Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Guide to the Operating Theater on $25 a Patient
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such as pontocaine. After the first dose of 1 ml or less is drawn up, a sterile cotton
ball is used to cover that vial for use a couple of hours later. While not ideal, this
does work if a hospital is down to its last vials.
An oxygen concentrator is very cost-effective, especially in areas where bottled
oxygen is difficult to obtain or is very expensive. An oxygen concentration of over
30% can be achieved reliably. With a cost-effective operating theater and laboratory
and anesthesia service in place, let us now consider specific disease entities where
cost-savings and improvisations can be made. For a comprehensive review of the
basic work-up and treatment of these diseases, standard texts and other chapters of
this book should be consulted.
Burns
Care of burns is an extremely expensive, time-consuming process. Yet burns occur
all too frequently in areas where cooking is done on open fires. Mortality is often
high and the morbidity of a tragic fire can lead to a lifetime of misery. Aggressive
treatment can limit those however. After the resuscitation phase, aggressive wound
care can make a major difference in the outcome and can save long-term costs. For
example, early excision and grafting of a third degree burn greatly speeds up the
healing process. A skin grafting blade is used to progressively shave off the nonviable
outer layers till a healthy, bleeding bed is apparent. One must be sure all nonviable
dermis is shaved off, even if it necessary in some places to go to the subcutaneous
tissue. It can be especially advantageous in the hand and foot. Burns over 15-20%
probably are not candidates for this method which is associated with considerable
bleeding, but the technique greatly accelerates healing and reduces cost. Dressings
are applied and primary grafting are done in a day or two. There is a huge difference
in the costs of various dermatomes. Brown dermatomes are favored by many surgeons
but are expensive, require a pressure power source and use fairly expensive
blades that can be used only a few times. The Padgett is also popular but relatively
expensive. The very popular Humby knife is an excellent substitute and should be in
every operating room in the developing world. But the cost of their blades is significant
too, and at times they will be “out-of-stock’, an all too frequent phrase in many
places. The Weck dermatome fills a big vacuum in that it is inexpensive and uses
very inexpensive blades. The drawback is the maximal width of only 5.5 cm for the
graft. Meshing or “pie-crusting” can increase that however. An assistant has to create
tension and a slight convex curve to facilitate its use (Fig. 1). The author greatly
favors use of the povidone iodine solution as the lubricant for taking the graft rather
than sterile mineral oil which has been found to stay in the graft site for a prolonged
time. The povidone-iodine solution is applied immediately before taking the graft.
Topical therapy for second degree burns not treated with early excision can be
very expensive and the widely used silver sulfadiazine is difficult to keep in stock if
major burns are being treated. One readily available and inexpensive substitute is
that of honey gauze which has compared favorably with other standard topical agents.
The gauze is prepared by dipping sterile gauze in slightly warmed, unprocessed honey.
The honey gauze is covered with absorbent dressing and changed every 2 days. Needless
to say, mosquito nets must be used for all burns and certainly all those being
treated with honey. For very superficial second degree burns, amniotic membrane
rinsed with saline and then soaked in antibiotics has worked as well as the very
expensive porcine xenograft, but in an era of rampant HIV in many areas, this is
probably not safe, even if the donor’s HIV status is known to be negative. Superficial
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