No pulse oximeter! What do I do now?

  • Gelb, Adrian, MD
| Mar 12, 2012

You walk into your OR a little earlier than usual to set up for the challenging case of the day. There before you is a large note on the pulse oximeter: “Broken. No replacement until later or perhaps tomorrow.” What to do now? So much effort has gone into the medical and social arrangements for this patient that cancelling seems outrageous. Doing the case without a pulse oximeter though is inconceivable. The American Society of Anesthesiologists (ASA) and every other western anesthesia society view a pulse oximeter as a mandatory part of anesthesia.

Now imagine you’re in another country where you don’t have a pulse oximeter at all, ever. You saw one during your training, and you know how it works and what a difference it makes in terms of patient safety. Unfortunately, at your hospital it’s a good day when you have a manual blood pressure cuff and the electricity doesn’t cut out mid-procedure. There is a mother on the table with a ruptured uterus and at least ten other women lying in obstructed labor out on the ward, all of whom will likely need an emergency C-section.

This is the reality for anesthesia providers across Sub-Saharan Africa, India and Latin America – our colleagues who go into the operating room every day as we do, but without the most basic tools necessary to safely anesthetize their patients.

In fact, an estimated 77,000 ORs worldwide lack access to a single pulse oximeter—this in the face of the global volume of surgery steadily increasing. There are now more operations performed each year than there are babies born! This means that 31 million procedures take place annually without oxygen monitoring. It is therefore not surprising that anesthesia mortality in these settings is up to 1000 times higher than it is in the US.

But there is a way that we can help. The Lifebox Foundation ( is a charity set up by the World Federation of Societies of Anaesthesiologists, the Association of Anaesthetists of Great Britain and Ireland, and the Harvard School of Public Health and Brigham and Women’s Hospital. Their aim is to get a pulse oximeter into every operating room in the world.

The Lifebox team spent a year developing the ideal device for OR use in low-resource settings. Built to World Health Organization (WHO) specifications, it is robust (so if it falls onto the concrete floor of a rural hospital it won’t break), intuitive (so that an anesthesia provider with minimal training can use it effectively), and uses both AA and rechargeable batteries (so that when the electricity does cut out during a procedure, the oximeter won’t). Drs. Dubowitz and Bickler at UCSF validated the accuracy of the device in comparative studies.

Lifebox also provides the education platform crucial for making equipment donation a sustainable intervention, not a wishful pitch into a black hole. Each oximeter comes with a CD loaded with classroom workshops and materials for self-learning about pulse oximetry and WHO Surgical Safety Checklist in six different languages. The Checklist is a lifesaving surgical safety tool that is currently being rolled out across the US; safe anesthesia and a pulse oximeter are crucial components. Working directly with the manufacturer, Lifebox has secured each oximeter pack at a cost of just $250. This includes delivery directly to any hospital in the low-resource world.

Lifebox also runs larger donation and training programs, such as in Uganda last summer when a team spent two weeks in Mbarara with the Uganda Society of Anaesthesia, donating 80 pulse oximeters and delivering training to 130 anaesthesia providers from across the country.

In September, Lifebox sent a British resident back to Uganda to follow up on the oximeters, checking they were all still in place and answering any questions the providers might have. All of them (bar one, which had been taken to South Sudan in a job move) were in active use in the OR, proudly displayed and meticulously protected by the anesthesia providers.

If you were in Chicago last year at the Annual Meeting of the ASA, you might remember the Lifebox introduction (during Dr. Atul Gawande’s keynote address). A surgeon giving the keynote address at the ASA to tell us about an anesthesia-initiated lifesaving global initiative – this is serious!

Lifebox’s “Make it Zero” campaign is a drive for zero operating rooms without a pulse oximeter; zero operations to take place without the Checklist. The ASA has been instrumental in supporting the Lifebox campaign, with over $120,000 raised already. This is phenomenal, but we need to do more. We can give talks to colleagues and lay groups to raise awareness. We can encourage colleagues going abroad on medical missions to buy a pulse oximeter to take with them and leave behind as a legacy of their visit. And – like the University of Florida Department of Anesthesiology, which gave $33,750, or our own North California Kaiser Permanente Department of Anesthesiology, which has so far raised in excess of $12,000 – we can challenge our departments to raise and match funds.

Lifebox receives requests for oximeters every day. If you donate, you can be sure that your gift will be used entirely to purchase a pulse oximeter for a facility that needs one – you can even specify the country or hospital you’d like your donation to be used in. Donations are also tax deductible ( and can be made in honor of someone.

We can’t magically create the safe and well-stocked hospital all patients deserve but we can send a device, which, overnight, will make a difference to patient safety. We need to support our anesthesia colleagues and the ASA as they rise to meet the challenge of patient safety in the face of a growing surgical volume. Lifebox is a global anesthesia safety initiative that deserves the support of all of us.

This article was co-written by Adrian Gelb, MB ChB, FRCPC, Iain Wilson, MB ChB, FRCA and Sarah Kessler, BA (Oxon), MSc.

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