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

我今天要與各位分享

I study health systems in these countries.

資源貧乏環境中的醫療技術設計

And one of the major gaps in care,

在我進行健康照護體系研究的國家

almost across the board,

都有一個嚴重的不足之處

is access to safe surgery.

幾乎所有的國家

Now one of the major bottlenecks that we've found

都無法取得安全的手術

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

我們遇到的重大瓶頸之一

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

讓病患一開始就沒有取得手術的機會

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

或是即使有手術也不安全

for delivering anesthesia in these environments.

就是麻醉

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

事實上 這是我們期待的工作模式

or any other developed country.

提供麻醉的方式

In the background there

在這種環境中

is a very sophisticated anesthesia machine.

像這樣的場景

And this machine is able to enable surgery and save lives

在美國或任何其他已開發國家的手術房都很常見

because it was designed with this environment in mind.

照片的背景

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

是一台非常複雜的麻醉機

that this hospital has to offer.

這台機器

It needs an extremely well-trained anesthesiologist

讓手術得以進行 拯救生命

with years of training with complex machines

因為在設計時

to help her monitor the flows of the gas

已經把環境納入考量

and keep her patients safe and anesthetized

這台機器要運作 需要幾個條件

throughout the surgery.

醫院必須滿足這些條件

It's a delicate machine running on computer algorithms,

這台機器需由訓練精良的麻醉師操作

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

麻醉師對於複雜機器需有多年經驗

and it's going to break pretty easily.

才得以監控氣體的流動

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

確保病患安全無虞 維持在麻醉狀態

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

直到手術結束

and keep it saving lives.

這台精密的機器 仰賴電腦運算

It's a pretty expensive machine.

還有特別照顧 小心謹慎地使用 才能維持運作順暢

It needs a hospital whose budget can allow it

它很容易故障

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

故障時 要由一整團的生物醫學工程師

And perhaps most obviously,

了解這台機器複雜之處的專家

but also most importantly --

才能進行修復 替換零件

and the path to concepts that we've heard about

讓它繼續拯救生命

kind of illustrates this --

這台機器價格不斐

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

醫院

of compressed oxygen, and other medical supplies

必須有充足的預算 才能維持一台機器

that are so critical to the functioning of this machine.

成本高達五至十萬美金

In other words, this machine requires a lot of stuff

也許最明顯

that this hospital cannot offer.

也最重要的

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

是我們聽過的一種思考方式

In this hospital,

描述類似這樣的觀念

there is one person qualified to deliver anesthesia,

就是基礎建設

and she's qualified

必須能夠不間斷地供應資源

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

包括電力 壓縮氧氣

In the hospital and in the entire region

和其他醫療輔助

there's not a single biomedical engineer.

這些都是機器正常運作

So when this machine breaks,

不可或缺的

the machines that they have to work with break,

換句話說 這台機器需要的許多東西

they've got to try and figure it out,

這家醫院都不能提供

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

這是供電系統

Those machines go the proverbial junkyard.

地點是馬拉威郊區一處醫院

And the price tag of the machine that I mentioned

在這所醫院裡

could represent maybe a quarter or a third

有一個人 有資格進行麻醉

of the annual operating budget for this hospital.

她之所以合格

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

是因為她花了12個月 或是18個月

This hospital is connected to a very weak power grid,

接受麻醉訓練

one that goes down frequently.

在這所醫院 以及整個地區中

So it runs frequently, the entire hospital,

完全沒有生物醫學工程師

just on a generator.

所以當機器故障

And you can imagine, the generator breaks down

他們還是得想辦法繼續使用

or runs out of fuel.

必須試著解決故障問題 但大多數時候都束手無策

And the World Bank sees this

這些機器就被扔進垃圾堆

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

另外我剛剛提到 這台機器的價錢

can expect up to 18 power outages per month.

可能就占掉這所醫院

Similarly, compressed oxygen and other medical supplies

年度營運預算的

are really a luxury,

1/4或1/3

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

最後 我想各位看得出這裡的基礎建設並不牢固

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

這所醫院連結的電力網路非常不穩定

is taking those machines that were designed

常常斷電

for that first environment that I showed you

所以整家醫院

and donating or selling them to hospitals in this environment.

常常只靠一個發電機

It's not just inappropriate,

各位可以想像 發電機會故障

it becomes really unsafe.

或是燃料不足

One of our partners at Johns Hopkins

世界銀行注意到這種情況

was observing surgeries in Sierra Leone about a year ago.

並估計在低收入國家環境中的醫院

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

一個月可能發生

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

多達18次跳電

to save her life and the life of her baby.

同樣的 壓縮氧氣和其他醫療輔助

And everything began pretty auspiciously.

都是奢侈品

The surgeon was on call and scrubbed in.

都可能常常供應不足

The nurse was there.

長達數月或一年的時間

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

所以雖然看起來很瘋狂 但我們現有的模式

because of the emergency nature of the situation.

就是把這些機器

And everything began well

這些專為第一張照片裡那種環境設計的機器

until the power went out.

捐獻或賣給

And now in the middle of this surgery,

這種環境中的醫院

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

這不僅不合適

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

還可能很不安全

But the nurse is literally running around a darkened operating theater

我們在約翰‧霍普金斯的一位同事

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

在獅子山共和國觀察手術

to keep her patient asleep.

時間大概是去年

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

當天的第一場手術是難產手術

This routine surgery that many of you have probably experienced,

一位婦女被推進手術室 她需要緊急剖腹生產

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

才能救自己和寶寶的命

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

一開始都還蠻順利的

this happens across the developing world.

醫生待命 準備就緒

35 million surgeries are attempted every year

護士也在場

without safe anesthesia.

她很快地麻醉病患

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

這點很重要 因為情況十分緊急

He was the chief of anesthesiology

一切都很順利

in a hospital in Malawi, a teaching hospital.

直到電力突然中斷

He went to work every day

手術才進行到一半

in an operating theater like this one,

醫生正努力加快速度要把手術完成

trying to deliver anesthesia and teach others how to do so

他做得到 因為他有頭燈

using that same equipment

但是那位護士

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

就在黑暗的手術室裡團團轉

And after umpteen surgeries

試著要找能用來麻醉病患的任何東西

and, you can imagine, really unspeakable tragedy,

讓病患維持睡眠狀態

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

因為她的機器沒有電就無法運作

There has to be something better."

在座許多人可能都經歷過這項例行性手術

He took a walk down the hall

其他人可能經由這項手術而誕生

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

但現在成了一場悲劇

I think that's the scientific term,

讓人氣餒的是 這不是單一事件

and he started tinkering.

這種事情在開發中國家屢見不鮮

He took one part from here and another from there,

每年要動的3500萬次手術

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

都沒有安全的麻醉

in the reality that he was facing.

我的同事 保羅‧芬頓博士

And what he came up with:

就身臨其境

was this guy.

他是麻醉部門的主任

The prototype for the Universal Anesthesia Machine --

服務於馬拉威一所醫院 教學醫院

a machine that would work and anesthetize his patients

他每天去上班

no matter the circumstances that his hospital had to offer.

就在這種手術室裡工作

Here it is, back at home

他試著進行麻醉 也教導其他人

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

如何使用這種設備

working on patients from pediatrics to geriatrics.

這種在他的醫院中變得不再可靠

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

又不安全的設備

Voila!

在無數次手術之後

Here she is.

還有 各位應該可以想像 難以言喻的悲劇之後

When you have electricity,

他終於說：「夠了 我受夠了 到此為止

everything in this machine begins in the base.

一定有更好的辦法」

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

因此他走到大廳

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

他們把所有壞掉的麻醉機都堆在那裡─

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

─我想那是個科學專有名詞

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

然後他開始七拼八湊

And the mixture that the patient inhales

從這裡抓一個零件 那裡抓一個零件

needs to be at least a certain percentage oxygen

試著組裝成一台機器

or else it can become dangerous.

能夠在他所面對的現實環境中運作的機器

But so in here when there's electricity,

結果他組裝出來的是就這個玩意兒

the oxygen concentrator takes in room air.

通用麻醉機的原型

Now we know room air is gloriously free,

這台機器能夠運作

it is abundant,

讓他麻醉病患

and it's already 21 percent oxygen.

不論他所工作的醫院提供的環境如何

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

這張照片是它回到家

and send 95 percent pure oxygen up and across here,

12年後它略為改善 回到同一所醫院

where it mixes with the anesthetic agent.

從小兒科服務到老人醫學

Now before that mixture hits the patient's lungs,

現在讓各位多看一點這台機器如何運作

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

鏘鏘！

but there's an oxygen sensor here --

就是它

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

當有電力時

Now if you don't have power,

一切都從機器的底部開始運作

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

這裡有內建的氧氣壓縮機

this machine transitions automatically,

各位剛剛已經聽到我提起氧氣好幾次

without even having to touch it,

基本上 要進行麻醉

to drawing in room air from this inlet.

純氧要越多越好

Everything else is the same.

因為最後這些純氧會被稀釋

The only difference is that now

會跟空氣混合

you're only working with 21 percent oxygen.

病患吸入的混合氣體

Now that used to be a dangerous guessing game,

必須至少有一定比例的氧氣

because you only knew if you gave too little oxygen

不然會很危險

once something bad happened.

因此 有電力的時候

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

氧氣壓縮機會吸取室內空氣

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

我們都知道 室內空氣不花一毛錢

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

又源源不絕

because they can adjust the flows

而且氧氣含量達21%

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

因此壓縮機吸取 過濾室內空氣

In both cases, whether you have power or not,

然後送出濃度達95%的純氧

sometimes the patient needs help breathing.

上面送達這裡

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

就是混合麻醉劑的地方

And so we've just added this manual bellows.

混合氣體

We've seen surgeries for three or four hours

到達病患肺部之前

to ventilate the patient on this.

會先通過這裡

So it's a straightforward machine.

各位看不到 不過這裡有一個氧氣感應器

I shudder to say simple; it's straightforward.

會把資訊送到這個螢幕

And it's by design.

可以看到送出氣體中氧氣所占的百分比

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

但是如果你沒有電源

to use this machine,

或是天公不長眼 電力在手術時中斷

which is good because, in these rural district hospitals,

這台機器會自動切換

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

連碰都不用碰

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

換成從這個開口吸取室內空氣

This is an incredibly rugged machine.

其他都一樣

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

唯一的差別是

that happens in hospitals in these rural districts.

你現在只有氧氣濃度21%的氣體

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

在以前 這會是個危險的猜謎遊戲

but if it does, virtually every piece in this machine

因為只有情況惡化時 你才會知道氧氣供應不足

can be swapped out and replaced

但我們這裡放了一顆長效備用電池

with a hex wrench and a screwdriver.

這是唯一有備用電池的部分

And finally, it's affordable.

麻醉師可以藉此掌控情況

This machine comes in at an eighth of the cost

不管有沒有電

of the conventional machine that I showed you earlier.

他們都可以調整氣體流動

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

按照所看到的氧氣濃度 調整病患吸入的份量

and save lives,

在這兩種情況中

because it was designed for its environment,

不論有電或沒電

just like the first machine I showed you.

病患有時就是需要幫助才能呼吸

But we're not content to stop there.

麻醉的實情就是如此 肺部可能會癱瘓

Is it working?

所以增加了這個手動的鼓風扇

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

我們遇過3或4小時的手術

Well, we've seen good results so far.

就靠這個讓病人換氧

This is in 13 hospitals in four countries,

因此這是一台直截了當的機器

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

我不想說它簡單

with no clinically adverse events.

它非常直接

So we're thrilled.

但是是精心設計的成果

This really seems like a cost-effective, scalable solution

你不需要

to a problem that's really pervasive.

受過嚴格 專門的麻醉師訓練才能使用這台機器

But we still want to be sure

這是優點 因為在這些農村醫院

that this is the most effective and safe device

你也得不到那種程度的訓練

that we can be putting into hospitals.

它是為了所服務的環境而設計的

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

也是一台非常耐操的機器

with NGOs and universities,

能夠耐得住

to gather data on the user interface,

高溫 耗損 磨蝕

on the types of surgeries it's appropriate for,

這些在農村醫院發生的情況

and ways we can enhance the device itself.

所以它不會輕易故障

One of those partnerships is with Johns Hopkins

但如果故障了 機器裡的每一個零件

just here in Baltimore.

都可以拆下來換新

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

只要有六角扳手和螺絲起子就做得到

So we're taking this machine

最後 它的價格合理

and recreating some of the operating theater crises

這台機器的成本

that this machine might face

是剛剛讓各位看到的

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

傳統型機器的1/8

and in a contained, safe environment,

因此換句話說 我們現有的

evaluating its effectiveness.

是一台讓手術得以進行 能拯救生命的機器

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

因為它是因應環境而設計的

with real-world experience,

就像我讓各位看到的第一台機器

because we're putting two of these in hospitals

但是我們並不就此滿足

that Johns Hopkins works with in Sierra Leone,

它有效嗎？

including the hospital where that emergency C-section happened.

這種設計是最適當的嗎？

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

目前我們看到的結果都不錯

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

這是分佈在四個國家的13所醫院

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

從2010年起

until we don't have access to it,

我們已經進行超過2000次手術

and then it becomes a gatekeeper.

都沒有臨床上的不良反應

Who gets surgery and who doesn't?

讓人十分振奮

Who gets safe surgery and who doesn't?