Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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168 Surgery and Healing in the Developing World
autoclave tape or other markers can assure full sterilization. The author spent some
time at a hospital in the rain forest where all autoclaving was done with a pressure
cooker on a wood-burning stove.
Gas sterilization is very useful for items that cannot tolerate the high pressure
steam of autoclaving. Yet the actual equipment for this can be very expensive. And
the standard chemical used for this, ethylene oxide, is a very flammable solution that
cannot be transported by air and is unavailable in many developing countries. Every
day in many places in the developing world disposable equipment is used and discarded
after each operation, often at a cost of several hundred dollars (US). However,
equipment such as electrocautery pencils and laparoscopic trocars are being
reused in hospitals with severe cost restraints after sterilization with formaldehyde.
Several studies have confirmed the efficacy of re-use. A very economical chamber for
this sterilization is an old refrigerator with a good seal on the door. Leaving equipment
overnight in a stainless steel pan, exposed to 5% formalin fumes or paraformaldehyde
tablets in a refrigerator can be a major cost-saving practice. One protocol
uses 7 g of formalin tablets per cubic meter. A light bulb in the refrigerator helps the
vaporization process. The area around the refrigerator must be well-ventilated for
the periods when the chamber is emptied and the sterilized equipment rinsed with
sterile water or saline and aerated. A minimum of 12 h is recommended, and all
organisms are killed within 24 h, including HIV. Some hospitals will use soaks during
the day for equipment such as laparoscopes, cystoscopes and connecting cords
but do a gas sterilization with formalin at night. Equipment such as disposable
trocars and cautery pencils will be used only once between formalin sterilizations.
Most cost-conscious hospitals where labor costs are quite inexpensive reuse sterile
gloves. The heavier orthopedic gloves are especially useful for this practice. And,
on the other hand, good surgical gloves should not be wasted on routine dressing
changes. Instead, plastic bread bags which are cheap and readily available are excellent
for dressing changes, doing rectal exams and for generalized protection of the
examiner for evaluating such areas as groin and axilla or for other contacts with
bodily secretions. A pocket in the white coat should be kept full of them.
In addition to strict sterile technique, high quality surgery with good outcomes
requires high quality monitoring in the theater. Continuous electrocardiography
may not be available in some centers, but all hospitals should invest in a continuous
oximetry monitor. These monitors carry a warning that they should not be used
with flammable anesthetics. If ether is a mainstay inhalation for a hospital, the battery-operated
rechargeable model is probably safe and will be one of the best
$US1,000 investments the hospital can make. Regular blood pressure monitoring
and continuous auscultation of the precordium through a single earpiece stethoscope
add to safety.
The cost-conscious hospital can save a great deal on suture in a number of ways.
In places where nylon might be used, fishing-line will substitute nicely. Skin can be
closed with 4 pound test line. Fascia can be closed with 12 pound test line. If retention
sutures are desired, 20 pound line works well (and large buttons from the market
work well as bridges for tying these). At least four square knots (5 throws) should
be used for the fish-line. A board 18-inches long with a V-notch cut at each end is
used to wrap the nylon or to lay it straight for autoclaving. It is best to autoclave
only that amount of nylon needed for one case so that autoclaving is not repeatedly
done on the same nylon. The nylon is threaded onto small cutting needles for the
skin and round-body needles elsewhere. The author and many colleagues have used