Meet Mahmoud

Mahmoud is a ten-year-old who needs to have his tonsils and adenoids removed. Not only has he had frequent bouts of tonsillitis, with repeated absences from school, but he has also had difficulty with his breathing. This difficulty occurs at night and Mahmoud often stops breathing for short periods. The problem is related to blockage of the upper part of the throat passage and is known as  obstructive sleep apnoea. This is a condition where people stop breathing while asleep. Each time the person stops breathing, he or she has a period where they do not get enough oxygen. Sleep apnoea patients often have noisy and restless sleep as they snore, gag and splutter.

Mahmoud’s condition is caused by his enlarged tonsils and adenoids. These are glands in the throat and the back of the nose, which mop up infections. However, these glands themselves can become the seat of repeated infections, as in Mahmoud’s case, and they need to be removed.

Mahmoud is overweight. He doesn’t sleep very well and is tired during the day, so he doesn’t take part in many sports at school, however he likes computer games.

His operation was arranged by the Ear, Nose and Throat surgeon after Mahmoud spent a night in hospital having his breathing monitored. Part of this sleep study involved measuring the oxygen in Mahmoud’s blood, using a special clip like a clothes-peg, called a  pulse oximeter. This is attached to a finger or thumb, and is also part of normal monitoring during anaesthesia. Only in Mahmoud’s case, the oximetry was carried out to help determine the severity of his obstructive sleep apnoea.

Although Mahmoud’s parents have spent a lot of time explaining things to him, he is not too pleased about having to have the operation.

“It’s not fair. It’s the start of the holidays and my friend, Sammy, is having a birthday party.

Now I’m going to miss it.”

At the hospital

It is the day of Mahmoud’s operation. He has missed his breakfast, which doesn’t make him happy. He ate some biscuits last night before bed, and he had a drink of apple juice this morning as soon as he got up at half-past six.

Mahmoud isn’t saying much. He’s actually quite frightened inside, even afraid of dying or having something dreadful happen to him, like having his insides pulled out while he’s asleep. These fears of death or mutilation are not uncommon at his age, but are rarely expressed. Mahmoud clutches his handheld computer game and his teddy bear.

Mahmoud and his parents proceed to the surgical admission centre where the nurse welcomes them and points out the playroom full of toys and video games, as well as a tank full of brightly coloured tropical fish. The first thing the nurse does is weigh Mahmoud.

Next she enquires about Mahmoud’s medications and if he has any allergies. Mahmoud’s father, Hussein says, laughing, that Mahmoud is allergic to spinach.

“What sort of reaction does he have?” asks the nurse.

“Well, none, he just doesn’t like it,” replies Hussein.

“Oh, that sort of allergy!” responds the nurse, smiling at Mahmoud. “I meant real allergies – leading to rashes and other reactions.”

After learning that Mahmoud does not have any allergies, the nurse asks other questions about his eating habits, sleep patterns, favourite toys, etc. Then she applies a white cream to the backs of both of his hands and covers the cream with clear, adhesive plastic film.

“This is local anaesthetic cream,” she explains. “When the anaesthetist uses a small needle, it won’t hurt because your skin will be numb.”

Mahmoud is not too sure.

“The anaesthetist, Dr. Hansen, will be along to see you shortly.”

Sure enough, Dr. Hansen arrives and introduces herself. She explains to Mahmoud what an anaesthetist is:

“The doctor who looks after you during your operation and makes sure that you stay asleep until it’s all over”.

She then asks if Mahmoud has had any previous anaesthetics or if there had been any problems in the family with having anaesthetics. She also asks if Mahmoud has had any major illnesses, takes any medications, or has any allergies. Spinach is not mentioned. Dr. Hansen asks about the sleep apnoea to find out how severe the breathing problem is, then asks Mahmoud to open his mouth wide and to tip his head back as far as he can. She takes her stethoscope and listens to Mahmoud’s chest, front and back. She also takes Mahmoud’s hand and explains about the needle and how it won’t sting because of the cream. She invites Hussein or Fatima, Mahmoud’s mother, to accompany Mahmoud until he falls asleep with the anaesthetic. Fatima says that she will go with Mahmoud, and Hussein nods in agreement. Dr Hansen explains that after the needle, she will give Mahmoud some medicine through it, and that he will fall asleep within ten seconds or so.

Dr. Hansen also explains that Mahmoud will have a sore throat after the operation, and that nausea and vomiting are common after operations to remove the tonsils and adenoids. She states that she will administer enough painkillers to make Mahmoud comfortable but not enough to get rid of all his pain, as that might lead to a decrease in his rate of breathing. She also indicates that she will give a combination of drugs to try to avoid the nausea and vomiting.

“But I can’t guarantee that he won’t be sick afterwards. One of the reasons is that there will be a little blood in his stomach – from the tonsils. And it may be enough to make him vomit, possibly just once, to get rid of the blood.”

She then asks if Mahmoud and his parents have any questions, but none are forthcoming. Dr. Hansen detects that Mahmoud is quite anxious. She asks if a sedative might help, but Fatima says that Mahmoud will be calm if she can stay with him until he is anaesthetised. Finally Dr. Hansen prescribes some mild painkiller (paracetamol or acetaminophen) for Mahmoud to drink before the operation. That done, Dr. Hansen leaves and Mahmoud returns to his computer game.

The anaesthetic

Just after ten o’clock, the nurse comes to tell Mahmoud and his parents that it’s time to go to the Operating Room.

“Can I take my computer game?” Mahmoud asks.

“Of course” is the reply, “and your teddy bear”.

The four of them, Mahmoud in his pyjamas and slippers, walk to the elevator for the journey up three floors to the Operating Suite. There they are met by another nurse, who checks certain details on a form, including items from the  chart and Mahmoud’s name-band, before the ward nurse returns to the ward.

Everyone here is dressed in pale blue pyjama suits. Some have brightly coloured hats, while others are wearing what look like shower caps.

Mahmoud is shown a trolley with sheets, a blanket and a pillow.

“This is your trolley, Mahmoud,” says the nurse. “You don’t have to get on it yet – there are some toys over there, plenty of books to look at, or computer games to play with.”

Mahmoud looks around nervously. Sensing his son’s anxiety, Hussein challenges Mahmoud to a car race on the computer. Mahmoud doesn’t need to be encouraged. Hussein knows he will be beaten one more time!

Soon, Dr. Hansen appears. Her hat is covered with green frogs and she sees Mahmoud and Hussein intently watching the computer screen.

“Come on, Mahmoud, time to go,” says Fatima.

“Not yet, not yet!” replies Mahmoud, contorting his body as the racing car veers from side to side on the screen.

Hussein solves the problem by conceding defeat and Mahmoud, with a small victor’s smile, agrees to climb onto the trolley. He kisses Hussein and holds his Mum’s hand while Dr. Hansen and her assistant wheel the trolley down the corridor and into a small room.

“This is the sleep room, Mahmoud,” says Dr. Hansen. “Emma, here, is my assistant and he’s going to wipe that cream off your hands. Then he will put a special clothes peg on your finger to tell us what your pulse is. It will start to go ‘beep-beep’ soon.”

Sure enough, a high-pitched beep begins and Mahmoud turns to look at the  monitor with all its squiggly lines.

Mahmoud’s mother stands by one side of the trolley, holding his hand, while Emma takes his other arm and squeezes it gently below the elbow. Dr. Hansen takes Mahmoud’s hand and taps it gently on the area where the cream had been, saying how good Mahmoud was and asking if he has a name for his teddy bear or is it just ‘teddy’.

“Teddy”, says Mahmoud quietly, as Dr. Hansen takes a very fine  cannula and needle and proceeds to insert it through the skin and into a vein on the back of Mahmoud’s hand.

He gives a little flinch as the needle enters, but otherwise shows no reaction.

“There, that’s all done,” says Dr. Hansen. “That was OK, wasn’t it? No more needles. And now I’m going to give you some special sleeping medicine. How does that feel? Sometimes it’s a bit cold and then you might get a funny taste, but in just a few seconds you’ll be asleep and when you wake up you’ll have a bit of a sore throat.”

Very quickly Mahmoud begins to stare blankly into space, and then falls asleep. Fatima is comforted by the smooth manner in which Dr. Hansen takes hold of the mask, places it over Mahmoud’s face, and adjusts some gas controls on the equipment by her side.

“You can give him a kiss and then nurse will show you the way out,” says Dr. Hansen.

“I’m just amazed at how quick it is,” says Fatima, as she leans over and kisses Mahmoud on the part of his cheek not covered by the facemask. “Look after him, won’t you?”

“We’ll take good care of him,” replies Dr. Hansen.

After the anaesthetic

Mahmoud arrives in the  recovery room with Dr. Hansen having supported his jaw and monitored his breathing all the way down the corridor from the Operating Room. He is lying on his side on the trolley. There is a little blood and mucus around his mouth and a trickle of blood from one nostril onto an absorbant pad.

The nurse who will be looking after Mahmoud takes the oximeter and places it on his finger, to again monitor his pulse and oxygen. Teddy is tucked under his arm.

Dr. Hansen and the surgeon then speak briefly to Hussein and Fatima who are sitting in the waiting room.

“Everything is fine. Mahmoud is in the Recovery Room, still sleeping. You’ll be able to be with him shortly. The nurse will give you a call.”

A few minutes later, they are called to the Recovery Room to be with Mahmoud as he wakes up. He begins to get quite restless and tries to get up on all fours. Fatima rushes to the end of the trolley to reassure him. The nurse explains that children often go through a period of restlessness as they wake up from anaesthesia.

“It’s because they’re half asleep and half awake – disoriented in a strange environment and sometimes they get quite upset, but it usually doesn’t last too long.”

After about 15 minutes, Mahmoud settles back to a comfortable doze. A few minutes later he opens his eyes and complains that his throat is sore and asks if he can have a drink. The nurse offers him a sip of water from a paper cup.

Dr. Hansen returns to the Recovery Room with the next patient who has also had a tonsillectomy. She asks Mahmoud and his parents if everything is OK.

“He was a bit restless for a while,” says Hussein, “but he didn’t seem to be too uncomfortable and nurse explained that kids often are a bit out of sorts as they first wake up.”

“Yes,” says Dr. Hansen, “it’s just that they’re not sure of their surroundings and you know how some kids wake up grumpy in the morning – I’ve got three of them and they’re all like that!”

Hussein nods understandingly.

“It’s interesting,” continues Dr. Hansen, “how some kids sleep like logs. If they have an anaesthetic which extends into their normal sleep routine, we can’t tell when they wake up from the anaesthetic and when they fall asleep. We sometimes see it, especially after anaesthetics at night. Parents find it a bit unnerving.”

Mahmoud has his drink of water and then is collected by the ward nurse. On arrival back in the ward, he is transferred to a bed where he curls up, clutching his teddy bear, and promptly goes back to sleep.

An hour later he is awake and thirsty. He drinks some apple juice and the nurse gives him some pain-killing syrup mixed in some more juice. He says he feels fine and is soon ready for something to eat.

“No hamburgers yet,” says the nurse, “but what about ice cream?”

Mahmoud nods with a hint of a smile and then lies back to watch the cartoons on television.