Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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198 Surgery and Healing in the Developing World
the area. Often these are lethal depending on the distance of the victim from the
mine.
Pattern 3 injuries result from handling mines. This may from attempting to
disarm them or playing with them as toys. The injuries often cause loss of one or
both hands or blindness.
The initial treatment of these injuries is basic good trauma care, if the patient
arrives in time. Remember that half of the victims never get care. In many countries
the patient is two or three days from a surgical facility by horse drawn cart. A tourniquet
may be placed on an extremity and left on for a day or two. In many countries
in rural hospitals there may be no anesthetics, antibiotics, or blood unless the
patient or his family has cash to pay for them. Most bedside nursing care including
feeding is done by family. Without that family care, the patient may well die.
If the patient does arrive, he is probably in shock. In many hospitals prebottled
IV fluid is too expensive. It is easy to make a still in most hospitals to make distilled
water to locally manufacture IV saline and dextrose solutions.
The ICRC has made many videos and written many manuals on extremity trauma.
Their basic philosophy is to radically debride the wound initially remembering a
mine forces dirt up into the extremity underneath skin flaps and muscle planes.
Dead dirty tissue may be well proximal to the initially perceived wound. Debride
and dress the wound open. Then bring the patient back to the operating room in
four or five days for dressing change, redebridement, and possible closure. Do not
change dressings on the ward. The ward is not as clean as the OR and dressing
changes are painful and really, even if “wet to dry” do not debride a wound well.
Only return to the OR earlier if there are signs of sepsis.
In the experience of the ICRC, whose field hospitals are much better equipped
than many rural surgical hospitals, most mine victims are in the hospital for an
average of a month.
Rehabilitation
Once an amputee is discharged, hopefully he will get a prosthesis. In many developing
countries there is no good tax base, so rehabilitation facilities may exist,
but production may be very low as the prosthetists are often not paid. A great deal of
prosthetic work is done by voluntary nongovernmental organizations (NGOs).
Making a prosthesis once for a patient is not enough. All parts wear out and need
repair. These desperate war torn countries need permanent prosthetic industries to
care for the disabled. The ICRC and Handicap International (HI), as well as many
other groups, do excellent training of local staff to make strong, well-fitting prostheses
out of locally available inexpensive materials that can be repaired easily. Maintaining
these shops is difficult once the outside agency leaves.
Clearing Mines
Mine clearing is the only effective way to prevent injuries in many countries.
Mine detection can be done my metal detectors or dogs. Both methods are expensive.
Once a mine is suspected as being present, the mine clearing must probe the
ground inch by inch to find the mine and destroy it. Most alerts by mine detectors
are false positives from shells or bottle caps. Mine clearing therefore is slow and
dangerous. New methods to detect mines are being developed, but no new technology
yet equals the hand method. Big mine clearing machines are good to get most of the
mines out of the ground for military breaching of a mine field but are not thorough
enough to allow a field to be farmed.