Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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384 Surgery and Healing in the Developing World
working on the border between Zaire and Sudan; that is, 1,300 km away from
Kisanga and 450 km from Nyankunde. For the moment we have five nurses in
training (with a short programme of orthopedic training).
The nursing background (A2=4 years of training in a nursing school as secondary
level or A1=3 years in a Technical Medical University College) means that they
are already familiar with basic elementary professional techniques such as venipuncture
for intravenous fluids, vesical probind, and resuscitation methods. In their previous
Health Centres, they had gained experience in conducting consultations and
in the differential diagnoses of obstetric cases. They are able to perform normal
deliveries, to apply a vacuum extractor and, especially, to diagnose different complications
indications for caesarean section. Upon this background we have built the
practical surgical training of 18 months.
The nurses are able to do most of the surgery listed in Table 5 except laparoscopy.
They perform reductions of fractures and pinning of bones. Briefly, they are able to
do urgent and routine surgery including gynaecology-obstetrics, general surgery and
traumatology.
Discussion
Nurses can usually be found in remote areas in Zaire. The lack of available medical
personnel in isolated health districts means that much of the medical work is
done by the nurses. Our results show that much of the urgent, vital and routine
surgery can be done by nurses, provided that they are specifically trained.
To allow nurses to do surgery is not without precedent in the history of our
country. One will remember that at independence, hospitals (and surgical centres)
were left to personnel with only basic practical training, who treated all illnesses and
often managed operating theatres. Sometimes the only surgeon was the orderly. The
situation has not changed in some areas of our country where the lack of specialists
in surgery is critical. A well-trained surgical nurse, as shown by our results, can help
enormously and can save many lives.
The training of nurse practitioners has been attempted in other countries, especially
in general medical areas, with encouraging results. 3 The duration of the training,
longer in our programme than in the Ethiopian experience, can be explained by
numerous factors, amongst which is the basic level of training of our nurses (3-4
years) which is less than that of doctors (7 years). That period allows us to establish
surgical aptitutde that we believe to be necessary for someone who will eventually
work in an isolated area, without him/her assuming unauthorised responsibilities.
The specialisation in surgery for nondoctors is gaining popularity throughout
Africa. We cite the experience of the Malawi Orthopedic Project which trains Orthopedic
Clinical Officers, who offer services of tremendous value in that country. 4
Given the services that nurses trained in surgery can give in the remote areas of
our country, we believe that their training enables them at least to do urgent, vital
and routine surgery such as caesarean sections, laparotomies for ectopic pregnancies
and manage trauma patients. This is a necessity for some African countries where
there is a critical lack of surgeons. We cannot compare ourselves with rich countries
which have sophisticated infrastructures and sufficient qualified medical-surgical
personnel. We encourage consultations such as those at the recent conference in
Blantyre 5 where ideas and experiences can be exchanged and a policy of orientation
in surgical disciplines in the tropics can be formulated for nondoctors. Poverty and
the limitation of resources, as well as the potential competence of nurses, have encouraged
us to use this option.