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Finger on the pulse

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WRITE CHOICE: When he is not busy operating, Dr Gawande pens articles and books on medicine and public health concerns. His latest book 'The Checklist Manifesto' is a non-fiction bestseller

A simple machine that checks the level of oxygen in a patient's blood stream and sounds an alarm as soon as it detects the slightest change is making surgery rooms in far-flung hospitals across India much safer. This has happened because of the vision of an American surgeon of Indian origin. Dr Atul Gawande, an associate professor at Harvard Medical School, has been providing operation theatres (OTs) across the world a crucial tool - a pulse oximeter - and saving countless lives as a result. "We shipped over 140 such machines to Indian hospitals last year, " says Gawande, speaking to TOI-Crest from Harvard. It is estimated that as many as seven million people suffer from preventable surgical injuries every year, a million of them even dying during or immediately after the procedure. According to the World Health Organisation, 234 million surgeries take place every year globally with one in every 25 people undergoing it at any given time. However, more than 77, 000 OTs worldwide have to make do without pulse oximeters to monitor patients - ranging from 41 per cent in Latin America to 49 per cent in South Asia and 70 per cent in Sub-Saharan Africa. The rampant lack of this basic yet crucial tool in hospitals made Dr Gawande start notfor-profit organisation Lifebox in 2010 along with the World Federation of Societies of Anaesthesiologists. Their dream is to equip every OT in the world with an oximeter. The organisation has launched a global campaign 'Close the global pulse oximetry gap - Make It Zero' beginning with a two-year, $1. 25 million initiative to provide 5, 000 pulse oximeters to anaesthesia providers in Africa, Asia, Eastern Europe and Latin America.

"A pulse oximeter can greatly improve the safety and quality of surgical care in low-resource countries like India. But a single machine can cost thousands of dollars, " says Gawande. "We at Lifebox have now started to make it available for just $250. Hospitals which are very poor are getting it for free, thanks to the funds we are raising. "

Lifebox has raised $300, 000 so far and aims to have one million dollars by the end of this year. Gawande's doctor parents - father from Maharashtra and mother from Gujarat who settled in Ohio - were the first donors to Lifebox. "The British Medical Journal made it a Christmas plea to donate to Lifebox last year, " says Gawande.

So why is a pulse oximeter so important ? Gawande says once a patient starts losing oxygen during surgery, the surgeon has less than three minutes to prevent risk of brain damage, heart failure and death.

The level of oxygen in a healthy body should never fall below 95 per cent oxygen saturation, and oximeters can detect changes as small as one percent. Before oximeters were available, clinicians would only notice signs of hypoxia (oxygen starvation ) when patients became cyanosed - when their skin began turning blue, with oxygen saturation damagingly low at 85 per cent.

Introduced in 1985, pulse oximeters were rapidly adopted by anaesthesiologists as the universal standard of care in OTs, emergency, neonatal units and all wards, especially paediatric wards. While most top public and private hospitals have pulse oximeters, many smaller facilities still rely on observation to know if the patient is slipping during surgery. The Lakhnadon Christian Hospital, which had been catering to patients from several villages in Seoni district, Madhya Pradesh, without a pulse oximeter, was among the Indian hospitals that was given the machine for free.

Dr K Lalitha from Indraprashtha Apollo's anaesthesia department says it is almost impossible to proceed with any case without the oximeter. "With emergency patients like those who are facing breathing difficulty or those who have suffered a heart attack, the oximeter tells us the measurement of oxygen in their blood and helps us decide which patients need to be put on the ventillator. It is now mandatory in an OT, irrespective of whether the procedure is being done under anesthesia or not. "

Gawande points out that in most highincome countries where pulse oximetry is universal across the perioperative process, anaesthesia has become very safe: rates of mortality directly attributable to anaesthesia are typically less than 1 in 50, 000 procedures. "In low income countries, the rate is often at least ten times higher than this, and can be up to 1, 000 times higher, " he says.

The oximeter is also a key component of the WHO's Safe Surgery Checklist. The checklist - a simple 19-point roster for doctors, similar to the one pilots refer to before taking off - has been found to dramatically lower surgery-related deaths and complications. The list asks doctors to mark the correct site for surgery, give an antibiotic within 60 minutes of making an incision, check the patient for allergies, count sponges and needles to ensure that none are left in the patient's body and so on. It is believed to have reduced OT complications by over 30 per cent.

Surgical teams in eight hospitals across the globe including India who followed the list while conducting 7, 500 surgeries found that the rate of major complications following surgery dropped from 11 per cent to seven per cent. Patient deaths following major operations fell by more than 40 per cent. "The oximeter is the only thing in the checklist that one needs to pay for, " says Gawande, adding that they had sent 2, 000 such machines to 40 countries last year.

The countries that have benefitted include Azerbaijan, Bangladesh, Bolivia, Cambodia, Cameroon, China, Ethiopia, Georgia, Ghana, India, Kazakhstan, Pakistan, Paraguay, Sri Lanka, Tajikistan, Tanzania, Thailand, Uganda and Zambia.

In a recent study, An Estimation of the Global Volume of Surgery, published in the medical journal The Lancet, the WHO says that safety of patients during surgery had emerged as a substantial public health concern. According to the organisation, China conducted the highest number of surgeries followed by Russia and India. The study said nearly three to16 per cent of all in-patient surgical procedures in developed countries resulted in unnecessary complications with death rates being nearly eight per cent. In developing countries, the death rate was around 10 per cent for a major surgery. Mortality from general anaesthesia affected one in 150 patients while infections were reported in three per cent of surgeries with the mortality rate being 0. 5 per cent. Nearly 50 per cent of the adverse effects of surgery were preventable.

"As each oximeter is used on 25-30 patients a week, this year alone we have helped improve the safety of surgery and anaesthesia for around two million patients, " says Gawande, a general and endocrine surgeon at the Brigham and Women's Hospital. Tony Kirby of The Lancet writes in a report on pulse oximeters: "Today, 58 countries have established anaesthesiamonitoring standards, and all include pulse oximetry as a minimum requirement. " Kirby adds that introduction of the devices into developed countries such as the UK reduced death rates by 20 times, from one in 10, 000 operations to one in 185, 000. In stark contrast, anaesthesia mortality in low-income countries today has been reported to be as high as one in 133.

AWARD FOR CREST STORY


Kounteya Sinha, assistant editor at The Times of India, won the REACH Lilly MDR-TB Partnership Media Award 2012 for best reporting on tuberculosis for his report 'TB? You can't be positive' published in Crest on January 7. The article drew attention to the dangerous consequences of the serological (blood) tests which often misdiagnose TB. The award was presented in Delhi on the eve of World TB Day on March 23. Launched in 2003 to strengthen the battle against TB, the Lilly MDR-TB Partnership is fighting the spread of drug resistant TB in developing countries

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