- Email: [email protected]
OR team changes life for Hondurans
Ruth Ellen Lahde, RN
OR team changes life for Hondurans
In remote parts of Central and South America, there a r e villages where little girls with cleft lips, who venture out into the sunshine to play, a r e stoned by o t h e r children who t h i n k t h e y a r e freaks. Adults in the community often regard the parents as evil, thinking the defective child is punishment for a terrible past sin. A boy with cleft palate was locked in a closet by his family for years, unknown to the villagers, so his parents could protect their standing and livelihood in the community. Instances such as these a r e well documented. The children are not only ostracized but a r e also unproductive liabilities to their families and communit.ies. In 1968, one such child, 14-year-old Antonio Victoria, came to the United States from his native country, Mexico, so Donald R Laub, MD, could repair his cleft lip and palate a t no cost to t h e boy. Antonio had been unproductive and isolated, but following surgery, his life changed overnight. He was no longer a pariah or parasite; he became a normal looking teenager who was beginning a productive life. Dr Laub subsequently traveled to
Ruth Ellen Lahde, RN, BA, is a staff nurse I l l in the operating rooms at Stanford (Calif)University Hospital A nursing graduate of Fayetteville (NC) Technical Institute,she received a bachelors degree in Spanish from Seattle University
Mexico and was surprised to discover a large patient population with similar defects t h a t could benefit from surgery. His experience with Antonio left a strong m a r k on him. Dr L a u b said, “Looking a t t h a t event changed my life at Stanford University Medical Center from being a researcher to taking care of people with this great weapon of recons t r u c t i v e s u r g e r y . ” H e founded Interplast in 1969. Interplast, Inc, h a s t h r e e primary goals: (1) taking care of the poor, ( 2 ) teaching a n d thereby raising levels of medical consciousness, and ( 3 ) making friends a n d developing international friendships. The organization has performed more t h a n 6,000 operations free of charge on children a n d a d u l t s in c o u n t r i e s w h e r e specialized plastic surgery is unavailable. Typically, the procedures correct or improve such conditions as burn contractures, congenital deformities, and traumatic injuries. H e a1t h profession a 1s i n cl u d i n g nurses, surgeons, pediatricians, anesthesiologists, orthodontists, and surgical a n d a n e s t h e s i a r e s i d e n t s h a v e traveled in groups offrom 5 to 28 to such countries as N i c a r a g u a , H o n d u r a s , Peru, Ecuador, Guatemala, Samoa, Mexico, a n d parts of Africa, where these services have been needed. All professional services a r e donated. Supplies and travel accommodations a r e provided by manufacturers or purchased with contributions to the program.
I thought I was dreaming when this severely malnourished two-year-old girl clasped my finger. She was successfully treated at the Honduran hospital
Interested local citizens in t h e s e countries provide housing and meals for each visiting team member. There a r e now approximately six trips a year; each lasts for one to two weeks. In October 1981, I traveled to Honduras with 25 other health care professionals As a n OR nurse a t Stanford for three years, I had heard about t h e program from other nurses who had used thcir vacation time to go Our Honduras group included people from Stanford and other California hospitals, as well as from West Virginia and Toronto. Several family members of the health care team accompanied us; they paid thcir expenses and carried a full workload We met in New Orleans, a n d after ii short sight-seeing tour, we traveled to San Pedro Sula. San Pedro Sula, the second largest city in Honduras, derives its income largely from corn, beans, and tobacco, which arc grown not only on huge acre-
ages as you travel away from the city but also in tiny plots within the city center. The climate in October was hot and humid, and the vegetation, animal and bird life was tropical. Although we were exhausted after the long trip, excitement suddenly woke everyone. We were stirred by t h e immediacy of our mission. As a group of strangers, we were about to get to know one another and this country in a special closeness. Once through customs, we loaded 67 crates and boxes of supplies and equipment, plus our personal luggage, onto three trucks t h a t awaited us. As we drove toward the hospital to unpack, the class differences were strikingly apparent. People appeared either extremely rich or extremely poor, with no group falling in between-a characteristic of most C e n t r a l a n d S o u t h A m e r i c a n countries. In the hub of the city, we saw t h e poor farming crops on a corner of a wealthy
family's land and living in dwellings t h a t barely protected them from t h e weather. In contrast were the modern, landscaped mansions of property owners who lived a few feet away from the poor. As we approached the hospital, i t was gratifying to see a large group of small but well-built, clean living units under construction and nearly completed. The Honduran government intends these units to be affordable for any person, in a lease plan with a n option to purchase, which may create more stable homeowners and may begin to reduce the vast class differences. It was easier to see some of the hardships of t h e poor because of the evidence of government interest in providing aid for them. After bouncing through t h e countryside in our trucks, wondering if our luggage and electrosurgical units would fall off, laughing all t h e way in our exhausted euphoria past, cattle, shanty villages, lovely homes, and rich tropical greenery, we finally arrived a t the hosp i t a l a n d u n l o a d e d t h e boxes a n d equipment. We were given a tour of the facilities by t h e hospital's head physi-
cian. We walked through the maternity and gynecology wards, a r e a s for orthopedic and pediatric patients, a n d a n isolation ward for infants. The impressions were vivid. Leonard0 Vicente Martinez Hospital is the equivalent of our county hospitals in respect to patient population and in funding sources; it h a s similar, in fact far worse, difficulties in getting adequate money to function optimally. My first impressions were of less t h a n optimal asepsis, inadequate staffing, crowded rooms, and disrepair. Walking through the pediatric ward, I saw a handful of a girl lying in a crib motionless, whom I guessed to be 12 or 14 months old. I watched the still child and then softly asked h e r name. To my astonishment, she opened her saucer eyes and answered me. When I asked h e r age, she told me serenely she was two years old. I thought I was dreaming when her tiny wrinkled hands, above a n a s c i t i c belly a n d e d e m a t o u s l e g s , reached u p a n d clasped my finger. There was a strange awareness t h a t this little puff of existence and I were both actually here in the same world,
People lined every hallway on Clinic Day, hoping for a miracle. They traveled to the clinic from all parts of Honduras.
197
;ind that hoon neither of us might be, for distinctly dtft'erent reasons. A victim of hc~verrmiilnutrilion, s h e could not be cbxp(xted t o l i v e long. At the end of'the wcck, I wiih delighted to be proven w rong Wtb saw m a n y more patients t h a t evening, both surgical a n d nonsurgical, and t h e n toured the operating rooms. r, 1 hero w ~ r five e rooms-Interplast was given two The larger of' these two rooms contained two operating room tables, and thc other was quite small with limitcd storage space, b u t our facilities lookc4 iide(luate It wiis dark a t this point. We had all goni' without uninterrupted sleep for i n o w t h a n 24 hours We were dropped of1't)y our trucks at the homes of various 1londur;in friends of Interplast where hot, dcblicious meals awaited us, to be f'ollowcd bv w a r m , we1 I - f u r n i s h e d
roomh
Fiixrlly, the first day of work began. While tlw five OR nurses readied t h e
What is Interplast? lnterplast performs operations free of charge overseas and in Central and South American countries where specialized reconstructive surgery is unavailable. Its activities are made possible entirely through contributions, donated materials, volunteered medical services, and the generosity of its international friends. A domestic program has also begun, in which patients are brought to the United States for more complicated surgery and preoperative care. Individuals interested in lnterplast may contact Mary Cottrell,Executive Director of Interplast, Inc, 378-J Cambridge Ave. Palo Alto, Calif 94306. operating rooms, the anesthesiologists took screwdrivers a n d borrowed Swiss Army knives to put together and test their equipment. T h e rest of the team held "Clinic Day." Villagers came from all areas of Honduras to bring themselves or their children t o t h e place
Sutures and supplies ale shown in the largerof the two operating used by Iriterplast The hshmg tackle box, at left, which stored easily lost items, proved invaluable rooms
An exhausted nurse rests after her fourlh 73-hour day. At right, a Mayo stand cover has been converted into a garbage bag. Extra drapes, used for the next patient's bed cover. can be seen at left.
where "miracles" were done for free twice a year by Interplast. Hallways and reception areas were mobbed with patients waiting to be evaluated. One by one, a surgical resident, using a student interpreter from a nearby international school, interviewed a n d examined each patient and documented his findings. The patient was then seen by one of the four staff surgeons to corroborate findings and to make plans. Where there was a problem, such as a n infection t h a t might affect healing of a surgical wound or a respiratory ailment t h a t might endanger the patient under anesthesia, the pediatrician or anesthesiologist would be called in for a consultation. A thorough work-up was done on each of these patients. More t h a n 200 people were seen on t h a t first day. Of these, the best candidates were chosen on the basis of safety a n d those most likely to heal postoperatively without complications. We scheduled 89 pu-
tients for corrective plastic surgery. In t h e meantime, the nurses organized s u p p l i e s a n d reviewed t h e sterile technique to be used. Supplies were limited to exactly what we brought-no possibility of c a l l i n g another floor or hospital to get a n urgently needed item. We had to cut corners every possible way without compromising technique and thus, endangering t h e patient. We were extremely conscious of not wasting supplies and of recycling everything possible. We drew u p one vial of medication and, keeping the syringe tip sterile, used t h a t vial all day for several patients. Methylene blue a n d lidocaine were conserved this way. A minimum of sterile drapes was available. Wherever possible before a case began, the unused drapes would be passed off the field and used as sheets for the next patients' beds. We recycled electrocautery ground pads a s often a s was safely possible. At night,
we washed and repackaged our instruments in sets that included an eye basin and sponges to minimize the amount of packaging needed. The sets would be sterilized overnight in large plastic bags using anprolene gas cartridges. The hospital’s own steam sterilizer was not counted on and was available only for dire emergency. It was old, had a 45-minute cycle, and was usually full processing the hospital’s own items. That first afternoon we did a cleft lip and a cleft palate repair so all members of the team could become accustomed t o working with one another, in the environment, and with these new systems. On the whole, we quickly developed a bond. There were a few minor problems initially with complaints about supplies and instrument shortages, which had been allowed, if not encouraged, in pampering hospitals back home. A combination of tact, outright argument, and realizing there were no other selections resulted very shortly in a tightly knit, cooperative group focusing on the patient and the work, rather than on the differences in accouterments. Systematically and carefully, the 89 procedures were performed over our six operating days. An occasional preoperative infection developed,necessitating a cancellation or postponement of the procedure, t o the dismay of many families. One case could not be done be-
cause the patient, a retarded 28-yearold man with severely cleft lip and palate was terrorized when he saw the strange operating room and the foreign physicians. Despite a quiet explanation from a native physician about what to expect, his fear did not lessen or his understanding increase. He clung to a doorjam, unwilling to enter but also unwilling to leave for fear of reprisals from his parents. I was worried about those reprisals, knowing the tremendous hope the parents must have had for their son, but later word was received that the parents commented, ‘‘It’s all right. We expected something like this might happen.” We worked 10 to 14 hours a day. Every ounce of kindness, every bit of high school Spanish was dredged up and was used. A few of us had a minimal command of Spanish; we could comfort in the language. A bilingual Honduran priest, who commuted 200 miles daily t o help Interplast during its visits, was of immeasurable help in explaining procedures and expectations and in reducing fear. Even with our boxes and equipment and efforts to foresee any likely problems, we could not carry enough supplies to cover every possible emergency. And, of course, the unexpected came. A power outage occurred on our first day of surgery, but we had not begun our
With a shortage of gurneys, patients had to double up.
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AORN Journal, August 1982, V o l 3 6 , No 2
Darlynne Ibsen, RN, holds Blanca postoperatively. Her head has been wrapped with cast padding to protect her from the OR‘S air conditioning.
cases. In t h a t w a r m e a r l y morning darkness, we held our first three babies and sat quietly talking and waiting for the world t o s t a r t up again. After a n hour, the power returned, a n d we went to work armed with flashlights should a power outage recur with operations underway, There were occasional ominous flickerings, but t h e power did stay on during the remainder of the trip. Another unforeseeable problem occurred when both a n t i q u a t e d t o u r niquets simultaneously failed. (Since my trip, new tourniquets have replaced them.) Among our group were two int e r n a t i o n a l l y recognized h a n d s u r geons; consequently, more hand cases were scheduled to t a k e advantage of’ their expertise. A tourniquet was needed for each case. Without them, the surgeons continued their work and bec a u s e of t h e i r s k i l l , t h e completed
surgery was quite impressive. Two of our major crises occurred when members of our group were suddenly asked to help with cases being done by Honduran surgeons in the other three operating rooms. Uterine surgery had been performed two weeks earlier on a woman who was now in septic shock, with a severely lacerated uterus being removed. Her blood pressure dropped suddenly, and we were asked to help. Our anesthesiologist began blood transfusions, changed t h e anesthetic agent to one without hypotensive effect, a n d gave other instructions to reverse her course. We did not have a n extra blood pressure cuff, needed to push the unit of blood in rapidly, so we simply stood there and pushed t h e blood in by hand. We were in t h a t operating room for more t h a n a n hour when the patient began to stabilize, and t h e Honduran
The result of Blanca’s uncomplicated procedure can be seen.
anesthesiologist resumed charge. The second incident occurred at the end of a 13%-hour day. A voice broke through the calm of the end-of-the-day cleaning: “Code!” We streamed into an operating room ta see a Honduran surgeon standing by a 12-year-oldboy who had accidentally eviscerated himself on a machete in a fall. The surgical repair was finished, but the boy could not be aroused, and then his heart stopped. His skin was extremely hot to touch. He was anuric throughout the case. It was not known how long his pupils had been fixed and dilated. He resembled a patient with that rare anesthesia reaction, malignant hyperthermia. Few anesthesiologists ever see one in their lifetime. The Stanford team members had seen one or two cases and, fortunately, had a few reflexes in response to this tentative diagnosis. We needed dantrolene sodium to reverse the calcium release 202
process, the only drug known to do so. But we had no dantrolene. The boy’s body needed to be packed immediately in ice to lower the skyrocketing temperature damaging his brain. We had no ice. The two vital things were unavailable. We began to look for ways to improvise. The only cold thing in the hospital was a chest of soda pop provided for the Interplast staff. In a minute, the child looked like an arrangement at a barbecue, with pop bottles under armpits, bottles around the groin, pop being poured over his chest, and intravenous (IV) tubing wrapped around the bottles to cool IV solutions. A fan was set up, and alcohol was poured over the body core. While the cooling efforts were made, other teams were working simultaneously elsewhere. Medications were being pushed in: large quantities of an-
AORN Journal, August 1982,V o l 3 6 , N o 2
W
e were astonished by the trust the Hondurans had in us.
tibiotics t o cover the possibility of a diagnosis of septicemia a n d sodium bicarbonate. We did not know how long t h e eviscerated boy had lain in t h e emergency room or i n the OR hallway with his peritoneal contents exposed. A team attempted a cutdown on a femoral vessel. Another team had from the beginning given c:irdjopuImonary resuscitation in con~junctionwith t h e anes t he si o 1o gi st w h o w;I s a era t i ng t,he lungs. We h a d no electrocardiogram monitor, but iis someone pointed out, it really did not m a t t e r bclcause a t t h a t time we did not have a defibrillator. All ears were riveted to progress sounds: “His temperaturcl is 105. Down to 104.8. Slowly coming down. I c a n ’ t g e t a peripheral pulse. No, thchre’s a very light one. Oh, it’s gone.” WP worked and worked. We tried t o will t h a t boy to live. You c a n ’ t d i e . you h e a u t i f u l c h i l d . “Temperature down to 104.6. There’s a c a r o t i d p u l s e . b u t it’s w e a k a n d thready.’’ After 45 eteimal minutes of’ t u n n e 1- v i s i o n ed tea ni wo r k and cre a t i v ity, we realized his heart would not beat, and his pupils were st ill fixed and dilated. So it, was ended. I find it hard to talk ahout still. I t was an emotional. hinding experience for all; a single-mindt.d drive was shared a s though we were one person during this event. I do not recall another nursing experience t h a t co m pa ITS, Every o n was devastated even though each of us had seen many deaths i n our careers. A (3
Honduran doctor told t h e family waiting outside t h e OH doors, and a terrible wailing arose t h a t went directly to our bones. It broke every heart. We hugged one another, wept. and after cleaning up. talked long into t h e night to salve this wound we had sustained. We became better friends. The mutual support was invaluable, and t h e lessons learned about the capabilities and depth i n other people were rarc. A haggard group stumbled toward the finish line on t h e last day. It was a six-hour day because t h e equipment was packed, but it was more chaotic than usual with lust minute cancellations and substitutions. Most o f t h e few remaining supplies were left for t h e Honduran hospital staff‘s use. We worked in it microcosm ofreality there. with a known beginning and a n end. We met people who astonished us with their unconditional t r u s t in t h e strange foreigners a s they handed u s their infants, and left with a glow in their eyes. Of the 89 cases, we did skin grafts and some unusual lesions, in addition to t h e more usual procedures. There were cases t h a t looked minor but became major, and others t h a t started as serious but in t h e end were minor. I h e emergency and major cases we did require good follow-up care, and it is not, known how t h e patients will recover. The native surgeons received full reports and requested considerable instruction, but we were concerned about r ,
many cases we w o u l d n o t be able t o foll o w up. F o r example, an emergency patient, whose t r e a t m e n t w e assisted in upon request, had a hand severed and an arm m a n g l e d by a w r i n g e r . T h e w o u n d was debrided and casted with f u r t h e r debridement and s k i n g r a f t s s t i l l r e q u i r e d w h e n h e vanished f r o m t h e hospital t h e night after surgery. T h i s kind o f fear and ignorance i s our and h i s enemy. In each case, an effort was made t o d e t e r m i n e a t t i t u d e s and l o n g - t e r m complications o f t h e surgery and t o b e considerate o f c u l t u r a l attitudes. I t was d i f f i c u l t t o conclude that an operation
that w o u l d be absolutely indicated f o r a c h i l d in t h e U n i t e d States w o u l d b e contraindicated in H o n d u r a s because o f t h e c u l t u r e t h e p a t i e n t w o u l d r e t u r n to. M o s t o f t h e procedures w e did, however, were those in w h i c h t h e wounds w o u l d h e a l q u i c k l y and r e t u r n t h e pat i e n t s t o a l i f e o f c o n t r i b u t i o n t o society. T h e c h i l d r e n w i l l b e productive. G r o w n fathers unable t o use a hand w i l l n o w be able t o m o r e fully f u n c t i o n and m o r e e a s i l y s u s t a i n t h e i r f a m i l i e s . These were t h e d r a m a t i c cases that daily del i g h t e d us. In t h i s w a y w e saved lives. N o t h i n g could keep m e f r o m going back. 0
Audiovisual review: Electrosurgery This audiovisual program uses good instructional design through cartoon stills to provide an overview of how an electrocautery unit functions, placement of grounding pads, and hazards associated with electrocautery usage. This portion of the program is quite basic, emphasizing practical "how to and how not to" information rather than technical knowledge. An instructional guide is provided, which gives more in-depth discussion of the points covered in the audiovisual. The combination of the instructional guide and the cartoon stills provides good content for an inservice workshop on electrosurgery. The audiovisual may be used alone and serve as a review for nurses who are already cognizant of electrocautery, leading to discussion and recall of more technical aspects. A pretest, posttest and references are provided. Those who dislike humor mixed with serious information may find the cartoon stills distracting. They do highlight important points, however, and aid in retention of the subject matter. The target audience is OR nurses. Information contained in both the audiovisual and the instructional guide has been derived from seminars presented to
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OR nurses throughout the country. Hectrosurgery is available in slide/ cassette (41 slides) and 314 inch U-matic videocassette and runs about 11 minutes. The cost is $125 and comes with an unconditional 30-day money back guarantee. It may be ordered from Medfilms, Department 3A, 5632 E Third St, Tucson, Ariz 8571 1. Patricia Ball, RN, CNOR Audiovisual Committee
Military makes positive changes in field hospitals Two years of research have resulted in a much improved field hospital. Now the critical elements of field hospitals, such as ORs and ICUs, are in environmentally controlled shelters. These shelters can be assembled in a half hour and are constructed of aluminum over paper honeycomb. The shelters, with slight alterations, can be used for communication centers, machine shops, or kitchens. Each unit has blackout shades to prevent enemy troops from observing the activities within the shelter. The new shelters can be disassembled and packed quickly.
AORN Journal, August 1982, V o l 3 6 , No 2
OR team changes life for Hondurans
In remote parts of Central and South America, there a r e villages where little girls with cleft lips, who venture out into the sunshine to play, a r e stoned by o t h e r children who t h i n k t h e y a r e freaks. Adults in the community often regard the parents as evil, thinking the defective child is punishment for a terrible past sin. A boy with cleft palate was locked in a closet by his family for years, unknown to the villagers, so his parents could protect their standing and livelihood in the community. Instances such as these a r e well documented. The children are not only ostracized but a r e also unproductive liabilities to their families and communit.ies. In 1968, one such child, 14-year-old Antonio Victoria, came to the United States from his native country, Mexico, so Donald R Laub, MD, could repair his cleft lip and palate a t no cost to t h e boy. Antonio had been unproductive and isolated, but following surgery, his life changed overnight. He was no longer a pariah or parasite; he became a normal looking teenager who was beginning a productive life. Dr Laub subsequently traveled to
Ruth Ellen Lahde, RN, BA, is a staff nurse I l l in the operating rooms at Stanford (Calif)University Hospital A nursing graduate of Fayetteville (NC) Technical Institute,she received a bachelors degree in Spanish from Seattle University
Mexico and was surprised to discover a large patient population with similar defects t h a t could benefit from surgery. His experience with Antonio left a strong m a r k on him. Dr L a u b said, “Looking a t t h a t event changed my life at Stanford University Medical Center from being a researcher to taking care of people with this great weapon of recons t r u c t i v e s u r g e r y . ” H e founded Interplast in 1969. Interplast, Inc, h a s t h r e e primary goals: (1) taking care of the poor, ( 2 ) teaching a n d thereby raising levels of medical consciousness, and ( 3 ) making friends a n d developing international friendships. The organization has performed more t h a n 6,000 operations free of charge on children a n d a d u l t s in c o u n t r i e s w h e r e specialized plastic surgery is unavailable. Typically, the procedures correct or improve such conditions as burn contractures, congenital deformities, and traumatic injuries. H e a1t h profession a 1s i n cl u d i n g nurses, surgeons, pediatricians, anesthesiologists, orthodontists, and surgical a n d a n e s t h e s i a r e s i d e n t s h a v e traveled in groups offrom 5 to 28 to such countries as N i c a r a g u a , H o n d u r a s , Peru, Ecuador, Guatemala, Samoa, Mexico, a n d parts of Africa, where these services have been needed. All professional services a r e donated. Supplies and travel accommodations a r e provided by manufacturers or purchased with contributions to the program.
I thought I was dreaming when this severely malnourished two-year-old girl clasped my finger. She was successfully treated at the Honduran hospital
Interested local citizens in t h e s e countries provide housing and meals for each visiting team member. There a r e now approximately six trips a year; each lasts for one to two weeks. In October 1981, I traveled to Honduras with 25 other health care professionals As a n OR nurse a t Stanford for three years, I had heard about t h e program from other nurses who had used thcir vacation time to go Our Honduras group included people from Stanford and other California hospitals, as well as from West Virginia and Toronto. Several family members of the health care team accompanied us; they paid thcir expenses and carried a full workload We met in New Orleans, a n d after ii short sight-seeing tour, we traveled to San Pedro Sula. San Pedro Sula, the second largest city in Honduras, derives its income largely from corn, beans, and tobacco, which arc grown not only on huge acre-
ages as you travel away from the city but also in tiny plots within the city center. The climate in October was hot and humid, and the vegetation, animal and bird life was tropical. Although we were exhausted after the long trip, excitement suddenly woke everyone. We were stirred by t h e immediacy of our mission. As a group of strangers, we were about to get to know one another and this country in a special closeness. Once through customs, we loaded 67 crates and boxes of supplies and equipment, plus our personal luggage, onto three trucks t h a t awaited us. As we drove toward the hospital to unpack, the class differences were strikingly apparent. People appeared either extremely rich or extremely poor, with no group falling in between-a characteristic of most C e n t r a l a n d S o u t h A m e r i c a n countries. In the hub of the city, we saw t h e poor farming crops on a corner of a wealthy
family's land and living in dwellings t h a t barely protected them from t h e weather. In contrast were the modern, landscaped mansions of property owners who lived a few feet away from the poor. As we approached the hospital, i t was gratifying to see a large group of small but well-built, clean living units under construction and nearly completed. The Honduran government intends these units to be affordable for any person, in a lease plan with a n option to purchase, which may create more stable homeowners and may begin to reduce the vast class differences. It was easier to see some of the hardships of t h e poor because of the evidence of government interest in providing aid for them. After bouncing through t h e countryside in our trucks, wondering if our luggage and electrosurgical units would fall off, laughing all t h e way in our exhausted euphoria past, cattle, shanty villages, lovely homes, and rich tropical greenery, we finally arrived a t the hosp i t a l a n d u n l o a d e d t h e boxes a n d equipment. We were given a tour of the facilities by t h e hospital's head physi-
cian. We walked through the maternity and gynecology wards, a r e a s for orthopedic and pediatric patients, a n d a n isolation ward for infants. The impressions were vivid. Leonard0 Vicente Martinez Hospital is the equivalent of our county hospitals in respect to patient population and in funding sources; it h a s similar, in fact far worse, difficulties in getting adequate money to function optimally. My first impressions were of less t h a n optimal asepsis, inadequate staffing, crowded rooms, and disrepair. Walking through the pediatric ward, I saw a handful of a girl lying in a crib motionless, whom I guessed to be 12 or 14 months old. I watched the still child and then softly asked h e r name. To my astonishment, she opened her saucer eyes and answered me. When I asked h e r age, she told me serenely she was two years old. I thought I was dreaming when her tiny wrinkled hands, above a n a s c i t i c belly a n d e d e m a t o u s l e g s , reached u p a n d clasped my finger. There was a strange awareness t h a t this little puff of existence and I were both actually here in the same world,
People lined every hallway on Clinic Day, hoping for a miracle. They traveled to the clinic from all parts of Honduras.
197
;ind that hoon neither of us might be, for distinctly dtft'erent reasons. A victim of hc~verrmiilnutrilion, s h e could not be cbxp(xted t o l i v e long. At the end of'the wcck, I wiih delighted to be proven w rong Wtb saw m a n y more patients t h a t evening, both surgical a n d nonsurgical, and t h e n toured the operating rooms. r, 1 hero w ~ r five e rooms-Interplast was given two The larger of' these two rooms contained two operating room tables, and thc other was quite small with limitcd storage space, b u t our facilities lookc4 iide(luate It wiis dark a t this point. We had all goni' without uninterrupted sleep for i n o w t h a n 24 hours We were dropped of1't)y our trucks at the homes of various 1londur;in friends of Interplast where hot, dcblicious meals awaited us, to be f'ollowcd bv w a r m , we1 I - f u r n i s h e d
roomh
Fiixrlly, the first day of work began. While tlw five OR nurses readied t h e
What is Interplast? lnterplast performs operations free of charge overseas and in Central and South American countries where specialized reconstructive surgery is unavailable. Its activities are made possible entirely through contributions, donated materials, volunteered medical services, and the generosity of its international friends. A domestic program has also begun, in which patients are brought to the United States for more complicated surgery and preoperative care. Individuals interested in lnterplast may contact Mary Cottrell,Executive Director of Interplast, Inc, 378-J Cambridge Ave. Palo Alto, Calif 94306. operating rooms, the anesthesiologists took screwdrivers a n d borrowed Swiss Army knives to put together and test their equipment. T h e rest of the team held "Clinic Day." Villagers came from all areas of Honduras to bring themselves or their children t o t h e place
Sutures and supplies ale shown in the largerof the two operating used by Iriterplast The hshmg tackle box, at left, which stored easily lost items, proved invaluable rooms
An exhausted nurse rests after her fourlh 73-hour day. At right, a Mayo stand cover has been converted into a garbage bag. Extra drapes, used for the next patient's bed cover. can be seen at left.
where "miracles" were done for free twice a year by Interplast. Hallways and reception areas were mobbed with patients waiting to be evaluated. One by one, a surgical resident, using a student interpreter from a nearby international school, interviewed a n d examined each patient and documented his findings. The patient was then seen by one of the four staff surgeons to corroborate findings and to make plans. Where there was a problem, such as a n infection t h a t might affect healing of a surgical wound or a respiratory ailment t h a t might endanger the patient under anesthesia, the pediatrician or anesthesiologist would be called in for a consultation. A thorough work-up was done on each of these patients. More t h a n 200 people were seen on t h a t first day. Of these, the best candidates were chosen on the basis of safety a n d those most likely to heal postoperatively without complications. We scheduled 89 pu-
tients for corrective plastic surgery. In t h e meantime, the nurses organized s u p p l i e s a n d reviewed t h e sterile technique to be used. Supplies were limited to exactly what we brought-no possibility of c a l l i n g another floor or hospital to get a n urgently needed item. We had to cut corners every possible way without compromising technique and thus, endangering t h e patient. We were extremely conscious of not wasting supplies and of recycling everything possible. We drew u p one vial of medication and, keeping the syringe tip sterile, used t h a t vial all day for several patients. Methylene blue a n d lidocaine were conserved this way. A minimum of sterile drapes was available. Wherever possible before a case began, the unused drapes would be passed off the field and used as sheets for the next patients' beds. We recycled electrocautery ground pads a s often a s was safely possible. At night,
we washed and repackaged our instruments in sets that included an eye basin and sponges to minimize the amount of packaging needed. The sets would be sterilized overnight in large plastic bags using anprolene gas cartridges. The hospital’s own steam sterilizer was not counted on and was available only for dire emergency. It was old, had a 45-minute cycle, and was usually full processing the hospital’s own items. That first afternoon we did a cleft lip and a cleft palate repair so all members of the team could become accustomed t o working with one another, in the environment, and with these new systems. On the whole, we quickly developed a bond. There were a few minor problems initially with complaints about supplies and instrument shortages, which had been allowed, if not encouraged, in pampering hospitals back home. A combination of tact, outright argument, and realizing there were no other selections resulted very shortly in a tightly knit, cooperative group focusing on the patient and the work, rather than on the differences in accouterments. Systematically and carefully, the 89 procedures were performed over our six operating days. An occasional preoperative infection developed,necessitating a cancellation or postponement of the procedure, t o the dismay of many families. One case could not be done be-
cause the patient, a retarded 28-yearold man with severely cleft lip and palate was terrorized when he saw the strange operating room and the foreign physicians. Despite a quiet explanation from a native physician about what to expect, his fear did not lessen or his understanding increase. He clung to a doorjam, unwilling to enter but also unwilling to leave for fear of reprisals from his parents. I was worried about those reprisals, knowing the tremendous hope the parents must have had for their son, but later word was received that the parents commented, ‘‘It’s all right. We expected something like this might happen.” We worked 10 to 14 hours a day. Every ounce of kindness, every bit of high school Spanish was dredged up and was used. A few of us had a minimal command of Spanish; we could comfort in the language. A bilingual Honduran priest, who commuted 200 miles daily t o help Interplast during its visits, was of immeasurable help in explaining procedures and expectations and in reducing fear. Even with our boxes and equipment and efforts to foresee any likely problems, we could not carry enough supplies to cover every possible emergency. And, of course, the unexpected came. A power outage occurred on our first day of surgery, but we had not begun our
With a shortage of gurneys, patients had to double up.
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AORN Journal, August 1982, V o l 3 6 , No 2
Darlynne Ibsen, RN, holds Blanca postoperatively. Her head has been wrapped with cast padding to protect her from the OR‘S air conditioning.
cases. In t h a t w a r m e a r l y morning darkness, we held our first three babies and sat quietly talking and waiting for the world t o s t a r t up again. After a n hour, the power returned, a n d we went to work armed with flashlights should a power outage recur with operations underway, There were occasional ominous flickerings, but t h e power did stay on during the remainder of the trip. Another unforeseeable problem occurred when both a n t i q u a t e d t o u r niquets simultaneously failed. (Since my trip, new tourniquets have replaced them.) Among our group were two int e r n a t i o n a l l y recognized h a n d s u r geons; consequently, more hand cases were scheduled to t a k e advantage of’ their expertise. A tourniquet was needed for each case. Without them, the surgeons continued their work and bec a u s e of t h e i r s k i l l , t h e completed
surgery was quite impressive. Two of our major crises occurred when members of our group were suddenly asked to help with cases being done by Honduran surgeons in the other three operating rooms. Uterine surgery had been performed two weeks earlier on a woman who was now in septic shock, with a severely lacerated uterus being removed. Her blood pressure dropped suddenly, and we were asked to help. Our anesthesiologist began blood transfusions, changed t h e anesthetic agent to one without hypotensive effect, a n d gave other instructions to reverse her course. We did not have a n extra blood pressure cuff, needed to push the unit of blood in rapidly, so we simply stood there and pushed t h e blood in by hand. We were in t h a t operating room for more t h a n a n hour when the patient began to stabilize, and t h e Honduran
The result of Blanca’s uncomplicated procedure can be seen.
anesthesiologist resumed charge. The second incident occurred at the end of a 13%-hour day. A voice broke through the calm of the end-of-the-day cleaning: “Code!” We streamed into an operating room ta see a Honduran surgeon standing by a 12-year-oldboy who had accidentally eviscerated himself on a machete in a fall. The surgical repair was finished, but the boy could not be aroused, and then his heart stopped. His skin was extremely hot to touch. He was anuric throughout the case. It was not known how long his pupils had been fixed and dilated. He resembled a patient with that rare anesthesia reaction, malignant hyperthermia. Few anesthesiologists ever see one in their lifetime. The Stanford team members had seen one or two cases and, fortunately, had a few reflexes in response to this tentative diagnosis. We needed dantrolene sodium to reverse the calcium release 202
process, the only drug known to do so. But we had no dantrolene. The boy’s body needed to be packed immediately in ice to lower the skyrocketing temperature damaging his brain. We had no ice. The two vital things were unavailable. We began to look for ways to improvise. The only cold thing in the hospital was a chest of soda pop provided for the Interplast staff. In a minute, the child looked like an arrangement at a barbecue, with pop bottles under armpits, bottles around the groin, pop being poured over his chest, and intravenous (IV) tubing wrapped around the bottles to cool IV solutions. A fan was set up, and alcohol was poured over the body core. While the cooling efforts were made, other teams were working simultaneously elsewhere. Medications were being pushed in: large quantities of an-
AORN Journal, August 1982,V o l 3 6 , N o 2
W
e were astonished by the trust the Hondurans had in us.
tibiotics t o cover the possibility of a diagnosis of septicemia a n d sodium bicarbonate. We did not know how long t h e eviscerated boy had lain in t h e emergency room or i n the OR hallway with his peritoneal contents exposed. A team attempted a cutdown on a femoral vessel. Another team had from the beginning given c:irdjopuImonary resuscitation in con~junctionwith t h e anes t he si o 1o gi st w h o w;I s a era t i ng t,he lungs. We h a d no electrocardiogram monitor, but iis someone pointed out, it really did not m a t t e r bclcause a t t h a t time we did not have a defibrillator. All ears were riveted to progress sounds: “His temperaturcl is 105. Down to 104.8. Slowly coming down. I c a n ’ t g e t a peripheral pulse. No, thchre’s a very light one. Oh, it’s gone.” WP worked and worked. We tried t o will t h a t boy to live. You c a n ’ t d i e . you h e a u t i f u l c h i l d . “Temperature down to 104.6. There’s a c a r o t i d p u l s e . b u t it’s w e a k a n d thready.’’ After 45 eteimal minutes of’ t u n n e 1- v i s i o n ed tea ni wo r k and cre a t i v ity, we realized his heart would not beat, and his pupils were st ill fixed and dilated. So it, was ended. I find it hard to talk ahout still. I t was an emotional. hinding experience for all; a single-mindt.d drive was shared a s though we were one person during this event. I do not recall another nursing experience t h a t co m pa ITS, Every o n was devastated even though each of us had seen many deaths i n our careers. A (3
Honduran doctor told t h e family waiting outside t h e OH doors, and a terrible wailing arose t h a t went directly to our bones. It broke every heart. We hugged one another, wept. and after cleaning up. talked long into t h e night to salve this wound we had sustained. We became better friends. The mutual support was invaluable, and t h e lessons learned about the capabilities and depth i n other people were rarc. A haggard group stumbled toward the finish line on t h e last day. It was a six-hour day because t h e equipment was packed, but it was more chaotic than usual with lust minute cancellations and substitutions. Most o f t h e few remaining supplies were left for t h e Honduran hospital staff‘s use. We worked in it microcosm ofreality there. with a known beginning and a n end. We met people who astonished us with their unconditional t r u s t in t h e strange foreigners a s they handed u s their infants, and left with a glow in their eyes. Of the 89 cases, we did skin grafts and some unusual lesions, in addition to t h e more usual procedures. There were cases t h a t looked minor but became major, and others t h a t started as serious but in t h e end were minor. I h e emergency and major cases we did require good follow-up care, and it is not, known how t h e patients will recover. The native surgeons received full reports and requested considerable instruction, but we were concerned about r ,
many cases we w o u l d n o t be able t o foll o w up. F o r example, an emergency patient, whose t r e a t m e n t w e assisted in upon request, had a hand severed and an arm m a n g l e d by a w r i n g e r . T h e w o u n d was debrided and casted with f u r t h e r debridement and s k i n g r a f t s s t i l l r e q u i r e d w h e n h e vanished f r o m t h e hospital t h e night after surgery. T h i s kind o f fear and ignorance i s our and h i s enemy. In each case, an effort was made t o d e t e r m i n e a t t i t u d e s and l o n g - t e r m complications o f t h e surgery and t o b e considerate o f c u l t u r a l attitudes. I t was d i f f i c u l t t o conclude that an operation
that w o u l d be absolutely indicated f o r a c h i l d in t h e U n i t e d States w o u l d b e contraindicated in H o n d u r a s because o f t h e c u l t u r e t h e p a t i e n t w o u l d r e t u r n to. M o s t o f t h e procedures w e did, however, were those in w h i c h t h e wounds w o u l d h e a l q u i c k l y and r e t u r n t h e pat i e n t s t o a l i f e o f c o n t r i b u t i o n t o society. T h e c h i l d r e n w i l l b e productive. G r o w n fathers unable t o use a hand w i l l n o w be able t o m o r e fully f u n c t i o n and m o r e e a s i l y s u s t a i n t h e i r f a m i l i e s . These were t h e d r a m a t i c cases that daily del i g h t e d us. In t h i s w a y w e saved lives. N o t h i n g could keep m e f r o m going back. 0
Audiovisual review: Electrosurgery This audiovisual program uses good instructional design through cartoon stills to provide an overview of how an electrocautery unit functions, placement of grounding pads, and hazards associated with electrocautery usage. This portion of the program is quite basic, emphasizing practical "how to and how not to" information rather than technical knowledge. An instructional guide is provided, which gives more in-depth discussion of the points covered in the audiovisual. The combination of the instructional guide and the cartoon stills provides good content for an inservice workshop on electrosurgery. The audiovisual may be used alone and serve as a review for nurses who are already cognizant of electrocautery, leading to discussion and recall of more technical aspects. A pretest, posttest and references are provided. Those who dislike humor mixed with serious information may find the cartoon stills distracting. They do highlight important points, however, and aid in retention of the subject matter. The target audience is OR nurses. Information contained in both the audiovisual and the instructional guide has been derived from seminars presented to
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OR nurses throughout the country. Hectrosurgery is available in slide/ cassette (41 slides) and 314 inch U-matic videocassette and runs about 11 minutes. The cost is $125 and comes with an unconditional 30-day money back guarantee. It may be ordered from Medfilms, Department 3A, 5632 E Third St, Tucson, Ariz 8571 1. Patricia Ball, RN, CNOR Audiovisual Committee
Military makes positive changes in field hospitals Two years of research have resulted in a much improved field hospital. Now the critical elements of field hospitals, such as ORs and ICUs, are in environmentally controlled shelters. These shelters can be assembled in a half hour and are constructed of aluminum over paper honeycomb. The shelters, with slight alterations, can be used for communication centers, machine shops, or kitchens. Each unit has blackout shades to prevent enemy troops from observing the activities within the shelter. The new shelters can be disassembled and packed quickly.
AORN Journal, August 1982, V o l 3 6 , No 2