not an artifact

While looking at x-rays in medicine we often talk about air-fluid levels. Its a pretty simple concept, really.  Its like a glass of water: air on top, water on bottom, and a line in between.

We usually see air-fluid levels in the stomach or in the small bowel when there is an obstruction.

 Last week, I saw the most impressive air fluid level yet- an entire-abdomen air-fluid level:

That line is the air-fluid level created from all the stool, gas, and pus free in the abdomen after several days of leaking from holes in intestine caused by typhoid. I've never seen a whole abdominal air-fluid level like that. (Mostly because it is usually so obvious that these patients need an operation that we don't get x-rays because of the cost).

skull and neck bones

Its been awhile since I've shared any medical stories...but, never fear, the steady stream of interesting, difficult, and heart-wrenching cases has not stopped (or even slowed down). Here are a few cases from the last month. Check this out:

normal neck x-ray

abnormal

I think almost anyone can see in this x-ray that something is horribly wrong. His upper neck bones are completely separated from the lower ones. When we saw the x-ray, we could not believe he was still alive- talking and breathing, but paralyzed. Unfortunately, we couldn't do much to help other than to make him comfortable.


In happier news, a couple of months ago we had a young man come in with a skull fracture. The story was told like this: he was in a tree and was frightened by seeing three demons, fell out of the tree, and hit his head on a rock.

his x-ray

depressed skull fracture

lateral view

putting the bone back in place after pulling it off the brain

His skull was smashed in on the right side, and he couldn’t move his left arm but everything else was normal. My partner, Dr S, took him to the OR to elevate the fracture and release the pressure on his brain so he could hopefully regain function in his arm. After the operation, the man still couldn’t move his left arm. I was pretty disappointed that the operation hadn’t helped him. We sent him to rehab therapy (another story about that on my our therapist's blog here). Last week when I saw him in clinic I could hardly believe my eyes. I asked him if he could move his left arm. He didn’t just move it, he waved it around- completely normal function!

Brace yourself (or stop reading here). This next story is one of the more disturbing things I have witnessed here. Last week a woman came in one-month after a C-section. We knew something was wrong when she walked into clinic and all the other patients covered their mouths and noses because of the foul smell. Our most experienced obstetrician saw the patient and found a hard object stuck in her birth canal…Then she called me over the see the patient since I was on call for the weekend and would be the one operating the next day. Even though we do several C-sections every day here, she was still able to recall the details of this particular C-section because it was so distubing. The midwife had called to tell her that the baby’s brain was coming out, but the rest of the baby wouldn’t deliver. So, a C-section was done to remove the already dead, mutilated baby. The woman was discharged a few days later doing well, but then started having foul-smelling discharge. Finally, one month later, she came back to be seen. When we took the woman to the OR, and this is what we found:

Yes, that is the top of the baby’s skull that was stuck in the birth canal. She had to cut out piece of it in order to remove it. One of the many examples of why we desperately need to educate and empower women here. 

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

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. 

Hearts

In honor of Valentine's Day, I played heart surgeon.  When I was on call last night a young man came in with abdominal pain. My intern evaluated him in the ER, noted his abdominal tenderness and some difficulty breathing. Then he did an ultrasound and reported to me, "His abdomen is tender and. I think he has a pericardial effusion ["fluid around the heart"]...but I can't be sure."  I'm proud of him for doing the ultrasound and looking at the heart- its not something a surgeon always looks at when consulted for abdominal pain!

I took the ultrasound to the ER to evaluate the patient. He couldn't breathe well while lying down, his liver was enlarged and tender...then on ultrasound I saw a HUGE pericardial effusion. Biggest I've ever seen  It was like the heart was a tiny, quivering ball surrounded with fluid.

A picture of a small pericardial effusion from the internet. Probably measuring about a centimeter.  Now imagine the fluid space to be wider than the heart...that's what I saw

I measured the distance from the heart muscle to the sac: over 9 cm! Usually pericardial effusions are graded as small (less than 1cm), moderate (1-2 cm), and large (>2cm). This effusion was off the charts. We also got a chest x-ray:

a normal chest x-ray (thanks Wikipedia)

His chest x-ray...his heart shadow took up half of his chest!

Amazingly, his heart rate was only a little bit fast and his blood pressure was normal. Obviously he had had the fluid for a very long time. Months probably (likely from tuberculosis). His liver had been hurting for three weeks because of the pressure build-up. After seeing an effusion that big, I wanted to rush him straight to the operating room to get the fluid off.   But it was the middle of the night, he was stable, and the effusion had been there a long time. So, we took him this morning. I opened the heart sac, put a drain in it, and got over 1 1/2 liters of fluid out! It was a pretty satisfying operation and I got to literally touch someone's heart on Valentine's Day. :)

Yesterday, we got a package from my mom with some amazing Valentine's treats (just in time!). She included some heart-shaped sprinkles. I happened to have a box of cake mix and some frosting and was inspired to make a last-minute Valentine's cake to bring for the OR staff.

The power went out, so I ended up baking the cake mostly in the dark ...but it still turned out.

When I gave it to the OR supervisor, he was a confused when I said "Happy Valentine's Day." It took a few minutes to explain why I brought a cake because I didn't know the French word for Valentine's Day and its not really celebrated holiday around here. Most of the OR staff didn't even know it was Valentine's Day, but now they do and they were very happy to eat some cake! :)

I also made some Valentine cookies last weekend...

The cookie press was left here by a missionary several decades ago. Still works fine!

Usually I would make Spritz  wreaths for Christmas....but the Christmas red hots came in January this year. So I made the Valentine version of Spritz...What do you think? Perhaps a new Valentine's tradition has been started.

Happy Valentine's Day!!!

on a good day...

Not gonna lie. Its been a bit rough around here lately. There hasn't been just one major tragedy, but multiple tragedies (big and small) and the every day struggle has been wearing me down. Patients dying, difficult operations, barriers to good patient care...the list could go on. I could write a blog post every day about the continual frustrations of trying to provide good medical care in a resource-limited setting. But then, no one wants to hear about that every day any more than I want to write about it every day. :)

Instead I will write about today. It was a good day. A really good day. Nothing earth-shattering happened...but it was just one of those days that things went well. Here is how it went...

I woke up before my alarm and actually felt rested. While making some tea, I checked online and learned that the Seahawks won the Superbowl. I don't get too excited about football...but I did grow up in Seahawk territory and I'm happy they won. :)  AND...it was cold enough this morning that on my walk to work that I wore my sweatshirt (it got all the way down to 75F last night)!

During morning report, I got a few words of encouragement (its nice to have some positive reinforcement sometimes).

Then, I rushed off to the OR for an emergency C-section for fetal distress. When I opened the abdomen, I saw an amniotic sac with a baby in it...but it wasn't in the uterus. My heart sank. Another dead baby. I took the limp, blue baby out and then... he moved!!! He was alive and started crying! What a happy surprise! A live baby is very rare after uterine rupture.

Between cases, one of the residents asked for help exchanging a gastrostomy (stomach) tube. The patient was a little six year old that had accidentally swallowed some of her mom's cleaning chemicals a couple months ago. The chemical caused her esophagus to scar shut so she can't swallow anything (even her own spit). She was very thin and dehydrated when she was referred to me for placement of a stomach tube.

Little F....she looked like she had gained about 10 pounds! She wouldn't smile or look at me because she was still upset that I had exchanged her tube. 

She will need esophageal replacement surgery, which we cannot do safely here. Hopefully we can find a way to get her to another country to have the operation performed.


Next, I did a washout and closure in a patient who had had a perforated stomach ulcer. Then, my next operation was for a girl in her late teens with a huge abdominal mass (she looked like she was 7 months pregnant). When I saw her in clinic, I couldn't quite tell where the mass was coming from on ultrasound. It definitely wasn't her uterus. Probably not her liver. At the start of the case, I told the team that the case would take one hour or six hours...turned out it took less than thirty minutes! It was a huge ovarian mass that almost literally popped right out. All I had to do was divide the vessels and tubes that attached it to the uterus.

the mass

checking it out

trying to explain where the mass came from in Hausa. its quite difficult since there is no word for "ovary" in Hausa!

When I cut it open I found clumps of hair, chunks of bone, lots of fluid and creamy white sebaceous material. This is good news because it means it was a benign dermoid cyst.

Last case of the day: an inguinal hernia. I am becoming much more proficient at performing inguinal hernia repairs without mesh (not something we do often in America). Now, the tissue based inguinal hernia repair is among my favorite operations here. It was a good way to end the day.


.

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.