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AUSTERE SURGICAL SITUATIONS

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According to RS Bransford, a Western surgeon working in a Sub-Saharan hospital, “The OR [operating room] is only marginally clean. You can see through the cloth you put on your operating table. Most in the OR, including their doctors, are marginally safe with regard to sterile technique.” (Personal communication, January 21, 2007.)

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In 2007, Anaesthesia published [2007;62(suppl 1):54-60] the following composite description of an OR in a very poor country, written by Drs. BA McCormick and RJ Eltringham, anesthesiologists with considerable developing-world experience:

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The general theatre has a cement floor painted red and polished, with pale green-washed walls. The windows are open because of the stifling heat and flies hover overhead, occasionally coming to rest on the surgeon’s mask or even the patient himself. The patient lies on an archaic-looking operating table. One end is supported on a trolley that prevents its faulty tilt mechanism from allowing it to collapse to the floor. The surgeon is calmly rejecting numerous drapes that are riddled with holes and can serve no purpose in maintaining a sterile field. Normal saline is running in through an 18G cannula that the patient’s family were asked to buy from the local pharmacy; the best we could offer from the department stores was a 22G. The surgeon is keen to start operating as the procedure was delayed for 2 h waiting for supplies of sterile and nonsterile rubber gloves to arrive. Shortages of all consumables have been a major problem since additional financial support to the hospital and medical school from a European government programme was withdrawn 6 months ago. It appears that the infrastructure for procurement, storage and delivery of essential items dwindled during this time of plenty, when supplies were ‘parachuted in’ via alternative routes.

John administers 50 mg of pethidine—this may be the last analgesic the patient receives until the unpredictable visit of the night matron to the ward in 9 h time. The surgeon asks for some antibiotics to be given and we enquire whether he would like chloramphenicol, gentamicin or both, as this is all the pharmacy can currently supply to us. The ex-pat surgeon nods at his lockable trolley, packed with privately procured goods for use in this theatre only. A sense of irony hits me as I reach past his iPod and speakers for a vial of cefotaxime, taking care not to interrupt the tones of Steve Harley and Cockney Rebel.

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Essential Surgical and Trauma Care

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The surgeons who run the international “Primary Trauma Care” course, which is taught in many developing countries, take issue with using the normal Advanced Trauma Life Support (ATLS) methods in those regions. They wrote that “the reality of trauma management in developing countries is, however, substantially different. The reasons for these differences are multifactorial, but they include geographical factors, relative lack of resources, funding, manpower and education.… The [ATLS] so-called ‘golden hour’ ...

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