Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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.