Appropriate Technology?

When I first arrived at Tenwek, I remember being amazed at how well equipped they were for a missions hospital in the developing world. They have ventilators! They have a defibrillator (machine that gives the heart a shock, used in life support stuff)! They have scopes of all sorts--for endoscopy (looking into the stomach), colonoscopy, cystoscopy (bladder), and laparascopy (abdomen/pelvis). This is the biggest shocker--we have cardiac teams come out a couple times a year and somewhere in the recesses or the OR basement is a BYPASS MACHINE. Seriously? This is a machine that is used in open heart surgery and basically acts as a heart and lungs for the patient undergoing surgery. Unexpected.

Also, because of the various teams of surgeons that come through Tenwek, people are always brining new equipment with them to donate to the hospital. We recently got something called a Ligasure donated to the hospital. It is a clamp used in surgery that also employs electrocautery to seal any blood vessels in your clamp. Most hospitals in the US have them, but I'll bet most hospitals in the developing world don't. I've used it. It's great!

But sometimes I have to stop and wonder about how appropriate all this stuff is. When I can use cutting edge technology to do a hysterectomy (which is nice, but the surgery can also be done with far more basic equipment), but I can't find a simple metal speculum to examine my OB patient, or a clean sheet to put on the bed for her, is there something wrong? Should we be focused more on stocking the basics needed to provide better patient care before we move on to high tech? Or should we say, hey, the Ligasure was a free donation! Use what ya got!

One of my former OB attendings, Bryan Popp, is now working with me at Tenwek. He was known as somewhat of a laparoscopic guru, and I was looking forward to doing some L/S cases with him to keep up my skills. Above is a photo of us doing our first laparoscopic case together. It looks like we are engaged in great medical discussion about how to care for the patient, but instead, we are shooting the breeze while waiting for the L/S stuff to get set up. About 45 minutes after the patient was put to sleep, we still hadn't started, because of some problem with the carbon dioxide gas valve. In fact, we ended up just making a small incision and doing an open case. Other L/S cases have been cancelled for similar reasons. We have the technology, but sometimes don't have the ability to maintain it or work with it. So, I could keep trying, or I could decide that what works in the US and is "best" for the patient, might not work or be the best option for my patient at Tenwek. And there are also issues about WHO gets to take advantage of the technology. When you have ventilators, but only two, which patients should get them? The sickest patients? The youngest? The ones most likely to get better? We're still trying to figure out some of this stuff...it's an ongoing process. Hopefully we'll have some more blogs in the future addressing some of these issues as well.