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Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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Medic<strong>in</strong>e Writ Large <strong>in</strong> <strong>the</strong> Raw, without Power or Plumb<strong>in</strong>g<br />

hospital ambulance. The fish<strong>in</strong>g l<strong>in</strong>e is calibrated to a certa<strong>in</strong> test weight break<strong>in</strong>g<br />

strength <strong>and</strong> comes <strong>in</strong> 100 meter rolls at <strong>the</strong> same price as a s<strong>in</strong>gle swaged-on suture!<br />

Sk<strong>in</strong> Graft Knives <strong>and</strong> Reusable Resharpenable Equipment<br />

I have found <strong>in</strong> my own personal experience, with not atypical perversity, that I<br />

do not abuse equipment that I will have to live with, as I know <strong>the</strong>re will be no<br />

replacements. I frequently pry <strong>and</strong> stress with disposable needles, bend<strong>in</strong>g or even<br />

snapp<strong>in</strong>g <strong>the</strong>m <strong>in</strong> First <strong>World</strong> ORs s<strong>in</strong>ce <strong>the</strong>re will always be ano<strong>the</strong>r h<strong>and</strong>ed to me<br />

to test aga<strong>in</strong> <strong>the</strong> tensile strength of man, memory <strong>and</strong> equipment. I do not break a<br />

“permanent” needle, s<strong>in</strong>ce I know I cannot abuse it, s<strong>in</strong>ce <strong>the</strong>re will not be ano<strong>the</strong>r<br />

to replace it—perhaps that is what makes it, as it is called, “permanent.” I must<br />

respect its uses <strong>and</strong> limits <strong>and</strong> its f<strong>in</strong>ite life if abused. Most good equipment does not<br />

wear out <strong>in</strong> <strong>in</strong>dicated use. Almost all such require ma<strong>in</strong>tenance, however, to keep<br />

<strong>the</strong>m useful—<strong>in</strong> <strong>the</strong> case of such needles <strong>and</strong> <strong>the</strong> next item to be discussed—<strong>the</strong>y<br />

need to be sharpened.<br />

Sk<strong>in</strong> graft<strong>in</strong>g is a frequent operation <strong>in</strong> tropical sett<strong>in</strong>gs, for resurfac<strong>in</strong>g burns,<br />

scars, tropical ulcers <strong>and</strong> necrotiz<strong>in</strong>g <strong>in</strong>fectious complications. Every general physician<br />

should have <strong>the</strong> capability of sk<strong>in</strong> graft<strong>in</strong>g as one of <strong>the</strong> half dozen operations<br />

that each should know <strong>and</strong> be able to do.<br />

Padgett, or Brown dermatomes <strong>and</strong> <strong>the</strong> compressed air supply to run <strong>the</strong>m are<br />

dist<strong>in</strong>ctly absent <strong>in</strong> develop<strong>in</strong>g world sett<strong>in</strong>gs. The Humbie knife may be available,<br />

<strong>and</strong> is appropriate technology for most of such sett<strong>in</strong>gs but most often <strong>the</strong> best way<br />

to take a split thickness graft is to learn <strong>the</strong> freeh<strong>and</strong> Thiersch graft method. This<br />

can be done without special order<strong>in</strong>g any k<strong>in</strong>d of dermatome. A large, long<br />

carbon-steel breadknife is <strong>the</strong> device that is most useful for harvest<strong>in</strong>g a split graft,<br />

provided it is sharp. It can be sharpened <strong>the</strong> same way that <strong>the</strong> barber-surgeons<br />

would have advised earlier <strong>in</strong> our profession’s history—a lea<strong>the</strong>r strop. With a knife<br />

thus sharpened <strong>and</strong> an assistant hold<strong>in</strong>g <strong>the</strong> sk<strong>in</strong> taut, a th<strong>in</strong> flap of sk<strong>in</strong> can be lifted<br />

with this reusable blade.<br />

Once aga<strong>in</strong>, all reusables are safe if well-ma<strong>in</strong>ta<strong>in</strong>ed, <strong>and</strong> if scrupulous, compulsive<br />

attention is <strong>in</strong>vested <strong>in</strong> <strong>the</strong> tra<strong>in</strong><strong>in</strong>g <strong>and</strong> monitor<strong>in</strong>g of <strong>the</strong> clean<strong>in</strong>g <strong>and</strong> steriliz<strong>in</strong>g of<br />

each piece of equipment before any reuse. This is an important feature of any tra<strong>in</strong><strong>in</strong>g<br />

program, s<strong>in</strong>ce ALL equipment, whe<strong>the</strong>r marked permanent or disposable, is sure<br />

to be reused until it falls apart our obligation is, <strong>the</strong>refore, to make sure that it is<br />

cleaned, ma<strong>in</strong>ta<strong>in</strong>ed <strong>and</strong> sterilized appropriately before its next use. This process, <strong>in</strong><br />

my op<strong>in</strong>ion, though perpetual, is not as <strong>in</strong>surmountable as <strong>the</strong> cont<strong>in</strong>uous procur<strong>in</strong>g<br />

of unaffordable supplies from <strong>in</strong>secure sources. This system of reuse works for a<br />

very simple reason— because it must.<br />

IV Fluids <strong>and</strong> Blood<br />

Even if I had blood available for my use <strong>in</strong> Central Africa, it is unlikely that I<br />

would choose to use it for a variety of reasons that hardly need be spelled out to<br />

anyone attuned to <strong>the</strong> frequency of transmissible lethal blood-borne diseases <strong>in</strong> this<br />

area of <strong>the</strong> world. I must make policy decisions on what k<strong>in</strong>ds of operations can be<br />

done <strong>and</strong> on whom to do <strong>the</strong>m based on <strong>the</strong> fact that <strong>the</strong>re is no blood bank <strong>and</strong> on<br />

<strong>the</strong> assumption that, with few exceptions, <strong>the</strong>re are no available “walk<strong>in</strong>g blood<br />

bank donors” with<strong>in</strong> <strong>the</strong> family that are suitable. Even before <strong>the</strong> spread of HIV<br />

seropostivity, <strong>the</strong>re was <strong>the</strong> simpler fact of <strong>the</strong> Rob<strong>in</strong> Hood policy of tak<strong>in</strong>g blood<br />

from someone with a hematocrit <strong>in</strong> <strong>the</strong> twenties to give to some relative with a<br />

29<br />

5

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