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Old Industry, New Fixes

A new generation of innovators is leveraging new technology for public health.
By TR Pakistan

At first glance, the healthcare sector in Pakistan appears so bureaucratic and inflexible, it may seem immune to disruption by innovators. However, a new generation of technology researchers is trying to change that. Their products range from ventilators to complex simulators. Their common goal? To leverage new technology to fix an old industry. These fixes were sometimes found against the backdrop of tragedy. At other times, it was just a stroke of genius. Here are some of these interventions and the circumstances in which they were invented.

In Brief

  • A report submitted by the provincial government to the Supreme Court in August 2016 said that of the 885 ventilators available across the province, at least 122 were dysfunctional.
  • An infusion pump is a device which delivers fluids, nutrients or medication to a patient’s circulatory system at a controlled rate. The pump is used to deliver fluids such as insulin, antibiotics, chemotherapy drugs, pain relievers, and hormones.
  • Teaching hospitals across the world are now using training simulators which can assess surgicals skills of students and provide feedback on potential areas for improvement.

The Ambulator

“If death had a sound, it would be the sound humans make when they are struggling to breathe,” thought Mujeebur Rehman as he stood in a hospital ward in December 2015, surrounded by dozens of patients gasping and wheezing. Most of these patients were children with a variety of respiratory diseases including, but not limited to, pneumonia. Around each bed, families stood guard. They looked on as their loved ones fought for their lives. To make matters worse, some of these family members were bent over a machine, pumping air into the lungs of their children.
Rahman, who holds a doctoral degree in electrical engineering, was one of them.

“My nephew was referred to Lahore from Sahiwal when he began having trouble breathing. But even with the medical facilities of the big city, his condition continued to deteriorate because no ventilator was available. We were given an ambu bag, which is generally used as a stop-gap arrangement to save a patient’s life. Three of my family members and I took turns on this bag to make sure the child had enough oxygen.”

The state of ventilators, or lack thereof, in public hospitals across the Punjab is notorious. A report submitted by the provincial government to the Supreme Court in August 2016 said that of the 885 ventilators available across the province, at least 122 were dysfunctional (nearly 14 percent).

“At a glance, these figures do not seem so bad,” says a doctor from Mayo Hospital, Lahore’s largest public health facility. “However, they do not seem to take into account the huge demand for the machines. There are many patients with respiratory diseases and very few ventilators between them.” The doctor says Mayo Hospital has three ventilators for each of its intensive care units (ICUs). “Ventilators are last minute interventions for when the patient is critically ill. Sometimes after a patient has passed away in one ICU, we get a call from another ICU, saying their ventilator has freed up. It is too little, too late.”

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The report adds that while many faults in ventilators were repaired locally, major defects could not be resolved due to the unavailability of certain high-tech parts which must be imported from manufacturers abroad.

With a low number of working ventilators, it is a challenge for most people to gain access to the machine, especially in public hospitals. Most private hospitals have a much better ventilator-to-bed ratio compared to public hospitals, but they charge exorbitant rates for the use of the machines, rates that most Pakistanis cannot afford. For example, at National Hospital and Medical Centre (NHMC), a private facility in Lahore, the anesthesia ward has 12 beds and 12 ventilators. “The medical ward of the hospital has fewer ventilators compared to the anesthesia ward but we generally do not have a shortage,” says a doctor at NHMC. She says a patient is charged Rs60,000 (approximately $600) per day for the use of a ventilator.

The human heart works like an engine. It regulates the pace and pressure of air into the lungs and when it is unable to pump enough air, intervention is necessary and ventilators become essential. Rahman’s young nephew remained in the public hospital for three days and nights, breathing through an ambu bag. It wasn’t enough and the child passed away.

Having completed his postdoctoral research in electrical engineering from California Institute of Technology (Caltech), Rahman had recently returned from the United States. Now, he felt helpless.
“As an engineer, I couldn’t reconcile myself with the state of affairs in the ward – that too in the 21st century,” says Rahman, who is now an assistant professor of Electrical Engineering at Information Technology University (ITU). “I had a choice to make: either I could sit and fume, or I could use my engineering acumen and look for a solution.”

The engineer chose the latter.

The idea was not to reinvent the wheel but to create a product that could minimize human error while using an ambu bag as a ventilator. Rahman decided to automate the ambu bag. “It is easier to accept something familiar,” he says. “If we had built something completely different, it may not have been so easily accepted in the medical community.”
Rahman was joined by a colleague who was a mechanical engineer. Together, they made some preliminary sketches at University of Engineering & Technology (UET), Lahore, from where Rahman had earned his undergraduate degree. Later, they moved towards mechanical designs, and soon the design was ready. At this point, Rahman felt that a full-time resource was needed and that’s when Saad Pasha came on board as a research associate provided by the ITU.

They put together what they call Version 0.1 of the ambu bag ventilator system. “When we developed it, there was a lot of room for optimization in weight, size, and form of the device,” Rahman says. “The device also needed to be tested before it was rolled out.”

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At the heart of the invention, now known as the Ambulator, is a motor which regulates the flow rate and the tidal volume of the ambu bag. These parameters can be monitored via sensors connected to the motor and the ambu bag. These sensors help deliver the correct amount and also come in handy when or if the device develops a fault. A standard 12-volt battery powers the device. “Originally, we wanted this to be a handheld device,” says Rahman.

The low-cost infusion pump with air bubble detector.

In 2017, the Ambulator team began preparing the device for clinical testing. This included surveying public hospitals to understand the demand for these devices. The prototype was then upgraded with a complete set of sensors to ensure safe clinical operation. The device was also tweaked according to the recommendations made by medical practitioners and two versions were created – one for adults, the other for infants.

“Interviews with doctors proved very helpful,” says Shaheer Piracha, a researcher who is currently working on the ambulator. “They told us exactly what they needed in order for the ambulator to be effective.”

Shaheer’s research indicates that doctors prefered an easy to-use portable device whose functions would not be disrupted by frequent electricity load shedding.

“We were able to make great upgrades to the device once we received feedback from doctors. For example, we installed a battery and a user interface. It enabled us to develop an efficient way to deliver oxygen to a patient over a long period of time.”

Developers of the ambulator were able to test this device on a patient with muscle degeneration in July 2017. The disease had rendered his lungs inactive. “The device performed remarkably well,” says Shaheer. “Doctors were very impressed with the ambulator’s precision.”

“We are now looking to not only continue the system development but also to determine the best path for regulatory approvals to make sure this device can reach to those in need,” Shaheer says.

Low-Cost Infusion Pump

Shortage of basic health care equipment at hospitals in Pakistan contributes significantly to neonatal deaths from preventable causes. Doctors working at major public hospitals believe that shortage of incubators, cardiac monitors, phototherapy, resuscitators, apnea alarms, jaundice meters, infusion pumps, pulse oximeters, and oxygen checking machines adversely affect patients at their hospitals. Currently, all infusion pumps in Pakistan are imported from either Poland or the United States and cost between PKR 90,000 and 105,000.

It is against this backdrop that a group of ITU students invented a low-cost infusion pump.

An infusion pump is a device which delivers fluids, nutrients or medication to a patient’s circulatory system at a controlled rate. The pump is used to deliver fluids such as insulin, antibiotics, chemotherapy drugs, pain relievers, and hormones. It is most commonly used for intravenous infusions, but subcutaneous, arterial, and epidural infusions can also be used.

By controlling the amount of fluids being delivered to a patient, infusion pumps eliminate the chances of inaccuracy which exist if the task is performed manually by doctors. They infuse amounts as small as 0.1 ml per hour. The infusion pumps also allow patients in pain to administer their own pain medication in a safe manner.
Infusion pumps are mostly used in the ICUs, cardiology, obstetrics, and gynecology, and in pain management for post-surgical patients.

“Some medicines are given based on the weight and condition of the patient. In cardiology, we have to give patients medicine to raise their blood pressure and sometimes we have to titrate medicine with infusion pumps. When infusion pumps are not available, we have a big problem because we have to rely on drips and microburettes and control the rate of medication by adjusting the speed of the drops manually,” says Dr Nooria Ashfaq, a house officer at Mayo Hospital, Lahore. “This is not a very accurate method because you are just making an educated guess about the dosage of the patient’s medicine.”

The infusion pump developed by eight students of the ITU can change this situation. Their infusion pump consists of a small 3D printed structure, not more than 6-inch long, with a syringe inside. It is attached to a keypad through which the medicine dosage can be controlled. The infusion pump is also connected to a bubble detector which stops the device if any air bubbles are detected in the tubes. This infusion pump and the ones imported from abroad work along the same principle and rotate a stepper motor slowly to move the injection. However, unlike the imported devices, this locally-produced infusion pump will cost less than PKR 15,000.

“Our infusion pump is cost efficient. We will be able to make it and fix it locally rather than wait for months to have a product imported or repaired,” says Ahmed Bilal, one of the students who developed the infusion pump.
“There is a huge market for any equipment that can be produced locally since the imported ones are not affordable for all healthcare providers,” says Dr Khalil Bukhari, a consultant physician at Jinnah Hospital and assistant professor at Allama Iqbal Medical College.

Read more: Locally Developed Simulator Promises to Train Surgery Students on MIS Procedures

The working prototype of the infusion pump would have to undergo extensive testing before it is commercially produced. Ahmed Bilal and another student Rana Muneeb Ashraf are currently working on the device as their final year project and are making the infusion pump more accurate and up to industry standards. They also aim to include a medical library containing correct dosages of medicines with the infusion pump in the future.

SmartSim Simulator

Traditionally, medical students go through apprenticeships for training in minimally invasive surgeries (MIS). Junior doctors are placed with seniors for on-the-job training.

“Apprentices first observe seniors perform surgeries. After some time, they start assisting seniors. Finally, they start carrying out surgeries by themselves under the supervision of a senior doctor,” says Dr Naeem Zia, professor of surgery at Rawalpindi Medical College (RMC).

However, teaching hospitals across the world are now using training simulators which can assess surgicals skills of students and provide feedback on potential areas for improvement.

“Teaching hospitals around the world are using training simulators like LapSim, LapMentor, and ProMIS but these devices are expensive as their license can cost up to $50,000,” says Dr Osman Hasan, an assistant professor at the School of Electrical Engineering and Computer Science (SEECS) at the National University of Sciences and Technology (NUST).

These simulators have not been introduced to any public sector teaching hospital in Pakistan because of the prohibitive cost of license.

Realising the importance of such a device, a team headed by Hasan as the principal investigator has prepared a simulator called SmartSIM which is one-tenth the price of other commercially available simulators. Zia from RMC was also among the collaborators for this project.

This virtual reality surgical simulator for minimally invasive surgeries is an outcome of joint efforts by the School of Electrical Engineering and Computer Science at NUST and the Holy Family Hospital, Rawalpindi. The team behind the simulator comprises more than 20 professionals with expertise in electrical, mechanical and software engineering as well as surgery.

Hasan says the aim of this project was to develop a cost-effective solution for training surgeons for minimally invasive procedures.

The final product – the fruit of nearly two years of research and development – was initially named Al-Zahrawi, after the great Muslim physician and surgeon of the 10th century. Later, the simulator was renamed SmartSIM. It was first showcased at a meeting of the Society of Surgeons in Rawalpindi and officially launched at NUST in 2014.
Since then, the team has been showcasing the product at various competitions, including the IBA Invent Entrepreneurial Challenge, TiE International Business Plan Competition, P@SHA LaunchPad, and 2013 Global Innovation through Science and Technology (GIST) Tech-I Competition in Malaysia. The simulator is also being used at training workshops during surgical conferences across the country.

Laparoscopy or minimally invasive surgery is a procedure in which a laparoscope (a thin-lighted tube) and other surgical instruments are inserted into the human body through small incisions rather than relatively larger incisions commonly used in conventional open surgeries. The surgeons can then visualize the internal operating field on a video monitor connected to the laparoscope.

Open surgeries can result in large wounds which take longer to heal. Due to the smaller size of incisions needed, this type of surgery leads to quicker patient recovery, less discomfort and scarring, and a smaller chance of post-operative infections and complications. The time for the procedure might be longer but the hospitalization time is significantly reduced.

Over the past few decades, laparoscopic surgery has become important for many sub-specialties of surgery. It can now be used for gynecologic surgery, gastrointestinal surgery (including bariatric procedures for morbid obesity) and urology. Advanced procedures also include laparoscopic cholecystectomy (removal of the gallbladder), colectomy (removal of all or part of the colon), and nephrectomy (removal of the kidney). The use of this minimally invasive procedure helps in reducing the risk of post-operative morbidities such as incisional hernias in patients. The procedure is also useful for veterinarians to perform on animals.

However, at the moment there is limited use of this surgical procedure in many specialties as compared to the numerous benefits that patients receive.

Virtual reality training simulators play an important role in teaching surgeons skills such as hand-eye coordination and improving their cognitive, clinical, and technical aptitudes. This hands-on practice can help improve the efficiency of surgeons at performing laparoscopic surgery.

SmartSIM simulator has been developed for basic MIS training, using open-source tools and libraries, including a generic physics engine called the Simulation Open Framework Architecture (SOFA) which helps make realistic medical simulations.

The simulator consists of three parts: a mechanical interface, a controller circuit, and a software application.
The hardware interface is custom built and easy to replicate. The VR simulator has a mechanical manipulator that is designed to mimic the actual laparoscopic tool, both in terms of structure and functionality. SmartSIM, like a laparoscopic instrument, is a five-degrees of freedom (DoF) mechanical structure. The instrument’s point of entry into the body inhibits its free movement and acts as a pivot around which the tip can move. The surgeon is then able to carry out five possible movements: pitch, yaw, roll, depth, and open/close the gripper.

The controller circuit gauges the five mechanical movements made by the instrument with the help of a microcontroller and sends them to the computer via a duplex communication protocol on the USB interface.

The software application of SmartSIM consists of the graphical user interface and runs the simulation scene based on selection from an installed list of scenarios. It also contains an intelligent evaluation mechanism which analyzes the competency of surgeons at performing a specific task, and facilitates unsupervised and independent learning.

Such innovations are coming to the fore as a result of collaborations between various universities and intersection of specialities. These out-of-the-box ideas, with technology as the main driving force, have the potential to transform the healthcare industry with their low-cost solutions, for training of professionals and for delivery of services.

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