Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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146 Surgery and Healing in the Developing World
have time to ship by ocean, gas sterilization systems can be ordered from H. W.
Andersen Co.
A gas sterilization system can be improvised using an otherwise-useless refrigerator
that still has a good airtight seal. An electric light is placed inside the refrigerator
next to a bowl that has a couple of formaldehyde tablets in it and another bowl with
water. The formaldehyde vaporizes and sterilizes everything in the sealed refrigerator.
This certainly would not meet American hospital standards, but it has been
successfully used in “bush” hospitals where commercial gas sterilization systems are
not available. A technique that is common in less developed areas but foreign to
American operating room culture is the use of transfer forceps. The forceps, which
can be any kind of grasping instrument, are kept with the tips of the instrument
soaking in an antiseptic solution. Whenever a sterile instrument needs to be transferred
from one place (a soaking solution pan) to another (a sterile OR instrument
table) the transfer forceps are used. Remember, sterility is relative!
Equipment
Most of the equipment you find in DW hospitals won’t approach any American
hospital standards. The hemostats, needle drivers, and forceps are usually “sprung”.
These instruments can, however, be used for some if not most of the basic operations
you will perform. It is best to carry a good set of basic instruments in your
suitcase to use for any operations that require more precise manipulations. We recommend
needle holders, tissue forceps, hemostats, and an assortment of scissors,
especially fine curved iris scissors. If you protect them with your life, they will last a
long time and make your difficult cases a lot more fun. There are some other pieces
of equipment that will improve your outlook on life during your tenure in the DW.
A fiberoptic headlight is phenomenally useful. A small unit will fit into a part of a
suitcase and is well worth your time in packing it. Many regions where you are
going use 220 volt current, (necessitating) and you will need to take along a transformer
of some kind. Try to take the smallest and most light-weight one that will do
the trick for you. (Talk to Radio Shack about travelers’ transformers.) An electrocautery
is quite useful but most units are bulky as well as heavy. They also require a
relatively heavy transformer. If you are going to do very extensive dissections, it is
well worth the excess baggage charge; but, believe it or not, hernias and appendectomies
can actually be performed without an electrocautery. Operating loupes are
quite valuable for older surgeons (like the authors) when performing precise operations
such as pediatric cases and tendon/neurovascular repairs. Disposable operating
tourniquets can be obtained from most American operating rooms and are quite
helpful in DW situations. A standard football or bicycle pump can be used for
inflation. With a little imagination a manometer can be placed in the system using
a 3-way stopcock with all 3 ways opened.
After the correct pressure is obtained while pumping, the tube going to the tourniquet
proper is clamped securely. The pressure that you set will be maintained
quite well as long as the tourniquet has no leaks and the clamp is tight enough. A
rechargeable cordless drill can be gas sterilized after proper charging and used on
low speed (to prevent burning of the bone) for orthopedic cases requiring a lot of
drilling such as external fixator placement. An assortment of drill bits from a US
hardware store is also helpful.