Biomed StopGap

The state of biomedical technical support at Mulago continues to be an issue, thought small, tangible improvements are being made.

In an effort to support equipment donations we have been working with BMEs from several universities to try and coordinate efforts to teach and maintain equipment, especially that which we (visiting groups) are leaving behind.

The biomedical engineering technicians at Mulago are using the "biomed repair" room created by Duke/GPAS Engineer Ike a few months back. When I arrived Mulago biomed technician Daniel was working to salvage parts from broken propaqs and was able to successfully repair 4 units.

According to senior Mulago BME Edward Kataaha, the biomed tech room in the main theatre has offloaded 80% of the requests he gets for repairs in the main workshop. I would speculate based on observations that most of those requests wouldn't get addressed by the main BME workshop for a number of logistical reasons.

So the biomed room - as a stopgap, is working. The next step for the room is to get a computer so the technicians will be able to update the inventory (including broken equipment and parts needed) and keep an electronic database of repair manulas. Ike and Gerald will be bringing this out in a couple weeks and the BMETs at Mulago are working to wire the internet.

As for the next step for biomed in Uganda - this is unclear. Makerere is hoping to create a BME degree program while Kyambogo University is hoping to start a diploma/technical program as well as a degree level program. The first steps are being taken to link these two groups as sharing the already limited BME academic resources in Uganda will be a major challenge. Going from zero to three programs in a country with virtually no BMEs is going to be interesting. Several outside universities are interested though communication among everyone continues to be a big challenge.

This month Kyambogo will hear about a grant from the MOH for the degree program and hopefully some dialogue will begin between the various parties.

The next BME visit will be in 4 weeks.
I will post the list of broken equipment, needed parts and tools soon.

Riots in Kampala: healthcare ironies/tragedies

Uganda is one of the poorest countries in the world with annual income 1/50th that of the US, healthcare expenditure per capita of ~$135 (vs ~$6000 in the US) and thus it is not surprising that Uganda has a life-expectancy (52yrs vs 80 yrs in the US) and other health outcome indicators that reflect this.

Also true is the fact that Uganda receives billions of dollars in aid with thousands of registered NGOs and many more medical tourists coming through annually.

In this environment there is no shortage of healthcare tragedies.

The failure of aid in environments like this has been highlighted in Kampala and elsewhere before, but was once again apparent while spending time at the Mulago emergency room during the riots this trip.

Mulago is the national referral hospital: 1500 beds, most subspecialty practices one can think of (neurosurgery, oncology, hematology, infectious disease, ENT, ophtho, etc). There is a new neuro ICU, expensive operating micorsopes, two heart-lung bypass machines, a state-of-the-art ICU with equipment as good as anywhere in the developed world, thousands of visiting healthcare professionals (annually) with millions of dollars of equipment and manpower donated.

But that is only one side of it - unfortunately many of these resources are not readily available to the general public.

During the first night of riots earlier this week, about 75 wounded were brought into the emergency room - mostly by police and lay-first responders. Side note - The riots were initially sparked by conflict between the government and local tribal politics... but the buzz around Kampala was that the unrest was more a reflection of building discontent with current ruling political party.

The riots highlighted for me once again the tragic irony apparent at Mulago: despite the donated equipment and wealth of health care resources pouring into Uganda (some of which I referred to above) - - there were only two working vitals monitors in the emergency department... There were not nearly enough stretchers or wheelchairs to move patients... No flashlights (which would have been useful for the basic evaluation of one young girl who was shot in the eye on her way home from school)... Only one bed with oxygen... I could go on with this list.

There was one patient in shock who needed to be transferred to the ICU emergently. As a public patient - he was not eligible for the private ICU (where the nicest equipment resides). He was not triaged to the one bed with oxygen and there were not ventilators around- which made ventilating him once intubated suboptimal.

Perhaps these cases and shortages would not be so frustrating to had I not known from prior visits what exists around Mulago and Kampala for that matter. For example, in the hospital storage facility are 10,000 brand new flashlights, 100s of new wheelchairs, numerous mechanical ventilators and much more donated to the hospital years ago but remaining unused for a variety of reasons I can't begin to go into in this post - suffice it to say that the blame is shared by the donors as much as it is shared by the recipients.

If you happen to be a patient at Mulago on the right day, with the fortuitous alignment of local and visiting resources, one can be successfully treated for even the most complicated heart or neurosurgical conditions. However, if you happen to be an ordinary patient on an ordinary day you may struggle to get your blood pressure checked, receive life-saving oxygen or receive what anywhere else would be considered "ordinary" care.

Good first step

April 28, 2009
Location: Mulago Hospital, Kampala, Uganda

Today, we finished cleaning out the future clinical engineering workspace for the technicians at Mulago Hospital.

The picture to the left was the room before we started cleaning. We started an equipment triage and assessed what was worth saving. Many of the items had no hope of ever being repaired for use. The problem was that some of these things were so old that the company that originally manufactured them were either no longer in business or no longer supporting the device. All those items - immediately in the "Return to Main Stores" pile, which grew steadily throughout the day. Some items required proprietary disposables that there would be no hope of getting replenishing supplies for, as Mulago Hospital was not ready to import large quantities of disposable medical supplies. So on to the pile they went... Ancient machines - Gone!

Sabo Rashid, the environmental services guy (who really takes pride in his work), really did a good job! Here is the "After" photo of the same room after Rashid (pictured below) sweeped and mopped the room. We then put back the equipment that survived the scruitiny. Approximately 70% (by volume) of the equipment went to the trash bin. Anesthesia carts from the sixties and the seventies - gone!

Next, we needed to clear out the actual lab space next door where the technician benches will be located. We are hoping to put in three benches.





April 29, 2009
Mulago Hospital, Kampala, Uganda

Somewhere near Operating Theater 4, there is a door marked "Maintenance." This is the new home of Mulago Hospital Clinical Engineering deptartment. Here is the room before we got there:

The stack of papers to the right included OR records (they were pretty articulate and thorough) back to 1994. All record keeping is still done on carbon copy paper. Please help! We need to get them a better way to keep track of expenses and OR activities.

As before, most of these equipment went to the stores. Notice the ZEISS microscopes... I think they have three total. Very nice units.




Once again, Rashid did his magic and voila!

Cleanliness! All is well. Now to fill this space with three technician's benches, fully stocked. We shall see how this goes in the coming days. We finished the day by putting together a pediatric ventilator using some spare parts. This was a good day.

Peace Out,
Keita Ikeda, PhD.

Donation Dilemmas

Provision of adequate medical supplies and equipment has been a problem for Mulago since its inception.

Donations have been pouring into Mulago for decades... all well-intentioned... but not all can be utilized as invisioned.

Here are some pics of the warehouse which contains vast stores of partially sorted and misplaced equipment donations to the Hospital.

There are many reasons why equipment lands here unused and doomed including:
-No trained staff to use them
-Multiple packages of supplies separated in shipping never to be reunited (proprietary cables and power adapters are missing for millions of dollars of equipment here)
-No use at Mulago
-No labels (hundreds of unlabelled boxes sit on the shelves)

It is difficult to even start to systematically go through these stores... but today we did manage to find a few power supplies that belong to propaq vitals monitors that have been sitting inoperable in the theatres until today.
We are working through a system - possibly picture-based - to help staff sift thru the stores to find the useful parts.

More to come soon.

BioMed Needs Reassessment

We have arrived in Kampala once again to follow-up on several ongoing projects, primarily focusing on the state of biomed engineering at Mulago. The team this time includes Keita Ikeda (Biomed engineer from Duke) and Helder Chin (UCSF anesthesia research assistant).


First order of business was checking in with operating theatres to update the Mulago equipment inventory list and to make sure each operating theatre has a functioning anesthesia machine vent/vaporizer, pulse oximetery, capnography, and vitals signs monitors.

Though we haven't been able to test the functionality of the equipment (because the step-down transformers are kept under lock and key on the weekends), each theatre did have "full set" of machines. Most had the usual homemade/makeshift cables, as well as "disposable" BP cuffs and pulse ox probes which seem to have been on their last life quite some time ago. Between the vitals monitoring, vent, and capnography there are a hodge podge of at least 3-4 manufacturers per theatre to complete a set.

Some of the machines were obviously missing cables (an thus not likely functioning or being used) and others (like a vent which was slowly but obviously leaking oxygen) were in need of some quick fixes.

We also have met with engineers at the hospital to identify some of the major problems the encounter around the hospital. They have identified several areas that we began brainstorming about how best to support them.

One area identified was providing some support resources such as access to service manuals and basic repair equipment.

Another was helping to define rules for donated equipment. Equipment donationes are a double edged sword at Mulago. Inappropriate equipment donation is as much of a problem as the general lack of equipment.

Engineers here say they spend significant amounts of time trying to make donated equipment functional. Because they have no clinical and/or engineering support or training for these devices their efforts are often unsuccessful and equipment ends up in piles in hospital store rooms - making it impossible to keep track of smaller parts like proprietary cables, etc...

Through the course of this trip we hope to make some progress in the areas idenitifed by the engineers.

We were excited to hear that progress is being made with a technical biomed engineering program to begin at Kyambogo University here in Uganda in the Fall of 2009. Mulago is likely to be the skills training center for the program.