Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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28 Surgery and Healing in the Developing World
often perfect operating technique, since there are few safety nets of consultation or
redundant systems of substitution for surgical skill.
For fixed suction devices, such as receptacles for chest tubes after tube thoraco
stomy, nothing beats the simplicity and reliability of water seal drainage. A bottle
(not necessarily medical) is half-filled with water and two glass or metal tubes are
inserted through the stopper, one advanced to nearly the bottom (which is hooked
to the patient’s chest tube) and one to just a few centimeters under the water’s surface
(the one open to the atmosphere). The difference in depth between the submerged
depths of the two tubes is the number of centimeters of “water seal” for the
thoracostomy. This simple system works flawlessly—until and unless—the bottle is
broken, kicked over, or the patient is moved, and someone tosses the bottle on its
side in the litter to go with the patient.
The way I might handle this is to tell the patient, that he or she is the guardian of
the bottle and it must stay in just this position, and demonstrate how it must be and
how it must not. I then make sure that someone else in the family also knows, and
they are delegated to take turns around the clock making sure that nothing disturbs
the genie in the bottle. Thus involved in their own care on their own terms, the
frequency of finding a bottle lying on its side in the patient’s bed with the fluid
drained into the patient’s chest and a sucking sound coming from the fluttering end
of the atmospheric tube is somewhat reduced.
Cautery and Hemostasis
Electrocautery is a nonstarter. The small hand-held, battery-powered “disposable”
pencil cauteries have been quite helpful, especially since I have scavenged the
once-used items from First World ORs and reused them until they were disposed of
only when they ran out of energy completely. I have also carried the skin staplers
that had only a few fired from the capacious clip in developed world ORs, and been
able to reuse such a device on multiple patients. Since these “single-use devices” are
designed to be disposable and would self-destruct if the manufacturer were told that
they are being reused, they cannot be reloaded with new batteries or clips. So much
the worse for the manufacturer’s imagination, and the better for your own ingenuity
in coaxing new life and multiple purposes out of the disposable world’s products!
Suture ligature is more commonly employed than cautery (and certainly more
than topical hemostatic agents—just not worth it) in the settings of the developing
world. The best means for applying sutures is by means of a suture threaded through
the eye of a permanent needle, or, particularly, the use of “French-eye” needles for
rapid suture loading. Swaged-on needles are, by nature, disposable, and they are also
limited in the utility they have for a given patient. They must all be imported as
“luxury items”. We have even resorted to smuggling by volunteer physicians since
they have been taxed at a tariff higher than their already exorbitant purchase cost. In
two possible areas—vascular suture (which is fortunately rare to nonexistent in the
developing world anyway), and ophthalmology, I would prefer to stay with permanent
needles (resharpened and “unbent” periodically) and save considerable money
through the simple labor of threading needles.
Almost all physicians working in Third World settings know the tremendous
advantages of monofilament fishing line as a very useful “general closure” nonabsorbable
running suture for fascial closure. One hospital in Tanzania switched to
monofilament fishing line from specially prepared monofilament suture, and by the
end of the year had realized cost savings enough to purchase a Land Rover as a