we were finally ready to start are trek towards Sisne. On our trip this far we had seen amazing sceneries, however the best was still to come, as you can see in the gallery below.

One of our initial goals with AHCN was to reach an area that was as rural as possible, where we would document the health care situation. Rukum is not a frequently visited are by tourists and in effect it was virtually impossible to find out how long it would take to reach a given village prior to our departure. Due to a limited budget we only had one day to walk and we wanted to reach all the way to Sisne. While we did not manage to reach Sisne village it self (at the foot of Sisne peak), we did reach the village of Bhattechaur, which is located in the Sisne Village Development Committee region.

We suspected on the way, that we would have a long walk ahead of us. The locals had told that Bhattechaur took a full day to reach. We quickly found out however, that a distance which would take a local a day too reach may very well take two days for a city folks. Finally we ended up walking 14 hours to reach our goal before we, with soar feet and aching legs, reached Bhattechaur and had the best portion of traditional Nepali food in our lives.

AHCN and davidkvcs Back After Exam Period

Dear all!

AHCN and davidkvcs (author) is back after an unpleasantly long break due to a December exam-period.

Starting tomorrow you can expect 20+ updates on behalf of Access Health Care coming to you directly from Nepal.

From February you will find updates from Guatemala, where I will be working with Engineering World Health from December 28 – January 20.

davidkvcs.com has been growing rapidly these past six months, and I am looking very much forward to the upcoming year. Overall I will have a large range of exciting articles and posts coming up about developing countries, culture, health care and international development.

I can’t wait to share all this content with you all!

With warm regards
David

The Harsh Reality for the People of Rural Nepal

The featured image above is a labour bed. This is where mothers of the region give birth – if they go to the hospital at all.

At Access Health Care Nepal we believe that health care is a human right: Everyone has the right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment.

After seeing the current state of the Salle Bajjar District Hospital however, we had to conclude, that if one of us was a patient in this region, we would avoid all contact with its health care system if possible at all. Looking through this gallery speaks for it self. You don’t have to ask yourself whether or not you would like to be admitted here to know the answer. This is the largest public hospital in Rukum and the condition of it is devastating for the people.

After an initial meeting with the doctors of the hospital we were given a tour of the hospital. A quick inventory (made during the tour) showed that more than 66% of the equipment is out of order – and we were not counting the piles of broken equipment in the storeroom as the storekeeper was on leave.

The hospital has 15 beds and an occupancy rate at all time of at least 150% – and 200-300% is not uncommon. The hospital has no biomedical engineering staff and in consequence they have no preventive maintenance program. If something breaks, a request for new equipment is made to the government. Whether the request is met or not is completely unpredictable.

During the Maoist insurgency Doctors Without Borders were active in the region and the hospital was quite well off. However, since activity of the Maoists came to an end around 2011, the activity of Doctors Without Borders did the same, and today the hospital has become completely neglected.

At a hospital like Salle Bajjar District Hospital, the presence of Access Health Care Nepal as well as Engineering World Health would not only be helpful, but would be a part of fulfilling every individual’s fundamental human right to health care.

A central aim of for Access Health Care Nepal is to create awareness of the health care circumstances in rural Nepal. You can help us by sharing this article.

AHCN #8 – Meeting with the Local Development Officer of Rukum

Before proceeding to Rukumkot, we had a meeting with Mr. Bharat Sharma, the Local Development Officer of Rukum, to talk about the health care needs of the district, and about and how AHCN and possibly also EWH could help the region. We agreed with Mr. Bharat Sharma to arrange a visit to the Salle Bajjar District Hospital that very same day (post about the visit coming up tomorrow). Furthermore Mr. Bharat Sharma ensured that it would be possible to bring EWH volunteers to the region and we agreed to collaborate in phase 2 and 3 of the AHCN effort in Rukum.

AHCN #7 Musikot

Musikot (in the same area as Jumlikhalanga and Salle Bajjar) is the administrative centre of Rukum. Dr. Justin of our team lived here while still a child, before moving to Kathmandu. During our visit we stayed at their beautiful traditional Nepali house, where Justins grandmother still lives.

During our stay we also met Mr. Chandra Bahadur Malla, a teacher from Rukumkot, who would be our guide on the way to Sisne and back the following 3 days.

AHCN # 6 Reaching Rukum on Impossible Roads.

On the third day of our trip we would emerge from the flat Terai region in south into the mountains and on the fourth we would have to drive on roads so poor, that it took us 8 hours to drive 35 kilometres.

At times the road would be too narrow for two vehicles and either one or the other would have to back up several hundred meters to find a spot with sufficient room to pass. Seeing people sitting on the top of busses and jeeps in this setting plainly seemed extremely dangerous.

Mountain side terrace-farms were everywhere on the way. We came across numerous small villages and we met many local people. We came across some view points as well and several times Sisne, the tallest peak in Rukum of 5916 metres, would reveal it self in the north. At one of the viewpoints we were lucky to catch an absolutely beautiful sunset over the peak.

We reached Rukumkot, the last location in Rukum that can be reached by car, in the dark at about 9 pm. We received a warm welcome in the village where we stayed with relatives of Dr. Justin Jung Malla.