Empty operating room at Baguio General Hospital
A favorite topic among medical people when discussing working in a third world country is “how bad things are over there”, referring to the the limitations on supplies and equipment as well as the weirdness of the pathology. I like to reply with, “It was really bad. They wash and reuse gloves!” Then I like to show them pictures of the rusty chairs and equipment that looks like it was left over from the 1960s. Those kind of stories make us in North America feel fortunate that we have the latest equipment and technology at our disposal. We can all be proud of the health care industrial complex that we have built! But those stories also highlight the ingenuity of people when challenged to work with the limited resources in developing countries.
Sterile surgical instrument set, covered with reusable cloth.
THE SINGLE-USE, DISPOSABLE CULTURE
One way to contrast the two medical systems is to focus on the use of disposables. If you are the type of person who cares enough about the environment to recycle, shop for groceries using canvas bags and avoid buying bottled water, you would think the amount of medical waste we generate in this country is obscene. Health care produces a massive amount of garbage, and operating rooms and labor and delivery suites together produce the largest fraction of it -- 70% of a hospital’s waste. It is not all paper drapes and plastic containers, but also includes highly engineered, precision instruments. There are a number of reasons for this. There is a trend to make everything single-use and disposable. Prepackaged, single-use instruments guarantee sterility and quality. Also, hospital infection control committees have increased efforts to totally eliminate any risk of hospital-acquired infections, especially methicillin-resistant staphylococcus aureus (MRSA). They do this by making sure nothing that touches a patient gets reused, especially when used on patients who have had any history of MRSA. I also can’t help but wonder if the profit motive also influences the decision of medical equipment manufacturers to push single-use disposable devices as well.
A list of the devices in anesthesia practice which used to be reusable and now are routinely individualized and disposable includes pulse oximeter probes, blood pressure cuffs, EKG cables, laryngeal mask airways (LMAs), patient gowns, towels, surgical table covers and linens, arms restraints, and Hovermatts (a inflatable mattress used to move extremely obese patients -- an increasingly important piece of equipment these days). Someone must have calculated that it costs more to wash, process, and resterilize all this stuff, especially if you are short-staffed. Many anesthesia technicians and nurses I have spoken with about this issue actually prefer disposable equipment because they don’t like having to clean used equipment, especially if it is something covered with blood or secretions. Even after my hospital contracted with a medical recycling company to clean and reprocess this stuff, the nurses would still throw them away rather than toss them into the recycle bin.
In my hospital, we are not allowed to use injectable drugs from one vial in more than one patient, even if the drug vial states that it is intended for “multiple use”. This is ostensibly to prevent cross-contamination from one patient to another, although this is easily avoided if you simply don’t use a dirty syringe to draw up your medications. The real reason has to do with accounting and billing: pharmacies can charge a patient for the cost of an entire vial, but can’t charge multiple patients for the cost of a fraction of the drug taken from one vial. We are supposed to dispose of any unused medications, which means that a lot of half-filled vials of expensive drugs get thrown away. The exception to this has been whatever drug of the week is currently in critically short supply, then we are allowed to save the unused portions of that particular drug.
Surgical instruments are also totally disposable now too. Manufacturers say having prepackaged, sterile equipment helps expedite the device preparation process. They argue that reusable instruments have hidden costs: instrument repair, the labor associated with cleaning and sterilization, and OR time lost because of instrument failure. With prepackaged, single-use instruments the cost of cleaning and sterlization is eliminated. Probably more importantly, like with drug vials, it is easier to track the cost of the instrument and pass that on to the patient.
There is a hidden cost to single-use instruments too and that is cost of disposal, not to mention the environmental impact, a cost that is passed onto the public. There are also human costs. Most single-use stainless steel surgical instruments are manufactured in factories in Pakistan and undergo final finishing and quality control in Germany before being shipped throughout North America and Europe. Since Pakistani factories only pay their workers $1 for a 12 hour day -- less than a living wage -- they rely heavily on child labor.
In contrast to single-use instruments, high quality long-lasting German made steel surgical instruments intended for repeated use can be resterilized and reused about 3000 times. Although the initial cost and carbon footprint is greater, with repeated use the overall cost and environmental impact is much less compared to single-use instruments. But for reason this doesn't seem to make financial sense anymore.
REDUCE, REUSE, RECYCLE
On our mission we had to make the most of our limited supplies and conserve our disposables as much as possible. I took inspiration from the resourcefulness of the locals. I didn't reuse my gloves, but I used the same anesthesia breathing circuit for a week, and just changed a disposable bacterial filter/humidifier at the patient end. The anesthesia mask, made for single use, was washed between cases, along with the disposable oral airway and non-disposable laryngoscope blade. I had a more than dequate supply of endotracheal tubes. These were donated because they were past their expiration date or the packages had already been opened; it is common practice to open sterile equipment before an operation to save a few seconds, and not use it.
To conserve needles and syringes I mix drugs in the same syringe and deliver them concurrently, such as ondansetron and dexamethasone. Before doing this it is important to consult a compatibility chart to see whether they are truly compatible. Lack of visible precipitation alone is not evidence of compatibility.
We used facemasks folded over and tied around the patients arms as arm restraints, and used the same pair all week. In the United States our containers for hazardous sharps waste are single-use and specifically manufactured for that purpose, with a lot of safety features (colored red, with a lid that automatically prevents overfilling and locks down for final disposal). Instead we improvised with empty plastic IV bottles with a hole cut on the top.
Improvised sharps container
THE PROBLEM OF HYPOTHERMIA
One problem that we could have dealt with better is intraoperative hypothermia. You would think this might not be a problem in a tropical climate, but since Baguio is over 5000 feet above sea level the weather is usually cool and we also kept the operating rooms is air-conditioned. A patient's drop in core temperature in the first hour of surgery is primarily due vasodilation produced by the induction of anesthesia. Vasodilation redistributes heat from the core to the periphery, and the only way to prevent a drop in core temperature is to actively warm the patient for about an hour before surgery. Additional heat loss during surgery is caused by conductive heat loss by contact with the OR table, radiative loss from exposed skin, irrigation with room temperature solutions (into an open abdominal cavity for instance), infusion of room temperature IV fluids, and ventilation with cold, dry gases. On arrival to the recovery room, we had patients as cold as 33.2 degrees C. Hypothermia is not only uncomfortable for patients; it also slows emergence from anesthesia, increases oxygen consumption by inducing shivering, inhibits coagulation, suppresses the immune system, and increases the risk of postoperative wound infection. If severe enough, it can cause life-threatening cardiac arrhythmias.
Unfortunately, we lacked any practical, effective means to prevent intraoperative hypothermia. The best way is to use a forced air warming system, which works by blowing hot air into a single-use, disposable inflatable blanket. Imagine turning a big hair dryer on "high" and blowing it underneath a blanket -- toasty! Even regular blankets were hard to come by. After some discussion with the recovery room nurses, the surgeons agreed to turn the air conditioner off in the OR. They suffered under the hot gowns and had to have nurses wipe their brows, but the patients came out a little warmer.
The BGH recovery room nurses use an improvised radiant warming device, which is a single lightbulb surrounded by a thin plywood shade hung over the patient. They let our team use them when there was enough to go around. I think the yellow light gave more of an impression of warmth than actual heat. It only used a 60 watt bulb.
The Canadian recovery room nurses put on knit wool hats (“toques”) on patients, and also came up with the idea of putting blankets and hats on our patients preoperatively to keep them from getting cold while waiting for surgery. For the next mission they are planning to bring a bigger supply of toques and socks to give to patients.
Remember the patient who had the the large dermoid cyst removed? I caught up with rounds on the gynecology ward just as they were seeing her on the first postoperative day. She looked very happy. She wanted to see pictures of the mass, which she referred to as her “monster”, so Katya ended up printing out pictures for her to take home with her. Our anesthesia coordinator Dr. Hoskin told me that all three of my patients from the day before were comfortable overnight. Despite only receiving Tylenol and ibuprofen the night before, the only thing that they complained about was discomfort from the urinary catheters, so the paravertebral nerve blocks we performed must have worked well.
[Photographs copyright Katya Palladina]