I had all day Friday and Saturday morning to rest up from my overnight flight from Bangkok to Tel Aviv. We saw a few patients on Saturday afternoon. One touching story was that of a 23 month-old girl with a condition called a "tethered cord". As her spine grew it put tension on her spinal cord, that would result in damage to the lower spinal nerves. This would impair her ability to walk and control urinary and bowel activity. The more serious problem was her congenital heart disease. Her heart defect caused diversion of blood from her lungs and was not correctable. Her lips and nail beds were blue, her breathing was labored and she was febrile. Her parents were well educated. I explained to them that the risks of anesthesia and surgery for their child were very high, with a great chance that the baby would die. Despite that, the parents were adamant that they wanted surgery and offered to sign any document necessary to absolve us of responsibility. After discussion between the members of the team we decided not to proceed with surgery. The baby had very little if anything to gain and her likely outcome would reflect badly on the foreign surgical team. She was admitted to the hospital with pneumonia and passed away two or three weeks later.
Two other patients were more rewarding. The first boy came in on Saturday. He was a 16 month old child with multiple intracranial cysts that caused hydrocephalus. He'd had shunts placed in the past, but they failed because of positioning or infection. His father cared for the baby at home, draining the boy's head with a needle and syringe. When his father brought the boy in the baby wasn't feeding and had "sunset eyes", downward-deviated gaze that comes with increased intracranial pressure.
One of the surgeons drained some fluid from the baby's head and we put him on the schedule for the next day. The anesthesia presented a challenge because of the size and shape of his head, but by putting a pack of towels beneath his shoulders I got him into a position where he could be intubated.
Despite the drainage procedure the baby's intracranial pressure was quite high at the time of surgery, as shown below by the flow of cerebrospinal fluid from the new shunt.
The new shunt was working well two days after surgery. The baby's gaze was more normal and he was feeding vigorously.
The child's days are numbered because of the pre-existent brain damage, but he won't have to have painful drainage procedures performed by his father.
The second case was a seventeen day-old child who came in with sunset eyes and a decreased level of consciousness. The baby's fontanelles were tense. The more alarming finding (to me) was his heart rate: mid-70s. This is distinctly abnormal (slow) for a child his age. We had the baby admitted to hospital for surgery later that afternoon. When I called for the patient to be brought to surgery, I got a note saying that they were unable to start an IV or draw blood for the battery of lab tests the admitting doctors ordered. I asked the staff to bring the child to the operating room, saying that we would take care of those problems down there. When the child arrived he was lethargic, with a heart rate of 80. His hands and feet were mottled with a capillary refill time greater than 6 seconds. His poor circulation explained the difficulty with an IV. I gave the child some intramuscular atropine, did an inhalational induction, intubated him and tried to get an IV. After about forty minutes I got a cannula in a scalp vein. Not my first choice of a site for a shunt, but I was not in a position to be choosy. I had a Palestinian first-year anesthesia resident helping me. When my back was turned the young doctor adjusted the child's head managing to remove the IV and extubate the patient. I was disappointed, but we got him intubated and another IV started. The shunt placement went well. Three hours later his heart rate had climbed to 130, a more appropriate value. His extremities were better perfused. The next day the NICU nurses were able to start a better IV, and two days later he was nursing every three hours. In the photo, you can see the shunt coming out from his skull, traveling behind his ear and continuing down his chest and onto his abdomen. Not much subcutaneous fat on this child.
This last photo is interesting because of the mallet. The surgeons are using a mallet to drive in screws that will hold the plate in place over the skull defect. Why use a hammer to place a screw? The plate and screws are made by the Synthes company, and you need a Synthes screwdrive to twist in a Synthes screw. Unless Israeli customs confiscates your Synthes screwdriver at the airport. Then you use a mallet.
Two other patients were more rewarding. The first boy came in on Saturday. He was a 16 month old child with multiple intracranial cysts that caused hydrocephalus. He'd had shunts placed in the past, but they failed because of positioning or infection. His father cared for the baby at home, draining the boy's head with a needle and syringe. When his father brought the boy in the baby wasn't feeding and had "sunset eyes", downward-deviated gaze that comes with increased intracranial pressure.
The new shunt was working well two days after surgery. The baby's gaze was more normal and he was feeding vigorously.
The child's days are numbered because of the pre-existent brain damage, but he won't have to have painful drainage procedures performed by his father.
The second case was a seventeen day-old child who came in with sunset eyes and a decreased level of consciousness. The baby's fontanelles were tense. The more alarming finding (to me) was his heart rate: mid-70s. This is distinctly abnormal (slow) for a child his age. We had the baby admitted to hospital for surgery later that afternoon. When I called for the patient to be brought to surgery, I got a note saying that they were unable to start an IV or draw blood for the battery of lab tests the admitting doctors ordered. I asked the staff to bring the child to the operating room, saying that we would take care of those problems down there. When the child arrived he was lethargic, with a heart rate of 80. His hands and feet were mottled with a capillary refill time greater than 6 seconds. His poor circulation explained the difficulty with an IV. I gave the child some intramuscular atropine, did an inhalational induction, intubated him and tried to get an IV. After about forty minutes I got a cannula in a scalp vein. Not my first choice of a site for a shunt, but I was not in a position to be choosy. I had a Palestinian first-year anesthesia resident helping me. When my back was turned the young doctor adjusted the child's head managing to remove the IV and extubate the patient. I was disappointed, but we got him intubated and another IV started. The shunt placement went well. Three hours later his heart rate had climbed to 130, a more appropriate value. His extremities were better perfused. The next day the NICU nurses were able to start a better IV, and two days later he was nursing every three hours. In the photo, you can see the shunt coming out from his skull, traveling behind his ear and continuing down his chest and onto his abdomen. Not much subcutaneous fat on this child.
This last photo is interesting because of the mallet. The surgeons are using a mallet to drive in screws that will hold the plate in place over the skull defect. Why use a hammer to place a screw? The plate and screws are made by the Synthes company, and you need a Synthes screwdrive to twist in a Synthes screw. Unless Israeli customs confiscates your Synthes screwdriver at the airport. Then you use a mallet.
