Jessica is only three weeks old, after having been born four weeks prematurely. Last week, as her mother was drying her after her bath, she noticed a small lump in Jessica’s left groin area. Very worried, she immediately called the doctor who said to bring Jessica to the clinic. He diagnosed a small hernia. The doctor suggested that, although it wasn’t troubling Jessica at the moment, the hernia should be repaired right away. Sometimes hernias can become stuck in the abdominal wall, causing blockage of the bowel, with the lump becoming painful, swollen and hard. Because Jessica was born prematurely, she had an increased chance of developing a hernia on the right, and so both sides would be repaired.
When faced with the prospect of her baby having to have an operation, Jessica’s mother said, “I didn’t know what to do. The thought of handing my baby over to some strangers frightened me, although I know it’s a good hospital. But you never know. I mean, you read about lots of problems in the papers, kiddies dying. They’re so small and helpless. How can a baby, especially Jessica who was a premmie, cope with having an anaesthetic, and an operation?”
Jessica and her mother arrive at the hospital at seven o’clock in the morning. The operation is scheduled for eight o’clock. Jessica is first, as it is usual to try to operate on the youngest (or sickest) patients first, so that they don’t have to go without food or drink for so long. Jessica is breast-fed and she had her last feed at three o’clock in the morning.
Jessica is admitted to the neonatal ward – the ward for babies less than four weeks old or born prematurely. This is a children’s hospital, so there are lots of babies. Some are in small cots. Others who are very tiny or seriously ill are in special heated cribs, and are attached to various tubes and wires, surrounded by monitors.
Jessica is quite well, although small. She weighs 3.1 kilograms, having been just 2.2 kilograms when she was born. She has been feeding and growing well, doing all the right things. Jessica’s mother thinks that it is such a setback for Jessica to need an operation.
Most children who have operations are basically well – they don’t have the same chronic illnesses that many adults have, like heart disease, high blood pressure, or a smoker’s cough. A few children, of course, are seriously ill and require highly specialised care, especially when they need surgery and anaesthesia.
Jessica and her mother settle into the ward. The nurse attaches name tags to Jessica’s wrist and ankle and then takes down all the details about her birth and subsequent development, including her feeding pattern and if she has required any medications or had any immunisations.
Very soon, Dr. Solomon, the anaesthetist, comes to see them. He asks Jessica’s mother the same questions again, as well as asking her about her own experiences with anaesthesia. All appears to be normal. He listens to Jessica’s heart and lungs with his stethoscope and checks her weight and temperature chart. The nurse has already applied some local anaesthetic cream to the backs of both Jessica’s hands and covered them with a clear plastic dressing.
In response to questions from Dr. Solomon as to whether or not she is happy with everything, Jessica’s mother becomes a little tearful and asks if Jessica will be all right.
“She’s so tiny, isn’t it dangerous?”
“There are risks with anaesthesia at all ages,” replies Dr. Solomon, taking a chair and sitting down beside her. “In looking after someone of Jessica’s age and size, we are careful to measure the doses of all the drugs so that she gets exactly the right amounts, and all the equipment we use is designed specially for someone her size. As you might imagine, we also give anaesthetics to premature babies who are very ill and much smaller than Jessica. That’s why you’ve come to a children’s hospital, where we deal with children and babies like Jessica every day.”
“Well, thanks, that does help to reassure me.”
Dr. Solomon smiles at her and then adds, “As part of her anaesthetic I’ll be putting in a type of epidural. Did you have one during your labour and delivery with Jessica?”
“Yes,” replies Jessica’s mother, “it worked brilliantly. But is it necessary, or safe, in someone as tiny? I thought she was having a general anaesthetic?”
“She is indeed having a general anaesthetic first, and then once she is asleep, I’ll put an injection of long-acting local anaesthetic into the base of her spine. We call this a caudal anaesthetic. It’s a type of epidural, but without the long fine plastic tube that you probably had. Jessica will have a single injection of local anaesthetic, which will numb the nerves that supply the area of the operation. This will help during the operation, so that she won’t need as much general anaesthetic and will recover more quickly. More importantly, the caudal will ensure that Jessica doesn’t have any pain for the first four or five hours after the operation.”
“But is it safe?”
“Yes, it is quite safe – it’s a very common method of providing excellent pain relief. Most likely Jessica will only need some paracetamol or acetaminophen when the local wears off. That means that she probably won’t need an injection of a stronger drug like morphine, which is a good pain reliever but which can also decrease the rate of breathing.”
“How long after the operation before she’ll be awake?”
“She should be awake within half an hour of the end of the operation – although there is a very small possibility with babies who are very tiny or who were born prematurely that they forget to breathe properly after the anaesthetic.”
“What happens then?” asks Jessica’s mother, worriedly.
“If that were to happen, then I would stay with Jessica until she is breathing properly and I am absolutely satisfied that it is safe for her to come back to the ward. This is a rare problem in some of these babies, due to their young brains forgetting to breathe. Very rarely we need to leave a little plastic tube in the mouth or nose to help them with their breathing, for a few hours after an anaesthetic. In any case, we like to monitor the breathing of babies like Jessica for at least 12 hours afterwards, just to be sure that everything’s OK.”
“Won’t she starve? She hasn’t had a feed since three this morning.”
“We will be careful not to let her get dehydrated or hungry. I’ll be putting in an intravenous line so that we can give her some fluid and sugar if necessary. It’s quite likely, though, that she’ll be able to breast-feed before 10:00 o’clock, in other words, within an hour of the operation.”
“That will make both of us feel better,” says Jessica’s mother. “Can I be with her until she goes to sleep?”
“I’d prefer not,” answers Dr. Solomon. “At her age, your presence is not so critical. Babies just like to be cuddled and I know she would rather be cuddled by you than by anyone else. Nevertheless, she won’t be too upset being separated from you. Children over about the age of six months, on the other hand, do resent being taken away from their mothers. In any case, my job is to look after her. I don’t want to have to look after both of you. She deserves my 100% attention and that’s what she’s going to get – until the operation is over and she’s safely in the recovery room, breathing well on her own.”
Dr. Solomon picks Jessica up from her mother’s arms and cradles her in his own. He then invites Jessica’s mother to give her a kiss on the forehead.
Jessica’s mum tearfully clutches one of her daughter’s tiny hands and asks, “She will be alright, won’t she?”
“She will be fine. I will take very good care of her and I’ll come back and see you as soon as it’s all over.”
Dr. Solomon takes Jessica to the Operating Room, which he has previously prepared. In Jessica’s case, he does not use the separate anaesthetic induction room, so that everything he needs is at hand in the Operating Room. In addition, the temperature of the Operating Room has been turned up so it is very warm, almost tropical.
The operating table is covered with warm air mattress. Dr. Solomon places Jessica carefully on her back and asks his assistant to steady her with a hand. Overhead is an infrared radiant heater to keep Jessica warm. The assistant peels off the plastic dressing which covers the backs of both of Jessica’s hands, wipes away the cream, and applies a tiny wrap-around sensor to Jessica’s left thumb. Soon after connecting this to the lead on the anaesthetic monitoring system, a rapid beep-beep is heard and the figures “96” and “142” appear on the screen. These numbers indicate that Jessica’s oxygen saturation is 96% and her heart rate is 142 beats per minute.
Dr. Solomon nods approvingly. “Good. Now for the IV. Is everything ready?”
His assistant takes Jessica’s right arm and grips it firmly but gently. Dr. Solomon picks up a tiny intravenous cannula and inserts it into a vein on the back of Jessica’s hand. There is a small drop of blood at the end of the cannula where Dr. Solomon attaches a connector. He asks his assistant – who hardly needs prompting – to secure the cannula with adhesive tape.
Dr. Solomon then switches on a flow of oxygen into the anaesthetic circuit, checks the attachment of the mask and reassures himself that the other equipment is ready. He picks up three syringes – one with an induction drug, one with a muscle relaxant, and one with sterile saline (with which to flush the other two into the intravenous line). He injects the drugs and over the next few minutes proceeds with unhurried intensity to take over Jessica’s breathing and insert an endotracheal tube. Once he is satisfied with her condition, and her breathing is controlled by the anaesthesia ventilator, Dr. Solomon proceeds with the caudal anaesthetic. He inserts a small needle at the base of her back and injects local anaesthetic. All the time, Dr. Solomon watches and listens, alert to any signs that might require urgent attention.
Once this is done, the equipment is rechecked. Dr. Solomon listens with his stethoscope to both of Jessica’s lungs, and his assistant then covers Jessica with an insulating blanket.
“We’re ready,” says Dr. Solomon to the surgeon who is now standing patiently, gowned and gloved.
The surgeon proceeds to wash both Jessica’s groins with an antiseptic solution.
“That was quick,” he murmurs, nodding his head toward the clock. “Seventeen minutes by my reckoning and no hiccups – nice to work with you.”
Less than an hour later, Dr. Solomon proceeds to the Waiting Room, just down the corridor from the Operating Suite.
“Jessica’s fine,” he says to Jessica’s mother. “She’s in the Recovery Room and is virtually awake. You’ll be able to see her shortly.”
Soon, Jessica is reunited with her mother. Jessica appears perfectly comfortable, but before long, starts to cry irritably. The nurse asks Jessica’s mother if she thinks Jessica is hungry.
“Certainly sounds like it.”
“Do you want to try her at the breast?” asks the nurse.
“Is it OK, so soon?”
“Yes, Jessica will tell us if she’s not ready.”
In a few minutes, Jessica is sucking contentedly and her mother smiles, giving a little sigh of relief.
“Isn’t she beautiful?” she asks the nurse.