Global oximetry: an international anaesthesia quality improvement project

I have visited anaesthetic departments from the Americas, across Africa, to the Indian subcontinent and South East Asia. I have seen enough discarded anaesthetic equipment to fill a hangar suitable for large aircraft. Almost all of this equipment has been given, but some has been purchased by officials obliged to spend aid money back in the country that gave that ‘aid’. I have seen a new operating theatre built unnecessarily when the old one needed minor updates and also a CT scanner, unused 50 weeks into the 52 weeks' maintenance contract, because the electrical supply, on a different contract, had never been connected. Many of these centres are ravaged by hurricanes, typhoons, dust and an electrical supply that is intermittent at best. On one day during my visit to a large teaching hospital there was no water supply. Everywhere I see and hear the same stories. The users of the equipment are never asked if they want it, or if they have greater priorities. Critically, there is never the money or expertise to service machinery and never an overarching policy for equipment's purchase and maintenance. Yes, I would want pulse oximetry for myself, though not to detect endo-bronchial intubation [1]. However, before that, I would like to make a plea for adequate supplies of simple anaesthetic drugs including oxygen and morphine. Apparently, oxygen was available to those who took part in the Global oximetry project but it is far from guaranteed in some countries, where, in addition, there is neither universal clean water nor sewerage. In their insightful article Walker et al. [2] enlighten us with their thoughtful summary of the problems of managing equipment donated by the rich to middle- and low- income countries, but I cannot agree that they have demonstrated that currently available oximeters can be used in settings with constrained circumstances. These oximeters were donated by GE Healthcare and after 9–15 months 13 of the 49 TruSat™ oximeters (GE Healthcare, Buckinghamshire, UK) were not working, seven seemingly due to simple battery problems. As usual, the expertise and/or the money to maintain functioning equipment is not there. Had the oximeters been purchased the cost would have been passed on to the patient, directly or sometimes indirectly, and patients who live on a few dollars a day may not be able afford the increased cost of the operation. A splenectomy conducted on ketamine is a reflection of the state of medical care and I just wonder if the patients could make an informed choice whether they would agree with our ideals for their public health.