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.)

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:

Essential Surgical and Trauma Care

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’ must be extended into the ‘silver day’ or the ‘bronze week.’” They also note that the goals of transferring a stabilized patient on a firm stretcher for definitive care and of treating people in intensive care for complications from trauma are “often unrealistic in the developing world with minimal resources.”¹

The World Health Organization (WHO) lists what they consider essential to treat abdominal (Table 23-1) and chest (Table 23-2) injuries worldwide, varying with four levels of hospital capabilities (described in Chapter 5).

Should You Operate?

Clinicians may find themselves in situations in which they must perform a critical procedure with which they are not completely comfortable. In these situations, “time is the critical factor. Basic life-saving surgery can be done with simple standard equipment under intravenous (IV) ketamine anesthesia. The procedures must not be delayed and should be done by the surgeon at hand on dying patients or dying limbs when the alternative to nonintervention may be death.”⁴ The surgeon should also not be deterred when surgery is required urgently, but a trained anesthetist is unavailable.⁵

The following guidelines, while primarily for surgeons, also apply to clinicians doing other invasive procedures on patients, such as placing drainage tubes, intubating or placing a surgical airway, and placing central or intraosseous (IO) vascular access lines. The real skill of a medical practitioner is making the decision about when to do a procedure; nearly anyone can be taught to actually do the procedures. These questions, adapted from King and colleagues, can help you make the decision⁶:

1. 
   

   What happens if you don’t do the procedure?

   
   
2. 
   

   How difficult is the procedure? Will you be able to do it?

   
   
3. 
   

   How safe is the procedure in your hands? What disasters may occur? Can you deal with them?

   
   
4. 
   

   Do you have the necessary equipment and staff to do the procedure?

   
   
5. 
   

   Are you inclined to do procedures too readily—or not readily enough?

Improvised Surgery

If surgery will be performed in austere circumstances, the clinician must understand that “this is minimum-level surgery and you have to improvise.… Select an assistant for the surgery. Instruct him on the need to keep everything sterile, and not to touch anything without your explicit permission. His main function is to provide manual retraction in the wound.”⁷

Surgical Location

Surgery can be and has been performed in many settings. If there are several locations to choose from, consider factors such as lighting, space where equipment is located, temperature, and ventilation in relation to the type of surgery, assistants, etc. Operating outdoors provides light from the sun; in addition, it may actually lessen the chance of infection. If operations are being performed with non-vented volatile anesthetics (e.g., open-drop ether), fresh air quickly dilutes the gases so that the surgical team is not affected.

A concern with operating outside, however, is the ambient temperature. This may be a significant factor with young or elderly patients who cannot easily regulate their body temperatures. It may also affect patients with extensive burns, whose body cavities are open for a prolonged period, or who have suffered significant trauma. A rule-of-thumb is that basic lifesaving surgery with severe bleeding should not last >1 hour to prevent hypothermia.⁸ Insects, inclement weather, and the onset of darkness also may limit the ability to operate in the open.

Cleanliness

Patients who survive a thoracotomy done in the emergency department (ED) have the same or lower incidence of infection than patients whose thoracotomies were done in the OR. Sterility is important, but it is the time the patient is open that matters most in terms of infection.

Even so, it is harder to maintain total sterility when operating outside the OR; you will have to be prepared for minimal sterility.

“Scrubbing Up”

Surgery may need to be done bare-handed. If so, it is best if the surgeon does not have an open wound on the hand or arm, to avoid either contracting or transmitting an infection. This, of course, may not be possible. Try to scrub with ordinary soap and water for 10 minutes prior to surgery.^9,10

In less-austere circumstances, clean tap water (not sterile water, as has been required in some countries) is more than adequate for scrubbing before surgery. Rather than using special soaps and sterile brushes, gently rub the hands and forearms under tap water with a standard disinfecting soap (e.g., 7.5% povidone iodine or chlorhexidine gluconate). Using a quick-drying alcohol-based disinfectant scrub as the final step may be helpful. The faucets should be kept clean, and the water’s chloride level should be >0.1 ppm.¹¹

Using nonsterile gloves out of a box for wound repair (not surgery) in immunocompetent patients has an equivalent risk of wound infection as does using sterile gloves. The caveats are that the clinician must wash his or her hands before—and, for safety, after—the repair and that the box of gloves must be kept dry between uses. Damp glove boxes may become contaminated with fungus. While comfort in austere circumstances is not a huge issue, some clinicians may find working with poorly fitting nonsterile gloves to be awkward.¹²

Telesurgery

Modern telecommunication allows clinicians who have never done a procedure to do it under audio, and sometimes even video, guidance from more experienced clinicians at a remote location. This technology is still not used as frequently as it might be. On occasion, however, the use of telemedicine in austere situations has expended resources that could have been used more productively elsewhere; this situation must be avoided.^13,14 See Chapter 3 for a further discussion of telemedicine.

Bowel obstructions are common and it is tempting to see if they will respond to time and nonoperative measures. However, waiting >3 days to operate increases these patients’ morbidity and postoperative hospitalization.¹⁵

Cholecystitis and Appendicitis

When imaging, laboratory, and surgical resources are limited, practicing “elegant” medicine involves using only those resources that are absolutely necessary. That means making diagnoses on history and physical examination alone.

Cholecystitis

Clinical findings may help you decide who needs further evaluation or intervention in patients with suspected cholecystitis. Table 23-3 ranks them in order of their helpfulness in making a correct diagnosis.¹⁶ If the patient has a Murphy’s sign (and still has a gallbladder), this is the person who should get the ultrasound rather than laboratory tests. Confusing for many clinicians, the tenderness of Murphy’s sign may actually be located in the epigastrium, rather than further laterally. In the absence of evidence for acute cholecystitis, unrelieved emesis or pain, biliary obstruction, or perforation, treat the patient with analgesics and have the patient return if symptoms do not resolve.