So, how did I end up sitting in a colonial house, converted into an eye hospital in Southern Nepal, giving a very basic anaesthetic for major ear surgery to someone whose language I did not understand, nor they mine, while being bitten to death by mosquitos?
I was sitting in theatre in Gloucestershire Royal Hospital during a long (and rather tedious) ear operation, when another consultant otolologist entered the room, really keen to see what was going on.
We struck up a conversation, during which he asked me if I would like to come and work with him in Nepal at an ear camp. He explained that ear disease was a particular problem with these people – they lived in a marshy lowland area of Nepal near the border with India.
Ear infections were common and antibiotics were expensive and difficult to obtain. Treatment was also expensive and only available in the distant cities.
There were, he explained mainly subsistence farmers who were crushingly poor.
My first thought was that this sounded exciting. When else would one have a reason to go to Nepal? And it also sounded very worthwhile – an opportunity to pay back a little of the great good fortune I had received in being given a free medical education and being trained to a very high level as a consultant in Anaesthesia, Intensive Care Medicine and Pain Relief.
I was definitely interested. He wisely left it at that for the moment.
My mind started to whirr... What sort of people were they? What facilities were available in this place? What sort of anaesthetic equipment and drugs were available? A thousand and one questions went through my mind.
The next time I saw my colleague, I was able to ask him all sorts of practical questions. What sort of anaesthetic apparatus did they have there? What gases were available? What drugs were available and what monitoring was available for the patients?
The answers filled me with dismay. In addition to the fact that I would be required to take most of the drugs I needed with me, there was an antiquated polio ventilator, originally from America which ran on electricity. The only problem with that, and with monitoring, was that power cuts were regular and totally unpredictable – as was the voltage supply. And the supply of oxygen was erratic and expensive.
So, what was I to do? Fortunately, one of my other colleagues in Gloucester was Dr Roger Eltringham, who had invented and developed the original Glostavent anaesthetic machine for use in exactly the circumstances I was about to encounter. Not only that, but Diamedica, who devloped the Glostavent with Dr Eltringham had just introduced a portable “suitcase” version of the machine – even better! He kindly allowed me to borrow one of these apparatus – a DPA02.
I practised using it on a list in a local cottage hospital, much to the interest and consternation of the theatre staff there. It is a simple draw-over machine, that draws the patient’s inspired breath over a low resistance vapouriser. The expired breath passes out by way of a non return valve at the patient end of the circuit, thus reducing the chance of re-breathing.
It was extremely easy to use and with the attachment of a spirometer at the expiratory end I was able to measure the patients’ tidal and minute volumes. There is a capability of introducing extraneous oxygen and the beauty of this is that a small inclusion of Oxygen (2 l/min) will give and FiO2 of 0.4!
The next problem was the drugs. It is part of my routine anaesthetic practise to include Alfentanil in the induction. This is an ultra short acting but most potent opioid narcotic. There was none available in Nepal. I contacted the Foreign Office about transferring a small supply there.