DECEMBER I99 I , VOL 54, NO 6 AORN JOURNAL

Perioperative Nursing on the Amazon River

AN EXPERIENCE THAT MADE A DIFFERENCE

Cathleen Harrison, RN

We had been traveling for 22 hours, and we had not ye t reached our destination of Santare’m, Brazil. We were in the port city of Bele’m awaiting the next f l ight that would bring us to our destination 500 miles up the Amazon River where the Tapajoz River meets the Amazon River, in the northern state of Para’. I needed sleep and a change of clothes, but my needs were minimal compared to the people I was to encounter in the next two weeks.

his was my second trip as a part of a vol- unteer team for the project “Esperanca,” T which performs needed surgical proce-

dures on the poor villagers in northern Brazil. If not for these voluntary surgical teams, the peo- ple of this area would have no access to surgi- cal care. Medical care consists of one physician for 2,500 people.

When I was asked to be a part of the team, my sense of adventure was renewed, and I eagerly looked forward to the challenge of OR nursing in less-than-ideal conditions. Our four- member team included a plastic/reconstructive surgeon (Albert Babcock, MD), an anesthesiol- ogist (Richard Kemp, MD), another OR nurse (Kathy Upson, RN), and myself.

There are no direct flights to this area of Brazil, so we were prepared for many layovers between flights. We tried to catch some sleep whenever possible because we knew our work would begin soon after our arrival. We finally reached Santare’m more than 24 hours after we had left Hartford, Conn.

Project Gives Hope

he word esperanca means “hope” in Portuguese. The project Esperanca gives T hope to people who would not have even

basic medical care. The project is supported by private and government grants, contributions, and donated supplies and services.

The project was founded by the late Father Luke Tupper, a physician and priest. He went to Brazil in 1969 and found overwhelming medical problems and poverty. Half the chil- dren did not live to celebrate their second birth- days, and families suffered from malaria, polio, and malnutrition. In response to these condi- tions, he founded project Esperanca. It is a non- denominational, international organization ded- icated to alleviating suffering among the poor. The project now helps people in Bolivia, Africa, and Mexico as well as Brazil. The mis- sion is twofold. The teams provide surgical care to those who would otherwise have no access to this type of care and also train local doctors, nurses, and paraprofessionals.

The clinic at Santare‘m opened in 1972. Hundreds of people now receive basic medical care each week. Many travel 10 hours by river- boat to reach the clinic. Voluntary surgical

Cath leen Harr ison, RN, is head nurse, OWarnbulatory surgery, St Francis Hospital, Hartford, Conn. She earned her nursing diplo- ma at St Francis Hospital School of Nursing, Hargord, Conn.

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Members of the Esperanca team (from left) Cathleen Harrison, Richard Kemp, Albert Babcock, and Kathy Upson.

teams come to the region four times a year to give their time and skills to these people. In addition to the clinic, a ferryboat was pur- chased and converted to a hospital boat. It was a floating clinic and operating room, traveling many hours to reach people in remote villages. The boat has since sunk, and the facilities have moved to shore, but the care delivered is the same.

Along the river, villages have formed a net- work of medical outposts that are staffed by “barefoot doctors” who are trained in basic medical care and provide immunizations, sim- ple suturing, and health education.

San ta rein

antare‘m has a population of more than 100,000. It has a one-runway airport and houses ranging from two-room shanties

to large, Spanish-style stucco homes. Most roads are unpaved and contain huge potholes. Taxi drivers tend to drive on both sides of the road, depending on where the road still exists. Cattle and goats roaming the streets is not

unusual, and vultures perched on buildings are quite common.

This region has a two-season climate. It is either rainy or dry, and it is always hot (ie, more than 90 O F [32 “C]) and humid.

Triage

u r work began four hours after we arrived. The patients had been screened 0 initially by the American and Brazilian

physicians who staff the clinic. Those who could benefit from surgical intervention were asked to return to be seen by our team. The waiting room was filled to capacity, and, one- by-one, each patient was evaluated.

Many of the patients were children with cleft lips and/or palates. Others presented with prob- lems ranging from hypospadius to breast tumors. The most urgent cases were added to the surgical schedule, which filled quickly. The rest would have to wait for the next team to come in three months.

What was most remarkable during this triage session was the marked improvement in the

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room with an autoclave to sterilize linen packs and gowns. We had brought peel packs, which were invaluable.

The OR itself looked similar to those in the United States 20 years ago. We were fortunate enough to have an air conditioner in the win- dow. The windows were frosted glass but windows none the less. I was not accustomed to seeing win- dows in an OR. The room had two OR beds. The re a l so were two s tacked , wooden cabine ts that A typical home along the Amazon River. housed sutures and supplies.

The substerile room was fairly general health of these people since our last visit three years before. We noted that the chit- dren looked healthier, better nourished, and more in line with the normal growth and devel- opment of children their age. The impact of the project was readily apparent.

large and had floor-to-ceiling cabinets that con- tained unsterile instruments. There was quite an abundance of instruments, but the scissors were not very sharp. Many of the other instruments were usable.

We spent a few hours that first afternoon unpacking our own instruments and supplies. After we were somewhat organized, it was din- ner time, and we all needed sleep.

Facilities, Supplies

fter triage, we headed to the OR to prepare for the next day ' s A cases. The general rule when

traveling to an area such as this is to assume that nothing is available and to bring everything. We brought basic instrument sets, a dermatome, dress- ings, sutures. blades, gloves. suction devices, and everything else we could think of that would f i t in our luggage without exceeding the airline weight limit.

Whatever we did not use during the two-week period was left behind for other teams. In addition to supplies left by other teams, much has been donated through the years. We found gloves and sutures i n abundance. Dressings and sponges were available, but Kerlix and Ace bandages were in short supply. We found a cabinet with donated instru- ments and made up some additional small sets. There was a central service

The American surgeon and nurse train Brazilian surgeons during surgical procedures.

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Surgery

e began surgery a t 7:30 AM the W next morning.

We met for breakfast each morning at a kitchen set up near the building that housed the OR and recovery room. You know the sur- geon will be on time for his case when the surgical team has breakfast together. Working with the same peo- ple for many cases can be advantageous when you have a superb team like we did.

Many of the patients came to the facility the night

Dr Babcock (right) and a Brazilian surgeon during a young patient’s postoperative visit.

before because they lived 10 hours away by riverboat, a common means of transportation in this region. Physicals and lab work had been done in advance by the physicians who staff the clinic. The patients’ medical records also were avail- able at the time of surgery.

The Brazil ian physician reviewed each patient’s chart with the team before surgery. Medical histories often included things like malaria or blackwater fever. Having a physi- cian who was knowledgeable of tropical dis- eases was a definite asset.

Each patient walked into the OR and was positioned on the bed. It was difficult to imag- ine what it must be like for someone from a remote village without even electricity to walk into an OR. Good preoperative teaching helped the patients adjust.

A Brazilian nurse or a paraprofessional assisted us by positioning patients and by retrieving supplies not found in the OR. They also explained to patients in Portuguese what we were doing. We were amazed at the cooper- ation of all the patients.

After anesthetic induction, surgery pro- gressed almost as it would in any OR in the United States, with some noticeable differ-

ences. The two cautery machines were very old and worked only part of the time. The cloth drapes and our gowns were a variety of colors. It was interesting, to say the least.

My colleague and I alternated scrubbing and circulating procedures. Nurses with diverse backgrounds and extreme flexibility are assets under these conditions because the cases are diverse and the equipment is not reliable.

The second part of our mission was to pro- vide a learning environment for the Brazilian nurses and physicians. Several Brazilian sur- geons assisted or observed cases. The nurses worked side by side with us. Our surgeon spoke Portuguese, but when no interpreter was avail- able, we relied on hand signals and role model- ing to communicate with the nurses. It all worked beautifully.

Postoperative Care

fter surgery, the patients were trans- ferred to a small, three-bed recovery A room. The Brazilian nurses recovered

the patients and then transferred them to a larg- er step-down area where they were reunited

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with their families. The difference in this step- down room was that the patients rested in their “hegees,” or hammocks. Wall hooks held IV bags as well as hammocks. Many patients had never been in a bed as we know it, so most spent their sleeping hours in these oversized hammocks.

Many patients left for home the same day, while some stayed overnight. The determining factors were the patients’ suitability for dis- charge, the distance they had to travel to reach home, and the conditions to which they were returning. Many homes have dirt floors, and the patients’ usual diets may not be optimum for wound healing .

We saw all the patients on one of our last days in Brazil. We removed sutures as neces- sary and checked wound healing. We were sur- prised that most of the dressings had been kept fairly clean and dry, and the wounds were heal- ing well. Patients who required follow-up care were seen in the regular medical clinic after our departure.

Summary

e held a conference at the end of the team’s visit. W e concluded that W there was a continuum of learning in

both directions from both countries. Some of the problems and frustrations in medicine are the same worldwide.

Leaving the US medical system to work in a remote area is a fascinating and exciting experi- ence. Clean water, electricity, transportation, and food are not taken for granted in this area of the world.

The next decade in an area like this holds many different plans, hopes, and projects. Nothing can be taken for granted. All that has been developed could be lost tomorrow.

What we do makes a difference, whether it is in the jungles of Brazil or an OR in the United States. To see the health of the general popula- tion so markedly improved from our previous visit emphasked that point.

Your skills as an OR nurse can be translated to other countries. An instrument may have a

different name, but the use i s the same. Operating room nursing on the Amazon River is the same, and it is different. You can and do make a difference to your patients each day. We found that the difference is less subtle in an area that has so little. ~

T I

Pregnancy -Induced Hypertension Reduced Recent analysis of data from six research stud- ies found that low doses of aspirin taken during pregnancy may reduce a woman’s risk of hypertension. Pregnancy-induced hypertension (PIH) includes a group of disorders known as toxemia of pregnancy. It is a major cause of obstetric and perinatal morbidity and mortality, and it occurs in 5% to 15% of all pregnancies. The cause of PIH is not known.

According to an article in the July 10, 1991, issue of the Journal of the American Medical Association, researchers used meta-analysis to get more precise information regarding the effect of low doses of aspirin on PIH, severe low-birth-weight (SLBW) infants, and perina- tal mortality and the risk of adverse effects. Meta-analysis is a new research method that is useful when several trials have low statistical power and negative results. Meta-analysis pools the results of several trials and can lead to more precise estimates of treatment effects.

Previous clinical trials with small groups of patients suggested that low doses (ie, 60 to 150 mg/day) during the second and third trimesters can reduce the risk of PIH and improve mater- nal and neonatal outcomes. A total of 394 women were in the six trials. Meta-analysis found that low-dose aspirin reduced the risk of PIH by 65% and the risk of SLBW infants by 44%. There were no adverse effects. The effect on cesarean section rates was inconclusive.

The authors encourage more research to determine the optimal dose and duration of treatment, according to the article. They sug- gest that ongoing randomized trials be conduct- ed to confirm the benefits found in this study.

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