Encore

As I was seeing another bunch of men with prostate problems today, this man came in. He had a foley, but he also had fevers so I checked him for malaria. No surprise...positive. What I found ironically hilarious was this:

That turban on his head is a mosquito net!! Well sir, I said, mosquito nets are more effective around your bed...not around your head.

Isn't it ironic?

I gotta admit, in clinic I get a little tired of seeing old men who have problems peeing because of an enlarged prostate. Another rectal exam...ugh. I think we could take out a prostate every day and still not cure all the BPH (benign prostatic hyperplasia) in the country. 

Last Thursday, I had a bit of a chuckle when I saw how this guy had his urinary catheter plugged- with a vial of furosemide, a medicine used to make people urinate. Ha. The irony.

x-ray of the week

The story is thus: Motorcycle accident...six months ago.  He still can't walk so he came to the doctor.  To start, take a quick look at these normal knee x-rays:

This is his x-ray:

can you spot the difference?

totally dislocated

in diagram form (from crashingpatient.com) 

Normally, a posterior knee dislocation would be a surgical emergency. But, after six months, it was hard to be in a hurry to do anything  It might have to wait for the orthopedic surgeon...and even then there may not be much we can do.

the list gets longer

Thursday clinic had quite a few difficult, mysterious, sad, or just plain unusual cases...

It started with a woman whose co-wife had bitten off half of her bottom lip. This is the second time I have seen a woman whose bottom lip was bitten off by a co-wife. What I want to know is- how do they get close enough to bite each other's lips during a fight? Seems quite difficult to do.

Then, I saw a woman with breast cancer. She had noticed a mass for six months which is a relatively short time here. Often women will wait for over a year before being seen for a breast tumor and by that time the tumor is often necrotic (rotting). Its terrible.

She came because she was starting to have chest and back pain.  Her tumor wasn't rotting, but when I examined her I found two masses. One was central in her breast and the other was fixed to her chest wall just under her collarbone. I listened to her lungs and couldn't hear any breath sounds on the side of the tumor. I tried to ultrasound her lungs. I couldn't see much so I moved to more familiar territory- her abdomen. I looked at a liver to see if the cancer had spread there. This is what I saw:

It took me a little while to figure out that I was looking at a huge malignant pleural effusion (fluid around the lungs) that was pushing the entire liver toward the center of the abdomen. Stage IV cancer. 

On x-ray we could see that part of her third rib had also been destroyed by the cancer. Not much we could do except offer to drain the fluid if her breathing became too uncomfortable.

After that I saw a series of less-acute problems most of which did not belong in the standard American "general surgery" category:

1. An elderly woman who ten days ago "suddenly" couldn't open her jaw. Denied any trauma, etc. She couldn't eat anything that wasn't liquid. I sent her to the operating room to have her jaw re-located. 
2. Man with non-displaced fracture of his 2nd and 3rd metatarsals. We put a short-leg cast on two weeks ago. Can it come off now?
3. Two year old with a fluid-filled mass on the top of her head, there since birth. 

fluid filled congenital skull mass...anyone know what this is?

We saw her one year ago. The mass had grown about 1/2 cm since then but otherwise didn't seem to be causing problems. I tried to ultrasound it to get more information.

I'm not entirely sure how to interpret this...

       4. Man with history of leprosy treated 30 years ago for whom we amputated one of his legs for a chronic wound. I put in a call to our occupational therapist and we gave him the phone numbers for what we think is the only place in the country that makes prosthetics (although I have yet to meet anyone with a prosthetic made here).

      5. Man who was in a fight yesterday and had a deformed nose and jaw pain. Nasal fracture.
      6. Young, breast-feeding woman with a solid breast mass that had eroded through the skin and was exuding milk.
      7. Old lady who was in a motorcycle accident two weeks ago, but had lots of shoulder pain and couldn't raise her shoulder. X-ray:

Her dislocated shoulder

So, my five and a half hour “½ day” of clinic left me with about five days worth of reading topics added to my ever-expanding list:

1.     How to read a shoulder x-ray

2.     How to re-locate a shoulder…after ten days (thankfully the OR staff know how to do this without my help!)

3.     Jaw dislocation 

4.     Midline fluid-filled congenital skull masses. What is it? An encephalocele (brain)? Can you see a connection with the brain on ultrasound? When do you remove or observe?

5.     Operative indications for nasal fractures- when do you have to fix it?

6.     Masses in lactating breasts…eroding through the skin

7.     Chest ultrasound for pleural effusion

8.     Breast mass ultrasound

9.     Pediatric skull ultrasound

10.  Metatarsal fracture management

I was so tired after getting up at six am for teaching rounds that I went home and when I was about to take a nap, had to go do a C-section.

And that is why my reading list just keeps getting longer and longer!

made my day (its the small stuff)

I had a small moment of victory in clinic today amid a morning of mysterious and difficult cases. A young man came in with a week of pain in the right abdomen. No fever, no nausea, nothing else. Just pain. On exam he was tender in the exact right spot for appendicitis. McBurney's point. At this stage, many surgeons would feel comfortable going straight to the OR to operate for appendicitis (although in the States we would check the white blood cell count, the urine, and might still get a CT scan or ultrasound).

Well, I tried the "just operate" approach yesterday. First for a man with almost the same story and pain in the same place. But, when I operated I found not appendicitis but typhoid that was almost perforated. I had to make a second incision to fix his intestines. Not only did he get two incisions, but it was a bit frustrating and made the operation last longer.

Next, I operated on a little boy whom I thought had appendicitis, but his story and physical exam weren't as clear. I tried to ultrasound but couldn't see the appendix. Since I didn't want to end up making two incisions again, we just started with the bigger incision (its not that common here to have straightforward appendicitis, anyway). Turns out it was ruptured appendicitis.

So, with my patient today I was determined to try to find the appendix on ultrasound again. Third times the charm, right?! After just a few minutes with the probe on his belly, I almost couldn't believe my eyes. There it was!  So clearly! A thickened, inflamed appendix.  I could even see the hardened stool ball (fecalith) blocking the appendix and causing his appendicitis. Look!:

see the appendix?! It measured 1.2 cm in diameter.

I sent him over to the operating room to have his appendix removed. There was a lot more to be seen in clinic, but nothing a straightforward as the appendicitis. Here are a few pics:

For seven years this man has had a growing mass dangling off the first part of his arm. What is it? I do not know, but we will take it off and see. 

This man showed me these stones that had come out in his urine six years ago. (He saved them a long time!)

Unfortunately, he now has more stones. (those bright round things).

Mouth tumor...I'm so happy that we have a head and neck surgeon coming to visit us in just a few weeks!!!

large, fixed chest wall mass, there for two years and growing...should we try to take it off?

another one for the urologist...a narrowing of the urethra (stricture) so this man has to urinate from a tube in his bladder

"Suspicion du stenose du pylore." I read the referral paper then looked at the tiny two week old baby in front of me.  The mom says he's been vomiting for a week.

I ask "What has he been vomiting?" 

Which gets translated into, "He has been vomiting milk, right?" 

Mom says, "Yes."

I ask, "Does he vomit bile? Green vomit?"

Which gets translated into, "He vomits green stuff, right?"

Mom says, "Yes, its green."

Me, "Is it milk or is it green?"

Mom, "He vomits after I feed him."

And so it went...now this "run-around" may not seem like a big deal, but one of the most important things to know in vomiting babies is, "Is the vomit bilious (green) or not?"  Green vomit is often a big emergency. Milk, not an emergency. Despite multiple questioning attempts, I just couldn't get a clear answer but it seemed most likely he had projectile vomiting of milk.  

I decided to move on to physical exam. Of course, a two week old baby isn't going to tell you if it hurts. He just cried. His abdomen felt pretty normal, although I thought I could see his stomach contracting under his skin.

I  briefly recalled my three months of pediatric surgery training at Seattle Children's hospital. I knew the next step for this vomiting baby: ultrasound. In Seattle, I would just order the ultrasound and wait for a report from the pediatric radiologist. It came back with numbers, measurements, and an interpretation: pyloric stenosis- yes, no, or maybe. Those were the days.

But now, it was just me, the antiquated ultrasound machine, and the baby. I laid the baby on the exam table and grabbed the ultrasound probe.  I've never done an ultrasound for pyloric stenosis...but there wasn't anybody else to do it.  I started scanning and eventually I found something that I thought (hoped) looked like an enlarged pylorus.

I found something that looked kind of like this...fuzz and all

I measured it all the while thinking "Hope this is right....what I wouldn't give for a ultrasonographer right now." I admitted him to the hospital to prepare him for the operation and put him on the list for the first case Saturday morning. 

Saturday morning OR list

The next morning, as we put him on the OR table,  I felt the full weight of my decision to operate. What if I was wrong?  What if his pylorus is normal? Then what? What if he doesn't need an operation? What if I am putting him through the risk of an operation for nothing? 

We prayed and I cut. I found his little stomach and followed it down to the pylorus and...breathed a sigh of relief. It was clearly abnormal.  In just a few minutes, I taught my intern how to fix a little baby's hypertrophied pylorus so the milk can once again empty out of the stomach. 

Within twenty-four hours he was breastfeeding without any problem and two days later he is on his way home!   

crowd sourcing

How old?

When is your birthday? Most Americans grow up celebrating their birthday every year. Its kind of a big deal, especially as a kid. I bet you remember at least some of your more "important" birthdays like the day you reached double digits, the day you became a teenager, or the day you  turned 16 and could finally get your driver's license. What about 18 when you were finally an "adult," 20 and no longer a teenager. The big 21. After that, birthdays aren't quite as cool. You turn 30, life is nearly over! Nothing special happens except you are no longer in your twenties and feel old. That's me.  How did that happen so fast? And 40...it won't be long.

You can imagine that it was a bit shocking to me when I started asking people's ages here and the most common response was silence or "I don't know." What?!!! How can you not know how old you are? 

And, we had some really funny guesses on the patient's cards. Like the guy who said he was a 120! He looked old, but he wasn't that old. :)  Usually, I just accept the age that is written on the patient's card, but sometimes it is obviously wrong. Then I start the guessing process with my translator. How many kids do you have? How old is your oldest child? Are you in school?  etc...  

The  patient card of the boy in the picture said he was twenty...but there is no way he is that old. He looked about 13. So I asked his father, he said "I think he is twenty." Then, as often happens, most of the other patients in the room chimed in to help, "He isn't twenty!"  "He's probably 12"  "No, I think he is 15"  "He's not more than 14" "Does he go to school?  No, he's not in school." "We think he is 14."  So, I crossed out the "20" and wrote "14" on his card. Back to minor status for you!

image of the week

A snapshot from my first day back in clinic:

so precious

One month ago, this little 2-year-old girl had her left eye removed for a tumor (most likely retinoblastoma). Now, the tumor has re-filled her eye socket. Retinoblastoma is a type of tumor that is 95% + curable with the correct treatment. But we don't have that so, as always, we'll do what we can and hope for the best. 

It's textbook...

Sometimes, I look at a patient in clinic and think, "This patient belongs in a textbook...in fact, I think I saw a picture like this in a textbook in medical school. If only I could remember what it is..."

This girl was one of those patients who looked like her picture belonged in a book. You can't tell as much from the picture, but she was short/stout.

She is an adolescent with a goiter that had been growing since she was a child. Her parents said that she used to speak as a child but for the past eight years she hasn't made much sense. Although, she understood when I asked her to come and could say her name. But she didn't say much else, she just looked at me with a somewhat vacant, sad stare.

huge goiter

We checked her thyroid function and her TSH was 26. (very high, which means her thyroid isn't working). All of her symptoms (mental deficiency, goiter, stunted physical growth) seem to be from congenital hypothyroidism, which causes cretinism. 

Cretinism. Thats the textbook diagnosis I was looking for. Cretinism is a condition of severely stunted physical and mental growth due to untreated congenital deficiency of thyroid hormones. Its a condition that has been all but eliminated in developed countries due to the introduction of iodised salt and other iodine supplementation. It was so effectively eliminated that I had only seen it in the black-and-white pictures of my medical school textbooks...until now.

typical textbook cretinism photo

I did a little reading and found some quite interesting information:

• According to the World Health Organization, "Iodine deficiency is the single greatest preventable cause of mental retardation."  The Lancet, Iodine deficiency- way to go yet. 
• When iodized salt was introduced and became widely used in the USA in 1924, there was a gradual increase in average intelligence of one standard deviation. IQ increased up to 15 points in iodine deficient areas!  (fascinating article here)
• Millet (one of the staple foods here) decreases iodine absorption (cabbage, corn, and radishes can also).
• We are on the UNICEF list of sixteen "Make-or-Break" countries with high numbers of unprotected newborns, low levels of salt iodization, and a need for a high level of support in attaining universal salt iodization. (UNICEF report here).

The same report shows that from 1995 to 2005 iodine intake has increased from 7% to 46% of households here. Perhaps that is partly due to the ubiquitous, iodine-containing Maggi chicken bullion cube used in cooking here.

Don't forget the iodised salt and MSG!  

what did you eat today?

the old man that I scheduled for a prostate removal today had high blood pressure. it had come down with medicines, but was still slightly elevated so we started talking to him about eating a healthy, nutritious diet to improve his nutrition and blood pressure before his operation. the conversation went a little like this:

us:  "you should eat less salt in your rice and beans and make his sauce separate with less salt. you should eat fish and meat, just not seasoned with to much salt."
patient: "we can't eat fish or meat except maybe once a week"
us: "he needs to eat vegetables."
patient: "we don't have any, just beans"
us: "You don't have cabbage or spinach or any other vegetable?! Can't you find them in the market?"
patient: "No, not in our market. We just have beans."
us: "What about kuli kuli [balls made of peanuts after the oil has been removed]?"
patient: "yes, we have kuli kuli."
us: "ok, eat that too and take these multivitamins."

Can you imagine eating only rice and beans and millet...every meal, every day??? They are farmers and beans is what they grow, so that is what they eat. Seems kind of ironic to be giving him medicine for high blood pressure when he can't even find vegetables or fruit to eat. Counting my blessings.

why now?

It may not always be an appropriate question. But sometimes I just can't help myself. I am curious. I don't understand. ..and sometimes the answer is important.

What causes someone to finally come to the doctor after waiting months or even years? Every day in clinic I see more advanced pathology then I ever did in training. Its "the worst" of this and "the biggest" of that.

Why do patients wait until their condition is so bad it often can't be fixed? What finally pushes them to decide to come? How many people never come? Likely it is a combination of lack of education, lack of money, and a fatalistic worldview...but I'm still asking questions... looking for clues. So I'll ask. "Why now? Why today?" Then, I try to figure out if we can help.

some people may find the following medical images disturbing

Here are some examples from the past few weeks.

An all-too-common story. Little boy whose dad brought him in 2 weeks after an elbow dislocation/fracture. His arm below the fracture was so tightly wrapped in the traditional manner that all the skin was dead and had to be removed.

Young boy complaining of trouble walking after a motorcycle accident two years ago. He came in because he has been having more and more knee pain. Check out his x-ray:

Yep, its broken!! It healed..just not straight and he's putting stress on the knee joint causing permanent damage.

Several years after an elbow dislocation...chronic nerve injury. Not much we can do.

there's  been something wrong with my foot for the past year...now we have to amputate

Advanced male breast cancer (there for a year). Breast cancer is more rare in men, but we have about 1-2 women a week come in with an advanced breast cancer similar to  this.

A woman my age...huge mass involving the lower abdomen and hip. I had to tell her that there is nothing we can do.

Two years with an infected, exposed tibia bone.  He sat on the floor in front of me because he can't walk (he can't straighten his knee). I asked him why he waited so long (Imagine two years as a kid...not being able to walk without help from his mom). He showed me his elbow fracture that had healed on its own (with a small residual deformity) and said he had hoped his leg would heal too. Now the only thing we can do is amputate...but at least then he'll be able to walk with crutches.

I bumped my elbow...

A year...probably longer than that for a tumor this size. Now she needs an amputation.

"Doc, I've had it 50 years...can you please take it off?" At least it looks benign. :)

Seeing all these people reminds me of how broken, physically and spiritually, we are. Sometimes its not as obvious...but we all need healing.

Psalm 103

 Bless the Lord, O my soul,
    and all that is within me,
    bless his holy name!
² Bless the Lord, O my soul,
    and forget not all his benefits,
³ who forgives all your iniquity,
    who heals all your diseases,
⁴ who redeems your life from the pit,
    who crowns you with steadfast love and mercy,
⁵ who satisfies you with good
    so that your youth is renewed like the eagle's.

now bones are fun

You know what is amazing?!  Having a real, live orthopedic surgeon in clinic!  Its like being a medical student again. As usual, patients arrive with orthopedic problems that I don't even know how to begin to solve. But this Friday, I was not alone in clinic struggling and trying to figure out what to do. Dr. J was there to help! After asking a some questions, examining the patient, and looking at the x-rays...KAZAM!!! within a few minutes Dr. J would deliver a diagnosis and a plan!

For example, check out this hip x-ray:

We saw many patients with hip pain and x-ray's like the one above. The right hip joint is in bad shape. Too destroyed for a hip replacement. 

But, did you know you could do this?

Same patient, but the head and neck of the right femur bone was removed by Dr. J a couple years ago when he came. Guess what?! She can still walk! She has a significant limp, but is very happy because she doesn't have pain.  Amazing.

Dr. J is here for a couple more weeks and I am looking forward to learning a lot more about bones so they aren't such a mystery when he leaves and I am the orthopedic surgeon again. :)

sometimes it gets better...

Its not always depressing around here. We do have moments of victory. Remember this kid?

I saw 47 patients in clinic that day, but one of the highlights was hearing about this boy that I saw a couple of weeks ago. We weren't sure what this mass was, but we decided to treat him with chemotherapy for Burkitt's lymphoma since that was the most likely treatable diagnosis. Guess what?! He came back to clinic this week, happy and smiling because after just a couple rounds of treatment the tumor has shrunk to about half its original size and he can eat again! Yay! Thankfully, Burkitt's is very treatable and he has a good chance at complete cure.

Friday Clinic

Have I told you that I do NOT like Friday clinic? We alternate Friday clinics so that the surgeon that is taking weekend call also does clinic on Friday. Well, Friday clinic overwhelms me. First of all, all of the orthopedic patients are told to come to clinic on Friday (remember, I am a general surgeon...bones are not my thing). In addition, most of the inguinal hernia patients are told to come to clinic on Friday and there always seem to be plenty of emergencies. It's can be a lot for one person to manage.

This Friday's clinic was no exception. I left conference early to get started. I spent the first 20 minutes trying to decipher charts to figure out who needed follow-up x-rays so I could send them all to radiology first thing. After sending about ten people to radiology, I started with a couple of inguinal hernia patients.

The first patient had had a successful left inguinal hernia repair here, then last year he went to have his right inguinal hernia fixed at another hospital. Only, he told me, they just "made an incision, looked, and closed without fixing it." Huh? I took a look. Yep, there was a nice incision and an obvious, reducible hernia. I don't know what they did at the other hospital. As usual, we don't have any records. But, he has a hernia and I know how to fix that.

After that, I continued on with the usual smattering of neck masses, mastitis,  non-specific abdominal pain, and spina bifida. After seeing about 10 non-orthopedic cases, I finally started in on the bones. X-rays, X-rays, X-rays. Keep the cast, take it off...not too bad. And then there was this: 

I wish..Proceed with caution: stop here if you don't want to see some slightly disturbing medical stuff.

A bent leg, an x-ray with a metal rod and a loose screw...its been three years since the operation and he is here for follow-up. I guess I should take the dressing off to see what's underneath.

As I unwrapped, suddenly some white things fell out of his ankle and onto the floor. White, wriggling things. Worms. Gross. Gross. Gross. Yep, his wound was full of worms...on the bright side it was otherwise pretty clean because they had been eating all the dead tissue. Once, while I was in training,  I put "sterile" maggots on a wound  to help with healing. Its not always a bad thing.

Fully unwrapped...exposed bone, exposed metal, and a pile of worms. Just when I think, "that's the worst... I've ever seen" I'm wrong again. He needs an amputation, but he refused to have the leg amputated.

That's the biggest...

There are a few key phrases that are uttered repeatedly throughout the day by doctors here:

"That is the biggest ... I've ever seen"

"I've never seen anything like that before"

"That is the worst case of... I've ever seen"

"What is that?"

Here are a few personal examples from the past two weeks:

 

First clinic case of the day. "What is that?" And "Biggest jaw mass I've seen...so far"

Biggest leg mass in a teenage girl

 Its not always the biggest...sometimes it is the lowest or highest...or both.

Hypertension and severe anemia?!

This is one of our outpatient clinic cards. If you look closely, you will see that the patient's hematocrit (blood level) is 12%. Normal is about 40%. Often we transfuse if the hematocrit is less than 21%, sometimes if it is less than 30%.  Where I trained, a hematocrit of 12% was pretty rare and would cause a flurry of frantic activity. Admission to the ICU, extensive work-up for bleeding, immediate transfusion. Here, its almost routine. I think this was the third or fourth patient I saw in clinic this week with a hematocrit of less than 15%. The amazing thing about this woman was her blood pressure. It was high. 160/90. With a hematocrit of 12%. It makes you wonder if the blood pressure was accurate...but I wouldn't be too surprised if it was. I've seen stranger things around here. She was walking and talking.  She also had one of the biggest abdominal masses I have ever seen. It was pushing her whole liver up into her chest. We aren't sure what it is, but we are planning to operate next week.

Her CXR with the liver up in the chest pushing her heart over the the left side (arrow)