I am surprised that the Global Pulse oximetry project has progressed so far. The evidence for improved outcome with pulse oximetry is not clear and has certainly not been demonstrated in poor countries. Anaesthesia with ketamine, spinals and no opioids in patients with lower cardiac risk and undergoing less complicated surgery is probably much less ‘risky’. A randomised control trial in poor countries is ethically justifiable before advocating governments of countries with limited resources spend money on a technology for which the immediate need is doubtful . Vietnam and the other countries chosen are not in the same category as the poorest countries, and all fall into the Medium Human Development group, according to the 2009 Human Development Report.

The authors responding to Dr Adams, who state they have worked in low-income countries, consider pulse oximetry to be the single most important monitor to improve patient safety. Again, where is the evidence? This may just be a matter of comfort and familiarity.  The argument that none of the investigators would wish themselves or members of their families to undergo anaesthesia without pulse oximetry is rather simplistic. I may equally argue I would not wish myself or my family members to undergo anaesthesia in a poor country at all. However, in the real world of limited resources and difficult choices, I would much rather be anaesthetised by someone vigilant and trained, who did not have a pulse oximeter than the opposite, who is in possession of a pulse oximeter. In a resource-limited setting Dr Adams would like oxygen and morphine before pulse oximetry. I thinkI would choose some kind of cheap oesophageal detector device, interosseous needles, an oxygen concentrator perhaps, a bougie or LMAs before pulse oximetry.   

At a ‘World Anaesthesia’ GAT meeting a few years ago I showed a video of an anaesthetic administered by a physician-anaesthetist in Cote d’Ivoire with many years of experience. It clearly demonstrated that even though a pulse oximeter was available, it was not used appropriately. It was positioned after induction/ intubation,  and even then probably only because ofthe camera. The anaesthetist did not react to the disappearance of the pulse oximeter recording. The fall in blood pressure due to blood loss was treated with adrenaline, which produced arrhythmias on the ECG (again only placed for the benefit of the camera).  The patient was eventually transfused and survived, and the anaesthetist saw no reason to change his practice. 

The Global Pulse Oximetry project is clearly political, and it is important that we understand the agendas of the interested parties: WHO, the academics and the industry. Further debate is warranted.