The surgical scene

The countries of the third world and the surgical scene within them differ widely. Ethiopia and Brazil, for example, are about as different as two countries could be. Typically, the people of the developing world are poor, hungry, and rural, although they are rapidly migrating to the towns. The population of sub-Saharan Africa, whence these manuals come, is increasing at an inexorable 3% annually. Meanwhile its per capita food production and its already meagre gross national product are falling.

One feature developing countries do have in common. It is that most of the surgery that is done has to be done in their district hospitals. These typically have between 50 and 200 beds and are staffed by two to four doctors, assisted by nurses and auxiliaries. Fortunately, the ''one doctor hospital', which was common until recently, is now unusual. Each hospital serves about 150[nd]250,,,,000 people living in an area which may be as large as 3000 square miles.

Over the world as a whole these hospitals range from the excellent to the indescribable. At one end they provide care which anyone would be fortunate to have, at the other the few patients brave (or foolish) enough to enter them lie largely untended.

If you work in a hospital in the middle or at the lower end of this spectrum, expect to find your wards overcrowded, with more than one patient in a bed. ''Clean' and infected cases will not be separated, so that a patient with an open fracture may lie next to one with a perforated typhoid ulcer. Your maternity ward will be particularly overcrowded, and resist all your attempts to decongest it. Cultural reasons may make it impossible to restrict the number of visitors to the wards. Defects in their construction will make keeping them clean and tidy a major task. Your equipment will be limited and poorly serviced. When it does break down, it may take years to replace. Trees may be so scarce that your staff have to go a long way to collect firewood.

If your hospital is at sea level on the equator, expect to operate at 30[de]C in 95% humidity, your clothes wet, and everything which can go rusty or mouldy doing so. Only insects enjoy such conditions, and you will find plenty of them.

You may have to rely on locally trained staff with only primary education who find the idea of sterility almost incomprehensible. Most of them will experience considerable hardship, and be so poorly paid that they will have to grow the food they need. Their ability to monitor a patient postoperatively on the wards may be so poor that you may be forced to assume that, once a patient has left the theatre, he is on his own as far as recovery is concerned (A 4.5).

Your anaesthetic facilities will vary greatly. If you are lucky you will have two or three anaesthetic assistants, trained to do most of the methods in Primary Anaesthesia. Your laboratory facilities will be minimal. Although AIDS has recently made it much more dangerous in many areas, blood transfusion should always be possible[md]if you can put enough effort into organizing it. Often, relatives will give blood for a patient, but for nobody else.

So be prepared to find everything[md]or nothing. On occasion expect to find no water, no steam, no gauze, no bandages, no catgut, no suxamethonium, no gloves (or only gloves with holes in them), no plaster, (or only plaster that does not set)[...] When you need the autoclave for a Caesarean section, expect that there may be no kerosene, and that the patient's relatives may have to go out to the market to buy it. When you go into the maternity ward late one night, don't be surprised if the last sphygmomanometer is missing. Try not to blame your staff too harshly, they may not be responsible[md]and even if they are, their families may be starving. If you do have electricity, be prepared for it to fail at 3 a.m., just when you are in the middle of a Caesarean section.

Even when you have your ''normal' supplies, you will not have solutions for parenteral nutrition, or plasma, and probably no dextran. Don't be tempted to imagine that the teaching hospital has everything: it too may be without water, spirit, or linen. One teaching hospital is said to have had no temperature charts for 10 years.

You may be cherished, supported, praised, and congratulated by your Ministry of Health, or you may not[...] You may be in a health service which is steadily improving, or in one which seems to be getting steadily worse, if that were possible. Expect that you may be cut off from the rest of the world for four months of the year. On top of everything else, AIDS may now be endemic in your district[...] Finally, your greatest blow may be that your predecessor, who was promised that he would be posted to your hospital for only a short time, never ordered any stores, or planted any cabbages[...]

But you have great blessings. In coping with all this, in creating and caring and leading and serving, you will have done something that your colleagues in the more comfortable circumstances of private practice will never have done. You are an all-rounder, and have one of the last remaining opportunities to practise the totality of medicine, rather than some infinitesimal corner of it. Sub specie aeternitatis, in the mirror of eternity, you are a hero and will surely be recognized and remembered as such.

You will need: (1) A willingness to learn from the culture of your patients. This will enrich you greatly, whether you are a a national from the urban elite or a foreigner, and will greatly increase their trust in you. (2) An almost pathological desire for hard work under conditions that are not conducive to it. (3) An unfailing ability to improvise and make the best of things. (4) The capacity to withstand prolonged periods of cultural isolation. If your morale is high, so soon will be that of your staff also. Your patients will be grateful for anything you can do for them, and they will not yet have learnt to litigate against you. If you serve your hospital and the community round it for a lifetime, you will earn a unique place in its affections.

Just to prepare you, here is the kind of thing you may have to cope with.

DIDIMALA (4 years) was severely burnt. You worked for hours to put up a reliable drip and took great care to ring up for a bed in the referral hospital. When you pass by the ward an hour or two later, you find that she has indeed been sent there by ambulance, but the drip has been left behind. You ask ''Why was this?'' To which you get the reply, ''There was no hook in the ambulance''. MARIA (5 months) presented with intermittent vomiting and abdominal swelling and was diagnosed as having intussusception. Unfortunately, the first hospital she went to had run out of anaesthetic gases and so could not operate. Her mother had to take her through three states stopping at four hospitals before she found one which could anaesthetize her (A 18.1). LESSON (1) Anaesthesia is often the limiting factor in surgery. (2) There is no need to have to rely on a supply of nitrous oxide (A 9.1). Crofts TC, ''Trials and Tribulations of Surgery in Rural Tropical Areas' Tropical Doctor 1980;10:9-14. Fig. 1-2 THE SCENE IN INDIA. An improvised ward in a small hospital in Madhya Pradesh. Most patients are accompanied by members of their families or by friends. If they are away from their villages during the planting and harvesting season, they will go hungry. After GR Howard, with the kind permission of the Editor of Tropical Doctor.