First ultrasound guided regional nerve block in Mbarara, maybe in all of Uganda!

Recovery trolley in theatre

So the precious elixir of oxygen still hadn’t arrived. Many phone calls are followed by promises that the cylinders will arrive in the afternoon. Some paediatric elective theatre work resumes – ENT, not a time when you want to run out of oxygen. Something we wouldn’t have worried much about in the past except for the fact that we’ve now seen that red alarm on the ventilator more than once! Not good for one’s own heart. As we took the 3 year old off the table and placed him in the corridor the anaesthetic officer from next door wandered out and kindly informed us that the ventilator had started alarming and all dials were in the red...although not good news we had a big inward sigh of relief as we looked at the boy sleeping off his ketamine/halothane anaesthetic in the corridor. Only a few minutes before he had been obstructing his airway and needing supplemental oxygen.

The emergency list was long as always with plenty of lower limb work. In theory the patients could receive a spinal anaesthetic and stay awake for the procedure hopefully not needing to be converted to a general. However crossing fingers isn’t enough and a ‘spare’ O2 cylinder was found that would be enough for any emergency situation requiring someone to be ventilated. Therefore work re-commenced.

Over the last few weeks we have been teaching ultra-sound guided regional anaesthesia (USSRA). Right – not what we expected either. A brand new, high spec ultra-sound machine had been obtained by the anaesthetic department. At first we thought the same as I am sure many of you. Surely this money could have been put towards more essential things. It certainly was not what we envisaged our teaching sessions would be on before we arrived. However having spent a few weeks in theatre we could actually see its potential benefit. Upper limb work could be carried out without the risk of a general anaesthetic. Post-operative pain relief, which is poor here, could be vastly improved, especially post laparotomy with TAP blocks. And at times like this when there was enough O2 for an emergency but not enough to run GAs lists, work could carry on. 

We had completed 2 weeks of teaching with some ‘willing’ volunteers, Hugo included, acting as maniquins as the trainees attempted to visualise the nerves. No needles allowed! Ground rules were established that everyone’s anatomy had to be up to speed (tested –Katie’s a tough examiner), everyone knew how to treat the complications and it was only carried out in theatre with full resuscitation equipment. A logbook would accompany the machine so a record of cases, practioner and success would be kept.

As if by design there on the emergency list was a young man injured from a machete attack. He had a wound to the palm of his hand that needed urgent repairing. Perfect example of how, if successful, a block could be used to facilitate awake surgery thus sparing the O2 and allowing this time critical surgery to take place.

Katie proceeded to perfectly demonstrate Mbarara’s first USS guided supra-clavicular block. The man successfully had his hand operated on. Although without going into too much detail we might not have been quite as confident about the possibility of carrying this out awake if we had actually seen his wounds prior to theatre...

There is always a lot of pressure when demonstrating a new technique. We were delighted it went well and with a lot of interest from our colleagues, medical students, nurses and passers by..

Next week TAP blocks....

The events described in the blog are true although in the interest of confidentiality certain details and characteristics have been changed.