Friends of Mandritsara

Tips for isolated hospitals

Here are a helpful tips that we thought might be useful to those working in similar situations to ours. We are grateful to those who have passed them on to us and hope they may be of use to others.

1. Rectal tap water

The rectal route for administering fluids has a number of advantages over the intravenous route. Sterility is not required, so tap water is quite all right. This means it is much cheaper, readily available, presents fewer dangers and is less technically demanding than using intravenous fluids. In almost all patients it is quite safe and effective, with the exception of those with significant diarrhoea. The only disadvantage is that it does not provide a route for intravenous drug therapy.
All adult patients having had abdominal surgery (Caesarean section, hysterectomy, ectopic pregnancy, laparotomy for peritonitis etc) are given 500ml of rectal tap water every 6 hours until they are taking oral fluids normally. Under normal circumstances an intravenous infusion is maintained as well for the first 12 hours post operatively.

The water is placed in an intravenous fluid bottle connected to a giving set, and this is attached to a simple plastic urinary catheter size 10FG. The end of this catheter is introduced about 10-15 cm into the rectum, and the outer part is strapped to the thigh. Ordinary tap water can be used, or, particularly where resumption of oral fluids is likely to be delayed (bowel surgery or peritonitis), sodium and potassium can be added. We normally add 15g of salt (sodium chloride) to 5L of tap water to give 1/3 normal saline (0,3%). 5g of potassium chloride can also be added. If the patient is up and about, it is easy to remove the catheter, and replace it when the patient returns to bed. The same system can also be used for comatose patients as an alternative to naso-gastric fluids, though the disadvantage here is that feeding cannot be maintained.

2. Fishing line for suture material

Monofilament nylon fishing line can replace normal suture material in a number of applications. It is hugely cheaper and readily available. We use basically two different thicknesses.
0.20mm (4lbs breaking strain) can be used for skin suture, for tying off bleeding vessels subcutaneously, We also use it double for ligating the hernial sac at inguinal herniorrhaphy, and for closing the inguinal canal.
0.40 mm (15lbs breaking strain) is used for the repair in a herniorrhaphy (inguinal or umbilical etc). It is also used double in single layer abdominal closure (peritoneum plus sheath) using the technique described in Primary Surgery Volume One 9.8 p.135.
A reel of 700metres will only cost about £5. The line can be threaded on a normal suture needle, or can be threaded into an injection needle which is crimped and then broken off to form a home-made atraumatic suture as described in Tropical Doctor July 2001 p.166.

3. General anaesthesia
Anaesthetic gases are hugely expensive and difficult to obtain in the bush in Madagascar. Much of our surgery is therefore done under local or regional anaesthesia, especially spinal anaesthesia.
However it is sometimes necessary to have a general anaesthetic with muscular paralysis and intubation. Our basic technique is a ketamine drip (500mg ketamine in 500ml normal saline). We use atropine (0.5 – 1mg) as a premedication. The ketamine infusion is started. Once the patient is asleep, suxamethonium 50mg iv is given and endo-tracheal intubation is performed. Relaxation is maintained with pancuronium, and the patient ventilated with air enriched with oxygen from an oxygen concentrator. At the end of the operation the paralysis is reversed with neostigmine 2mg plus atropine 1mg. The technique is well described in Primary Anaesthesia chapter 8.
For routine D&C’s we place a butterfly needle and give atropine 0.5mg, diazepam 10mg and ketamine 100mg. Very occasionally there is a problem with laryngeal spasm, but if the ketamine is given as two boluses of 50mg, spaced a minute or two apart, this seems to prevent the problem. If the patient is small and particularly if significant dilatation of the cervix is not needed, 50mg or 75mg of ketamine is sufficient.
For short cases in children, bolus ketamine is very effective. This can be given as 1-2 mg/kg intravenously, either with syringe and needle, or via a butterfly needle. Alternatively, particularly in babies, it is easier to give an intramuscular injection of 5-10mg/kg. For a herniotomy or circumcision in a child, a single dose of 10mg/kg of ketamine intramuscularly is usually all that is required. We also use this technique for repairing a cleft lip in a baby or small child.
We routinely monitor the patient with a pulse oximeter, give oxygen by face mask from an oxygen concentrator where necessary and have intubation facilities available, though we have never had to intubate in an emergency when using bolus ketamine, even in laryngeal spasm.

4. Intrarectal Metronidazole

Metronidazole is a highly useful drug in many situations, particularly in intra-abdominal sepsis. Intravenous metronidazole is obviously the best route, but is expensive. We have found intrarectal metronidazole to be very effective. We do not have specially formulated suppositories, but use simple non-coated metronidazole 250mg tablets at a dose (for adults) of 4 tablets intrarectally every 8 hours. (See Primary Surgery Volume One 2.9 p.26)

5. Intraosseous transfusion

It can be very difficult and time-consuming to put up an intravenous drip on a baby or small child. We have found the intraosseous route to be simple, rapid, safe and effective for giving blood, for giving intravenous drugs, and for rehydrating dehydrated children. The basic technique is described in Tropical Doctor July 1999 p.142. We modify this and use a standard 19G disposable injection needle attached to a 2ml syringe. The needle is screwed into the tibia, and once it passes into the central bone marrow, blood is aspirated in order to clear the needle and then the syringe is removed and the giving set attached.

6. Gentian Violet paint (Crystal Violet)

We use this extensively for painting post-operative wounds, abrasions, superficial burns, infected scabies etc. The wounds are cleaned once a day with dilute antiseptic, Gentian Violet is painted and allowed to dry. The wound is left open. The only disadvantage is that it is a bit messy – staining clothes etc. It is very cheap. A pot of 25g of crystals costs around 1 Euro. This is dissolved in 5L of water (filtered or boiled) to give 0.5% solution – and 5L lasts a long time!

Books mentioned are:
Primary Surgery Volume One. Non-Trauma. Edited by Maurice King et al. Oxford Medical Publications ISBN 0 19 261694 3
Primary Surgery Volume Two. Trauma. Edited by Maurice King et al. Oxford Medical Publications ISBN 0 19 261599 8
Primary Anaesthesia. Edited by Maurice King et al. Oxford Medical Publications. ISBN 0 19 261 592 0
(These books are also available in a low-priced edition for developing countries).
Tropical Doctor (quarterly journal) – published by the Royal Society of Medicine

We will be very happy to receive comments and suggestions and other useful tips too!

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