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.