This month’s issue of Anaesthesia features a novel development of a prototype phone oximeter [1]. Interfacing mobile phones with stethoscopes [2] and microscopes capable of groundbreaking filming [3] are other examples where mobile phones have been adapted for use as other devices. In anaesthetic practice they have been reported for monitoring neuromuscular function [4], measuring 15-degree tilt in obstetric patients [5] and as an aid during resuscitation [6]. The rise in the use of mobile phones, from concern over their use near sensitive medical devices [7] to their ubiquitous presence in all clinical areas [8], and now their use as medical devices themselves, is extraordinary. These developments may arguably be most useful in the developing world setting. A 2009 World Bank policy paper classified the overall implications of mobile phones for sustainable poverty reduction in direct benefits (impact on GDP), indirect benefits (reducing market inefficiencies) and intangible benefits (e.g. implications for health and education) [9]. In this editorial we focus on the implications for health improvements for patients through the use of mobile phone technologies by anaesthetists in the developing world. Benefits of mobile phone technologies to the health sector are most obvious in the increased ability to respond to emergencies, communication to access transportation, and health-related information/expertise. In some specialities in the UK, such as dermatology, less expert clinicians can relay photographs to dermatology consultants for help with a diagnosis. This is obviously not an appropriate use for a pulse oximeter, as the person on the ground needs to have the skills to deal with the problem presented. It could, however, help with decision making when transferring a patient to a centre with the ability to provide ventilatory support, or to provide additional information in coming to a diagnosis [10]. In many developing countries there is a dire shortage of trained anaesthetists, raising the possibility of networks that could give advice/support about specific cases. Even in the developed world this is not without its difficulties [11], and if formally implemented would require ‘experts’ who could understand the context and working conditions in a specific hospital. In reality, informal arrangements already exist, facilitated by both mobile phones and email. Local support and advice offers the most sustainable solution and may be best supported by experienced UK anaesthetists through some type of mentorship scheme. In anaesthetic practice, the use of a pulse oximeter has been an internationally recognised standard since 2008 [12]. In the UK, it would be considered substandard to perform routine anaesthesia without a pulse oximeter; the Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommends the use of pulse oximetry before induction, through anaesthesia and in recovery [13]. However, the Lifebox project (see http://www.lifebox.org) has highlighted that three quarters of patients in Africa do not have access to a pulse oximeter, and that 70 000 operating theatres around the world do not have one. These are shocking statistics but would a modified phone help in this situation? Whether this device succeeds or fails for routine anaesthetic use in the developing world depends on battery life, the practicalities of having one’s phone ‘tied up’, and compatibility with a ruggedised cheap phone on a pay-as-you go contract. The mobile phone market in low-income countries is dominated by pay-as-you go contracts and certain models are too expensive to make them a sensible option on this kind of contract. From personal experience in the operating theatre (in both developed and developing countries), a rugged oximeter is also essential. Further development of the oximeter prototype should focus on overcoming these issues. In addition, mobile phones were never designed to be medical devices and their use as such raises some interesting regulatory issues, particularly in respect of electromagnetic interference [14]. Furthermore, software – for example, when used in a mobile phone to interpret signals from a pulse oximeter probe – is considered to be a medical device in its own right as far as the European Union’s Medical Devices Directive is concerned [15]. The intended market of the type of device described by Hudson et al. is not the developed world with its complex system of mandatory regulatory requirements, but the developing world, where possibly there might be no or few regulatory requirements for the use of medical devices on, or for, patients. However, we should perhaps not increase the risk to patients by using medical devices that do not comply with regulatory requirements just because the country in which they are to be used does not have any. As a simple example, the Medical Devices Directive states that devices “must be designed in such a way as to eliminate or reduce as far as possible the risk of infection to the patient, user and third parties” [15]; however, mobile phones have been implicated in increasing the risk of spreading methicillin-resistant Staphylococcus aureus (MRSA) [16,17]. Covers might not help in situations where unimpeded access to the touchscreen is essential, and they would also increase cost. In general, anaesthetists might use their smartphone for healthcare-related activities in the following ways: As a phone to contact other members of the team or to be contacted by others; As a resource for reference, either via the Internet or through texts or applications (apps) already downloaded on to the phone, as in the i-Doc project [18]; To help explain things to patients, either by using materials available on the Internet or resources downloaded to the phone, such as those provided by the Obstetric Anaesthetists’ Association (OAA) [19]; As a logbook and reflective learning tool [20]; To undertake e-learning such as the World Federation of Society of Anaesthesiologists’ (WFSA’s) Tutorial of the Week [21]. For telemedicine: in certain circumstances, advice to a less experienced anaesthetist or untrained worker could be facilitated by a visual link. For remote monitoring [22]. Mobile phones therefore have unprecedented reach as a resource for anaesthetists across the world. Logbooks, textbooks, guidelines, educational videos and more can all be utilised or viewed from modern smartphones. And let’s not forget their original function: a phone! In countries such as Liberia where there are only 60 nurse anaesthetists and no physician anaesthetists for a population of over 3.5 million (survey undertaken by Mothers of Africa at the Liberian Association of Nurse Anaesthesia Conference, Phebe Hospital, Liberia, February 2012), nurse anaesthetists work in difficult and isolated conditions. They maintain contact and provide support and advice for each other via their mobile phones and social media. Smartphones are one of the most efficient and accessible devices for reaching the world’s masses. With access to many rural and low-income populations, mobile technology has the capability of providing information and services to healthcare workers who would otherwise be excluded. These individuals are often eager for this support and work in professional isolation. With the advent of mobile phones using Android software and appropriately designed applications, these devices and technologies could be within financial reach of anaesthetists in developing countries. Last year a Chinese firm launched an Android smartphone costing US$80 (£51; €63) that has been sold to more than 350 000 Kenyans [23]. This is an impressive sales number in a country where 40% of the population lives on less than US$2 per day. The cost reduction has come about by using less powerful hardware (the RAM is 256 MB, about half that of the Apple iPhone 4 (Apple Inc, Cupertino, USA) and by utilising Android’s open source philosophy. Interestingly, only 50 MB would be used up if the British National Formulary, Oxford Handbook of Anaesthesia, Oxford Handbook of Emergency Medicine and Oxford Handbook of Tropical Medicine were downloaded as resources (personal communication, Henrik Anderson, MedHand International AB). Smartphones will increase in use across the developing world, including the setting of healthcare workers. Widespread use of adaptations for phones as other devices remains to be seen, but other uses such as reference materials and e-learning may be particularly useful where Internet access is patchy or expensive (since these resources are kept on the phone itself). This is of particular relevance in rural areas where internet cafes and 3G are likely to be out of reach, and mortality rates may be higher. The International Telecommunications Union (ITU) reports that in 2011, mobile broadband penetration in Africa has reached 4% (compared with under 1% for fixed broadband penetration). The equivalent UK figure for mobile broadband is 66%. In addition, fixed broadband prices in developing countries have dropped by 50% in just two years, meaning that the ability to update information on a smartphone should be made easier in the developing world [24]. Many anaesthesia resources are freely available on the Internet for download, for example the WFSA Anaesthesia Update, Royal College of Anaesthetists (RCoA), AAGBI and Difficult Airway Society (DAS) guidelines, and Advanced Life Support Group (ALSG) resuscitation guidelines. All could be used from a smartphone although some may not be that easily read from such a device. Generally these resources are available in standard formats that can be easily stored, accessed and distributed. These open access materials are all from reputable sources. There are also other open access materials relating to anaesthesia available free from the Internet that may not be quality assured. Lucas looked at information and communications technology for future health systems in developing countries, discussing the potential value but noting that much of the evidence in favour of these technologies comes from small-scale interventions. Particular problems for larger-scale schemes are maintaining electronic equipment, lack of expertise and resources. There may not be anyone with technological skills capable of resolving failures or malfunctions in some areas, and the cost of maintaining equipment can be problematic [25]. A study of computer skills in Tanzanian medical students found that only 40% were able to perform the core information technology skills assessed [26]. This highlights the importance of including training and support in any scheme intended to improve access to reference and educational resources for anaesthetists. Access to reference materials and educational resources in isolation is at best useless and at worst, dangerous. Equally, relying on the availability of information when needed in the heat of the moment may cause unacceptable delays to the treatment of patients, thus increasing morbidity and mortality. The best learning occurs when one’s own guidelines must be constructed to suit one’s particular circumstances. The use of quality assured, context-appropriate course such as the AAGBI’s SAFE (Safer Anaesthesia From Education) obstetric anaesthesia, piloted in Uganda, Liberia and Ghana, complement reference materials by simulating emergencies as part of the course [27]. In our privileged environment, we have received training that helps us to weigh up the pros and cons of materials from all sources, including those whose reputation is unknown. Anecdotal evidence suggests that medical students increasingly rely on online sources such as Wikipedia to provide information for their projects [28]. If training in the skills for critical appraisal of such information is not adequate, improved access to all the reference and teaching materials in the world cannot help make treatment and intervention for patients more effective. Perhaps the time has come for organisations such as the WFSA, RCoA and AAGBI to use their considerable expertise and experience to collaborate on an international on-line journal club? Other reference materials and e-learning materials are commercial ventures, which brings the issue of affordability to the fore. Can individuals or organisations in the developing world afford the most respected and user-friendly resources and their updates, e.g. the award-winning e-Learning Anaesthesia (e-LA) project [29]? The AAGBI in collaboration with the RCoA and e-Learning for Healthcare have developed an e-learning DVD appropriate for the developing world [30], which will be freely available. However, the UK-based e-LA project is currently only available for anaesthetists registered with the RCoA or via an annual subscription, which is beyond the reach of those in developing countries. The RCoA has generously provided many of its tutorials for use on the e-learning DVD. Once the DVD is widely available and if there is evidence that it is useful for anaesthetists in the developing world, consideration might be given to resolving the considerable barriers (including financial and intellectual property issues) that currently prevent this excellent resource from being more freely available. Anaesthetists in developing countries will undoubtedly purchase mobile phones. Concerns around networks, electricity, speed of downloads, spare parts, upgrades and compatibility with internet software remain, but these are likely to have their own solutions determined by the usefulness of these devices, market forces and the amazing ability of humans to innovate. In Kenya, students have come up with a device that uses a dynamo on a bicycle to charge a phone [31], and organisations promoting the use of solar power for this purpose are increasing [32]. So what should the anaesthetic community do to help all anaesthetists and their patients make best use of technology associated with the smartphone? The WFSA seems ideally placed, perhaps in partnership with the Society for Computing and technology in Anaesthesia (SCATA), to coordinate and evaluate the development of adaptations of phones to make them medical devices, and to coordinate the integration of educational and reference resources on to smartphones in a way that is safe, cost effective and useful for anaesthetists in developing countries. The WFSA already has considerable experience in the development of open access, quality assured teaching and reference materials, and could work with anaesthetists and industry in developing countries to support the development of their own materials and apps compatible with popular affordable smartphones. In the long term, the aim should be for the people within the developing countries to be designing and manufacturing the phones, any interfaces, apps, and teaching and reference materials that they need for their own individual use. Smartphones and their adaptations are not ‘the answer’ to the need for education, updates and equipment for anaesthetists in the developing world. There are many barriers outlined above, not least of which is the need to consider the whole system of training, updates, communication and variable working conditions. However, they offer some very promising developments, from which many of us in the developed world are already benefitting. No external funding and no competing interests declared.

Wilkins, H.; Hodzovic, I.; Sheraton, T.; Kilinwolo, M. Jr.; Goodwin, N. Author Information

Nitrous oxide pollution is common in paediatric anaesthetic practice. A questionnaire was sent to all UK members of the Association of Paediatric Anaesthetists requesting details of three areas of their paediatric practice relating to nitrous oxide: attitudes to its use; current usage; and availability of alternatives. Replies were received from 296 (68%) consultants. Of these, 169 (57%) stated that their use of nitrous oxide had decreased over the last 5 years. One hundred and fifty-eight (54%) considered theatre pollution a problem in paediatric anaesthesia. One hundred and sixty-nine (57%) reported that in normal circumstances potential deleterious effects on patients influenced their use of nitrous oxide, whilst only 70 (24%) felt potential effects on staff influenced usage. Fifty-five (18%) felt there should be some restriction in the availability of nitrous oxide.

Lewis, E.; Sheraton, T. E.; Hampson, M. A.; Wilkes, A. R.; Hall, J. E. Author Information

Breathing system filters are intended to prevent cross-infection during anaesthesia. However, there is a lack of information on whether filters prevent contamination of the breathing system by the patient. We measured the contamination of 235 used filters of four different types obtained from operating theatres: two pleated hydrophobic (BB25M and BB22/15M, Pall Medical, Portsmouth, UK) used for adult patients and two electrostatic (355/5430 Hygroboy and 355/5427 Hygrobaby, Tyco Healthcare, Gosport, UK) used for paediatric patients. The filters were swabbed over their internal surfaces on both the patient and the machine sides and these were assessed with the use of adenosine triphosphate bioluminescence. Contamination was present on the machine side of 20 (9%) filters. Current standards for testing of filters has no set "pass" level and is performed in the laboratory setting. Bioluminescence may be used in the clinical setting to elucidate factors that might increase the chance of cross-contamination between patients.

Introduction: Changing the colour of light produced by laryngoscopes may improve the view at laryngoscopy and facilitate intubation. This could be crucial in children with anatomically difficult airways and in acute airway emergencies. Infra red light has been shown to be detrimental to optimal laryngoscopy (1). Anaesthetists have expressed a preference for blue/white light output to facilitate intubation (2). Blue light corresponds to peak haemoglobin absorption (415 nm) and therefore enhances the view of capillary vessels within the surface mucosa.(3) Green light defines deeper structures more clearly (3). Specific combinations of blue and green light spectra may provide the best conditions for intubation. Light Emitting Diodes (LEDs) have the advantage of producing light in a more appropriate part of the spectrum. LEDs are not currently used in laryngoscopes available in the UK. The aim of this study was to compare the spectral irradiance of the ProAct Miller 1 Paediatric blade laryngoscope (containing an incandescent bulb) with a custom‐made laryngoscope containing an LED.Methods: The light spectral irradiance from the laryngoscope blades was measured under standardised conditions using the Bentham spectroradiometer. Blackout conditions were applied to eliminate background light. The tip of each laryngoscope blade was placed in contact with the sample port of the spectroradiometer. A mains voltage supply was set at 3 V for the Miller 1 blade (A) and 3.6 V for the blade with the LED (B), as specified by the manufacturers.Results: The Miller 1 paediatric blade produced spectral irradiance mainly in the infrared region (>660 nm) in contrast with the LED which produced most irradiance in the blue/green region of the spectrum (400–550 nm). image [ Spectral irradiance from the Miller 1 blade (A) and the blade with the LED (B). ]Discussion and conclusions: Paediatric laryngoscopes with LEDs may provide superior intubating conditions than that currently available with incandescent light sources. LEDs can be further modified to emit the optimal spectral irradiance required for laryngoscopy. This may prove invaluable when presented with a difficult airway.References 1 Crosby E, Cleland M. An assessment of the luminance and light field characteristics of used direct laryngoscopes. CanJ Anesth 1999; 46: 792–796.2 Scholz A, Farnum N, Wilkes AR et al. Minimum and optimum light output of Mackintosh size 3 laryngoscopy blades: a manikin study. Anaesthesia 2007; 62: 163–168.3 Watanabe A, Tsujie H, Taniguchi M, Hosokawa M, Fujita M, Sasaki S. Laryngoscopic detection of pharyngeal carcinoma in situ with narrow band imaging. Laryngoscope 2006; 116: 650–654.