Erica Frenkel: The universal anesthesia machine
Articles,  Blog

Erica Frenkel: The universal anesthesia machine

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


  • Pinocchio

    @chocomalk I've always said that technology takes a back seat to innovation. If you are innovative enough you can do just about anything with whatever level of technology you're working with. People give to much credit to technical ability and not enough to innovation and critical thinking. We can be as technologically advanced as we can become and not be innovative enough to know how to practically apply ourselves and our resources.

  • Kristoff B

    Basically to help developing countries we need equipment that was used when 1st world countries themselves were developing, upgraded with bits of new technology. Wouldn't it be quicker to dig out old designs?

  • coffesnale

    @FoneArc i got it from a nother video :3 i dont know how to make thim 🙁 fly away !! ส็็็็็็็็็็็็็็็็็็็็็็็็็็ส็็็็็็็็็็็็็็็็็็็็็็็็็็ส็็็็็็็็็็็็็็็็็็็็็็็็็็

  • civver3

    I see the comments criticizing the "money-grubbing" medical equipment industry are in full sway. Willing to bet they're from laymen who don't even have a year of schooling in medicine.

    @Shalek Yeah, that would have been great to know, actually.

  • civver3

    @chocomalk Outdo? How is this machine better than what is present in hospitals in developed countries? Once again, we weren't told what functions were missing in this apparatus. Until you can show me that it does what its advanced counterparts do and then some then I have no point discussing this with you.

  • Will Wegiel

    Once again developed countries need for greed dose not work in under-developed countries. At 1/8 the price that saves lifes not run up the cost of treatment. Medical cost should be affordable to everyone not just the wealthy. Time re-set the playing field again.

  • Eugen Afanasjev

    1. medical industry is not interested hospitals with low income
    2. artificial scarcity (due to need of highly trained specialist) allows them to put an unlimited price tag
    3. every industry tries to avoid rugged, long lasting, durable and easy-to-maintain designs; the more complicated and single-use it is, the more byproducts and supplies will be sold, the more people will get involved any thus payed.
    "A billion dollar medical industry" is just without empathy and greedy.

  • hexatentacle

    @chocomalk A billion dollar industry *would* not want to change the status quo and undercut it's own bottom line. Big companies are a bane to innovation. Our present copyright witch hunts (read DRM, DMCA, SOPA, PIPA, ACTA and others) are just a symptom of the concentration of too much power on the hands of a few shareholders. There's still lot's to come.

  • Masluxx

    @chocomalk I am sure they could have if the wanted to, but i fear thier real want is to maximize profits by making and selling newer bigger fancier instead of more practical, durable reliable.

  • Achwaq Khalid

    A recent study involving more than 5000 children suggests that anesthesia in early childhood might be linked to ADHD (Attention deficit hyperactivity disorder).

  • Achwaq Khalid

    @siegfried182005 you should by now have it in your inbox, and for those interested, the article has been published on MayoClinic(dot)org today just google (childhood anesthesia linked to adhd) for further info on the topic.

  • Duong Nguyen

    Innovation is driven by necessity, they needed a low cost solution to fit their needs, while western medical manufactures need a marginally better device to replace an older device thus driving their profits, different necessities.. That's the problem with for profit health care, though state sponsored health care also have issues there is no right answer yet.

  • freesk8

    @chocomalk And one of the main causes of this is over-regulation in the US. Bad liability laws, crazy-long FDA approval processes, and subsidies to large corps so that they can sell the most expensive stuff to govt orgs who don't care about costs. The reason Africa can do this, and the US can't is the over-regulation our govt saddles us with in the US.

  • elminz

    @chocomalk Note they don't mention many of the downsides. Really, first world countries can just afford better equipment. Sure you can get a cheaper version, but that why would you? 50k is nothing compared to a lot of hospital budgets in the first world.

  • Decateron

    @chocomalk Things are invented because of a need or inconvenience. There wasn't really a need for this in first world countries, so of course something like this would be invented in Africa.


    @chocomalk The billion dollar medical industry didn't need to build it, nor do they want to. That company designs their products according to their clients, and those are clients who can afford the best, instead of the safest during power outages (which you don't see everyday in the developed world, and even if you do, you have a good quality functioning generator filled with fuel)

  • theoriginalanomaly

    Why would the medical equipment dealers in the US design a device for use in Africa? Of course a device made in Africa for Africa would be better made to handle the conditions. A business must be profitable or else it wont be in business. US company would not sell these to high quality hospitals. Just like TVs when they first came out they were unaffordable and 3rd world countries didn't have the infrastructure. But due to gearing and profitable business model that has changed rapidly.

  • tastyfrzz1

    Why can't they compress the oxygen and store it in cylinders?
    Or, compress air and use it to operate the breather? It wouldn't use much air.

  • Smaug84


    I've no problem with them making money. I just think engineers should design durable, but yet high quality products. Make the money through more customers, rather than trying to squeeze every dime you can from each customer.

  • Georgiy Slobodenyuk

    @chocomalk Competition does not strive to make better and longer lasting products unless they are at a market disadvantage. Competition makes the most cost-effective product that has market advantage. Why make a product that lasts 40 years when your competitor's product only lasts 4? If the technology becomes too efficient then comes the price fixing. Take a look at computer monitor price fixing across many different companies. Samsung, LG, and Sharp as prime examples.

  • hardworker424

    @NickBlackDIN I'm not so sure considering an anesthesia machine cost thousands of dollars. Having a simple system that lets you add a battery to existing machines would be pretty useful in those areas. Honestly I'm surprised they don't already have battery backups considering even good hospitals get blackouts and the hospital generators can fail or take a few minutes to kick in. I think I'll call a manufacturer tomorrow.

  • thebloads

    @SEThatered Maybe so. But dont you think that there is a demand from hospitals who cant afford the standard medical equipment? Think China, Africa, Malaysia, South America, India. Thats a big market.

  • punkposer

    Your number 3 is wrong. Every industry yearns for rugged, long lasting, durable and easy maintain designs; this is probably the number one goal for all designers. There will always be an after market around for byproducts and supplies, even if there isn't an instantaneous need for replacements or extras. The driving force to the market would come from supplementary solutions to enhance the performance of a design. Keep in mind, everything can and will be improved upon–a cycle.

  • claudees

    I wonder how operations were carried out when there was scarcity of electricity and no generators? What would the surgeon do if a patient was in the midst of an operation and everything ran out? Modern medical Science has advanced so rapidly and comes with a high bill.

  • Eugen Afanasjev

    Wrong? So how come car wear out exactly in 2 year? How come shoes last 1-2 years?
    There is no point for engineers to have a detail that has a lifespan longer than the rest of the product, so they dial it down, make it cheaper to produce.
    There are quality products, but they never come from big manufacturers!
    Big companies are ONLY after the profit! They don't care about you, your needs or complaints, they care only about your money!

  • Eugen Afanasjev

    Second to that, sir!
    Mercedes benz once made a "tank" on the wheels 190E class.
    It still runs today (since 1985!!!)
    But instead of being proud M-Benz got scared: people wouldn't buy their next model, because 190E were that much robust and durable.
    Now it is in their policy- to have at least one vital car detail that wears off and is hard to replace. This is just how big companies make big buck today!

  • Razzfazz87

    @abemore actually we're way past the point by 6 minutes
    The point is that 1. world doesn't give a crap about being cost effective and creating applicable devices and ideas throughout the world

  • epicwisdom

    @ELuhn Unfortunately we have the reality that:

    1) Some people capable of figuring out solutions don't know about the problems. How many bright engineers know about anesthesia in developing countries?

    2) Many people who experience problems face a secondary one : the incapacity to find a solution, due to a lack of adequate education, finances, and so on.

    … which means we have to depend on people and awareness programs in developed countries, neither of which are as good as they should be.

  • AreUsure

    It's unfortunate that we lived in a world where the rich & powerful dictates who gets access to clean water, electricity, food and healthcare. The poor & disadvantaged just have to make do or die! Kudos to the unsung few who dared to make a difference.

  • ShadyEmp

    What 10 people dislike a video displaying simple tech to solve a fatal problem and save lives? If her presentation is poor just don't like the video but to say you dislike it, wtf? I'm not from a third world country and appreciate this, it should be in 1st world hospitals as a contingency plan. Things can go wrong anywhere.


    @chocomalk No, the actual point is, that industry with a lot of specialists and resources weren't looking for that. That's like saying that Ferrari is dumb because they didn't built a good all terrain car to ride in African savannas, that's my point, they don't want to build it.

  • ficktao

    @lightandbeautiful — Are you just pasting this completely insignificant text randomly on any video? Because I don't see any correlation to the video on a great medical-technoligical breakthrough that I just watched. (BTW there is no "gay agenda")


    @chocomalk It is an effort the company isn't willing to make, to such a poor market. They would have to start building new offices in poor African countries, start mass producing, just so they could sell a cheap machine in not enough quantities that would make the effort meaningless. If I was the CEO I wouldn't try that, but then again, I don't have CEO experience to say that. But if they didn't do it, it's probably because it wasn't worth it.

  • tastyfrzz1

    So why do hospital breather machines use oxygen if it is not required? As you said in your reply, Compressed oxygen (in the presence of a spark) is quite dangerous.

  • Grant Robertson

    A) Why the heck does it not have battery backup?

    B) It is possible for an oxygen concentrator to compress and store that oxygen in a small tank. That stored oxygen can then be used instead of room air if the power goes out. with the current design, as soon as the power goes out, the anesthesiologist has to reach over and readjust the flow of gas. If they delay for any reason, it could be deadly.

  • Rasenkrieger

    It is true, without that Oxygen readout a simple error in connecting supplies (oxygen with N2O) has killed patients before.

  • Kevin Saldanha

    Veterinary inhalation anesthesia machines do not need an electrical supply, just the pressure from 100% oxygen cylinders. Why risk human health by requiring the anesthesiologist to adjust the anesthesia flow rates in a power outage (when the machine automatically switches to room air) when so much else may be needing attention. Keep It Simple, Sweetheart!!!!

  • squirreljester2

    Think about using machines like this in "developed country" hospitals, and how much less costs would be, just there.

  • John B

    @ELuhn Yes, but most of us don't belong and never will to a technological elite. Still it shows more than anything else how over complex expensive technology can be reduced to a much more simple and cheaper form. It seems this is perfect way of reducing health care expenses and still keeping people safe. But don't tell the big boys who make these overengineered solutions 🙂

  • Tom Hoehler

    This is a solution, but in my opinion, this is still overly complicated. A simple veterinary anesthesia machine will fill the bill, are mass produced and are available at a modest cost. A central oxygen concentrator and storage system makes much more sense. Oxygen can be concentrated and stored when the AC power is available, then used as needed, with a reserve availalble, eliminating the need for using room air.

  • John Barr

    3. People who see a problem, sit down and figure out a solution.

    Boy, how to make yourself very unpopular because you've made everyone else look like an idiot. They don't like that.

  • Mark Proffitt

    @2n918 When she said they can continue with the surgery using normal air I wondered why they don't just do that in the first place? Wouldn't it be simpler and a lot cheaper to just have a gauge for the percentage of oxygen that adjusts the anesthesia appropriately?

  • Tom Hoehler

    @MarkProffitt You can do and a lot of surgeries are done with only air and inhalation anesthetics. However, the inhalation anesthetic from the vaporizer displaces the oxygen content of air, so you must be very careful to not go below 17% oxygen, or the patient's brain could be injured. Oxygen on tap and always available is very desireable in anesthesia, because misadventures do occur, and oxygen is essential for flushing out inhalation anesthetics and for quickly oxygenating a patient.

  • l1hao

    BAD IDEA for most applications. Cost savings on doctors will be undercut by gigantic liabilities and deaths. Wrongful death suits will bankrupt the company that takes this to market.

  • muslimgiga

    @rmm2000 you like pointless jargon by nobody's that talk about motivation or creativity or whatever crap? These people are actually making something and getting crap done in the world instead of talking.

    It was an inspiring talk. no offense.

  • rmm2000

    How can you possibly know what I like? Are you a mind reader? Maybe you should give a TED talk if you have that skill rather than pretending to have it. No offence.

  • MedicalAviator

    IV anesthesia would not require an entire anesthesia machine, you could just use a ventilator or even just a bag-valve device on room-air and also it would be safer for the staff that is just my opinion I do however like this idea of a simple anesthesia machine!

  • adwilkin14

    When talking about healthcare people often refer to their own personal experiences.  It is often overlooked that healthcare in other countries is very different than our own.  I never would have thought of an anesthesia
    machine being a problem because in America we have access to power grids and multiple resources.  It never dawned on me that this could be a huge problem elsewhere in the world.  I think that the development of the universal
    anesthesia machine was a great advancement in modern medicine and should be distributed throughout the world.  This would give underdeveloped countries the technology they need to safely and successfully complete surgeries with the ease of mind this machine provides.  Early results have shown the success of the machine with no clinically adverse events occurring over 2,000 surgeries.  As studies continue to draw on researchers need to focus on the impact that these machines are having worldwide in both real life and simulated environments. They need to ensure that the machine is safe, practical and affordable to countries that need it most.

  • Esel

    if the power goes out, you just need an oxygen cylinder and an ambu bag. why do you need a whole new design of machine? and there is already a basic "easy to use" machine called boyles machine. imo it is training and knowledge that is required, not new machines.

  • sleeping purpletiger

    CRNAs or nurse ANESTHETISTS (I’m one!) are Doctorate prepared anesthesia providers who administer the MAJORITY of the anesthesia in the USA. Almost all rural hospitals have solo CRNAs (I’m independent). So are military CRNAs.
    “.. Who administers anesthesia?
    In the majority of cases, anesthesia is administered by a CRNA.

    CRNAs work with your surgeon, dentist or podiatrist, and may work with an anesthesiologist (physician anesthetist). CRNAs are advanced practice registered nurses with specialized graduate-level education in anesthesiology.

    For more than 150 years, nurse anesthetists have been administering anesthesia in all types of surgical cases, using all anesthetic techniques and practicing in every setting in which anesthesia is administered..”

Leave a Reply

Your email address will not be published. Required fields are marked *