Wrap up on Beit CURE Blantyre Malawi

The anesthesia equipment and staff at the hospital were terrific. I had a monitor with end-tidal CO2 and agent analysis and some wonderful people to work with and help me.

I mentioned Polena in my last post. I also worked with Steve, a CRNA who is six months out of training (vs. thirteen years for Polena) and Ruth, a registrar from England who has been working in South Africa and Malawi for the last couple of years. They were all happy about learning to do an infra-orbital nerve block for the lips.

Steve and me in the staff room.

I told Steve that I didn't think he was as good as Polena, but not to feel bad because I don't think I'm as good as Polena, either. Ruth will return to England this fall to begin training to become a consultant anesthetist. After her work in Africa she is more experienced than some of the junior consultants she'll be working under. She's a good soul, seems very spiritual and I think she will tolerate the experience well.

My one disappointment was a 2 3/12 year-old girl for a cleft palate repair. It was an isolated defect (her lip was intact). She was very small for her age, only 7 kg, but seemed vigorous and had trouble with milk coming out of her nose. So, despite some misgivings we put her on the list. She was our first case on Tuesday morning. The induction was uneventful but try as we might, none of us could get an IV in her.  During the IV flail Roy came to me and said that the palate instruments had not been sterilized and that it would be fifty minutes before they were ready. We decided to reschedule her for Wednesday, rather than keep her anesthetized for an extra hour. Wednesday, after making certain that the gear was sterile, we went ahead with the induction. The IV was a problem again but I managed to put one in a vein (name unknown to me) in the right side of her neck. I thought we'd be in good shape, but between her small mouth and the Dingman retractor we had it wasn't possible to get exposure of her palate without kinking the endotracheal tube.

I don't have a scale marker here, but the distance between the blade and her upper incisors was less than two inches.

As we tried different maneuvers the endotracheal tube popped out of her windpipe (this is not a good thing) and I hurriedly--fat man moving at the speed of light--replaced it with a larger tube. Still the kinking! I didn't want to try putting in a yet larger tube, so we reluctantly cancelled the case. Roy had the task of explaining to the mother why we had anesthetized her child a second time to no purpose.

I'll finish up with my success story. A seventeen year-old woman came into screening, hoping to have her cleft repaired. She brought her three month-old daughter, who also had a cleft, with her. She had been told that her daughter was too young for the surgery. I explained to her the “rule of tens” that I like to follow: ten weeks, ten pounds and a hemoglobin of 10 g/dl. She was skeptical and wanted me to show how I had calculated the baby’s age. Fortunately the doctor whose exam room I was using had a calendar on his desk, so we counted out the weeks for her and she agreed to surgery. He was our youngest patient of the mission. We operated on mother Tuesday afternoon and child Wednesday morning. The photos were taken on Friday afternoon.  There’s nothing better than getting a twofer and having such good results.