Surgery and Healing in the Developing World - Dartmouth-Hitchcock

18
174 Surgery and Healing in the Developing World
Orthopedics: Osteomyelitis
Most osteomyelitis cases present late, and antibiotic therapy is a waste of time
and money. It should be reserved for cellulitis or soft tissue infection. Instead the
involved bone is widely unroofed, provided the involucrum is solid, and sequestrum
removed, and the wound is packed open. Granulation begins with the clean healthy
marrow, and the wound eventually closes from the deep portion out.
Pyloric Stenosis in Infants
Hypertrophic pyloric stenosis is a common condition in most populations, and
surgical pyloromyotomy is the optimal treatment if safe pediatric anesthesia is available.
The cost of the diagnostic work-up can be greatly reduced if reliance is placed
on the use of aspirate of stomach contents. If the volume is greater than 5 ml after
the child has been NPO for 4 hours, the likelihood of pyloric stenosis is high. A
palpable “olive” or positive ultrasound (if available) clinches the diagnosis. If the
aspirate is less than 5 ml, pyloric stenosis is unlikely. This approach saves the cost of
barium X-rays and avoids unnecessary surgery.
Trauma
There probably is no area where the difference in care between “third” and “first”
world medicine is greater than in trauma management. Trauma care often is very
expensive and advanced technology very helpful. Yet, much can be accomplished
with fairly basic principles and practice. The “poor man’s” CT scanner is a scalpel!
Following the basic ABCs of trauma care aggressively is lifesaving and more economical.
The sooner bleeding is stopped, the less the run on the blood bank, the less
ARDS, et cetera. Basic principles like neck stabilization and splinting of fractures
are good medicine and helpful with costs. If real-time ultrasound is readily available,
this is a very useful, inexpensive diagnostic modality for early detection of bleeding
in the abdomen (and chest). Diagnostic peritoneal lavage can be accomplished easily
anywhere in the world. If a peritoneal dialysis catheter is not available, one can
make a couple of side holes in a 14-18 gauge angiocath and insert this while injecting
saline into the abdomen. After infusing 1 L NS or lactated Ringer’s solution, the
aspirate can be analyzed. If >10,000 RBCs per high power field are seen, lasparotomy
is indicated. Alternatively, one can try to read newsprint through the infusion tubing
during efflux and if letters are not legible surgery is advisable. Analysis of the
fluid for WBCs, bacteria and amylase may be useful. A detailed description of treatment
for every traumatic injury is beyond the scope of this chapter.
Tropical Ulcer
Relatively minor trauma can lead to chronic tropical ulcers that are progressive
and occasionally, after time, become malignant. The infection is polymicrobial and
can include fusobacteria, aerobes, and spirochetes. Aggressive debridement, dressings
with Silvadene or dilute povidone iodine solution (1:100), followed by skin
grafting, is the most cost-effective way of treating these as opposed to months and
years of dressings. Granulation tissue can be stimulated in relatively clean wounds
with granulated sugar. If the ulcer is in an area where a muscle flap can be rotated
onto the ulcer bed after debridement, long-term results are especially good. For the
Buruli ulcer caused by the atypical Mycobacterium ulcerans, a surgical approach is
also more effective than medical therapy alone.