Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Guide to the Operating Theater on $25 a Patient
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this for many thousands of procedures without suture-related problems. When the
author mentioned this to a professor of surgery, he commented that he had always
known that the fishermen got the best nylon!
Spools of silk can be similarly autoclaved, then threaded onto French-eye needles
for bowel surgery, again at great cost savings. There are situations in many operations
where absorbable sutures must be used. In these cases, a surgeon must get used
to doing almost all tying using an instrument tie. One should be able to do a hysterectomy
with three or four packets of absorbable suture total, discarding only 3-5 cm
per tie. Visiting surgeons from abroad often need to have this emphasized.
The local fishing or camping store must be visited also for the purchase of a
battery operated headlamp for the inevitable time when the power goes off. Headlights
that use 1.5-volt batteries and can be focused are very effective and inexpensive.
A separate theater light made from an automobile headlight and connected to
a 12-volt battery is a valuable standby in many theaters worldwide. A system in
which this light comes on automatically when power fails is ideal. A portable footpowered
suction machine complements this for those occasions when power is lost
during an operation.
Re-sharpening of all instruments, particularly fine plastic and ophthalmic scissors,
will greatly prolong the life of these expensive surgical tools. One excellent
small instrument sharpener is made by Reciprocating Honing Machine Corporation,
1301 E. Fifth St., Michawaka, IN 46544 (email: rxhoning@michiana.org)
and retails for about $1,250. Hospital networks can pool resources and save a great
deal with this investment.
Economizing in the Laboratory
Most theaters in the developing world depend on a functioning lab for some
essentials. A packed cell volume (hematocrit) is a basic preoperative screen for any
procedure requiring more than local anesthesia. If a tourniquet is to be used in an
area where sickle cell disease is common or if there is anemia on the packed cell
volume, a simple sickling test, using 2% sodium metabisulphite should be performed.
A hemoglobin electrophoresis is ideal but will greatly add to the cost. A Wright’s
stain for a differential is another readily available, inexpensive test with a great deal
of information on RBC morphology and platelets as well as the WBC differential.
Not infrequently, the surgeon and anesthetist will need a potassium level on a
person who is dehydrated or who has had a great deal of emesis or diarrhea. The
equipment for this test may be non-functioning or reagents unavailable. Use of an
ECG machine or cardiac monitor will be very helpful. If a short strip shows a T
wave and there are no U waves, the likelihood is that an adequate level of serum
potassium is present for induction of anesthesia. On the other hand, the presence of
spiked T waves or a U wave mandates further therapy directed at potassium normalization
before anesthesia is safe.
A blood bank is essential for some operations, but no blood should ever be used
without good history and an HIV antibody screen on the donor. Every surgeon in
the developing world can recite stories of tragedies that ensued when that policy was
not followed. There are situations in which a hospital may have run out of typing
sera for determination of basic blood type. In this circumstance a laboratory can
make its own anti-A and anti-B if it knows of one person with type A blood (and
therefore an anti-B serum) and another with type B. There is no substitute for the
Coomb’s test, but in a life and death situation in a male or gravida 0 female, blood
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