Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Medicine Writ Large in the Raw, without Power or Plumbing
OR Lighting
We have all done operations under hand-held battery-powered flashlights, if there
is the luxury of someone nearby to hold it and knows the direction into which to
shine the beam to illumine what we are trying to see. This is a problem that has
made this effort much greater than the fleeting glimpses of what we wish to see and
thereby block the flashlight holder out of the line of sight of what should be illumined.
There has to be a better way. There is.
There are optical headlamps many of you may have used which are often
custom-fitted with loupes and other means of “designs for vision.” This is the right
idea, but the cost of such a system is more than the capital and operating budget of
at least one busy operating theatre I know that works very well on far less.
For any of you who may be mountain climbers, you may be familiar with the
Petzel type of headlamps, worn during the early starts (usually at midnight) on
summit assaults. These make for nearly perfect OR headlamps at a cost, that does
not carry the huge liability surcharge that comes along with the indication “for
medical use” stamped on other lamps—even though these may be every bit as much
“life-saving.” A very well-used model is seen worn by Dr. Laji Varghese in Lady
Willingdon Hospital, Manali, India where he wears it through a typical 30-case
theatre list.
For a more permanent overhead light there are also solutions that work—even in
the absence of an electrical outlet. Solar panels are useful in collecting daylight (remember
that an equatorial environment will have a “perpetual equinox” in which
twelve hours of sunlight are expected with the minor exception of periods of heavy
rain). This primary sunlight energy can be stored in large storage batteries. These are
often available as donations or at reduced rates to maintain the “cold chain” for
vaccine refrigerators from multilateral donor agencies. The output from such a storage
battery can be hot-wired to an overhead lamp—usually the rectangular automobile
sealed beam headlamps work best. This is a quite satisfactory “OR Light” with
the possible exception that it gets quite hot burning brightly next to the surgeon’s
ear. A full day’s solar power does not quite translate to a twelve hour running of the
lamp, however, and the surgeon would use this resource sparingly during only some
critical parts of the case. For example, one would not turn on the light for a skin
incision, if there are many more cases to be done that day, but would certainly use it
while dissecting the ureters free during a hysterectomy for a large fibroid uterus.
Twelve hours of sunlight gives about four hours of appropriately used illumination,
given the size storage batteries that can be carried to a field hospital and reconstituted
with their dangerous load of acid.
Suction to Clear the Field
Hemostasis is a principle more completely developed by those who operate without
the backup of a blood bank and the lack of such abundant means of clearing the
dissection field with unlimited sponges, use of electrocautery and suction with irrigation.
The latter is possible using a mechanical foot-pumped suction device. It is awkward
for the surgeon in some instances to be pumping the suction while attempting
to see and control a source of deep bleeding, but the foot pump can also be pumped
by an aid. It works—and just enough. Like most things that can be jury rigged in
Third World settings, there is not a lot of redundancy, and waste—of material,
effort, and time are minimized with a limited margin for error. These constraints
27
5