The setting: In low-resource countries, rapid motorization in the last 10 years has led to increasing traffic accidents, which often result in bone fractures. In Uganda alone, hospitals admit 10,000 road-traffic accident patients each year. Currently, low and middle income countries (LMICs) account for 90% of the road-traffic accident trauma burden in the entire world, but only have 10% of the world’s surgical resources – their hospitals cannot afford the proper equipment to provide timely and effective care. One of the biggest factors: a low supply of surgical drills, which severely limits the ability of orthopedic surgeons to care for trauma patients with broken bones. With infection rates ranging from 10-70%, and 3-4 week delays from surgery causing long-term disabilities, this is a major area needing improvement.
Without the proper resources, many hospitals in developing countries resort to hand-powered drills: old-fashioned hand-and-crank powered devices. Imagine a team of expertly-trained doctors and nurses providing emergency medical care for a trauma patient by slowly turning a drill bit with an eggbeater. Using this, a single hole into bone can take upwards of 10 minutes to drill, and can be dangerous because of the lack of accuracy and extra push force required to carve it out.
A few hospitals have received “donated” surgical drills, but these are mostly outdated and without technical support.
“One of the hospitals where we’re working – Mulago Hospital in Uganda – received a donated cordless surgical drill that was 13 years old,” says Lawrence Buchan, cofounder of Arbutus Medical and a graduate student at the University of British Columbia (UBC). “But the company had stopped making replacement batteries for it, so it was pretty much useless.”
Arbutus Medical is a UBC student spinoff company that’s now developing a cheap and effective alternative to expensive surgical drills. They want to turn everyday power drills from the hardware store into surgical devices. In the past, the biggest challenge in making this transformation has been the sterilization of the tool. Home power drills just aren’t built to be autoclaved, and the implications of infection from using non-sterilized tools are severe. So, Arbutus is thinking outside the box by creating a sterilizable cover to envelop the drill.
With help from surgeons and nurses at Mulago Hospital (Kampala, Uganda), the Arbutus team has designed a practical solution tailored specifically to the demands of low-resource settings. With ambitions to scale production in LMICs for a widespread improvement of surgical capacity, Arbutus applied for and just received a Grand Challenges Canada “Stars in Global Health” Phase I grant, and is now featured on their front page.
Medgadget had the opportunity to chat about the drill cover with Lawrence Buchan, cofounder of Arbutus Medical.
Ben Ouyang, Medgadget: What is the drill cover, and how does it work?
Lawrence Buchan: The drill cover is a waterproof, autoclaveable surgical bag that connects to the drill’s mechanics via a sealed bearing mechanism. In the past, surgeons had wrapped sleeves or towels around hardware drills, but the real challenge was sealing the opening where the chuck comes out. We’ve taken this simple concept of separating the sterile barrier from the drill, applied a mechanical engineering mindset, and figured out how to completely seal the drill using a closed bearing mechanism. It’s totally waterproof. You place the power drill into the bag, connect it to the bag’s external chuck, seal up the opening, and you’ve got a fully-functional surgical drill.
Medgadget: How is the drill cover solution better than the hand and surgical drills used right now?
Buchan: It’s orders of magnitudes faster and more accurate than a hand drill: in a case where 20 holes need to be drilled, having a power drill can save over two hours of operating room (OR) time. We’ve also got research data showing that the push-force required to drill holes with an egg-beater hand drill is so great that surgeons are at a major risk for plunging into deep neurovascular structures on the other side. A hardware drill requires less push force and we’ve found that surgeons can better control their plunge depth when they use the drill cover.
Compared to a surgical drill – even if the hospital were equipped with one, there’s downtime involved with having to resterilize the surgical drill in an autoclave after every case. At Mulago Hospital (Kampala, Uganda), we’ve heard estimates that operating room stoppages happen as often as three times per week simply because they don’t have access to a sterile surgical drill. Operations are brought to a complete standstill by this single limiting factor, and the hospital is forced to shut its door to incoming patients as a result. With multiple drill covers, surgeons can always be ready for the next case with a fresh bag. Effectively, a set of 5 drill covers turns one home power drill into 5 surgical drills.
Another huge application for the drill cover seems to be disaster relief. Field surgeons often have to respond at a moment’s notice and usually have to trek with a lot of their own medical supplies. Autoclave access is likely to be limited too. Rather than pack a sterile surgical drill for use in a single case, they could pack a DeWalt and 5 pre-sterilized drill covers for use with 5 patients.
Medgadget: Where did the idea for the drill cover come from?
Buchan: Surgeons, nurses, and staff from UBC Orthopaedics that had visited Uganda as part of the Uganda Sustainable Trauma Orthopedic Program (USTOP) had seen and used some basic drill covers, but noted that they weren’t actually maintaining a sterile barrier. We spoke with some of the early drill cover adopters – the Surgical Implant Generation Network and Dr Scott Nelson of CURE – who had both developed their own solutions after seeing desperate need around the world. We also spoke to about 50 surgeons at the Institute for Global Orthopedics and Traumatology International Summit in San Francisco, and discovered that they were using things like a sleeve from a surgical gown as a makeshift drill cover, or home-made designs that had open bearing systems, none of which could actually seal the drill from the patient to ensure sterility. So UBC surgeons brought the problem to our engineering team via the Engineers in Scrubs program, and we’ve been working on drill covers since January 2013.
Collaboration with Makerere University and Mulago Hospital in Kampala, Uganda has been pivotal for us. With their help we’ve been able to fine-tune the design for usability. It’s also been great talking to others who have seen the need for drill covers and used their own bootstrapped solutions – we now see ourselves as shepherds of a great idea trying to make high-quality drills as widely available as possible.
Medgadget: How much does it cost, and what’s the lifetime?
Buchan: We’re currently working to drive cost down to $300 for the chuck mechanism and $50 for the fabric bag. The chuck parts are all stainless steel and will last a lifetime. The bags are made with a sterile-certified surgical fabric, which we’ve currently tested it to be rugged enough to handle up to 100 sterilization cycles. (An average surgeon might do 200 surgeries per year.)
The DeWalt power tool we’ve been using currently has had rave reviews – it costs around $100 and comes with a replacement battery. We’d love to work with a company like DeWalt to make these drills more widely available and affordable in LMICs.
If an operating room has capacity for five patients per day, five bags and a drill is enough to get through a day’s worth of operations – no stoppage delay for autoclaving. In contrast, a state-of-the-art surgical drill might not even be able to take care of all 5 patients, and cost $30,000.
Medgadget: How is the drill cover being tested currently?
Buchan: The preliminary results from our research study are showing comparable performance to surgical drills and major improvements compared to hand drills. We’re also currently verifying that the bag forms a completely-sterile seal that prevents bacteria and virus transmission. Finally, we’ve got a clinical study starting this autumn to measure patient throughput and monitor outcomes. We’ll be evaluating metrics like case time, number of holes drilled, tools used, and complications.
In our pilot study, we’ve sent a few kits down to Uganda. It turns out the staff there save them for the most difficult orthopedic cases. While the eggbeater-type manual drills are still used for simple fixes like wrist fractures, severe trauma cases require the power drill and cover to be done in an appropriate time. To date, 500+ patients have been treated with the drill cover. We’ve recently done a quick turnaround to donate two drill covers to Canadian Relief for Syria, and two more to Save the Children for humanitarian use where access to autoclaving is limited.
Medgadget: What challenges are you facing now?
Buchan: Regulatory approval. We’d love to make this a venture that is sustainable through product sales. We’ve already had a number of unsolicited offers from surgeons in Uganda who want to own their own personal drill cover set, like they would a stethoscope. We also see huge potential in emerging markets like India and China where large sales volumes could supplement drill cover supply for places in extreme need. We’re constantly working towards verifying the safety and efficacy of our design for regulatory boards, but unfortunately many of these pathways aren’t designed for low-resource applications.
Medgadget: What kind of support do you have currently?
Buchan: We are currently funded by a Grand Challenges Canada (GCC) Proof of Concept grant, supported by the Bill & Melinda Gates Foundation. GCC is funded by the Government of Canada, and they support “bold ideas with big impact in global health”. As that winds down, we’re getting ready to apply for the second round of “Transition to Scale” funding. We’ve also been lucky to work out of the Centre for Hip Health and Mobility, which has been a major supporter of our endeavours.
Currently, we’re actively seeking partners who will match the GCC funds or help us with scaling implementation.
Medgadget: Who’s driving the venture, and what’s in the name?
Buchan: We have six cofounders of Arbutus – all engineers, entrepreneurs, and keen learners. We’ve got a good blend of mechanical design techies, strong leaders, and startup gurus. We’ve also assembled an experienced board of advisors to keep us honest.
The name? Arbutus (arr-byoo-tus) is a tree native to West Coast Canada in British Columbia. We picked it to represent a grassroots BC Canadian organization.
Medgadget: Where is this venture going?
Buchan: Are we a not-for-profit, for-profit B-corp, or hybrid social enterprise? I’m really not sure yet, but we’re working hard to validate a business model that will allow us to scale our impact as widely as possible.
What’s exciting is the potential for a simple device like this to have such a huge impact. Again, 90% of the trauma burden lies in LMICs, where only 10% of the world’s surgical resources are available. There are very few groups designing devices specifically for scalability in these low-resources setting. There’s also not a lot data about the needs in these places, so it’s really cool to get out there and create that information.