(a) Instruments are jumbled together in a pan for washing and (b) dumped on the table without regard for preserving the sharp cutting edges or preventing them from bending and breaking
Fig. 7.2
Instrumentand implant sets are often wrapped and sterilized in a location remote from the operating room. These sets cannot be inspected without breaking sterility. (a) Cloth wrapped (b) in somewhat more accessible metal containers
Hospital budgets routinely underfund orthopedic departments and may postpone purchases until another funding cycle. Purchasing departments are not run by surgeons or medical personnel, and the agent often chooses lower-cost suppliers who sell equipment that is not compatible with current systems or buys inappropriate items from friends, pocketing a kickback. Guiding donations is difficult as it may require saying “no” to some inappropriate items while waiting for more useful ones, which may never arrive. Equipment, whether purchased or donated, without local maintenance availability usually has a short life span. Items such as power drills, arthroscopy sets, and x-ray machines end up with other useless equipment as baggage, clogging hallways or equipment rooms (Fig. 7.3).
Fig. 7.3
Useless and broken equipment becomes a burden
These are some of the problems. This chapter will consider possible solutions including acquisition of local supplies, the ethics of donations, recent initiatives addressing the problem, and sources of purchased supplies.
Local Acquisition
Simple supplies can be arranged from local sources in most countries. Common things like rope and pulleys for traction, plaster of Paris, razor blades, and common bleach are usually available. Plaster rolls can be made from gauze strips covered with dry plaster of Paris and then rolled up ready for use. Although dangerous, razor blades have been used as scalpel blades. Dakin’s solution for dressing changes on open wounds is marketed under that trade name or can be made by diluting common bleach (see Chap. 14 for recipe).
In the past, implants have been made on-site using 316 stainless steels in a local machine shop, but without quality control, this is unsafe for the patient and should not be attempted. The exception is perhaps external fixation devices. While many ex-fix frames are a common donation, informally fashioned frames are a reliable substitute, and some can be reused. Simple solutions include pins and plaster, pins attached to a wooden bar, or more sophisticated metal devices (Fig. 7.4). They will, at least, serve in an emergency to gain fracture stability and wound access.
Fig. 7.4
One type of locally made external fixation device copied from the old French Army fixator
Centers with functioning prosthetic/orthotic workshops or training schools have access to a range of locally made splints, braces, and artificial limbs. While these vary in quality, a local source is invaluable. Often, physical therapy departments are able to fashion simple splints and braces; however, these will usually be not lightweight devices made from thermoplastic materials. Prepackaged elastic splints with Velcro closure are rarely available or are expensive. Simple wooden crutches made locally function well (Fig. 7.5), though many patients in Africa prefer to use a single, long walking stick, which they use in a poling maneuver and which may be more stable in mud than crutches.
Fig. 7.5
Wooden crutches made at a hospital in Ghana
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