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"If someone had asked me before whether someone can be vigilant and actively involved in such a process for 48 hours, I would have said definitely not,"

2 January 2020

– interview with anaesthesiologists dr. Erzsébet Ezer and dr. Katalin Szenohradszki

Three Hungarian anaesthesiologists took part in the narcosis of the separation surgery of the twins in Bangladesh: dr. Marcell Csapodi from Budapest, and from the University of Pécs dr. Erzsébet Ezer, Head of Unit at the Department of Anaesthesiology and Intensive Therapy, senior clinical doctor, and Dr. Katalin Szenohradszki, senior clinical doctor who all spent 36 hours in the operating room and then spent 12 to 14 hours a day in the intensive care unit during the first week of the post-operative period, spending their nights in a ward released for them. Due to their hard work, the children endured the extremely long surgical process.

As it is known, in 2017 the Hungarian medical team of the Action for the Defenceless People Foundation was invited to the separation of the then one-and-a-half-year old Rabeya and Rukaya. The first phase of the Operation Freedom separation surgery series, which is entirely Hungarian in planning and implementation, was the separation of the common cerebral artery by an endovascular method, then the second phase was plastic surgery, the implantation and gradual expansion of the special Hungarian-designed tissue expanding implant system. The final separation in early August 2019 was the third phase of the series of surgeries; the two experts from Pécs helped in this phase.

 

Written by Rita Schweier

 

- How did you from Pécs become members of the operation team?

Sz.K.: - In January, we participated as anaesthesiologists in the treatment of patients at an Onitsha Catholic hospital in Nigeria along with dr. András Csókay and dr. György Szeifert neurosurgeons, and based on the experiences of this joint work dr. András Csókay invited us for the big separation surgery to Bangladesh.

- This indicates that you were able to work well together in Nigeria as well.

Sz.K.: - Yes, we were prepared for the job in spirit and tried to adapt to the equipment and conditions there, which are already unacceptably low in Hungary. We were committed to solve the problems in unexpected situations and this attitude made a good impression.

- There were also unexpected situations in Bangladesh.

E.E.: - Indeed, also because of the nature of the task and it was not possible to prepare for it in advance. However, the circumstances were very different from those in Nigeria because we were working in a very professionally equipped operating room and post-operative intensive care unit of a military hospital in Bangladesh. Before that, we had already contacted our colleagues abroad and on a list - in consultation with our Budapest co-worker, dr. Marcell Csapodi - we indicated everything we will need during the surgery. In the weeks leading up to the surgery, the colleagues abroad said they were able to get everything but we took the most necessary equipment with us in the suitcase just to be sure. Fortunately, we did not need them due to the world-class equipment, whether it was a video laryngoscope or a variety of cannulas. So in that respect everything was at our disposal, the problem was the search for special blood but they were able to solve it as well.

Sz.K.: - Twins joined at their heads are called craniopagus and many attempts have been made to separate them around the world with little or no success. This was the first intervention in a developing country that was successful in terms of technically separating the children. The surgery was prepared by a group of doctors organized by the leader of the Action for the Defenceless People Foundation, dr. Gergely Pataki. At the Bangladesh site, the catheter closure of the common cerebral veins, which are the most dangerous in terms of bleeding, was performed by dr. István Hudák in more sessions. This was a prerequisite for performing the subsequent separation surgery. This group of doctors also chose the location of the final interventions, this is how we were placed in this high-quality location. For each child, two anaesthesiologist physicians and special assistants were present during the entire surgical period but we still worked non-stop. After several hours of preparatory plastic surgery, dr. András Csókay performed the very long neurological surgery. The separation was followed by the plastic surgery section, the reconstruction of the scalp led by dr. Gergely Pataki. In principle, we were scheduled for eight-hour shifts but we Hungarians did not dare to sleep; in total we only spent one and a half hours away from the operating rooms once.

E.E.: - If someone had asked me before whether someone can be vigilant and actively involved in such a process for 48 hours, I would have said definitely not. But it turned out that it is possible. Around the 54th  hour, we could sense that the sounds were coming from far away and then we knew that we should rest a little bit because we could make bad decisions from the fatigue. We slept for five or six hours, although at first our brains were spinning, then as if they had cut off everything.

- How can we imagine this lengthy process of anaesthesia?

Sz.K.: - In children with partially identical circulation, anaesthesia was initiated with a venous cannula secured on one of them, followed by securing the additional veins, central venous cannulas, arteries for invasive arterial pressure measurement, besides these the respiratory tracts for ventilation, and we also had to place the gastrostomy tube. The little ones had to be placed very specially at the surgery to ensure sterility and access for the doctors. Continued attention was needed to drug administration, which also required increased attention. Even with some of the major venous pathways previously blocked, there was a serious loss of blood during certain stages of the operation. Very significant amounts of red blood cell transfusions and coagulation factors had to be given to the children.

- I guess the many years of experience in neurosurgery here has given you the confidence, strength and faith to participate in such a heroic surgery.

E.E.: - Yes, especially the years spent in intensive neurosurgery and anaesthesiology have contributed for us to dare to undertake this task.

Sz.K.: - Over the past twenty years, there were such neural and cranial surgeries at the Department of Neurosurgery in Pécs that have provided a wealth of experience. We also perform very serious surgeries in connection with brain tumours and various injuries, from infancy to old age, but we have not been involved in such a long intervention before. After the major surgery, the post-operative, intensive care unit, very serious treatment and observation began, which also presented us with many unexpected situations to be resolved. We came home after two weeks, but our Budapest colleague still stayed with the little ones to continue their treatment.

- Human life - human life, be it adult or child. Yet there were two very tiny creatures lying on the operating table.

Sz.K.: - We are not specifically paediatric anaesthesiologists, even if we meet such little patients, so this made the job more difficult and, of course, it left deep emotional traces in us. In addition to the dilemmas, it was our job to focus on professionalism and we succeeded, adding that our stomachs were often squeezed to see if they could survive the intervention. When we took them to the intensive care unit in more or less stable condition after the separation, I still could not believe it was successful. Another reason for this was that there were many difficulties during the surgery, metabolic disorder, bleeding conditions, and respiratory problems.

E.E.: - The whole thing was all like Apollo 11 when the astronauts got in and they did not know exactly where they were going. We went with a backpack to complete a task, we knew we would not return to our accommodation for a while, we did our job, and when we were out of the intensive care unit, I asked myself if I had dreamed the whole thing or it had really happened to me. There I became aware of where I was and that we did it.

Sz:K.: - It was particularly difficult to work with a very kind, helpful, well-co-operative team from a completely different culture, speaking in a different language - using English in their own accents as well; we met them in person three days before the surgery. There were several logistical problems and communication difficulties along the way, so we had to make sure no one was hurt because we were not sure of the proper communication protocols.

- This surgery was also a great example of the two of you working perfectly together.

Sz.K.: - We have been working together for many years, our cooperation started in the intensive care unit. Currently I work mainly in the operating room and Erzsi leads the intensive care unit. We always try to complement each other effectively and fortunately, it also happened during the cooperation with our colleague in Budapest, dr. Marcell Csapodi. With him, we were able to make decisions quickly and effectively as well. I think the presence of the three of us was essential at many points during the surgery and our stay in Bangladesh. Before the surgery, we were looking for a suitable post-operative room for the children. The collaboration and flexibility of the Bangladeshi colleagues is demonstrated by the fact that after finding the place, they separated it and made the ward available in 24 hours and they also organized a 24/7 doctor and nurse service for each child. It was a tremendous experience and confirmation that it was possible to work in a friendly way with a team from a completely different culture who are thinking differently about certain issues.

- When did you meet the parents?

E.E.: - We first saw them in Budapest but it was only an introduction. In Dhaka we met every day since they were present all the time before and after the intervention. It was hard to see the anxiety in their eyes and that they were just sitting and waiting. After the surgery, the mother barely dared to go to her children and touch them, these were very moving moments.

- Is this a complete family?

E.E: - Yes, mother, father, and a sibling, a ten year old girl who learned Hungarian very well because she was in Budapest a lot. An intellectual family, the mother is a teacher, but during the pregnancy it did not turn out that there was a problem with the babies because ultrasound is not a daily routine there, so they only faced it during childbirth. During the surgery, they were living in a large ward that had been redesigned for them with a rug and toys as well.

Sz.K.: - The operating room - one of the most beautiful and state-of-the-art in the Dhaka hospital – was equipped with cameras the previous days and huge projectors were set up even at the dining venue to be able to follow what was happening. We were constantly watching the monitor, even during lunch and even waking up from the one and a half hours of sleep I thought of whether they were still alive. We pushed the boundaries of maintaining circulation and metabolism, there have often been unexpected changes with many problems. I cannot imagine what it meant for the parents to watch it. What is more, in that culture it is not appropriate to show their feelings, so we could see only a small part of what the mother was going through. We were looking at a serious face all the time and we did not know what was going on inside. It is quite natural in Hungary for a psychologist to help in such a crisis but it is not the case there. As a mother, I did not dare to think about how all this could feel. The mother also had the burden of being responsible for asking for and agreeing to the series of surgeries and the idea of ​​how to process it if something goes wrong.

E.E.: - We also see in the intensive care unit in Hungary that the relatives do not even dare to hold the patient's hand. If we see this at home, we step closer to them, touch them with support, encouragement, but we could not do it because their religion and culture forbids them. However, in the end all the rules were nullified because emotions broke out and we all hugged each other as one. This may not have happened before since a Muslim woman cannot hug a stranger, even if she is fully dressed. It is also forbidden to make friendly contacts there, which are common is Hungary. In this situation, however, it did not matter where we were, who we were, but the feeling itself. Both the father and the mother hugged us. After that, however, the order was restored, the usual maintain a distance.

- I am sure you will continue to monitor the fate of the children.

E.E.: - Of course, we have a Viber group with our colleagues abroad and with the Hungarian team members involved in the surgery and we are constantly communicating. We regularly receive indications about how the little girls are and we give advice to the colleagues abroad if necessary.

- Are you going to travel to Bangladesh again or has your mission ended with this surgery?

E.E.: - Hopefully we are going to travel since the treatment is not over and some smaller surgeries are still waiting for the little girls. We are confident that we will be able to participate in them as well.