Surgery and Healing in the Developing World - Dartmouth-Hitchcock

CHAPTER 1
CHAPTER 5
Medicine Writ Large in the Raw,
without Power or Plumbing
Glenn W. Geelhoed
How Can I Practice Surgery without the Tools that I Am
Used to Using Available in a Setting I Do not Understand?
It is not easy. But, it is not impossible. Medicine is not professional “stuff” it is
specialized information that is very easily portable and adaptable, even if its plumbing
and power fixtures are not. Adaptation of fundamental principles makes far
better sense for sustainability than the importation of fancy tools with embedded
chips, or nursing the cast-off obsolete equipment discarded by First World facilities,
often shipped (without spare parts) as “white elephants” to encumber the recipient.
I have operated on each continent in settings which were not equipped with running
water, autoclaves, electricity for light and power tools, relying often on the
ingenuity of those who are already there and who did not think it odd that some
indispensable (to my mind) piece of equipment was missing. Having never had the
experience of the use of such sine qua non they struggled on with what they do
best—getting the job done with what they can rig up at hand.
Scrub Sinks and Preop Prep
“Running water” is what I had described in my Congolese scrub sink when
Kigale would run for the water. After masking with cloth mask and donning the
cloth hats (in preparation for the later sterile cloth gown) I would scrub my hands
and arms with a bar of soap and a scrub brush. I had previously proven in the
decidedly First World setting of the National Institutes of Health that Rodac culture
plates had proven that mild hand soap was as good as most other prepping methods,
and was superior to stiff-bristle prolonged brush scrubbing with toxic bactericidal
soaps. At the conclusion of the scrub, Kigale would pour the water from a pitcher
over my hands for the rinse, and then a second pouring of a Hibiclens (or whatever
other solution was available, usually reconstituted from powder and made up fresh
locally) over the rinsed arms and hands.
The “theatre sister” had meanwhile prepped the patient over the area of the
operative field. This did NOT mean a razor shave for hair removal. Again, in my
First World studies of alternate skin prepping and hair removal methods in the
first-world context of George Washington University Hospital, the lowest bacterial
counts were obtained by means of the simplest skin preps and the worst were achieved
through razor shave and iodophor patient skin scrub. Deprivation, in this instance,
had made for superior preparation efficacy and timing, and our exotic “theatre time”
is not cluttered with a lot of nonoperative ritual preceding getting directly to the
Surgery and Healing in the Developing World, edited by Glenn Geelhoed.