Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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170 Surgery and Healing in the Developing World
can be crossmatched one time without it. It should be emphasized in the developing
world where coronary artery disease is rare, most patients can tolerate a packed cell
volume of 20% or even less if adequate intravascular volume is maintained.
The preferred blood transfusion is, of course, autotransfusion. The operating
theater on a very tight budget (the nature we are discussing) would not have access
to the very expensive cell savers in many modern theaters but can certainly afford a
stainless steel soup ladle.
Blood in the abdomen from a ruptured tubal pregnancy or ruptured spleen, for
example, where there is no contamination from a ruptured viscus, can be rapidly
scooped up—without hemolysis from suctioning—run through a gauze filter and
infused through a blood-giving filter.
A good microbiology lab is helpful, especially if antibiotic abuse is prevalent.
Such a lab however may be unavailable, and there are helpful hints to be obtained
from a Gram stain. A positive blood culture may be assumed if one spins a packed
cell volume microhematocrit tube and breaks it at the buffy coat and finds organisms
in the buffy coat. If an odor is present on an intraabdominal abscess, one can
assume there are anaerobes present. The Gram stain can predict the type with fair
accuracy that, if it is a gram negative bacillus, it is likely to be Bacteroides. If it is a
Gram positive coccus, it is likely an anaerobic streptococcus. If it is a Gram positive
bacillus, then one of the Clostridium species is likely present.
In this era a glucometer should be in every lab even though the reagent strips are
expensive. When a history suggests a need, spend a strip. Make sure the nocturia is
from benign prostatic hypertrophy and not diabetes if you are planning prostate
surgery.
In an ideal world there would be many tests available in every lab. Yet in many
countries the entire health budget per capita is spent with one basic lab test per
person per year.
Anesthesia Cost Containment
A complete discussion of anesthesia is beyond the scope of this chapter, but there
are some areas where cost savings can be safely achieved. There is not a surgeon
practicing in the developing world who has not said, “Thank God for ketamine.”
The author was present at the first announcement of the drug by pharmacologists at
the University of Michigan in the early 1960s. Not even they could have predicted
how many lives worldwide would be saved with ketamine anesthesia. A wide range
of operations from reconstructive to emergency surgery to obstetric and routine
general surgery are possible with ketamine at relatively low cost. Ketamine is best
used with anticholinergics like atropine to decrease secretions. In adults the addition
of diazepam will reduce the incidence of emergence phenomena. Oximetry
adds greatly to the safety of ketamine. If hypoxia occurs, airway manipulation with
a jaw thrust usually is all that is required although occasional oxygen by mask is
necessary as well. Surgeons and anesthesiologists must recall however that this anesthetic
is contraindicated with increased intracranial pressure, a history of seizure
disorders, uncontrolled hypertension and procedures in the upper airway such as
bronchoscopy for foreign bodies. In these situations the least expensive alternatives
are local block if feasible, spinal anesthesia if appropriate, ether or fluothane. The
newer drugs like ethrane and propofol would rapidly bankrupt a hospital. The author
is aware of and has seen in use a technique to do two consecutive cases with one
vial of spinal anesthetic, particularly with the less readily available long-acting agents