Theatre

On Wednesday I spent the day in theatre, observing a rectal biopsy (no 'punch biopsies' here) on a week old baby with suspected Hirschsprung's disease, a thoracotomy on a two week old boy with inspiration pneumonia resulting from oesophageal atresia and a tracheo-oesophageal fistula, and the removal of a dermoid cyst from a 10 year old girl's forehead.

The theatres are perhaps more like Western hospitals than many other aspects of the hospital. Everyone wears green scrubs, and there is the emphasis on sterility than you would expect of a operating theatre. The second of these patients sticks most in my mind, in part because it was by far the most complicated surgery, but also because of what happened before it even started. With the little boy breathing in the anaesthetic gases from the mask, they tried for about an hour to put a cannula into one of his veins (to administer drugs and fluids). Obviously in his short two weeks of life he had been poked and prodded almost continuously, and had also had many cannulas in before. As a result he was even more difficult to cannulate than a normal baby - the anaesthetist tried, the junior doctor tried, the surgeon and the nurse also had a go. They must have tried in excess of 15 times - his arms, hands, scalp and neck all failing to produce a significant vein. Yan asked if they were going to use an interosseus approach (direct into bone marrow - often used especially in emergencies when other methods fail), and the surgeon, Dr Chaudrey replied "send us some interosseus needles from Australia and we'll use them!". Instead, he tried venosection (incision into the leg looking for veins below the skin) while the cannulation attempts continued. Eventually someone got a line into a vein in his neck, and he was ready for surgery. In the UK it is quite common to use 'central lines' (direct into a large vein in the chest which stays in for longer periods) on such patients who become difficult to cannulate, but this is not without it's risks, and apparently is not commonly performed in Nepal.