Erica Frenkel: The universal anesthesia machine

譯者: Michelle Fan 審譯者: Chien-Ping 洪健彬 Hung

我今天要與各位分享

I'm going to talk to you today

about the design of medical technology for low-resource settings.

資源貧乏環境中的醫療技術設計

在我進行健康照護體系研究的國家

I study health systems in these countries.

都有一個嚴重的不足之處

And one of the major gaps in care,

幾乎所有的國家

almost across the board,

都無法取得安全的手術

is access to safe surgery.

我們遇到的重大瓶頸之一

Now one of the major bottlenecks that we've found

that's sort of preventing both the access in the first place,

讓病患一開始就沒有取得手術的機會

或是即使有手術也不安全

and the safety of those surgeries that do happen, is anesthesia.

就是麻醉

事實上 這是我們期待的工作模式

And actually, it's the model that we expect to work

提供麻醉的方式

for delivering anesthesia in these environments.

在這種環境中

Here, we have a scene that you would find in any operating room across the US,

像這樣的場景

在美國或任何其他已開發國家的手術房都很常見

or any other developed country.

照片的背景

In the background there

is a very sophisticated anesthesia machine.

是一台非常複雜的麻醉機

這台機器

And this machine is able to enable surgery and save lives

讓手術得以進行 拯救生命

because it was designed with this environment in mind.

因為在設計時

已經把環境納入考量

In order to operate, this machine needs a number of things

這台機器要運作 需要幾個條件

that this hospital has to offer.

醫院必須滿足這些條件

It needs an extremely well-trained anesthesiologist

這台機器需由訓練精良的麻醉師操作

with years of training with complex machines

麻醉師對於複雜機器需有多年經驗

才得以監控氣體的流動

to help her monitor the flows of the gas

and keep her patients safe and anesthetized

確保病患安全無虞 維持在麻醉狀態

直到手術結束

throughout the surgery.

It's a delicate machine running on computer algorithms,

這台精密的機器 仰賴電腦運算

and it needs special care, TLC, to keep it up and running,

還有特別照顧 小心謹慎地使用 才能維持運作順暢

and it's going to break pretty easily.

它很容易故障

And when it does, it needs a team of biomedical engineers

故障時 要由一整團的生物醫學工程師

who understand its complexities, can fix it, can source the parts

了解這台機器複雜之處的專家

才能進行修復 替換零件

and keep it saving lives.

讓它繼續拯救生命

It's a pretty expensive machine.

這台機器價格不斐

It needs a hospital whose budget can allow it

醫院

必須有充足的預算 才能維持一台機器

to support one machine costing upwards of 50 or $100,000.

成本高達五至十萬美金

也許最明顯

And perhaps most obviously,

也最重要的

but also most importantly --

是我們聽過的一種思考方式

and the path to concepts that we've heard about

描述類似這樣的觀念

kind of illustrates this --

就是基礎建設

it needs infrastructure that can supply an uninterrupted source of electricity,

必須能夠不間斷地供應資源

包括電力 壓縮氧氣

of compressed oxygen, and other medical supplies

和其他醫療輔助

that are so critical to the functioning of this machine.

這些都是機器正常運作

不可或缺的

In other words, this machine requires a lot of stuff

換句話說 這台機器需要的許多東西

這家醫院都不能提供

that this hospital cannot offer.

這是供電系統

This is the electrical supply for a hospital in rural Malawi.

地點是馬拉威郊區一處醫院

在這所醫院裡

In this hospital,

there is one person qualified to deliver anesthesia,

有一個人 有資格進行麻醉

她之所以合格

and she's qualified

because she has 12, maybe 18 months of training in anesthesia.

是因為她花了12個月 或是18個月

接受麻醉訓練

在這所醫院 以及整個地區中

In the hospital and in the entire region

完全沒有生物醫學工程師

there's not a single biomedical engineer.

所以當機器故障

So when this machine breaks,

the machines that they have to work with break,

他們還是得想辦法繼續使用

必須試著解決故障問題 但大多數時候都束手無策

they've got to try and figure it out,

but most of the time, that's the end of the road.

這些機器就被扔進垃圾堆

Those machines go the proverbial junkyard.

另外我剛剛提到 這台機器的價錢

And the price tag of the machine that I mentioned

could represent maybe a quarter or a third

可能就占掉這所醫院

of the annual operating budget for this hospital.

年度營運預算的

1/4或1/3

And finally, I think you can see that infrastructure is not very strong.

最後 我想各位看得出這裡的基礎建設並不牢固

這所醫院連結的電力網路非常不穩定

This hospital is connected to a very weak power grid,

one that goes down frequently.

常常斷電

So it runs frequently, the entire hospital,

所以整家醫院

常常只靠一個發電機

just on a generator.

And you can imagine, the generator breaks down

各位可以想像 發電機會故障

or runs out of fuel.

或是燃料不足

And the World Bank sees this

世界銀行注意到這種情況

and estimates that a hospital in this setting in a low-income country

並估計在低收入國家環境中的醫院

一個月可能發生

can expect up to 18 power outages per month.

多達18次跳電

Similarly, compressed oxygen and other medical supplies

同樣的 壓縮氧氣和其他醫療輔助

都是奢侈品

are really a luxury,

都可能常常供應不足

and can often be out of stock for months or even a year.

長達數月或一年的時間

So it seems crazy, but the model that we have right now

所以雖然看起來很瘋狂 但我們現有的模式

is taking those machines that were designed

就是把這些機器

這些專為第一張照片裡那種環境設計的機器

for that first environment that I showed you

捐獻或賣給

and donating or selling them to hospitals in this environment.

這種環境中的醫院

這不僅不合適

It's not just inappropriate,

it becomes really unsafe.

還可能很不安全

One of our partners at Johns Hopkins

我們在約翰‧霍普金斯的一位同事

was observing surgeries in Sierra Leone about a year ago.

在獅子山共和國觀察手術

時間大概是去年

And the first surgery of the day happened to be an obstetrical case.

當天的第一場手術是難產手術

A woman came in, she needed an emergency C-section

一位婦女被推進手術室 她需要緊急剖腹生產

to save her life and the life of her baby.

才能救自己和寶寶的命

一開始都還蠻順利的

And everything began pretty auspiciously.

醫生待命 準備就緒

The surgeon was on call and scrubbed in.

護士也在場

The nurse was there.

She was able to anesthetize her quickly, and it was important

她很快地麻醉病患

這點很重要 因為情況十分緊急

because of the emergency nature of the situation.

And everything began well

一切都很順利

until the power went out.

直到電力突然中斷

手術才進行到一半

And now in the middle of this surgery,

the surgeon is racing against the clock to finish his case,

醫生正努力加快速度要把手術完成

which he can do -- he's got a headlamp.

他做得到 因為他有頭燈

但是那位護士

But the nurse is literally running around a darkened operating theater

就在黑暗的手術室裡團團轉

trying to find anything she can use to anesthetize her patient,

試著要找能用來麻醉病患的任何東西

讓病患維持睡眠狀態

to keep her patient asleep.

因為她的機器沒有電就無法運作

Because her machine doesn't work when there's no power.

This routine surgery that many of you have probably experienced,

在座許多人可能都經歷過這項例行性手術

and others are probably the product of, has now become a tragedy.

其他人可能經由這項手術而誕生

但現在成了一場悲劇

And what's so frustrating is this is not a singular event;

讓人氣餒的是 這不是單一事件

this happens across the developing world.

這種事情在開發中國家屢見不鮮

每年要動的3500萬次手術

35 million surgeries are attempted every year

都沒有安全的麻醉

without safe anesthesia.

我的同事 保羅‧芬頓博士

My colleague, Dr. Paul Fenton, was living this reality.

就身臨其境

He was the chief of anesthesiology

他是麻醉部門的主任

in a hospital in Malawi, a teaching hospital.

服務於馬拉威一所醫院 教學醫院

他每天去上班

He went to work every day

in an operating theater like this one,

就在這種手術室裡工作

trying to deliver anesthesia and teach others how to do so

他試著進行麻醉 也教導其他人

using that same equipment

如何使用這種設備

that became so unreliable, and frankly unsafe, in his hospital.

這種在他的醫院中變得不再可靠

又不安全的設備

在無數次手術之後

And after umpteen surgeries

還有 各位應該可以想像 難以言喻的悲劇之後

and, you can imagine, really unspeakable tragedy,

he just said, "That's it. I'm done. That's enough.

他終於說：「夠了 我受夠了 到此為止

一定有更好的辦法」

There has to be something better."

因此他走到大廳

He took a walk down the hall

他們把所有壞掉的麻醉機都堆在那裡─

to where they threw all those machines that had just crapped out on them,

─我想那是個科學專有名詞

I think that's the scientific term,

然後他開始七拼八湊

and he started tinkering.

從這裡抓一個零件 那裡抓一個零件

He took one part from here and another from there,

試著組裝成一台機器

and he tried to come up with a machine that would work

能夠在他所面對的現實環境中運作的機器

in the reality that he was facing.

結果他組裝出來的是就這個玩意兒

And what he came up with:

was this guy.

The prototype for the Universal Anesthesia Machine --

通用麻醉機的原型

這台機器能夠運作

a machine that would work and anesthetize his patients

讓他麻醉病患

no matter the circumstances that his hospital had to offer.

不論他所工作的醫院提供的環境如何

Here it is, back at home

這張照片是它回到家

at that same hospital, developed a little further, 12 years later,

12年後它略為改善 回到同一所醫院

working on patients from pediatrics to geriatrics.

從小兒科服務到老人醫學

現在讓各位多看一點這台機器如何運作

Let me show you a little bit about how this machine works.

鏘鏘！

Voila!

就是它

Here she is.

When you have electricity,

當有電力時

everything in this machine begins in the base.

一切都從機器的底部開始運作

這裡有內建的氧氣壓縮機

There's a built-in oxygen concentrator down there.

Now you've heard me mention oxygen a few times at this point.

各位剛剛已經聽到我提起氧氣好幾次

基本上 要進行麻醉

Essentially, to deliver anesthesia, you want as pure oxygen as possible,

純氧要越多越好

because eventually you're going to dilute it, essentially, with the gas.

因為最後這些純氧會被稀釋

會跟空氣混合

And the mixture that the patient inhales

病患吸入的混合氣體

needs to be at least a certain percentage oxygen

必須至少有一定比例的氧氣

不然會很危險

or else it can become dangerous.

But so in here when there's electricity,

因此 有電力的時候

the oxygen concentrator takes in room air.

氧氣壓縮機會吸取室內空氣

Now we know room air is gloriously free,

我們都知道 室內空氣不花一毛錢

it is abundant,

又源源不絕

and it's already 21 percent oxygen.

而且氧氣含量達21%

So all this concentrator does is take that room air in, filter it

因此壓縮機吸取 過濾室內空氣

然後送出濃度達95%的純氧

and send 95 percent pure oxygen up and across here,

上面送達這裡

就是混合麻醉劑的地方

where it mixes with the anesthetic agent.

混合氣體

Now before that mixture hits the patient's lungs,

到達病患肺部之前

it's going to pass by here -- you can't see it,

會先通過這裡

but there's an oxygen sensor here --

各位看不到 不過這裡有一個氧氣感應器

that's going to read out on this screen the percentage of oxygen being delivered.

會把資訊送到這個螢幕

可以看到送出氣體中氧氣所占的百分比

Now if you don't have power,

但是如果你沒有電源

or, God forbid, the power cuts out in the middle of a surgery,

或是天公不長眼 電力在手術時中斷

這台機器會自動切換

this machine transitions automatically,

連碰都不用碰

without even having to touch it,

換成從這個開口吸取室內空氣

to drawing in room air from this inlet.

其他都一樣

Everything else is the same.

The only difference is that now

唯一的差別是

you're only working with 21 percent oxygen.

你現在只有氧氣濃度21%的氣體

Now that used to be a dangerous guessing game,

在以前 這會是個危險的猜謎遊戲

because you only knew if you gave too little oxygen

因為只有情況惡化時 你才會知道氧氣供應不足

once something bad happened.

但我們這裡放了一顆長效備用電池

But we've put a long-life battery backup on here.

這是唯一有備用電池的部分

This is the only part that's battery backed up.

麻醉師可以藉此掌控情況

But this gives control to the provider, whether there's power or not,

不管有沒有電

because they can adjust the flows

他們都可以調整氣體流動

based on the percentage of oxygen they see that they're giving the patient.

按照所看到的氧氣濃度 調整病患吸入的份量

在這兩種情況中

In both cases, whether you have power or not,

不論有電或沒電

sometimes the patient needs help breathing.

病患有時就是需要幫助才能呼吸

It's just a reality of anesthesia, the lungs can be paralyzed.

麻醉的實情就是如此 肺部可能會癱瘓

And so we've just added this manual bellows.

所以增加了這個手動的鼓風扇

我們遇過3或4小時的手術

We've seen surgeries for three or four hours

就靠這個讓病人換氧

to ventilate the patient on this.

So it's a straightforward machine.

因此這是一台直截了當的機器

I shudder to say simple; it's straightforward.

我不想說它簡單

它非常直接

And it's by design.

但是是精心設計的成果

You do not need to be a highly trained, specialized anesthesiologist

你不需要

受過嚴格 專門的麻醉師訓練才能使用這台機器

to use this machine,

這是優點 因為在這些農村醫院

which is good because, in these rural district hospitals,

你也得不到那種程度的訓練

you're not going to get that level of training.

It's also designed for the environment that it will be used in.

它是為了所服務的環境而設計的

也是一台非常耐操的機器

This is an incredibly rugged machine.

It has to stand up to the heat and the wear and tear

能夠耐得住

高溫 耗損 磨蝕

that happens in hospitals in these rural districts.

這些在農村醫院發生的情況

And so it's not going to break very easily,

所以它不會輕易故障

but if it does, virtually every piece in this machine

但如果故障了 機器裡的每一個零件

都可以拆下來換新

can be swapped out and replaced

with a hex wrench and a screwdriver.

只要有六角扳手和螺絲起子就做得到

最後 它的價格合理

And finally, it's affordable.

這台機器的成本

This machine comes in at an eighth of the cost

是剛剛讓各位看到的

of the conventional machine that I showed you earlier.

傳統型機器的1/8

因此換句話說 我們現有的

So in other words, what we have here is a machine that can enable surgery

是一台讓手術得以進行 能拯救生命的機器

and save lives,

because it was designed for its environment,

因為它是因應環境而設計的

just like the first machine I showed you.

就像我讓各位看到的第一台機器

但是我們並不就此滿足

But we're not content to stop there.

它有效嗎？

Is it working?

Is this the design that's going to work in place?

這種設計是最適當的嗎？

目前我們看到的結果都不錯

Well, we've seen good results so far.

This is in 13 hospitals in four countries,

這是分佈在四個國家的13所醫院

從2010年起

and since 2010, we've done well over 2,000 surgeries

我們已經進行超過2000次手術

都沒有臨床上的不良反應

with no clinically adverse events.

讓人十分振奮

So we're thrilled.

This really seems like a cost-effective, scalable solution

它確實像是個具成本效益 可擴展規模的方法

可以解決這個普遍的問題

to a problem that's really pervasive.

But we still want to be sure

但我們仍然想確定

that this is the most effective and safe device

它是最有效 最安全的設備

完全適合放在醫院裡

that we can be putting into hospitals.

因此我們發起了幾個合作計畫

So to do that, we've launched a number of partnerships

跟非政府組織和大學合作

with NGOs and universities,

從使用者介面取得資料

to gather data on the user interface,

on the types of surgeries it's appropriate for,

得知這台機器適於哪一種手術

以及如何強化機器的方法

and ways we can enhance the device itself.

這些合作計畫之一

One of those partnerships is with Johns Hopkins

就是跟巴爾的摩這裡的約翰‧霍普金斯大學合作

just here in Baltimore.

They have a really cool anesthesia simulation lab out in Baltimore.

他們在巴爾的摩這裡有一間很酷的麻醉模擬實驗室

So we're taking this machine

所以我們拿了這台機器

and recreating some of the operating theater crises

又重建了一些手術室裡的危機

這台機器可能

that this machine might face

in one of the hospitals that it's intended for,

在未來服務的醫院裡會遇到這些危機

我們在受控制 安全的環境中

and in a contained, safe environment,

evaluating its effectiveness.

評估它的效能

We're then able to compare the results from that study

然後就可以把這項研究的結果

跟真實世界的經驗做比較

with real-world experience,

because we're putting two of these in hospitals

我們放了兩台機器

that Johns Hopkins works with in Sierra Leone,

到約翰‧霍普金斯大學在獅子山共和國的合作醫院中

包括發生緊急剖腹生產手術的醫院

including the hospital where that emergency C-section happened.

So I've talked a lot about anesthesia, and I tend to do that.

我對麻醉做了許多說明 我常常會這樣

I think it is incredibly fascinating and an important component of health.

我認為它非常引人入勝

也是健康非常重要的要素之一

And it really seems peripheral, we never think about it,

這個議題似乎處於邊陲 沒有人會想到

until we don't have access to it,

直到沒得用了我們才會注意

and then it becomes a gatekeeper.

然後它成了守門人

Who gets surgery and who doesn't?

誰能接受手術 誰不能？

誰能接受安全的手術 誰不能？

Who gets safe surgery and who doesn't?

但其實 這只是說明

But you know, it's just one of so many ways

that design, appropriate design,

設計 合宜的設計

可以對健康結果造成影響的諸多例子之一

can have an impact on health outcomes.

If more people in the health-delivery space

如果醫療服務傳遞領域有更多人

really working on some of these challenges in low-income countries

確實努力解決低收入國家的這些挑戰

開啟設計的過程

could start their design process, their solution search,

尋找解決之道

from outside of that proverbial box

不墨守成規

and inside of the hospital --

而是設身處地為醫院著想

In other words, if we could design

也就是說 如果我們能夠

for the environment that exists in so many parts of the world,

替存在於世上許多地方的環境設計

rather than the one that we wished existed --

而不是替我們希望存在的環境設計

也許就能拯救無數的生命

we might just save a lot of lives.

感謝各位

Thank you very much.

(Applause)

(掌聲)