A field block for abdominal surgery

Field blocks are ways of delivering anesthesia to a region of the body via a strategically-placed injection. Say you're looking to numb up a fingertip laceration in order to suture it. Injecting lidocaine at the wound itself is not only excruciating, but can also distort the anatomy, since the lidocaine solution in itself takes up space. There's also the chance that you'll miss a spot. But you can numb the entire finger with a field block at its base (alas, not a painless injection). There are a number of field-block techniques out there--whether you're numbing up an ear, an ankle, an abscess, these techniques offer analgesia in a localized region of the body without requiring either wound injection or general anesthesia.

 An anesthesiologist recently told me about a field block for the abdominal wall. It's called a transversus abdominis plane block, or TAP block. Author Karim Mukhtar writes that the TAP block is "indicated for any lower abdominal surgery including appendectomy, hernia repair, caesarean section, abdominal hysterectomy and prostatectomy. Efficacy in laparoscopic surgery has also been demonstrated. Bilateral blocks can be given for midline incisions or laparoscopic surgery."

The TAP block would seem to be an awfully nice option for low-resource surgical practitioners. One can imagine the safety benefits in a setting where general anesthesia is impossible or risky. Mukhtar also describes an ultrasound-guided technique at the hyperlink above.

Daily wound probing reduces surgical-site infections

An article in the Archives of Surgery reports that a daily routine of poking between the staples of a healing surgical wound with a Q-tip (a wound-probing protocol or WPP) greatly reduced surgical-site infections in patients recovering from open appendectomies after perforated appendicitis.

"...SSI in contaminated wounds can be dramatically reduced by a simple daily WPP," the study authors write. "This technique is not painful and can shorten the hospital stay. Its positive effect is independent of age, diabetes, body mass index, abdominal girth, and wound length. We recommend wound probing for management of contaminated abdominal wounds."

The investigators note that the mechanism by which wound probing reduces SSIs is not clearly understood but that it may allow for drainage of contaminated fluid within the soft tissue.

Good nursing care prevents an awful lot of complications. It probably costs almost nothing to add this bit of wound care to the routine, especially if performed by trained family members, and may keep many recovering patients in low-resource settings out of trouble. A news article about the study can be found here.

Delayed appendectomy

This article reviews a recent study published in the September Archives of Surgery that suggests it may be safe to delay an appendectomy in adults, even for over 12 hours.

We're not in the US, but we can offer decent supportive care here in rural Indonesia, and from what I can discern from the article, I think this study is good news for low-resource or remote practitioners. Fluids, antibiotics, one gives those, of course, but we probably have time to safely transfer a patient to a surgeon if he presents to our remote clinic with suspected appendicitis. That's nice to know.

Breast cancer in developing countries

Cancers don't make top-ten lists of causes of death in poor countries, but that is because even larger numbers of people are killed by infections like diarrhea and TB. Make no mistake, those countries' cancer rates are high, and climbing. (The reasons for rising cancer rates are still unclear. Some think that nocturnal light as a byproduct of development is partly to blame.)

One of the worst offenders is breast cancer, now being called a worldwide epidemic at over a million new cases a year. I spoke last summer with Dr. Fred Okuku, a Ugandan physician who was at Yale learning medical techniques which he later took back to his own country. He told me that 95% of Ugandan women with breast cancer already have Stage IV disease when diagnosed. They notice a lump, then wait an average of two years before seeking treatment. As a result, many patients in Uganda recapitulate the terrible natural history of cancers with a thoroughness most Western doctors haven't seen in many decades. Okuku returned home with a mammography van and an ultrasound machine to try to change the grim statistics. (His colleagues there are well aware of the challenge and have risen to meet it: read on.)

What do doctors have to offer breast cancer patients in low-resource settings? What guidelines are available to those doctors? Which organizations are thinking about this?

Breast Health Global Initiative: Their 2008 Guideline implementation for breast healthcare in low-income and middle-income countries looks to be practical and comprehensive. They certainly know the need for such a guideline: "In high-resource countries, evidence-based guidelines...are resource neutral, they fail to consider variable resource distributions where overall standards of living are high, and they fail to recognize ubiquitous deficits in infrastructure and resources in LMCs. Moreover, they do not consider implementation costs or provide guidance on how a suboptimal system can be improved incrementally toward an optimal system. Such guidelines defining optimal breast care and services...have limited use in resource-constrained countries, and there is a need for resource-based guidance related to strategies for reducing the burden of breast cancer for settings in which optimal care is not feasible." 

Breast Surgery International: a group of surgeons interested in breast cancer in developing countries. Their 2002 paper is a summary of the breast cancer situation in Malaysia, South Africa, and Nigeria. It stops short of offering firm clinical guidelines. 

The Uganda Cancer Working Group, a group of Ugandan physicians based at Makarere Medical School in Kampala (Fred Okuku's school) in 2008 published a second edition of a set of guidelines for managing breast cancer in that country. (The first edition, report the authors, was well-received and heavily cited.) Interestingly, these guidelines emphasize breast self-examination while acknowledging that such measures are no longer being pushed in developing countries. What works in one context does not necessarily work in another.

Non-free journal articles on this topic include a set of guidelines from Stanford physicians, a review of treatment trends in the Arab world from the American University of Beirut, and a discussion of breast-conservation strategies in the developing world from Banaras Hindu University. Those with access to Breast Journal can find a number of relevant articles, including an article analyzing testimonials from patients in limited-resource countries which found several themes: "1) the experiences and fears of breast cancer survivors, 2) beliefs and taboos about breast cancer that hinder awareness programs and treatment, 3) the need for public education and breast cancer awareness programs in countries with limited resources, 4) difficulty in translating the concept and ethos of advocacy into many languages, and 5) the experiences in establishing and maintaining advocacy groups to promote breast cancer awareness and to inform public policy."

High-volume medicine: lower costs, and--surprise!--better care.

India is a poor country, but at least one hospital group there is managing to drive down costs in part by driving up volume. And guess what--outcomes are better, too. The Wall Street Journal reported yesterday that cardiac surgeon Dr. Devi Shetty of Bangalore has set up specialized surgical hospitals that allow for similar types of operations to be performed on huge numbers of patients, including the poor. These hospitals appear to be both cheap and safe by Western standards. The fact that doing the same operation over and over again improves patient safety and saves money is something Canada already knows; its Shouldice Hernia Centre, examined by Atul Gawande in his 2002 book Complications, has achieved good results for decades.

To wit: when setting up a clinic or hospital in low-resource settings, there are ways to beat Western-sized budgets, and not by just a little. Smarter expenditure can make all the difference. As Dr. Shetty put it, "What health care needs is process innovation, not product innovation." And it is low-resource practitioners who have perhaps the greatest incentive to make process innovation work.