Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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17 166 Surgery and Healing in the Developing World • Establish an institute or committee for the study of appropriate need-oriented and affordable evidence-based surgical training suitable for various national circumstances. • Establish seminars or colloquia for Third World surgeons to share experiences and techniques for solving surgical problems with innovative inexpensive measures. • Encourage governments and colleges to provide for the main surgical needs before moving to more complex and expensive options. • Establish a clearing-house with advice for surgeons traveling overseas to cover such matters as liability insurance, health needs, malarial and other prophylaxis, etc. • Explore options to assist new trainees with managing student loans and other matters in order to facilitate their involvement abroad. • Promote the establishment in General Surgery training programs of a “rural” training stream with a broader scope of experience. • Consider programs to bring patients from unserved regions to North America for surgical care. The needs in our world for surgical care are growing and the supply is dwindling. We can do better. We must do better. References 1. Blanchard RJW et al. The epidemiology and spectrum of surgical care in district hospitals of Pakistan. Am J Public Health 1987; 77(11):1439-1445. 2. Nordberg EM. Incidence and estimated need of Cesarean section, inguinal hernia repair, and operation for strangulated hernia in rural Africa. Br Med J 1984; 289:92-93. 3. Garrido PI. Training of medical assistants in Mozambique for surgery in rural settings. South African Journal of Surgery 1997; 35:144-145. 4. Ajayi OO. The effects of local pathology and disease patterns on the training and practice of surgery. Trans Coll Med South Afr 1987; 31:161-164. 5. Barker EA. Surgical techniques and priorities. Proc R Soc Lond B 1977; 199:69-72. 6. Du Plessis DJ. The development of surgery in Southern Africa. In: Cook J, ed. Collected papers (1958-1979). Edinburgh: International Federation of Surgical Colleges, 1982:50. 7. Loutfi A, McLean APH, Pickering J. Training general practitioners in surgical and obstetrical emergencies in Ethiopia. Tropical Doctor 1995; 25(suppl 1):22-26. 8. Ajayi OO. Surgical training in 21 st -century Africa. S African J Surgery 1999; 37:1,3-5.
CHAPTER 1 CHAPTER 18 Guide to the Operating Theater on $25 a Patient Glenn P. Verbrugge In many hospitals in the developed world, operations in the theater are preceded by very expensive preoperative evaluations and the cost of the operation itself may exceed several thousand dollars US. For example, resection of a rectal malignancy may be preceded by a CT evaluation of the liver and pelvis, an endoscopic ultrasound and an extensive cardiac work-up. Monitoring in the theater, the reusable equipment and the disposable supplies add large amounts to the final bill, to say nothing of the labor costs. By contrast, for hospitals in the developing world, the entire cost for evaluation and operating theater expense must be in the range of $US20-$US30 per case. In many countries the annual federal health budget is less than $US1 per person per year. And yet high quality of surgery with very satisfactory outcomes is possible even in these situations. In this chapter the emphasis will be on cost-saving measures that do not compromise quality as well as modifications and improvisations that may be necessary in a developing world environment. One key to excellent outcomes is an emphasis on strict sterile technique. Hospitals must strive for an infection rate of less than 1.5% for clean surgical cases. Monitoring the uncomplicated hernia infection rate is a useful marker since virtually all hospitals perform a large number of these operations. There can be no compromise on standard measures for assuring sterile technique, and these are not expensive. Restricted access areas where street clothes and shoes are not worn add no cost. Closed gloving techniques where one’s fingers never touch the outside of the surgical gown add no cost and yet are not strictly practiced in some theaters. Many of these theaters employ reusable masks, but this is probably not a major contributor to infections unless a foreign material such as a metal plate is being used. (However goggles and fine micropore masks are part of universal precautions especially important in an era of HIV and hepatitis C.) Flying insects can pose a problem. All windows must be screened and carefully checked for perforations. Some hospitals add plastic stringers to hang from the top of doorways to discourage flies. An expert with the fly-swatter is invaluable. For the pesky fly that will not settle down, a spray by the anesthetist of succinylcholine will quickly paralyze the insect. An autoclave in good working order is essential. Unfortunately, many hospitals are reliant on one autoclave. A breakdown of this equipment would force closure of the theater and delivery rooms and would compromise many routine procedures. A very useful backup device to keep on hand is a large pressure cooker of the type used for canning. The packs are put in a stainless steel platform above the water, and Surgery and Healing in the Developing World, edited by Glenn Geelhoed.
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Surgery and Healing in the Developi
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Contents Foreword .................
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25. Dentistry .....................
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Editor Contributors Harold P. Adolp
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Foreword Surgery and Healing in the
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“poor, but modern”, as for exam
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There may be at least one considera
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It is that higher accountability th
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1 2 Surgery and Healing in the Deve
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CHAPTER 2 Surgery in Developing Cou
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2 10 Surgery and Healing in the Dev
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CHAPTER 4 International Surgical Ed
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CHAPTER 9 Lab-in-a-Suitcase: Saving
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10 72 Surgery and Healing in the De
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CHAPTER 12 Communication in the Thi
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CHAPTER 13 Anesthesia in the Third
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13 100 Surgery and Healing in the D
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CHAPTER 24 Outreach Dentistry: A Wo
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CHAPTER 1 CHAPTER 26 Reconstructive
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Reconstructive Surgery in the Tropi
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CHAPTER 1 CHAPTER 27 Factors Influe
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Distribution and Incidence of Tropi
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CHAPTER 1 CHAPTER 28 Population Dyn
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Population Dynamics Of Surgical Tro
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Metabolic Maladaptation 289 Introdu
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Metabolic Maladaptation 291 some of
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Metabolic Maladaptation 293 In this
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Metabolic Maladaptation Table 1. Si
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Metabolic Maladaptation Table 4. Go
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Metabolic Maladaptation 299 the rev
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Metabolic Maladaptation Table 5. As
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Metabolic Maladaptation Table 6. Co
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Metabolic Maladaptation 305 the ris
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Metabolic Maladaptation Table 8. Go
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Metabolic Maladaptation Table 10. G
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Metabolic Maladaptation Table 12. C
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Metabolic Maladaptation 313 cell an
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Metabolic Maladaptation 315 Biologi
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Metabolic Maladaptation 317 from io
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Metabolic Maladaptation 319 25. Lon
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CHAPTER 1 CHAPTER 30 Nutrition and
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Nutrition and Development in Africa
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CHAPTER 1 CHAPTER 31 Uterine Ruptur
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Uterine Ruptures in Rural Zaire Tab
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Uterine Ruptures in Rural Zaire 329
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CHAPTER 1 CHAPTER 32 Vesicovaginal
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Vesicovaginal Fistula in Democratic
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CHAPTER 1 CHAPTER 33 Ophthalmology
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Ophthalmology Figure 2. Refractive
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Ophthalmology Figure 4. A tonometer
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Ophthalmology 341 ml of 40 mg/ml IV
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Ophthalmology Figure 6. Axis determ
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Ophthalmology 345 thalmic set prepa
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Ophthalmology 347 Procedures Region
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Accommodating Deficits in Material
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Abscesses and Other Infections Trea
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CHAPTER 1 CHAPTER 36 Surgical Train
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Surgical Training of Nurses for Rur
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Training of Medical Assitants in Mo
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CHAPTER 1 CHAPTER 38 Training Surge
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Training Surgeons in the Developing
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Mobile Surgery Figure 1. 405 of tec
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Mobile Surgery Figure 3. 407 Childr
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Mobile Surgery 409 We have realized
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CHAPTER 1 CHAPTER 40 Public Health
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Public Health Problems on Burma Fro
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Medical Adventures in the Nigerian
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CHAPTER 1 CHAPTER 42 Wanted Glenn G
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Wanted 431 Studies Center (//www.am
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Wanted 433 MacArthur (The John D. a
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Wanted 435 most pathologic presenta
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Wanted 437 “outliers” in the he
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World Health 439 challenge: name fo
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CHAPTER 1 CHAPTER 44 Treating Other
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Treating Others: Human Sciences in
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Treating Others: Human Sciences in
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CHAPTER 1 CHAPTER 45 The Impact of
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The Impact of a Volunteer Medical M
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CHAPTER 1 CHAPTER 46 Field Notes on
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Field Notes on a Typical Day in a H
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Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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