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. 

This is  the maternity record for one of the women I did a C-section for recently. Once again, I was shocked. In case you aren't familiar with the obstetric terminology, let me interpret:

Gravida (the number of times she has been pregnant): 15

Para (the number of times she has delivered): 14

Vivant (the number of children she has alive now): 4

D (number of her children who are deceased): 10

I did a C-section to remove her 15th child, a perfectly formed yet dead little baby boy. Most likely her uterus was too tired to push out another baby and she had started labor days before coming to the hospital. She told me that ten of her children died before they could walk. She didn't know why they died. They don't have a hospital near her village. Maternal and child mortality...not just a statistic but a personal tragedy for this woman and many more here in Niger.

2 am in the OR

Last week was...crazy. busy. weird. wild.  That describes every week here, but this week seemed busier  with one surgeon still away and a full weekend of call.  In seven days, I did 25 major cases and 22 (!) of them were emergencies including 12 C-sections, 4 typhoid perforations, gangrenous cholecystitis, perforated duodenal ulcer, and a perforated marginal ulcer. Even with a national holiday on Wednesday and no elective cases, I ended up spending the entire day operating.

And, lest you think, 12 C-sections...those are nice, easy, happy, short cases. Ya, sometimes. But here, more often than not, they are difficult, sad, and, occasionally, long cases. Let me illustrate with a series I'll call:

"True (Disturbing) Stories from 2am in the OR" 

WARNING: Graphic medical descriptions. 

2am Friday- Emergency C-section for a baby with hydrocephalus (enlarged head from a congenital abnormality). The head was too big for the mom to deliver. We got the baby out,  barely alive and obviously deformed with a very large, misshapen head. Per standard procedure, I handed the baby to the midwife. She took one look, gasped, shrieked, and quickly tried to hand him back to me. I'm not sure why...Did she want me to put him back?! Sadly, there is not much we can do for children with hydrocephalus here because we don't have the resources/surgical equipment and most of the patients cannot afford to travel to the capital city for treatment. Sad.

2 am Saturday- I'm elbow deep in one of the most horrendous "C-sections" ever. Its not really a C-section. She needed a C-section several days ago...now she needs a miracle. The teenage mother had been in labor for days. I was called to do a C-section because she hadn't delivered yet. As soon as I opened the abdomen foul-smelling, purulent, bloody fluid gushed out. At first I couldn't find the uterus because it was all the way up by her spleen and had shrunk to the size of a grapefruit. There was no baby in the uterus...just a gaping hole. I turned my attention back to the pelvis...her bladder was stretched up to her belly button and part of it was dead. Behind the bladder I found the tiny, blue hand of a decomposing infant who had clearly died several days prior. Extracting that baby was the most gruesome, disturbing thing I have done. Ever. I can't imagine being that mother. Why didn't she come to the hospital sooner? Maybe it took her several days to travel. Or she didn't understand. Or they didn't have money. It was probably a combination of factors...all of which are much too common here. Now, she can never have children of her own and will need major reconstructive surgery...both huge challenges for her to overcome in this society. Unfortunately, this is an all too common scenario here.

2 am Sunday- As I was falling asleep at midnight after returning home from a C-section, I heard an ambulance and thought “there comes another C-section…but I sure hope not.”  Sure enough, just after I had fallen into a deep sleep I was awakened by the phone call… “C-section, rupture utérine" (at least I could understand that much of the midwife's French). So I trudged back in. Opened the abdomen. First thing: blood. Second thing: a little hand. An infant, floating free in the abdomen. Not alive. Then, placenta, also free floating…and a ruptured uterus. I closed it as best as I could and did a tubal ligation. 3 am. Time to go home...after fixing this:

2am orthopedics
 

that doesn't look right

"There is a fracture" "Where?" "In the ER"  (if that doesn't make you laugh...check out the link for some doctor humor)