– surgery among most complicated done at Georgetown Hospital

By Neil Marks

JAVIER Lawson, of Kamarang in the Upper Mazaruni, was having one of his regular days at his school on February 22 this year. But things took a horrible turn.

The eight-year-old picked off a thumb tack which was holding up a poster behind the chalkboard and placed it in his mouth, using saliva to glide it from one side to the other.

Before he realised it, the tack went down his throat, sending teachers into panic mode when they realised he was panting for breath and coughing.

His grandmother, a retired medex who was taking care of him while his mother was on the coast, was quickly called in.

Javier was rushed to the Kamarang hospital, but the doctor there could do nothing to help and so referred him to the Georgetown Hospital – a one-hour flight away.

The regional administration made the arrangements, and Javier was on the next flight out to the city.

At the Georgetown Hospital, he was seen by the Ear, Nose and Throat team. A decision was made to remove the tack using a rigid bronchoscope – a stainless-steel tube which is put through the mouth into the airways of the lungs.

The bronchoscope carries a light at the bottom, enabling doctors to see where the tack was lodged. They then used a metal clamp to try to remove it, but that failed.

They tried the same procedure a second time, and failed again. The failure was due to the sharp end of the tack perforating the bronchial wall (wall of the airway) into the lung tissue.

It was a heart-rending moment for Javier’s Mom, Rosalyn Ferreira. She was desperate for some good news.

Javier was referred to Dr Cheetanand Mahadeo, the lone thoracic surgeon in the country.

He also used a rigid bronchoscope on Javier, trying to determine the exact position of the tack. He found that the tack was tightly stuck and the body had started to “wall” it off, sort of being built into the part of the lung it was stuck to. This process is called fibrosis.

Dr Mahadeo decided that he needed to open Javier’s chest, but there was a problem – the double lumen tubes that were required was not available in Guyana. These tubes are what would be connected to the ventilator, allowing selective collapse of one lung so the operation can proceed safely and allow removal of the tack.

A CT scan of the chest was also done to assist in surgical planning and 3D localisation of the tack. This scan showed consolidation and atelectasis of the lower lobe of the right lung (poor air entry and fluid filling).

Dr Mahadeo and the doctors at the Anaesthesia department at GPHC tried sourcing the tubes needed from overseas (namely Trinidad), but none could be found and Javier’s family could not afford to take him to Trinidad – one of the options which they thought was the only one left.

Javier’s mother’s heart sank. She was beginning to get out of sorts, unsure of what lay ahead for her boy.
Javier sat next to his Mom, looking at her intermittently during an interview at a relative’s house in Cummings Lodge, Greater Georgetown, where the Guyana Chronicle visited this week. She tried to hide the tears that had started to build up.

“I just didn’t know what to do or what would happen,” Mrs Ferreira said. She grasped Javier’s hand, water settling in her eyes.

“He was just there in the hospital.

“Then a week later, we were told Javier would be going into surgery.”

Dr Mahadeo and his team decided that they would use something called a “bougie,” which they would use to intubate one side of lungs (placing a flexible plastic tube into the trachea, or windpipe, to maintain an open airway) and allow the other side to collapse, so the operation can take place to remove the tack.

The team was assisted by the visiting paediatric anaesthetic doctor from “Baby Heart” mission, which was a bonus.
With Javier in the operating theatre, his Mom waited patiently and then she began to panic. Javier was taken into the theatre at 09:00 hrs, and she was told the surgery would take about three to four hours.

But that time had elapsed – one hour, two hours more. She kept thinking of all the prayers that were said from Javier – her own prayers and that of the school, his football team, the church, and family and friends.

Inside the theatre, Dr Mahadeo and his team realised that they could not just extract the tack – they had to remove the lower lobe (the right lung has three lobes) on the right side of his lungs.

To do that, they had to do a mobilisation of the lungs to ensure that the other two lobes on the right side of the lung would expand to fit the chest – once the one with the tack was removed – in order for Javier to breathe properly.

And so, the original time frame Javier’s Mom was given was going to take double the time. Of course, she had no way of knowing what was going on inside. Then at 15: 45 hrs, after what seemed like an entire lifetime, Javier’s Mom was overjoyed at news that the surgery was successful.

Post-operatively, Javier did quite well and was discharged five days following the surgery.

“Javier is able to breathe easily, and in a month’s time he can go back to playing football,” Dr Mahadeo told the Guyana Chronicle.

As far as Dr Mahadeo was told, this kind of surgery was never previously done at the Georgetown Hospital. In fact, he said less than two percent of humans who ingest a foreign object would need this kind of operation.

Dr Mahadeo is advocating the establishment of a Thoracic surgery department at the Georgetown Hospital, as this would more readily allow the hospital to respond to cases like Javier.

“I have been trying for the last three years to bring such a service to reality,” he said.

He said too that such a department could respond to the “endless amount of chest cases” in Guyana, and could lead to the early diagnoses of diseases, such as cancers, before they develop to a critical stage where they cannot be managed.

“I am very thankful for the residents, GMOs, Interns, Nurses,the anaesthesia team/ICU, the ENT department and Dr Zilo, all who volunteered their kind assistance to the ground-breaking surgery.

“This is entirely new to Guyana, so the medical community is not familiar with the nature/extent of care these patients require, however, the above persons were enthusiastic and integral to the outcome.

“It’s never a one-person operation, every link is important,” Dr Mahadeo told the Guyana Chronicle.

Meanwhile, Javier is getting ready to fly back to Kamarang – eager to get back to football. Unable to contain her tears, Javier’s mother told us to include in anything written about Javier, a world of thanks for the medical teams who worked on her son.

“I would [like] to thank the nurses and the doctors who were so very kind to us throughout everything.

“I would like to thank Dr Mahadeo who was so, very, very kind to us.”