An Unusual Delivery

1200px-newborn_baby_28may_72c_200529It is not uncommon for middle grade anaesthetists to be overwhelmed by simultaneous calls upon their time, especially out of hours. Thus it was in the early 90s that I was busy in A&E with some critically ill punter who needed admission to ITU, when I got urgently bleeped to labour ward for a top-urgent caesarean section.

Such cases are always of the highest priority. The mother, the baby, or both are at risk of losing their lives, or suffering life-long disability in consequence. However, I couldn’t just leave the super-sick guy in the resus’ room to take his chances with the very junior doctors present there. What was I to do?

My junior colleague was busy in theatre, and was not experienced enough to relieve me anyway. My Consultant was 20 minutes away. I let labour ward know that it would be at least 20 minutes until I got there, and that they should move the mother into theatre and prep for immediate operation. I dispatched my technician ahead of me to get everything ready for a rapid sequence induction of general anaesthesia. Meanwhile, I awaited the arrival of my boss, pacing up and down like an expectant father.

She arrived running. Very little time was wasted on hand-over, thankfully. I really had to be elsewhere. I scooted out of the casualty department, crossed two car parks, negotiated some builder’s shuttering and the obstetric block’s security door, then rode up four floors in the lift. I still had to run 3/4 of the way around the labour ward floor to get to the  theatre, and then I saw what I saw.

A caesarean section operation was in progress: the mother was supine upon the operating table, screaming and sobbing. The baby was screaming too, but healthily, lying upside down upon its resuscitaire, with a paediatrician in attendance.  Two surgeons and a scrub nurse were standing by the mother’s lower abdomen, and a surgical pack was being firmly pressed into the wound there.

The most obviously wrong thing about this picture was the presence of a man, dressed in the style of Bob the builder, whose unconscious body was slumped insensate over the mother’s chest, with his arms dangling to the floor.

I must admit to being a bit surprised by all of this.

The seemingly seven foot tall African surgeon, of very dark skin and a gleaming pearly-white smile let me know the score with his kindly deep bass voice (and I paraphrase from memory):

“This mother was so concerned for the well-being of her unborn child that she demanded that I perform the caesarean without anaesthetic, which I did. Her husband held her down, in accordance with her wishes. I infiltrated local anaesthetic into the wound as I went, but there was not perfect analgesia.  I delivered Baby safely, but have since awaited your arrival”.

This was a scenario I had never encountered before, nor since.

The only practical option then was to put mum to sleep and let the operation be finished safely and well. The first step was to remove her husband’s prostrate body from across her ribcage so that she could breathe properly. We placed his fainted form upon the floor in the recovery position and tasked a spare midwife to recover him.

Then I did the needful. Mum woke up about half an hour later in the usual pain and confusion that follows an operation under general anaesthetic.

I told her about her healthy baby son, and her eyes lit up joyously.

What I didn’t say was how I had just witnessed the greatest possible act of courage by a woman: She had been willing to sacrifice herself, her comfort and her very life, for the sake of her unborn child.

This is a true story, and I am willing to endure torture in defence of its veracity. So much nonsense is bandied about nowadays about how little worth an unborn child has. This mother’s practical witness demonstrates how much hogwash that presumed worthlessness is.

The mother and father were both Irish Catholics. The surgeon was a Ghanaian Catholic too. No coincidence, I suggest.


Membership In Danger

As a locum registrar in anaesthesia one Saturday night, I was presented with a one year old boy who had acutely inflamed foreskin (balanitis) which was making him very ill and was very painful for him, the poor little fellow. He needed an urgent circumcision to remove the offending tissues and allow the infected area to breath room air, which with antibiotics would allow the sepsis and inflammation to settle down.

We took him straight to theatre and I gave a gas induction: With the child held steady by his mum, I firmly held a little facemask over his nose and mouth and made him breathe a concentrated mixture of oxygen, nitrous oxide, and halothane. After thirty seconds of wailing and wriggling, the little cherub was rendered insensate. I quickly established intravenous access in one of his pudgy paws, and then he was turned on his left side to allow me to perform a caudal injection of local anaesthetic (LA).

At the bottom of everyone’s spine is a small triangular opening through which one may introduce a hypodermic needle and infuse LA, and thus numb the nether regions. My plan was to render the area of surgery free of pain, both during the operation, and also for a lengthy time afterwards. I was trying to be kind, and chose as my LA, bupivacaine WITH adrenaline. Bupivacaine has a long duration of action to start with, but the added adrenaline reduces local blood flow and extends its effects considerably.

Life is what happens while one makes other plans, and thus it was so. With the infant safely asleep, I donned sterile gloves and swabbed the skin over his lower sacrum with antiseptic solution. I then proceeded ten times or more to pass my green needle into his caudal space, but without success. I had performed this block many times before, and always with ease. I hadn’t expected this difficulty.

Finally frustrated, I turned the child onto his back and gave him a penile block instead. This would have been a fine plan B, except I thoughtlessly used the LA I had drawn up for the caudal injection.

There is a golden rule in medicine that says never to inject adrenaline-containing solutions into extremities, ie fingers, toes, and penises. The adrenaline causes such severe constriction of the local arteries, that the blood supply ceases and the extremity can die. I had just committed a cardinal sin of medicine.

I only realised my mistake after the boy was already on the operating table with surgery underway. I was writing up my anaesthesia chart when it dawned upon me. My face paled as my pulse accelerated. Sheepishly, I asked the surgeon how was the bleeding.

The cutter that night was also a locum, and a kindly experienced Sikh. As he turned his large smiling be-turbaned face towards me and announced in his sing-song accent that “It is remarkably bloodless!”, I felt that the world was about to end.

The surgery ended without incident, but I was left to recover this poor kid that I might have just mutilated by mistake. My thoughts raced madly. I even contemplated buying a ticket to South America, so selfish and irresponsible had I become. Then the honest and sensible voice inside my head suggested I call for help.

I could either call the Consultant or a professional peer. I chose my peer, dear clever Andy. “I urgently need your help, great mate”, I shouted down the telephone towards him. He arrived in a flash and appraised the situation, as he stroked his beardless chin.

This was his reasoning: At risk was a volume of vital tissue that may have no blood supply.

His solution was to attach a pulse-oximeter to the threatened tadger and see if there was a pulse. There was! The John Thomas was going to be alright! Gadzooks!!!!

Here is a picture of a pulse-oximeter probe, which is normally used on fingers.



The Major Incident



Ah, Ealing Hospital, my former love, aha!

In the late ’80s, I started my Registrarship in Anaesthesia at Ealing Hospital. I possessed the first part of the FFARCS exam, and was studying for the second part. I was a bit cocky as I had seemingly effortlessly gained a prestigious rotation through the Ealing, Hammersmith, and the Royal Marsden hospitals.

Anyway, one early evening in my first month there, I was fast bleeped by switchboard and told that a major incident had been declared at Heathrow Airport. I demanded to speak to my Consultant, and was quickly put through. Dr L. came on the line, eventually, and in an exceedingly relaxed voice told me to “Carry on dear boy……”. Apparently he had complete faith in me. I swear I could hear the Champagne bubbles popping in the background of his club.

I madly rushed to the Casualty department to meet the three other members of our team: two nurses and another doctor. We were all issued with backpacks containing God knew whatever, and were then bundled into a Police car to be be carried at speed to Boston Manor tube station.

We ran down onto the westbound platform and in no time a train arrived. It was full of people wearing healthcare uniforms just like us. The tube whisked us very briskly to Terminal 3 where we all alighted.

The platform was heaving with every variety of those who care for the sick and injured: nurses, doctors, physios, and OTs. There were even more volunteer types like the Red Cross and the St John’s Ambulance. I witnessed a rather sad and lonely fellow wandering around with a backpack radio calling incessantly for a ‘copy’, a response from anywhere. Deep underground, he didn’t stand a chance of getting a signal, I suppose.

During the two hours or so that we all waited on that platform, waiting to do battle with gruesome injury and death, I witnessed some unusual scenes. Perhaps the most memorable was the fistfight between the Red Cross and the St John’s Ambulance, as they fought over which of them were the more worthy to carry the stretchers. Hmmm.

At about 10pm we were all informed by public address that the whole thing had been a drill, and we all could go home. Tube trains would take us there for free etc.

As I got off at Boston Manor, and started my long walk back to Ealing Hospital, I thought:

“Well, all this is better than Labour Ward!”

Creepy Crawley

Nearly 25 years ago I did a locum night duty at Crawley Hospital. I should have suspected trouble at the moment I arrived, as the switchboard operator said to me as she handed me my bleep “But there’s something wrong surely, you are a white doctor”. She was being ironic, of course, or so I thought.

I proceeded to discover that the majority of  the staff and patients at that hospital were unable to speak to one another in fluid everyday English. I began to suspect the evolution of a terrible medical catastrophe.

My suspicions bore fruit at 3 am. A woman with child needed an urgent Caesarean Section.  Neither she, nor her surgeons could speak English. I proceeded to anaesthetise the woman, veterinary style, and the baby was safely delivered, but only after the surgical team had had some serious argy-bargy amongst themselves in their foreign language. I could not understand their intercourse and was left shaken by the whole experience.

Nowadays, this event may be described as racist. but I put it to the audience in judgement that this was a serious clinical situation.

Let me also make it plain that since that time, the standard of spoken and written English in the medical profession has been greatly improved, thanks be to God.


BB Returns

As I write this, it is 0330 GMT. I have just returned home from Israel after a 13 hour journey by coach, aeroplane, and coach. I am completely ‘wabbit’ (pronounced ‘wabbered’) which is Glasgow slang for exhausted. Nevertheless, my mind is fizzin’ with wondrous recollections about what I have experienced over the last nine days.

In brief, I have just gathered enough life experiences to bore all you readers rigid for months to come. You will be glad to hear that I am not going to dump all of them on you right now. Instead, let me offer you a picture that I took myself the other morning. Waking early I ventured out of the hostel to have a cigarette in the pre-dawn. I was a few miles west of Jerusalem. Silhouetted against the warming eastern horizon were the distant towers and tower cranes of the city. It was very chilly and the winds were near gale-force. I ran back inside to get warmer clothes and my camera then returned to a good vantage point. This is the best shot I took that morning:


Brother Burrito Takes A Break

This ultra brief post is to explain why there has been so little posted on this blog of late.

Since announcing my retirement from the NHS on September 11th, and following through with my letter of resignation and pension claim, I have just been very busy tying up loose ends and also dreaming hopefully of the future. I wish to retain my licence to practise medicine in the UK so I have had a few more hoops to jump through. The clinical work has also been heavy of late.

Between mid-January to mid February, I expect to hang up my clogs and become a pensioner, but I hope to return to work on a zero hours contract thereafter to help cover sick leave etc. I have many other plans to keep myself busy and produce a little extra income but at my own pace. This is how I see myself in six months:


The Higgs Bozo

After three months as a surgical houseman (FY1) for the ENT firm, I entered a completely novel environment, for me. My new boss was Mr Higgs, a general surgeon who also did urology. He was a superb surgeon: fast, decisive, and highly skilled.

Here is a video that portrays him somewhat: Mr Higgs was a Sir Lancelot Spratt sort of surgeon but a bit shorter and wearing tweeds and with a redder face. I am the hapless fellow who gives the wrong answer at the end (as portrayed by Dirk Bogarde).

Mr Higgs’ secretary was called Betty, and she remains the most nervous person I have ever met. Even at peace, her voice quivered, but in the presence of her master it quivered even to the max. Despite this nervous disposition, she adored Mr Higgs, whom she referred to titteringly as ‘H’. He refused to use new-fangled things like Dictaphones and so Betty had to follow him around everywhere and take down his every utterance in shorthand, to be typed up later.

In work he was a monster to be obeyed slavishly, but socially he was a genteel giant. When leisure permitted, he would take his junior staff off in his huge Jag’ to some expensive country eaterie and treat them to a slap-up feed and drinks galore. He had a generous soul.

He took a shine to me, perhaps because I was a bit of a hopeless case. My professional inadequacies were merely sighed at rather than bawled at. Sadly I caused him great distress on at least one occasion.

The patient required a LEFT orchidopexy. He had an undescended testicle that needed to be put into his scrotum before it became cancerous. Unfortunately, I consented him for a RIGHT orchidopexy because I was a completely incompetent doofus.

It was only after Mr Higgs made the opening incision in the wrong groin that I realised my awful mistake. “Mr Higgs”, I blubbered urgently, “I think you are operating on the wrong side!”

He stopped immediately and examined the patient’s scrotum. Indeed, the testicle in question was in the other groin. He then glowered at me with such ferocity that I wonder how I am still alive today.

After a few seconds consideration, Mr Higgs continued with the operation. Instead of opening the other groin, he managed to perform the correct operation successfully through the already open incision. Please don’t ask me how, I am only an anaesthetist..

As he delivered the last skin suture, he looked at me wearily and said: “I leave it to you to explain everything to the patient”.

What I had done, consenting a patient for surgery on the wrong side, would nowadays be termed a “Never Event”, the worst of medical sins. Fortunately, consent is now only taken from the patient by the surgeon who actually will perform the procedure, thus minimising the risk.

When I checked up on the patient the following day, he understandably wanted to know why his scar was on the wrong side.

With a lying wink, I told him that Mr Higgs liked to show off his surgical prowess occasionally. The patient, a young man, happily bought my explanation and went home, perhaps to dine out on the story for ages after.

In much later life, I met another surgeon who was just like Mr Higgs in temperament and outlook and surgical skills. He was known by his initials JLE

Silent Cockpit

I recently had to raise my voice obnoxiously to quell the silly chatter in theatre at a critical moment. Better discipline would prevent this happening again.

Burrito's Stable

There is a discipline practised by those who fly aircraft, that I believe deserves to be more widely implemented, especially in critical care environments and perhaps throughout the NHS .

It is called “SILENT COCKPIT!”.

In an aviation environment, the saying of these words by ANY crew member signals that all chatter and distraction must cease immediately and everybody’s, attention must focus on the job in hand, for life is at great risk.

One of the great pleasures of working in a hospital environment is the great camaraderie enjoyed by all. There is great craic to be shared by those fighting a good fight together. The armed forces surely experience a similar thing.

Sometimes however, reality violently subverts the dolce vita.

From out of the dark without warning arises a threat to life or lives. The first to notice this may not be the leader, their second or third. It…

View original post 192 more words

Poor Boy

A sure sign you are getting older is how much time you spend reminiscing. “Nostalgia ain’t what it used to be”, is an old quote, often rejoindered by  “but then it never was”.

I first found myself humming  and singing to myself tunes I used to love as a teen and tween just the other week. The tune that stayed with me the longest was “Poor Boy” by Supertramp, from their album “Crisis? What Crisis? (1975).

Here are the lyrics, which to me are clearly a simple love song. The video follows:

Can you believe me when I say, there’s nothing I like better,
Than just to sit here and talk with you.
Although I’ll rant and I’ll rave about one thing and another
The beauty of it is so pure to me, though,
I’m a poor boy,
I can still be happy,
As long as I can feel free.

So many people I know, get old way too early
(Well are you feelin’ kind of weary?)
Just to impress you with the money they’ve made
(You better, you better change your theory)
One drop of rain, they complain, it’s the same about the wage they’re earning.

Well, that is not the way I’m gonna be,
Don’t mind the rain, don’t mind snow, don’t mind nothin’
If I know,
You will be right here with me
“Well let’s say, don’t mind your point of view,
How can we all afford to live like you;
The simple life is simply not enough,
We have appearances we must keep up”.


-Poor Boy-
If that’s the way it’s gonna be
-Poor Boy-
It’s you for you and me for me
-Poor Boy-

I’ve tried all I can, understanding, all the fools and all their money,
When half of what they’ve got, you know they never will use,
Enough to get by, suits me fine, I don’t care if they think I’m funny.
I’m never gonna change my point of view,
Don’t mind the rain, don’t mind snow, don’t mind nothing, if I know
You will be right here with me, all the way.
Don’t mind the rain, don’t mind snow, don’t mind nothing if I know
You will be right here with me…