I wish that I had had better investigative equipment. I wish that I had had more energy and time to write things up on the spot. As we all know you cannot relive the past. So in my old age I dwell among memories. Some of them very special memories. And that includes this little girl.
She presented short of breath with a high fever, a very tender neck and looking into her mouth you could see a big retropharyngeal bulge, which meant we knew why she had her temperature and was having difficulty in breathing but that bulge was abnormal in a kid of that age in my experience. The X-Ray quality was terrible. We did not have CT scanning or even a decent viewing box in the wards. The following picture shows how we looked at films.
So I think you see some of our problems.
We tried for a soft tissue lateral film and a lateral bone film.
Please don’t be too critical of the films! In the upper soft tissue film you can see how far the air tube is away from the cervical spine. In the lower bony film you can see two bodies which look abnormal.
Where we were, you did something or let nature take its course! Your decision may have been very different from mine but we
Decided that it probably wasn’t TB and started her on high dose antibiotic.
With oxygenation and gentle sedation I did a tracheostomy under local anaesthetic.
We aspirated a huge amount of pus through a large needle through the mouth when she was fully anaesthetized with the trachy in place. This was sent for mcs but had to go to a private lab outside the hospital.
Made a POP encircling her forehead, strengthened a strip down the back of her neck and encircled the chest.
It was not TB but sensitive to our antibiotics. She was on this treatment for 6 weeks, except that her trachy was removed after several weeks when her temperature was down, and by testing she could breath around the tube comfortably.
Several further films were taken – here is an example
Either inspite of us or because of us – she got better and went home after about 10 weeks. She wasn’t always happy to have a photograph taken!
I’m not sure that I was ever really fit to be registered as a medical practitioner. In our junior resident’s year we were supposed to be placed under a variety of different specialties. As I remember I was only in three departments. Initially I did a surgical and a medical term each of three months (this was a basic requirement). Then I did a one months spell in the anaesthetic department which became a six months term. After one month I was made a temporary, maybe unofficial, and I’m sure in these days what would be illegal, acting anaesthetic registrar. This was very good for my future overseas time where, as a surgeon, I usually didn’t have an anaesthetist to work with me. The head of the department was either very lazy or very keen to see me get experience. Even on his private lists he would come and see the patient until they were asleep and then I would do the rest until he saw the awakening patient in recovery. I did the night on call duties alone and thus got experience with a great variety of emergency situations, which served me well in my later experience. I used to be amused when my first year contemporaries would ask the anaesthetic department for help in doing things, and then found me there as the one sent to fix the situation. Seriously thank God nothing went wrong.
At the end of that year I was invited to be an anaesthetic trainee, but declined. In my second year out I was in general practice and gave quite a few anaesthetics, both for other GP’s and for a few of the surgeons who were in the area. Fully trained anaesthetists were in short supply in those times even in the major cities.
In the intervening years after that, as I trained as a surgeon, until I arrived in Ethiopia in the late 60’s I didn’t have to think about the head end of the bed!
Sometimes right up until my retirement I would give the anaesthetic for another surgeon when the anaesthetic department felt unhappy to anaesthetise a very sick person. AS to the second foreigner, we had a lot of people do their electives with us.
Until about 2009, when I started working in University hospitals in Ethiopia, I rarely worked with a properly trained anaesthetic doctor. Thus I had to work out a system of how to manage two responsibilities at once.
Where I was initially we had to be careful how much oxygen we used as it was all cylinder oxygen which had to be brought from the capital 250 km away, and our budget was tight. Ether and ethyl chloride were cheap and plentiful. Succylmethoneum (scolinej, as a dried powder, was also plentiful. We had flaxedil and curare as longer term relaxants and an EMO machine for using a measured percentage of continuously supplied ether. Ether, as well as having hypnotic and analgesic properties, is a muscle relaxant. Ketamine was just being developed around then. We had a small stock of Pentothal.
Thus I developed a few principal concepts; –
Use Local anaesthetic if you safely can. LAs are very useful for spirals, cordals, blocks or by infiltration. They were specially useful in Leprosy patients with depressed sensation in many areas.
Not all anaesthetics were easy – as seen above there is certainly a tracheal deviation to the right and almost certainly a rotated larynx.
We did lots of prostates under spinal. In this man having sorted out the anaesthetic, you still have to get him into a satisfactory position to operate. For us prostatectomies were open operations.
I have done Caesarean sections under LA. The pain problem comes when placing the hand into the pelvis to get the head freed. Apart from the discomfort of that, by using a larger volume of dilute LA, it is possible.
After a while, for Caesarean Sections, I usually chose this other way. Having everything carefully set up with nurse having prepared the site for surgery and having draped the patient while I was pre-oxygenating her, I put the lady to sleep using Pentothal and scoline to intubate, then I hooked up the EMO Machine on 0% ether. I then rushed out had alcohol poured over my hands, dressed rapidly without scrubbing and began to operate. The reason to do things this way was so that no respiratory depressant nor paralysing drugs crossed the placenta to the baby. Time from the pouring of alcohol on my hands, until the baby was out was about 6-7 minutes. After that ether was added in the EMO machine for the remainder of the operation.
Ether in the lungs rarely makes people vomit. Ether in the stomach is nauseating.
In later years ketamine was very useful. Ketamine was being developed about that time. Its nasty nightmarish effects didn’t seem to worry small patients but in adults it needed to be covered by something like Valium.
Babies presenting like this caused particular anaesthetic problems.
Later ECG machines, pulse oximeters, automatic blood pressure machines helped me a lot, as after stabilising the patient and becoming the surgeon the anaesthetic end was monitored but by an untrained person. Well I trained them somewhat, and later one of them gave me an anaesthetic.
As I remember Maurice King, in a book about Anaesthesia in Developing Countries, wrote that a piece of string is an important part of anaesthetic equipment. Its purpose is to tie the anaesthetist to the machine to stop him wandering away. In one of my stints overseas we had a young Eastern European trained anaesthetic nurse attached to the hospital. I came into the operating room one day to find him looking out the window. His patient was dead and he was oblivious to the fact. We managed to resuscitate the patient. I had several other terrifying experiences with him, so reverted to doing my own anaesthetics and letting him watch. He didn’t want to listen to me. He was understandably offended but I have no regrets for doing so.
The anaesthetic difficulties of this case are discussed in A Large Jaw Mass
In my later years there were almost always either nurse anaesthetists or doctor anaesthesiologists. In that period, I had two interesting experiences, one very sad, and one to me amusing.
A nurse anaesthetist was intubating a patient while I was scrubbed waiting to start operating. It was obvious that the tube was in his oesophagus. The nurse absolutely refused to listen to me. I called the Ethiopian Head of the Surgical department in the next operating room. The nurse also refused to listen to him. I did not have a position with authority in that hospital, so was unable to insist and just take over the anaesthetic. The patient died.
The second occurred just as I was retiring. The head of anaesthetics came to me with a hernia which I agreed to repair for him. In the next breath he said to me please give my anaesthetic yourself, I don’t trust any of them!” I did it for him under local anaesthetic!
Medical Memoirs 