Mbale is a sleepy town of 100,000 people tucked into the verdant Mount Elgon region of eastern Uganda. Its major hospital, Mbale Regional Referral Hospital (MRRH), caters to an estimated one million people, and most days you’ll find caretakers and family members sitting on the grass outside, as patients receive care in the many wards and multiple operating theaters inside.

Women travel from all around the region to visit the Obstetrics and Gynecology Operating Theater at the hospital, often braving uneven, muddy roads that are next-to-impossible to use during the rainy season. Theater staff handle up to 10 operations each day, sometimes under trying – even dangerous – conditions.

Like too many operating theaters in Sub-Saharan Africa, the electricity is intermittent and the generator unreliable, which leads to surgeons and nurses operating by the dull glow of mobile phone flashlights at night.

Proper equipment is often inoperable or missing. Some maternity cases can be safely and successfully completed under spinal anaesthesia, but there is often a shortage of spinal needles, so anesthetic officers are forced to use larger, non-spinal needles, which come with an increased risk of postdural puncture headache and nerve damage.

Many patients require general anesthesia, which until recently was performed at MRRH with an old Epstein Macintosh Oxford (EMO) draw-over vaporizer – a device widely relied upon in Uganda. It uses ether, one of the first anesthetic agents to be used in operating theaters in the mid-19th century, and one of the last anesthetic agents you’ll see used in most of the world’s surgeries today (it was taken off the World Health Organization’s list of essential medicines in 2005).


Opponents of ether’s use claim that it is dangerous compared to agents like halothane, isoflurane, and sevoflurane, as it is flammable and explosive in confined spaces. Further, there is concern that it takes a long time to exit the body, so patients have extended recovery times, a drawback exacerbated by inadequate monitoring equipment and low staff levels.

Proponents hold that it is relatively easy to administer and is safer in obstetric cases with an elevated risk of hemorrhage. Recognizing its usefulness, some global health experts have lobbied the WHO to re-include ether on its list of essential medicines.

Dr. Jodie Smythe, a British anaesthetic trainee working in the Obstetrics and Gynecology Operating Theater as part of a partnership with the Uganda Maternal and Newborn HUB, saw surgeries performed with the EMO draw-over vaporizer, and thought that both patients and staff would benefit from a more modern anaesthetic device.

After seeing the TEDx Talk on the Universal Anaesthesia Machine (UAM), Dr. Smythe reached out to Gradian, and over the next few months a coalition of organizations, including MRRH itself, contributed funds to purchase a UAM for use in the Obstetrics and Gynecology theater.

Soon after, the UAM was shipped to Mbale. As with all installations, Gradian ensured that proper technical and clinical trainers came to the hospital to train staff on the use and maintenance of the UAM. A physician consultant anesthetist at Mulago National Referral Hospital and two biomedical engineers traveled to Mbale, where they trained over 30 surgeons, nurses, and technicians during two days of classroom and theater-based learning.

Transitioning from ether to more modern anesthetic agents is challenging. For years – in some cases, decades – the anesthetic officers had used an EMO draw-over vaporizer with ether, and switching to a hybrid continuous-flow/draw-over device with halothane or isoflurane is a significant change clinically and operationally. But because the anesthetic officers had high-touch, in-person tutelage during an operation, they quickly learned by doing, and were soon manipulating the bellows and the vaporizer with ease.

In a clear sign that the UAM found a satisfied customer, during training multiple anaesthetic officers asked how the hospital could procure another UAM for their hospital. Months later, the UAM is used every day.

There still aren’t enough spinal needles, and the operating theater loses power regularly. But, with the UAM to provide anesthesia, it is undoubtedly a better place for patients to undergo life-saving operations than it was before. The transition away from ether wasn’t easy, but it was smooth, and now patients receive safe, reliable general anesthesia monitored by professionals trained specifically on the use of the UAM.

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