Plugging the dam?

Today started in a much more relaxed fashion. Very pleasant really. We had gotten through a lot of work yesterday and there was a noticeable change of pace. I needed the respite and found myself noticeably enjoying this slower pace! There were no new patients for my review today, so the rounds were brief. I even had time to pop home for a cup of tea before the operating for the day started, two paediatric hernias and a hydrocelectomy.

First cheeky chappie making a

bid for the door. He liked his

Mzungu cuddles though!

The first hernia in a 2 year old was tricky (it was quite big – I am sure it would have been repaired some time ago in the UK) but went well. As a general rule, you can’t really use mesh in children, so I found myself being slightly creative with the repair of what was quite a big hole in the abdominal wall. The end result was very pleasing, I just hope that this ‘anatomical reconstruction’ will remain sound and strengthen as he gets older. The second case of a nearly 4 year old was much more straight forward surgically (it would have been a pleasure) but caused me huge anxiety with the process of anaesthetic….

Things seemed to be going well, the patient had been put to sleep and intubated without trouble. But then there was some difficulty in ventilating (this means it was difficult to for the anaesthetist to blow the air into the child’s lungs). My attention now with ‘the head end’, I could see that this was a minor issue, but from where I was observing it was likely that the child was fighting the anaesthetic. In other words, the child was trying to breathe himself – no bad thing necessarily – and this was making what the anaesthetist was trying to do difficult. The obvious course of action to me was to let the child breathe, start the anaesthetic gas and when he stopped trying, to then breathe for him. Instead, somehow, the endotracheal tube was pulled out (despite my reassurance that ‘the tube is good’ (tube ni nzuri)). This was a disaster, the child went into laryngospasm (completely shutting off his own airway and asphyxiating himself). Efforts to reventilate failed, the child’s saturations plummeted, he became tachycardic (heart races). “Put the tube back in”, “put the tube back in”. I was standing in the wrong place. But I knew that they could intubate this child so I tried to calmly support the process. The child started to wake up, trying to suck air into his lungs for himself, but to no avail. It is a horrible thing to watch, completely unnatural movements. Delay. He was looking a horrible colour. His efforts became less. He became bradycardic (heart slowed down) which is a very bad sign. I saw time jumping forward and the trauma of a full blown resuscitation unveil in front of me… “give some more drugs and put the tube back in”. I said this so much more calmly than I was feeling. However, these things happened quickly and the tube went in, we could ventilate the child. Some relief. The saturations came back up. Some further relief. He settled, heart rate returning to normal (first racing then calming down again). But it felt like an age had passed with what was undoubtably a prolonged hypoxic episode. Please let this child be ok. My fear was that he had suffered irreparable brain injury.

I was now faced with a horrible decision. To continue with his surgery or to abandon for another day. If such a thing was to happen in the UK (although unlikely), I am sure things would be postponed. But here, the child clearly needed the operation and my on the spot assessment was that the risk of exposing him to another anaesthetic in the future was far greater than proceeding (given that things were now apparently very stable). A difficult decision nonetheless and one for which I would have very welcomed the option to ‘phone a friend’. I switched back into surgeon mode and got on with his surgery that thankfully went very well. I encouraged them to recover the child slowly and the tube was removed without further trouble. He was quietly sleeping as he went back to the ward. I was just hoping he would wake up.

We then had a hydrocelectomy to do. I was considering cancelling this for my own benefit, but it proved to be a delightful distraction to the niggling concerns I had about the previous child. The operation was performed by one of the local surgeons with minimal support from me (I was just an able assistant). Perhaps not a big change for them, nevertheless the new-to-them technique was done beautifully. It is so pleasing to watch someone perform so well an operation you have taught them to do.

I went to see the child on my way home. He was still asleep. Will he be ok? I am very worried.

For the first time since being here, I went out to a bar in the evening for drinks with some of the local staff (we have socialised in other ways, but this was the first time I had ventured out after dark ‘on my own’). It was great fun and we had so much to chat about. Tanzanian beer is excellent, and a nice cold beer or two, setting the world to rights, is one of my favourite way to pass the time (many of you reading this may be nodding your head with a smile on your face reading that). It was a lovely evening and a very welcome distraction.

But I’d be lying if I said I didn’t go to sleep that night with a nagging concern in my mind.