9 Developing a Low-Cost, Ultraportable, Modular …
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ities and infrastructure are frequently unavailable. Procedures instead often occur
wherever dedicated space could be found, whether general-use rooms, outdoors, or
other suboptimal settings. Pathogen-carrying insects, dust particles, provider skin
squames, and numerous other dangers frequently breach the sterile field. Even in
state-of-the-art operating rooms, relatively modest breaches due to events such as
door openings have been associated with increased SSI rates. Indeed, decreasing the
number of times doors was opened decreased SSI rates by 36% in one study and
51% in another (Van der Slegt et al. 2013; Crolla et al. 2012). The absence of any
door at all, or of effective surgical suite ventilation, in the LMIC operating space is
therefore quite a concern.
The need to provide safe surgical care outside of traditional surgical facilities
is certainly not a new problem. However, solutions to the challenge have typically
started from the assumption that the core problem is to provide a sterile operating
room outside of a standard facility. This mindset informs solutions such as surgical
tents, operating rooms mounted on trailers or trucks, semi-portable laminar airflow
systems, and most other solutions to date. These devices unfortunately tend to share
several significant limitations in practice. They are challenging to transport to remote
or disaster-affected areas, requiring both time and logistical capability. Once at the
desired site, they require significant setup time. For example, surgical tents can take
a full team of technicians working around the clock for 72 h to fully set up. Several
of these systems have at least one external dependency, particularly availability of
electricity or requirement of flat terrain. They require significant resources not only
for sunk cost but also for marginal cost of each procedure. Personnel, a particularly
scarce resource, is also required to set up and maintain these complex systems. These
systems are not always robust to the high levels of external contamination, with sand
particulate ingress into the tents a particularly notorious phenomenon in the field
(e.g., as described by Stevenson and Cather 2008). Finally, any contamination in
these systems, including that generated by providers through squame shedding, can
still contaminate the surgical site.
9.1.3 Provider Safety in Surgery: Protecting Surgical Teams
Patients are not the only ones who can get infected during surgeries. Some 85,000
medical providers worldwide are infected every single year by patient bodily fluids,
with the vast majority of surgeons and obstetrician/gynecologists having experienced
at least one exposure in the past year (Butsashvili et al. 2012). Despite the lower volume of invasive procedures occurring in austere settings, 90% of providers infected
were working in such settings (World Health Organization 2011). Such chronic risks
were thrust into sharp relief during the Ebola epidemic, when, for instance, Sierra
Leone’s surgeons encountered 100-fold infection rate increases compared with the
general population, resulting in the death of 25% of the surgeons in the main teaching
hospital of the capital (Yasmin and Sathya 2015; Bundu et al. 2016). Unfortunately,
personal protective equipment (PPE) is costly and cumbersome to wear during surg-
99
ities and infrastructure are frequently unavailable. Procedures instead often occur
wherever dedicated space could be found, whether general-use rooms, outdoors, or
other suboptimal settings. Pathogen-carrying insects, dust particles, provider skin
squames, and numerous other dangers frequently breach the sterile field. Even in
state-of-the-art operating rooms, relatively modest breaches due to events such as
door openings have been associated with increased SSI rates. Indeed, decreasing the
number of times doors was opened decreased SSI rates by 36% in one study and
51% in another (Van der Slegt et al. 2013; Crolla et al. 2012). The absence of any
door at all, or of effective surgical suite ventilation, in the LMIC operating space is
therefore quite a concern.
The need to provide safe surgical care outside of traditional surgical facilities
is certainly not a new problem. However, solutions to the challenge have typically
started from the assumption that the core problem is to provide a sterile operating
room outside of a standard facility. This mindset informs solutions such as surgical
tents, operating rooms mounted on trailers or trucks, semi-portable laminar airflow
systems, and most other solutions to date. These devices unfortunately tend to share
several significant limitations in practice. They are challenging to transport to remote
or disaster-affected areas, requiring both time and logistical capability. Once at the
desired site, they require significant setup time. For example, surgical tents can take
a full team of technicians working around the clock for 72 h to fully set up. Several
of these systems have at least one external dependency, particularly availability of
electricity or requirement of flat terrain. They require significant resources not only
for sunk cost but also for marginal cost of each procedure. Personnel, a particularly
scarce resource, is also required to set up and maintain these complex systems. These
systems are not always robust to the high levels of external contamination, with sand
particulate ingress into the tents a particularly notorious phenomenon in the field
(e.g., as described by Stevenson and Cather 2008). Finally, any contamination in
these systems, including that generated by providers through squame shedding, can
still contaminate the surgical site.
9.1.3 Provider Safety in Surgery: Protecting Surgical Teams
Patients are not the only ones who can get infected during surgeries. Some 85,000
medical providers worldwide are infected every single year by patient bodily fluids,
with the vast majority of surgeons and obstetrician/gynecologists having experienced
at least one exposure in the past year (Butsashvili et al. 2012). Despite the lower volume of invasive procedures occurring in austere settings, 90% of providers infected
were working in such settings (World Health Organization 2011). Such chronic risks
were thrust into sharp relief during the Ebola epidemic, when, for instance, Sierra
Leone’s surgeons encountered 100-fold infection rate increases compared with the
general population, resulting in the death of 25% of the surgeons in the main teaching
hospital of the capital (Yasmin and Sathya 2015; Bundu et al. 2016). Unfortunately,
personal protective equipment (PPE) is costly and cumbersome to wear during surg-