The Keyword Is Improvisation

It is late in the afternoon and rain is coming down hard, I have just seen another patient with TB. After having the nurse escort him to the isolation unit, I go to look for Dr. P. to discuss the treatment plan for the patient.

I find him in the female ward, writing up a new admission. The patient is a woman with a ruptured ectopic pregnancy and needs emergency surgery. The TB patient will have to wait; I will be assisting the surgery. We get the theater staff ready and prepare for the surgery. First, we inform the staff to stand by and run the generator in case of an electricity outage. The theater nurse, who doubles as the anesthetist, informs us that, because the autoclave is not working, we will be using the last sterile tray of instruments. We push the patient down the outside rain-slick corridor to the operating theater. The nurses get the patient ready on the operating table while Dr. P. and I change into scrubs. There is no disposable theater caps, so shoe covers will be used as our caps. While we try to follow aseptic technique as much as possible, the theater set up sometimes makes it difficult. For example, the scrubbing area is INSIDE the theater. Because of the frequent power outage, the taps are dry today. We scrub, not with fancy chlorhexidine or iodine solution, but with plain old soap, and rinse with water that had been stored in a jug. The autoclave malfunction means there are no sterile cloth theater gowns, so we put on the last two backup disposable ones.

I prep the patient’s abdomen with sterile wash. The patient is lying on the very un-sterile canvas stretcher on which she was carried to the theater. The scrub nurse and I then drape her with a single layer of thin sterile drapes. The other nurse follows Dr. P.’s orders and injects ketamine and diazepam into the patient’s IV port. When the patient stops moving too much on pain test, Dr. P. makes the first incision. We are soon digging deep into the abdomen. Suction? Forget about a suction tip, it’s just the end of the suction tube. Overhead lighting? Only the one in the center is working; it might actually be better if someone stands there holding a flashlight. Electrocautery? Don’t even think about it; might as well wish for a theater with laminar flow ventilation. Dr. P. concentrates intensely on the surgery; the whole room is silent except for the clanging of the instruments and the whirring sound of the fan in the corner.

An hour into the surgery, the whole place goes dark – power is out. Dr. P. stands there elbow deep in the patient’s abdomen, I am holding the now suctionless suction tube. We stand there, waiting for the generator to kick in. After what seems like an eternity, the lights finally come back on. Dr. P. continues the surgery like nothing has happened, but we are all hoping the generator doesn’t run out of fuel anytime soon. Eventually, the surgery comes to a successful end. I do my part and close the skin. The two nurses mop up the blood from the floor and pack up the instruments to send to another hospital sixty kilometers away for sterilization. We all breathe a collective sigh of relieve, thankful that things had gone relatively smoothly.

With all the breach of aseptic practice from the beginning to end, you’d think the patient has no chance of avoiding some serious post-operative infections. But Dr. P. tells me that post-op infections actually do not happen that often here, despite the suboptimal conditions. So, from the post-op infection rates we are seeing in the West, are we getting diminishing returns from all the strict operating theater rules we practice?