Rollercoaster Fatigue

Today has been somewhat more stressful than yesterday. The first case of the day was the 8 month old baby boy that we had to postpone from Tuesday. He had an inguinoscrotal hernia with palpable bowel in (so a particularly big hernia for a child of his age) that needed repair. The risk of strangulation (it getting stuck and bowel dying is high (up to about 30%)) and so it needed doing. Whilst I was not especially keen to be undertaking that here, there was not really any other option unfortunately (many reasons discussed over the course of previous posts). My main concern was not so much the surgery, but the anaesthetic side. I had discussed all this carefully in advance with our anaesthetic team and we decided to proceed. I was told that it was possible to do any child above 6 months old here (they are expected to do such for an ENT list). In the UK, all children are only anaesthetised and operated on by experienced specialists. A limited number of routine operations are performed in most DGHs on children over the age of five. But any complex procedure, or children below that age, would be sent to a tertiary referral centre (usually a big teaching hospital). 

My apprehension was entirely justified, and a stormy anaesthetic induction ensued. There came a point when, once again, I found myself at ‘the head end’ trying desperately to help keep this baby alive and safe. The trouble with such small people is that they are so small! They have almost no reserve, desaturate and decompensate very quickly. Their anatomy is also tiny and so securing an airway is extremely challenging. Whilst I have become accustomed to a bit of excitement here, this was without doubt the most stressful 30 minutes of my time so far. At one point he went a very worrying colour (albeit for a very short time). After several attempted intubations, the final one by me (you don’t get long and have to bail out back to a bag and mask quickly), and a number of times when he was fighting the anaesthetic (we want to breathe for him, but the drugs are wearing off and he is trying to breathe for himself), eventually we got an LMA (a special tube that sits above the vocal cords which you can place almost blindly) in a good position to rescue the situation and managed to get him settled. At this point, we had all had enough and were about to call it a day and allow him to wake up. It was all feeling very uncomfortable (that is an understatement). However, he did not just settle, but he seemed to thrive. His numbers on the monitor were perfect and he became very stable. After such a difficult process, I reluctantly realised it would be madness to let him wake up now. To do that would mean that he would either have to live with the risk of no surgery or head to a distant centre and go through the same process again. We went ahead and repaired his hernias. I must say that I felt a little bit ‘under the cosh’ whilst operating, almost waiting for him to destabilise at any moment. Thankfully he remained very stable and the surgery all went well. The inguinal hernia was very large and whilst the defect was fairly tight (the reason why there is a high risk of strangulation) it was big enough that a simple herniotomy did not seem adequate. I reconstructed his deep inguinal ring with some absorbable sutures and I hope that this will reduce his risk of recurrence. We also repaired his large umbilical hernia.

The second child (nearly 4) almost seemed to know what had happened with the first case and was very unhappy about coming to theatre. But there is no such messing about tolerated in Tanzania and he was quickly bundled into the operating room for his surgery. Perhaps not the tactics we would usually use in the UK, it was nevertheless very efficient! In contrast to the first case, the anaesthetic was very slick (and I wish to emphasise such things to highlight the quality of the team that we have here). His procedures (inguinal herniotomy and umbilical hernia) also went very smoothly which I think we all needed.

The final case of the day was a big inguinoscrotal hernia in an older man. I knew it was going to be difficult (he’d had it for years), but I wanted to give the two local surgeons an opportunity to try without me. They did very well, but inevitably I was called to scrub in. It was most pleasing to see how far they had gotten, and their difficulty was entirely understandable. The scarring was dense and the anatomy not clear. It was back to basic principles with careful dissection and discovery of the expected anatomy. I helped them past the hurdle and then left them to finish off. Whilst they wont intentionally take on such cases on their own when I leave, excellent experience nevertheless.

So, I must say that I am feeling a little jaded this evening. Our time here has definitely been much more of a rollercoaster than we are all used to. The highs have been exceptional, the lows testing to say the least. It has certainly been one of the richest periods of our lives experientially, but I think it is fair to say that we could all do with a bit of stability and, dare I say it, ‘routine’ for a while. I certainly feel like I could do with a bit of a rest!