A very busy Tuesday (this is the one with pictures).

We got a bit of a late start and began our first case about 9:30. This was a two year-old girl with a misshapen head. As a result of a misunderstanding on the part of the intern on call, her head was completely and needlessly shaved. The surgeons peeled her scalp down and removed most of her frontal bone. They reshaped it and changed its contour with partial fractures, then repositioned it over the outer lining of the brain. They put mesh around the lower corners to accomodate growth and fixed it into place with tiny titanium plates. Very cool.

In this photo the frontal scalp has been peeled down, the forehead part of the skull removed, reconfigured to allow brain growth with a more normal head shape, and the skull stabilized with titanium plates, screws and mesh.

Next was a twelve year old girl with a bony tumor on the surface of her skull. She, too, had her head shaved. This case was a bit complicated for me because the only endotracheal tube that was appropriate for her size was a bit shorter than ideal and kept getting pushed from her trachea into her right bronchus. The case was done in collaboration between Samer, our neurosurgeon, a Palestinian oral surgeon and a Palestinian general surgeon. Every time I went in to adjust the tube I had to elbow one of those guys out of the way.

In this photo Samer, our surgeon, uses a mallet and osteotome (a chisel), to take the bony tumor off the girl's skull.

The third case was a six month old with hydrocephalus and a huge head. His intubation was rather difficult but a rolled-up towel beneath his shoulders allowed me to extend his head enough to visualize his vocal cords and intubate him. It's kind of a shame that the hospital doesn't have a resident working with me since these are good teaching cases. On the other hand, I'd have to let him do the airway stuff and that would drive me nuts.
The icing on the cake was a newborn, twenty hours old, for closure of a meningomyelocele. This is far and a way the youngest child I've ever anesthetized. The hospital opened a second room for us so I used an unfamiliar anesthesia machine and monitor and had the patient prone to boot. I was very happy they had an endotracheal tube small enough for him.

We celebrated our big day by going out for coffee, dessert and a little smoke before returning to the hospital.