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staff responsible for all aspects of scrubbing,
cleaning and autoclaving. They also worked
in the minor theatre where suturing and
dressing changes were performed as well as
acting as anaesthetic assistants.
Operating theatre
Our surgical workload was largely
determined by how much equipment was
available at a given time. The average was
about 110 cases per month but we
sometimes had to stop all elective
procedures when supplies were running low.
The average age of our surgical patients was
29 years. Except true emergencies, all
patients were reliably starved from 4am and
brought to theatre after the morning ward
round. I attended this with the surgeon and it
was satisfying to review all our patients from
the previous day’s surgery.
Pre-operative assessments were
limited despite having a nurse translator.
Fortunately there were very few patients with
chronic medical problems – the most
common was hypertension. All patients were
weighed and had their blood pressures taken
prior to coming to theatre. The only
investigations available were red cell counts,
ESR, malaria screening and urine testing.
There were no facilities for estimating urea
and electrolyte level or performing ECGs. X-
ray examinations were possible in another
hospital an hour’s drive away once a week.
There were a significant number of
children to be anaesthetised and I soon
realised trying to gain intravenous access in
a child without pre-treatment with topical
local anaesthesia is very difficult! Gaseous
induction of anaesthesia with the equipment
available was equally challenging and I soon
found the best method of inducing
anaesthesia was a quick intramuscular
injection of ketamine (8-10mg/kg) into the
buttock. Within a few minutes, I was able to
insert an intravenous cannula in a now
relaxed child and allow the operation to
proceed. Ketamine became my best friend in
the world of anaesthesia. My previous
experience with the drug had been limited to
using minimal doses in elderly patients
having their fractured hips repaired but I soon
discovered the benefits of having a drug that
allowed patients to maintain a patent airway
and did not cause them desaturate despite
receiving no added oxygen.
I found there were large differences in
doses required to induce and maintain
anaesthesia in my patients: often they
appeared to need far more than the 1-2mg/kg
300 Sex of patients
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intravenously quoted in the literature.
Sometimes they would seem awake and I
was concerned that they might be aware but
I was reassured by a survey I carried out. The
patients all seemed to be quite happy with
their anaesthetic and had no recollection of
their operation. They seemed to laugh off,
almost inappropriately, any dreams they had.
This may have reflected the nature of the
culture and the difficult environment in which
they lived.
Spinal anaesthesia was my other major
technique and was indicated for any
operation below the waist. As most of my
patients were very thin, my biggest problem
was avoiding puncturing the dura with the
introducer needle. During my time in Sri
Lanka, I performed 250 spinals and had one
definite spinal headache that resolved with
fluids and bed rest.
I always worried when we had to do a
laparotomy or other case that required
intubation. I would use a standard rapid
sequence induction with thiopentone and
suxamethonium and intubate the patient
using whatever endotracheal tubes were
available. I then maintained anaesthesia with
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Spinal
Males
Age of patients
61
Years