The day for departure came – November 5th as it happened, writes Malcolm Savige. We set off for Heathrow airport to find our Qatari Airlines Flight to Doha.

I was cautioned by my surgical colleague to be very careful when describing the Glostavent portable anaesthesia machine to the airport authorities. A suitcase containing a cylindrical metal chamber with fins might attract unwanted attention. He stressed particularly that the word “bomb” must not cross my lips.

So, when my turn for check-in came, I announced that I would like the Glostavent to go with my luggage into the hold. “What is it?” enquired the check-in girl. “An anaesthetic machine in a suitcase,” I replied. “Why are you taking this to Nepal?” she asked. “I am an anaesthetist and I am intending to use it there,” I replied. “How does it work?” she ventured. “It contains a fluid that turns into vapour for the patient to breathe.” “You cannot take it if it contains a volatile fluid or is pressurised” she announced. “But it doesn’t at the moment – it is empty,” I pleaded. “Well… What does it look like?” she pursued.”

“It is a round metal canister, with fins to stand it upright – and I must say that it might look a little alarming to anyone looking at an x-ray of my case,” I volunteered. “In what way?” she persisted.

All the time the queue was growing and I could feel my fellow travellers were becoming restless. “Well,” I said, “It might be confused for something else, particularly in these security conscious days.” “Such as?” she asked. “A bomb!” I replied.

At this point I could see out of the corner of my eye, my surgical colleague holding his head with his hands in despair. “Oh,” she said looking a little perplexed. “Is it fragile?” “Yes,” I replied. “In that case” she said, “I will have it taken on board by hand.”

We flew out of Heathrow watching all the firework displays beneath us and arrived in Doha the next morning. Then, after a short stop, evading the attention of the Qatari customs officials, we set off for Kathmandu.

Flying south of the Himalayas was spectacular, with the mountain peaks level with us at 33,000 feet. Our arrival in Kathmandu was greeted with more fireworks – not for us, I must add, but in celebration of Diwali, the Hindu festival of light.

The following day we flew courtesy of Buddha Air to Nepalgunj in the southern lowlands of Nepal, close to the Indian border and Lucknow. My first impression of this place was the crushing poverty, with half constructed buildings, and goats, sheep and donkeys roaming about on waste ground.

There appeared to be no evidence of any employment, except for subsistence farming and apart from the main road running through the town, most of the thoroughfares were no more than mud tracks.

We were to stay in a comfortable hostel run by a large and somewhat formidable, yet at the same time charming, American woman called Candy. It appears that love brought her to Nepal, or at least caused her to stay. She then separated from her partner and stayed to make her own way in this country. She ran the hostel as an ex-pat colonial with the help of a group of local men. It could not be called an hotel. This being very much a male dominated society, she ran the business with a rod of iron and it took either a very stupid or a very brave man to challenge her!

The first day was spent unpacking all the equipment, operating tables, lights etc and cleaning the two operating rooms we were to use in an eye hospital. The building had been the rather grand residence of a senior army officer. He had left it to the town as an eye hospital.

The organisation I was working for, BRINOS, (British Nepali Otology Service) had contracted with the authorities to use the upstairs area for the camps that took place twice a year. We consisted of three Otological Consultant Surgeons, one from Exeter, one from Frimley Park in Surrey and my colleague from Cheltenham, and were assisted by three scrub nurses, one of whom was my colleagues’ wife and another, her sister. I was the only anaesthetist and was occasionally assisted by a local man called Mr Roy.

At the end of the day, the surgeons saw a selection of the many patients who had descended on the hospital from all over the area. Many had walked many miles. They were alerted to our presence by the three Otology Technicians who work in the area full time and are Nepali graduates. These function rather like barefoot doctors, giving advice and where possible treating ear infections.

These infections often became chronic, leading to open discharging smelly ears which can lead to the formation of Cholesteotomata- boggy tumours of infected skin cells that destroy the ossicles, and eventually erode through the skull and cause Meningitis – and usually death.

A selection of patients was seen in the evening by the surgeons and assessed for surgery the following day. Fortunately most of them simply required Tympanoplasty. This operation was carried out under local anaesthetic. The area behind the ear was opened and access gained to the middle ear. A small sample of connective tissue was taken from behind the ear and a new ear drum was constructed from the inside of the middle ear.

This sort of surgery would not be tolerated under a local anaesthetic in the so-called developed world – that is was accepted here is a testimony of the hardiness of these people.

Occasionally, more advanced disease was noted – usually cases with Cholesteotoma. This would require more complex surgery and patients were referred to me to see if they were fit for general anaesthesia. My main concerns revolved around pulmonary TB which was common, and infective heart disease. I am happy to say that none of the patients referred to me was declined a general anaesthetic.

One of the saddest things was seeing droves of people turned away because we had a full day’s complement of work. They were all very philosophical about this and I never heard a word of complaint. They would all faithfully return the next day, along with the others who had arrived overnight, to take their chances again tomorrow.

Our day would begin around 6am before dawn. A hasty breakfast was followed by us mounting bicycles and cycling the two or so miles to the hospital across to the other side of the town. Theatre was prepared and the first patient anaethetised around 8.30am. The cases took two to four hours and anaesthesia was maintained easily with the Glotavent.

Initially I used high levels of Isoflurane to keep the blood pressure low to facilitate the surgery, but I soon found that the 150ml vapouriser was only lasting me for about three patients and they were a long time in waking up.

This was slightly concerning as there were no recovery facilities, apart from four beds next door and the patients’ relatives. This meant I was unable to start the next case until the previous patient was awake.

I soon learned to modify my technique and use less vapour and augment the anaesthetic with intravenous drugs, such as small increments of Alfentanil. This worked much better and allowed me to eke out my limited supply of Isoflurane – two 250 ml bottles for two weeks work!


Assessing and selecting patients for treatment Theatre porters at work Modes of local transport

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