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TEDxMidAtlantic

Erica Frenkel: The universal anesthesia machine

December 2, 2011

What if you're in surgery and the power goes out? No lights, no oxygen -- and your anesthesia stops flowing. It happens constantly in hospitals throughout the world, turning routine procedures into tragedies. Erica Frenkel demos one solution: the universal anesthesia machine.

Erica Frenkel - Medical technologist
At Gradian Health Systems, Erica Frenkel works to bring safe anesthesia to hospitals all over the world. Full bio

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Double-click the English subtitles below to play the video.
I'm going to talk to you today
00:15
about the design of medical technology for low resource settings.
00:17
I study health systems in these countries.
00:20
And one of the major gaps in care,
00:22
almost across the board,
00:24
is access to safe surgery.
00:26
Now one of the major bottlenecks that we've found
00:28
that's sort of preventing both the access in the first place
00:31
and the safety of those surgeries that do happen
00:34
is anesthesia.
00:36
And actually, it's the model that we expect to work
00:38
for delivering anesthesia
00:40
in these environments.
00:42
Here we have a scene that you would find
00:44
in any operating room across the U.S. or any other developed country.
00:46
In the background there
00:49
is a very sophisticated anesthesia machine.
00:51
And this machine is able
00:53
to enable surgery and save lives
00:55
because it was designed
00:57
with this environment in mind.
00:59
In order to operate, this machine needs a number of things
01:01
that this hospital has to offer.
01:04
It needs an extremely well-trained anesthesiologist
01:06
with years of training with complex machines
01:09
to help her monitor the flows of the gas
01:11
and keep her patients safe and anesthetized
01:14
throughout the surgery.
01:16
It's a delicate machine running on computer algorithms,
01:18
and it needs special care, TLC, to keep it up and running,
01:21
and it's going to break pretty easily.
01:24
And when it does, it needs a team of biomedical engineers
01:26
who understand its complexities,
01:29
can fix it, can source the parts
01:31
and keep it saving lives.
01:33
It's a pretty expensive machine.
01:35
It needs a hospital
01:37
whose budget can allow it to support one machine
01:39
costing upwards of 50 or $100,000.
01:41
And perhaps most obviously,
01:44
and perhaps most importantly --
01:46
and the path to concepts that we've heard about
01:48
kind of illustrate this --
01:50
it needs infrastructure
01:52
that can supply an uninterrupted source
01:54
of electricity, of compressed oxygen
01:56
and other medical supplies
01:59
that are so critical to the functioning
02:01
of this machine.
02:03
In other words, this machine requires a lot of stuff
02:05
that this hospital cannot offer.
02:08
This is the electrical supply
02:10
for a hospital in rural Malawi.
02:12
In this hospital,
02:14
there is one person qualified to deliver anesthesia,
02:16
and she's qualified
02:18
because she has 12, maybe 18 months
02:20
of training in anesthesia.
02:22
In the hospital and in the entire region
02:24
there's not a single biomedical engineer.
02:26
So when this machine breaks,
02:28
the machines they have to work with break,
02:30
they've got to try and figure it out, but most of the time, that's the end of the road.
02:32
Those machines go the proverbial junkyard.
02:35
And the price tag of the machine that I mentioned
02:38
could represent maybe a quarter or a third
02:41
of the annual operating budget
02:43
for this hospital.
02:45
And finally, I think you can see that infrastructure is not very strong.
02:47
This hospital is connected to a very weak power grid,
02:50
one that goes down frequently.
02:53
So it runs frequently, the entire hospital,
02:55
just on a generator.
02:57
And you can imagine, the generator breaks down
02:59
or runs out of fuel.
03:01
And the World Bank sees this
03:03
and estimates that a hospital in this setting in a low-income country
03:05
can expect up to 18 power outages
03:08
per month.
03:11
Similarly compressed oxygen and other medical supplies
03:13
are really a luxury
03:15
and can often be out of stock
03:17
for months or even a year.
03:19
So it seems crazy, but the model that we have right now
03:21
is taking those machines
03:24
that were designed for that first environment that I showed you
03:26
and donating or selling them
03:28
to hospitals in this environment.
03:30
It's not just inappropriate,
03:33
it becomes really unsafe.
03:35
One of our partners at Johns Hopkins
03:38
was observing surgeries in Sierra Leone
03:40
about a year ago.
03:43
And the first surgery of the day happened to be an obstetrical case.
03:45
A woman came in, she needed an emergency C-section
03:48
to save her life and the life of her baby.
03:51
And everything began pretty auspiciously.
03:54
The surgeon was on call and scrubbed in.
03:56
The nurse was there.
03:58
She was able to anesthetize her quickly,
04:00
and it was important because of the emergency nature of the situation.
04:02
And everything began well
04:05
until the power went out.
04:07
And now in the middle of this surgery,
04:10
the surgeon is racing against the clock to finish his case,
04:12
which he can do -- he's got a headlamp.
04:15
But the nurse is literally
04:17
running around a darkened operating theater
04:19
trying to find anything she can use to anesthetize her patient,
04:22
to keep her patient asleep.
04:24
Because her machine doesn't work when there's no power.
04:26
And now this routine surgery that many of you have probably experienced,
04:30
and others are probably the product of,
04:33
has now become a tragedy.
04:35
And what's so frustrating is this is not a singular event;
04:38
this happens across the developing world.
04:41
35 million surgeries are attempted every year
04:43
without safe anesthesia.
04:46
My colleague, Dr. Paul Fenton,
04:48
was living this reality.
04:50
He was the chief of anesthesiology
04:52
in a hospital in Malawi, a teaching hospital.
04:54
He went to work every day
04:56
in an operating theater like this one,
04:58
trying to deliver anesthesia and teach others how to do so
05:00
using that same equipment
05:03
that became so unreliable, and frankly unsafe,
05:05
in his hospital.
05:07
And after umpteen surgeries
05:09
and, you can imagine, really unspeakable tragedy,
05:11
he just said, "That's it. I'm done. That's enough.
05:14
There has to be something better."
05:16
So he took a walk down the hall
05:18
to where they threw all those machines that had just crapped out on them --
05:20
I think that's the scientific term --
05:22
and he just started tinkering.
05:24
He took one part from here and another from there,
05:26
and he tried to come up with a machine
05:28
that would work in the reality that he was facing.
05:30
And what he came up with was this guy,
05:33
the prototype for the Universal Anesthesia Machine --
05:36
a machine that would work
05:39
and anesthetize his patients
05:41
no matter the circumstances that his hospital had to offer.
05:43
Here it is back at home
05:47
at that same hospital, developed a little further, 12 years later,
05:49
working on patients from pediatrics to geriatrics.
05:52
Now let me show you a little bit about how this machine works.
05:55
Voila!
05:58
Here she is.
06:00
When you have electricity,
06:02
everything in this machine begins in the base.
06:04
There's a built-in oxygen concentrator down there.
06:06
Now you've heard me mention oxygen a few times at this point.
06:09
Essentially, to deliver anesthesia,
06:12
you want as pure oxygen as possible,
06:14
because eventually you're going to dilute it essentially
06:16
with the gas.
06:18
And the mixture that the patient inhales
06:20
needs to be at least a certain percentage oxygen
06:22
or else it can become dangerous.
06:24
But so in here when there's electricity,
06:26
the oxygen concentrator takes in room air.
06:28
Now we know room air is gloriously free,
06:31
it is abundant,
06:34
and it's already 21 percent oxygen.
06:36
So all this concentrator does is take that room air in, filter it
06:38
and send 95 percent pure oxygen
06:41
up and across here
06:43
where it mixes with the anesthetic agent.
06:45
Now before that mixture
06:48
hits the patient's lungs,
06:50
it's going to pass by here --
06:52
you can't see it, but there's an oxygen sensor here --
06:54
that's going to read out on this screen
06:56
the percentage of oxygen being delivered.
06:58
Now if you don't have power,
07:01
or, God forbid, the power cuts out in the middle of surgery,
07:03
this machine transitions automatically,
07:06
without even having to touch it,
07:08
to drawing in room air from this inlet.
07:10
Everything else is the same.
07:13
The only difference is that now
07:15
you're only working with 21 percent oxygen.
07:17
Now that used to be a dangerous guessing game,
07:20
because you only knew if you had given too little oxygen once something bad happened.
07:23
But we've put a long-life battery backup on here.
07:26
This is the only part that's battery backed up.
07:29
But this gives control to the provider,
07:31
whether there's power or not,
07:33
because they can adjust the flow
07:35
based on the percentage of oxygen they see that they're giving their patient.
07:37
In both cases,
07:40
whether you have power or not,
07:42
sometimes the patient needs help breathing.
07:44
It's just a reality of anesthesia. The lungs can be paralyzed.
07:46
And so we've just added this manual bellows.
07:49
We've seen surgeries for three or four hours
07:51
to ventilate the patient on this.
07:54
So it's a straightforward machine.
07:57
I shudder to say simple;
08:00
it's straightforward.
08:02
And it's by design.
08:04
And you do not need to be
08:06
a highly trained, specialized anesthesiologist to use this machine,
08:08
which is good because, in these rural district hospitals,
08:11
you're not going to get that level of training.
08:14
It's also designed for the environment that it will be used in.
08:17
This is an incredibly rugged machine.
08:20
It has to stand up
08:22
to the heat and the wear and tear that happens
08:24
in hospitals in these rural districts.
08:26
And so it's not going to break very easily,
08:29
but if it does, virtually every piece in this machine
08:31
can be swapped out and replaced
08:34
with a hex wrench and a screwdriver.
08:37
And finally, it's affordable.
08:40
This machine comes in
08:42
at an eighth of the cost
08:44
of the conventional machine that I showed you earlier.
08:46
So in other words, what we have here
08:49
is a machine that can enable surgery and save lives
08:52
because it was designed for its environment,
08:55
just like the first machine I showed you.
08:58
But we're not content to stop there.
09:00
Is it working?
09:02
Is this the design that's going to work in place?
09:04
Well we've seen good results so far.
09:06
This is in 13 hospitals in four countries,
09:08
and since 2010,
09:11
we've done well over 2,000 surgeries
09:13
with no clinically adverse events.
09:15
So we're thrilled.
09:17
This really seems like a cost-effective, scalable solution
09:19
to a problem that's really pervasive.
09:23
But we still want to be sure
09:26
that this is the most effective and safe device
09:28
that we can be putting into hospitals.
09:30
So to do that we've launched a number of partnerships
09:32
with NGOs and universities
09:34
to gather data on the user interface,
09:36
on the types of surgeries it's appropriate for
09:39
and ways we can enhance the device itself.
09:41
One of those partnerships
09:43
is with Johns Hopkins just here in Baltimore.
09:45
They have a really cool anesthesia simulation lab out in Baltimore.
09:48
So we're taking this machine
09:52
and recreating some of the operating theater crises
09:54
that this machine might face
09:57
in one of the hospitals that it's intended for,
09:59
and in a contained, safe environment,
10:01
evaluating its effectiveness.
10:04
We're then able to compare the results from that study
10:06
with real world experience,
10:09
because we're putting two of these in hospitals
10:11
that Johns Hopkins works with in Sierra Leone,
10:13
including the hospital where that emergency C-section happened.
10:15
So I've talked a lot about anesthesia, and I tend to do that.
10:20
I think it is incredibly fascinating
10:23
and an important component of health.
10:25
And it really seems peripheral, we never think about it,
10:27
until we don't have access to it,
10:30
and then it becomes a gatekeeper.
10:32
Who gets surgery and who doesn't?
10:34
Who gets safe surgery and who doesn't?
10:36
But you know, it's just one of so many ways
10:39
that design, appropriate design,
10:42
can have an impact on health outcomes.
10:45
If more people in the health delivery space
10:48
really working on some of these challenges in low-income countries
10:50
could start their design process,
10:53
their solution search,
10:55
from outside of that proverbial box
10:57
and inside of the hospital --
10:59
in other words, if we could design
11:01
for the environment that exists in so many parts of the world,
11:03
rather than the one that we wished existed --
11:06
we might just save a lot of lives.
11:08
Thank you very much.
11:11
(Applause)
11:13

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Erica Frenkel - Medical technologist
At Gradian Health Systems, Erica Frenkel works to bring safe anesthesia to hospitals all over the world.

Why you should listen

Erica Frenkel helps lead Gradian Health Systems, a social enterprise enabling safe surgery through innovative anesthesia technology. She has been a Peace Corps volunteer, managed the Global Media AIDS Initiative for the Kaiser Family Foundation and helped shape public health initiatives as a consultant for the Clinton Foundation, the Liberian Ministry of Health, Merck Vaccines, and the Wellcome Trust.

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