Hydronephrosis Boy

There are a few cases which I didn’t fully blog about when I was in Nepal, this is one of them. The photos aren’t particularly great quality as the light was low and I didn’t think that using flash photography during a surgical procedure was prudent!

An 18 month old boy with hydronephrosis was sent down to CT prior to surgery, to establish the entry point for a percutaneous nephrostomy tube. Hydronephrosis is the retention and collection of fluid within the kidney. In this particular case, the left kidney had become so distended and dilated that the overall size was in excess of 15cm in diameter. This giant mass was palpable and visible, and obviously causing discomfort as well as internal damage.

The boy was understandably distressed, and therefore required sedation before the CT scan. I will admit it was difficult not to raise a smile watching this tiny child space out in front of me:

Even though he had been sedated, he was pretty feisty and fought the drugs and the doctors as much as possible, but it wasn’t long before he realised that resistance was futile:

Following the scan, the boy’s father carried him across the corridor to the ultrasound room where more sedation was administered- no general anaesthetic was given.

The boy was still quite happy and smiley at this point; waving and grinning at Daniela and I as we watched from the foot of the bed.

Within seconds the sedation took effect and he crashed out.

Then the room filled with white coats and the procedure began. Unfortunately the cold iodine swab brought him out of his nap, so he had to be restrained. The gloves may be “sterile” but the sheets and equipment are not.

Using ultrasound guidance, the initial incision was made, without local anaesthetic, and a large hollow needle was inserted into the boy’s left renal area. The noises that tiny little person made seemed impossible. He kicked and screamed and cried, but like no crying I’d ever heard before, this was terrified, tortured wailing. More hands appeared, holding his wriggling little body down, until it became nearly impossible to follow what was actually occurring:

The needle had to be forced through muscle and tissue to get into the distended kidney, and after a bit of “adjustment” (read: wiggling) fluid trickled out of the end onto the bed. What looked like a pig-tail catheter was inserted and the needle was retracted. The catheter was larger than the needle and required more force to put in place, but this didn’t result in more screaming and writhing, in fact, the boy’s body went limp and silent as he passed out from the pain.

I looked over my shoulder to where his father had been stood, but he had left the room, seemingly unable to watch his son endure such a traumatising procedure.

The catheter was fully inserted and a tube and bag were attached, and urine began draining out.

The assortment of tubes were connected and then sutured into place with a shaky hand rather than a needle driver, and the whole area was dressed and covered in sticking plaster. Then, as quickly as the swarm arrived, it left.

The boy’s father was standing outside the door, unsure of whether he should go in. Daniela and I motioned that he could come in and see his son, so he gingerly entered the room, but kept his distance from the tiny unconscious body in front of him. We left him to be alone with his child.

I don’t doubt for a second that he was immensely grateful to the doctors, after all, without the nephrostomy his son would have certainly been at risk of kidney failure and probably death. However, one major difference between Nepali and British healthcare (I can’t comment on any other as I haven’t experienced it) is that in the UK you are given armfuls of paperwork and forms both before and after any medical procedure. Next time you’re in A&E have a look at the number of leaflets on display, for everything from Caring for a dislocated shoulder to Walking with crutches.

Informed consent is an integral part of healthcare in the NHS. The doctors will explain everything in great detail before you’re even in a hospital gown, because you can’t fully consent to something if you don’t know what it entails. This means that you know exactly what’s going to happen, and in theory reduces the likelihood of legal action should things go awry.

At Manipal Hospital, walking through the doors is an expression of full consent. In turning up at the hospital you are declaring that you want to be treated by any means, with the only barrier being cost. It would be impractical to explain the procedure to every patient; they don’t care what size IV cannula you’re using, they just want the pain to stop so they can go back to work and provide for their families. I imagine it would also probably scare them if they knew every detail of what they were about to face.

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