It was one of the most extraordinary rescues in medical history. In 1995, Angus Wallace was settling in on a flight from Hong Kong to London. He was tired after a long week and had planned to spend the journey catching up on some reading, but it wasn't to be. The plane hadn't even left the ground when an announcement crackled over the address system: "If there is a doctor on board would they please make themselves known to the cabin staff."
Luckily this was no ordinary passenger – this was Professor Wallace, a highly respected orthopaedic surgeon and the inventor of the brace position. He soon found himself tending to a 39-year-old woman on the back row of economy. Paula Dixon had fallen off her motorbike on the way to the airport and was concerned about her right arm, which had begun to swell up. He diagnosed a simple fracture, splinted the arm and went back to his seat.
Barely an hour later, things began to look decidedly more seri ous. It turned out his patient hadn't just injured her arm – she had also broken several ribs. The plane was cruising at 33,000ft (10 kilometres) when he realised she had suffered a collapsed lung; one of her ribs had punctured the membrane surrounding her lungs, allowing air to rush into her chest and squeeze the breath out of them. Without urgent treatment, she could be dead in minutes.
The condition usually calls for a special machine known as an underwater sealed drain, which removes the gas without letting any more leak in. After rummaging around in the airplane medical kit, all Wallace had was a scalpel, a length of hollow plastic tubing and some local anaesthetic.
He was going to have to make a few substitutions. He cut open her chest and held the incision open with a knife and fork. Next he straightened out a metal coat hanger, sterilised it with a splash of brandy from the refreshments trolley and used it to guide one end of the tubing into her chest; the ot her end was submerged in a bottle of Evian water. The crowning touch was some sticky tape, which held it all together.
These are the Indiana Jones's of the medical world – making it up as they go along in remote corners of the globe and often risking their own lives in the process
Air flowed out of the chest, through the tube and bubbled into the water. It was all over in 10 minutes – then she sat up to eat her breakfast while Wallace slipped back to his seat with the rest of the brandy.
Back at sea level, his mid-air heroics were an instant sensation. But in many parts of the world – where low budgets, dodgy roads, or sheer remoteness mean even basic medical equipment is hard to come by – this kind of lateral thinking happens every day.
In these extreme environments, doctors must improvise with whatever is available, from fashioning ECG electrodes from bottle caps to stitching flesh together with superglue. These are the Indiana Jones's of the medical world – making it up as they go along in remote corners of the globe and often risking their own lives in the process.
One man who knows this all too well is Kenneth Iserson. He's practiced emergency medicine on all seven continents, including work for charities in Zambia, Bhutan, Ghana, South Sudan and a six-month stint in Antarctica. "It's important not to give up when you don't have the typical equipment – you have to think around the problem," he says.
(Watch the video below on how a new computer tablet is diagnosing heart problems in settlements far from medical facilities)
In his long and distinguished career, Iserson has improvised surgical utensils from paperclips and been called upon to extract rotting teeth from Russian sailors in the remote Arctic; he sat them in the captain's chair, covered it with bin liners and set to work with some wire cutters and a couple of screwdrivers he had borrowed from the ship's electrician. Ouch.
Back in 2010, Iserson was working at a hospital in rural Ghana when a three-year old girl was rushed into the emergency room. She had been hit by a car and found unconscious a couple of hours later by some relatives. He suspected she had a head injury. "The normal thing would be to get a CT scan to assess the damage, but we didn't have any of that," he says.
The hospital lights are so dim, during fiddly procedures Bamongo regularly resorts to using the light on her phone
Instead all the team could do was provide basic life support – and quickly – and hope she hadn't sustained any serious head injuries. The most important piece of kit in their arsenal was a "manual resuscitator", an air-filled bag which could be hand-pumped to assist with breathing. But there was a problem. "The tubes that go into your trachea [windpipe] have to be the right size for the person," he says. And they didn't have a child-sized tube.
Eventually they m anaged to cut a thinner length of tubing from another piece of medical equipment, but they still needed a way to link it to the resuscitator. Then Iserson had a brain-wave. He asked a member of staff to fetch him a plastic baby bottle. "We took the nipple off, cut a little hole in it and reversed it. It fitted perfectly on the resuscitator – then we were able to slide the tube in," he says. A few days later, the child had recovered enough to be able to go home.
For Iserson, it's not so much about how well the solution works, but if there's a better option. "When I was working in rural Mexico, every day we looked in this tiny cardboard box to see what kind of medicines we had for that day," says Iserson. When they ran out of something they wanted to use – such as for anaesthesia – they'd switch to common household drugs (aspirin, ibuprofen, paracetamol) instead. If they ran out of those, he'd inject his patients with medical-grade salt water because the pr eservative, benzyl alcohol, also works as a painkiller. As a last resort he'd turn to hypnotism.
In war-torn regions you can multiply these challenges by a factor of 10. Emmanuelle Bamongo has worked as a midwife in the Central African Republic for over a decade. The nation has been embroiled in a bloody civil war between the Seleka rebel coalition and government forces since 2012. It's an extremely challenging environment, in which medical professionals are few and far between and hospitals are regularly looted. That's not to mention the decades-old equipment, frequent electrical blackouts and the fact that most of her patients – women in labour – travel to the hospital, over bumpy roads, via motorbike. Other patients may be at a very late stage of their illness, because they dare not risk the roads.
The hospital lights are so dim, during fiddly procedures Bamongo regularly resorts to using the light on her phone. "Sometimes I have to hold my phone in my mou th, because I need both hands and I can't touch anything that's not sterile," she says. Tenacity and a willingness to make it up as you go along are essential, but she also stresses the importance of specialist expertise. If you know the rules, you know how you can break them.
I took out an ambulance splint that we use every day in the UK and it just froze and shattered into 25 pieces – Been Cooper, Antarctic medic
But there's one place that pushes even the most resourceful medics to their limits: Union Glacier Camp. This frozen Antarctic base, some 1,870 miles from the Southern tip of Chile, is home to the most remote hospital in the world. On average, the temperature outside is around -49C (-56F).
"In such extreme cold, plastic becomes brittle, dressings and tape are no longer sticky and vital medications freeze, so you have to learn to adapt," says Ben Cooper, who works as the camp medic. In 2005, he was called to the scene of an accident. A clim ber had been investigating a new route in some nearby mountains when he fell into a crevasse.
He had ruptured a muscle in his chest and broken a leg. The priority was to get him back to the camp as quickly as possible, but first Cooper needed to support the fractured bone with a splint. "I took out an ambulance splint that we use every day in the UK and it just froze and shattered into 25 pieces," he says.
What he needed was something hard that would be able to withstand the bitter cold. In the end he settled on a stove board, a heat-proof mat that stops the snowy ground from sucking up all the heat during cooking. He wrapped the board around the leg and secured it with some duct tape that had been wrapped around the handles of his ski poles. When they got back to the camp, he sedated his patient and began re-aligning their broken leg. "In hospital you'd put a block under the knee to help align the bones, but we didn't have any of that stuff so we used a larg e catering tin of peaches," he says.
Even in warmer climes, malfunctioning equipment can be a big problem. Thanks to donations from western charities, many hospitals which can barely afford disposable gloves are crammed with expensive kit – automated resuscitators, anaesthesia machines, infant incubators, laboratory equipment – but there's nobody to fix it or supply spare parts so it's often stowed away in backrooms or used as furniture.
In Antarctica, Cooper has pioneered the use of rolled up paper to treat asthma attacks
In these environments, Iserson has found that often low-tech, DIY solutions often make a lot more sense. This might mean simply making your own ultrasound gel from corn-starch and water "for the guys that helped me to do it, it was mind-blowing how easy it was compared to how much they had been paying for the commercial version" or improvising an incubator by hanging a large, inefficient lightbulb above a baby's crib.
In A ntarctica, Cooper has pioneered the use of rolled up paper to treat asthma attacks "if you squirt the inhaler into one end eight times you'll get a dose equivalent to using a hospital nebuliser" and superglue for – well, pretty much everything.
It was first invented in 1942 by accident, during an attempt at making a new type of clear plastic. When Harry Coover went to test the ocular properties of the substance, it glued all his equipment together. He never succeeded in making his plastic, but "Eastman 910" found a medical use as early as 1966 when it was used by surgeons in the Vietnam War.
Today it's invaluable for making equipment and sealing wounds in situations where stitches would be too time-consuming or fiddly, such as out in the field. "I use it on myself to fix cuts all the time, it's totally safe," says Cooper.
Many lessons learned in extreme environments may be useful in the developed world, or within the four walls of an ordinar y hospital
And you don't have to travel to the other side of the world to see this creative spirit in action. In his native city of Sheffield, one patient turned up with a wound stuffed full of tea leaves. "That's what their grandmother taught them to do in the Yemen," he says. Cooper was horrified, but when he cleaned away all the leaves five days later the wound looked remarkably clean.
And you never know when you'll need them. In 2011, five soldiers from Oxfordshire saved a man's life by improvising with credit cards. He'd been stabbed in the chest and was at risk of developing a collapsed lung, but they used the cards to prevent air from entering the wound – a technique they had been taught for use on the battlefield.
In fact many lessons learned in extreme environments may be useful in the developed world, or within the four walls of an ordinary hospital. "Any place, including the biggest hospital in London or New York, can certainly become resource poor," says Iserson. He cites a power cut early on in his career which left him dependent on a key light he had in his pocket.
Many places simply aren't prepared because they don't count on their basic infrastructure drying. Perhaps it's best to keep your phone to hand and not to stray too far from the brandy.
Many thanks to Sandra Smiley from Médecins Sans Frontieres for translating the interview with Emmanuelle Bamongo.
Join 700,000+ Future fans by liking us on Facebook, or follow us on Twitter, Google+, LinkedIn and Instagram
If you liked this story, sign up for the weekly bbc.com features newsletter, called "If You Only Read 6 Things This Week". A handpicked selection of stories from BBC Future, Earth, Culture, Capital, Travel and Autos, delivered to your inbox every Friday.
Source: DIY medicine at the edges of civilisation
No comments:
Post a Comment