Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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400 Surgery and Healing in the Developing World
Operations that last longer than 90 minutes, are complicated or potentially
life-threatening in one way or another or involve significant blood loss indicate the
need for an additional assistant with training in anesthesia. This is of course also
true for patients who are unstable or who require general anesthesia.
Surgeons have performed complicated and difficult surgery in a wide variety of
primitive settings, some of which may be important for surgeons in training to
experience. Almost any clean, well-ventilated, screened and well-lighted room (including
a tent) will serve as an operating room. The table only has to be long enough
and high enough, narrow, sturdy enough, and well-padded to protect the patient.
Operating room lights can be fashioned out of 12-volt automobile lights or standard
fluorescent lights in parallel or attatched to a square wooden frame. Although
air-conditioning has many advantages, it is not strictly necessary. If the operating
room is kept dust-free, a clean electric or battery-powered fan can cool both the
patient and the surgeons without significantly affecting the postoperative infection
rate. Suction can be provided by small electrical vacuum pumps (even a vacuum
cleaner attatched to a suction cannister) or by foot-operated pumps.
Suture material can sometimes be a problem. Residents should gain experience
with as many suture materials as is practical. They should also learn to use “fishline”
sutures. This kind of suture is made for 36 inch lengths of locally available fishline.
The precut lengths are soaked in a sterilizing solution and removed and rinsed with
sterile water as needed. These suture materials require that an appropriate selection
of sterile surgical needles be included in the autoclaved surgical packs.
A wide variety of techniques are used around the world to sterilize surgeons’
hands and forearms prior to gowning and gloving. In the developing world some
have resorted to boiling water in basins for surgeons to use in scrubbing themselves
and their patients. Our experience has not demonstrated that sterile water has any
advantage over scrubbing and rinsing with clean but untreated river or rain water in
preventing the development of postoperative infections.
The Resident’s Manual and the Yearly Contract
Below is a suggested list of subjects that should be spelled out in a manual for the
resident:
The Resident’s Manual
1. Responsibilities of the resident
A. Supervised and unsupervised ward rounds
B. Night and week-end call
C. Limits of responsibility
D. Team leadership
E. The resident’s operative logbook
F. Preparing and presenting monthly written case reports or research
projects (include examples)
G. Hospital rules and regulations
2. Responsibilities of the Program Director
A. “Hands-on” training from day 1
B. Formal teaching conferences
C. Reviewing and correcting written papers
D. Preparing in-service examinations
E. Developing the surgical library, ordering textbooks