Serendipity, systems, surgeons and household drills

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Dear colleagues,

Volume 71, Issue 49 of this Digest was a most serendipitous one. We
announced the new ICRC publication (War Surgery: working with LIMITED
RESOURCES) and read the press report about the Australian colleagues who
dealt with an extra-dural haematoma using a household drill to perform the
trepanation.

That the Australian system allows for a general surgeon in a remote region
to be "talked through" a specialist procedure by a distant expert as a
damage control procedure says a great deal about the circumstances of
working in the outback and the efforts to mobilise available human
resources. Our Australian colleagues have been well-known for this for quite
some time. Bravo!

In my opinion, this is what a system is for: analysing the prevailing
circumstances and finding the appropriate response. And each set of
circumstances (including the legal barriers in the US of A, which are part
of the system there) will require an adaptation of the human and material
resources available to set up the appropriate system. South Africa, as Tim
as mentioned, is also developing this tele-medicine approach. I mentioned a
case on this list last year, I believe: a Red Cross general surgeon,
experienced in war surgery, talked a Palestinian colleague in the Jenin
General Hospital through a craniotomy for a penetrating fragment wound
during the fighting in the West Bank in 2002 over a VHF radio.

This "tele-medicine" approach will not work everywhere. The damage control
procedure turns into a definitive procedure on the spot if further
evacuation is not possible; often the case during armed conflict (the
situation in Jenin at the time), but also very common in poor countries. And
your local specialist surgeon may not exist; try finding a neurosurgeon in
the eastern Congo or Sierra Leone. The "system" will be different, according
to the circumstances and resources available. The question then becomes what
sort of training the general trauma surgeon should have (another famous
topic of discussion among the members of this list) and how this, also,
should be appropriate to the working circumstances, the system. I doubt if
one formulaic model will meet all requirements.

Concerning the particular Australian case, the news reports seem to stress
the "household drill" aspect as much as anything else. This is the lay
response. As one colleague on this list has mentioned, this often occurs in
developing countries.

Take a long, hard look at the drills, hammers and screw drivers in the
armamentarium of your local neuro- or orthopaedic colleague. What is the
difference between these and the equivalent tools from your neighbourhood
hardware store?  The price! (I am not talking about the the specific plates
and screws that a surgeon puts in the human body.) Simply call a hammer or
drill "medical" and you can multiply the price by a factor of 10. Working
with limited resources -- in far-away places -- and improvising accordingly
is a well-known phenomenon in war surgery. And a great deal of surgical
"progress" has been accomplished by our predecessors in this respect.

So, I raise my cup to "imagination" and improvisation and mobilisation,
based on a sound scientific basis.

That's a bit more than two cents, best regards

-- 
christos giannou
Monemvasia Lakonia
23070 Greece
tel & fax: (++30) 27320-61772
mob: (++30) 69 74 83 28 18

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