The other side of the white coat

I'm used to being the doctor. Now that my practice of medicine has come to a temporary halt, I have found myself thrown full force into the patient's side of things. Let me tell you what you probably already know:

• Dealing with insurance is confusing and painful. 
• It can be hard to get an appointment with an obstetrician if you wait until your third trimester (even if you had a good reason). 
• Picking a surgeon and preparing your dad for heart surgery is, well, a bit frightening. Even if you know what you are getting in to.

After spending way too much money trying to keep our prior insurance  [expensive because I'm pregnant], we finally figured out that if you aren't making any money Medicaid might be a good option. But, it can only be used in the state where you are a resident. Therefore, I am now a temporarily unemployed, pregnant, general surgeon on Medicaid in Washington state.  Didn't see that coming. 

Shortly after we got back from Africa, I tried to get in for my first official obstetric appointment. I was still covered by our insurance, but since I was considered "high risk" being 26 weeks pregnant without the routine pre-natal care, the OB office wouldn't schedule me. It took several phone calls from my doctor friend M who knew a tenacious doctor who was married to an OB to get me in. Whew.  It makes some sense...with malpractice and everything. After getting the appointment, everything else was fabulous.  I felt relieved after getting labs and being seen by the super-nice, smart obstetrician who was willing to see me despite my past. :)  The baby looked great on ultrasound and it was nice to confirm that we are indeed having a little girl!

A couple of weeks ago my dad called me while we were in Minnesota and told me that his heart doctor said he needs his aortic valve replaced and his doctor was going to schedule the operation in a couple of weeks. This came as a bit of a shock to me since I hadn't even known my dad had heart problems. He couldn't completely describe to me what he had, but I knew it was serious if he was having symptoms and needed his valve replaced.

"Blausen 0040 AorticStenosis" by BruceBlaus - Own work. Licensed under CC BY 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Blausen_0040_AorticStenosis.png#/media/File:Blausen_0040_AorticStenosis.png

Then, he asked me if I knew anything about the surgeon he was supposed to meet with. I didn't. Now, open heart surgery is a BIG deal. I wanted to be sure he needed it before he got the operation...and that he had the right surgeon and hospital. Turns out, its really hard to figure out who is a good surgeon without inside information. (As an aside, almost every surgeon I have worked with is excellent...but I didn't want to chance it). So, I made him an appointment with a surgeon that I know and trust...even if it was a little farther from home.

Luke and I made it to Washington in time for the appointment. It was very strange being on the other side of the "you need a major operation" conversation. But, the visit was great and my dad is scheduled for a valve replacement next week...as long as we can keep him alive until then!

Severe, symptomatic aortic stenosis...can't stop me.

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. 

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!   

first stop

Saturday morning rounds are rough. Its not just because it is Saturday and I don't want to be working. Or that I know I am on call for two more days. Its more than that. Its discouraging. It can be frustrating. Its sad. Its a lot of patients.

First stop, first ICU patient. He is a tiny baby with a tube down his nose. An oxygen monitor is hooked up to a sensor on his hand, but it is adult-sized and isn't picking up a signal.

The resident tells me that the patient is three week old baby transferred from another hospital with a tracheoesophageal fistula. As he continues, the story doesn't make sense. "Yes, he has been breast-feeding."  "No, he hasn't eaten anything since birth."  "He is having stools." "We could get an x-ray." "They transferred him here for pyloric stenosis."  "We did get an x-ray, it showed the esophagus is just a pouch."

Me: "Ok, so he has been in our hospital for three days with a tracheoesophageal fistula and is unable to eat. What is the plan?! Babies can't live very long without eating."

Resident:  "Well, we talked about it with [a different attending] yesterday, and he was going to read and think about it and decide what to do."

[I fiddle with the oxygen monitor, still can't get a reading. So, I walk down the hall to the surgical office and find a pediatric oxygen monitor. I hook it up to the machine. Still can't get it to work.]

Me: "What are we going to do about his nutrition?"

Resident: "If we put in a feeding tube in his stomach milk would reflux back into his lungs."

Me: "So, what is your plan?"

Residents:   [No real answer, I conclude that the residents don't have a plan.]

The story doesn't add up.The baby has been in the hospital for three days. I suspect that a plan may have been made, but perhaps hasn't been communicated or the residents didn't understand it.

It is a very difficult problem. But there are some very simple conclusions we can come to. Mainly, if you do nothing for a newborn baby that can't eat, he will eventually die of starvation. Yes, sometimes there is nothing we can do, but we have to consider all the options before doing nothing and allowing the baby to die.

We move on to the next bed because we have already spent 20 minutes on that discussion and its not going anywhere. I need to think about it. And we have 50 more patients to see.

After rounds and an urgent C-section, I took a look a the baby's x-ray.

Contrast filling the first part of his esophagus, which then stops. Lots of air in his stomach and intestines. Yep, looks like a tracheoesophageal fistula. 

Type C tracheoesophageal fistula. The first part of the  esophagus ends in a blind pouch. The second part of the esophagus attaches to the windpipe then goes to the stomach. 

I called the other attending and he was able to explain the story to me. He was planning to take the baby to the operating room yesterday and at least put a feeding tube into his stomach/small intestine. But, the baby became very sick yesterday afternoon and he didn't look like he would survive a procedure or even live through the night.

We decided that if the baby is looking better today, it would be reasonable for me to put in a feeding tube. After taking care of a few more emergencies, I went back to the ICU to check on the baby and decide if he was well enough for a procedure. His bed was empty.

I don't have a nice wrap-up for this one. The baby died, likely from fluid that went into his lungs from the connection to his esophagus. In America, a pediatric surgeon would have taken this baby to the operating room, likely within the first 24 hours of birth, to re-connect the esophagus. Most of the time, babies recover well and go on to live normal lives. This baby didn't make it to us right away. Perhaps we could have done the operation if the baby had come in earlier. There isn't a pediatric surgeon available in this country to send patients to for emergency operations. We are the pediatric surgeons. We do a lot of pediatric surgery but it is still daunting to do major operations on newborn babies here.

In happier news, we have two newborn babies with congenital anal malformations that are doing well after we gave them colostomies this week.

Also, did you know that healthy newborns can survive for a week without food or water? Apparently we know that out from the 1985 Mexico earthquake when several "miracle babies" were buried alive for a week and survived! (Miracle Babies Survive Quake- Chicago Tribune, 1985).

you have a knot in your stomach...

About once a week (sometimes daily) I cut into someone and find something that mystifies me. Monday we had three exploratory abdominal operations for patients with peritonitis (severe abdominal pain).  Most of the time we find a typhoid perforation, a perforated stomach ulcer, or ruptured appendicitis. Sometimes its another surprise...The first laparotomy (done by one of my partners) was a sigmoid volvulus (the sigmoid colon twisted around itself).  Sigmoid volvulus is also relatively common around here- seems like we operate for one every few weeks.

Removing the redundant sigmoid colon. 

When I opened the second patient's abdomen, I found some gangrenous small intestine and large intestine. The weird thing was, the small and large intestine and their blood supplies were all twisted around each other. I couldn't figure out how to get them untwisted, no matter which way I turned them. They were just all wrapped too tightly together and the intestine was very fragile because its blood supply had been cut off for at least a day.

The intestine  looked kind of like this, except this ileosigmoid knot has been untwisted

I've operated on twisted bowel (called a volvulus) many times...but I'd never seen (or heard) about the small and large bowel getting twisted around each other. Well, guess what? Its a real thing, your intestines can literally tie themselves in a knot. I searched Google for answers after the operation and discovered that what I found is called a ileosigmoid knot or double volvulus. It is more common in African countries- for some reason (likely related to genetics and/or diet) many African's have longer colons that twist on themselves more easily.

When bowel twists on itself, the blood supply gets cut off and the intestine dies if you don't untwist it soon enough.His twisted bowel was dead, so I cut out both sections and dead bowel and made new connections. When I finished, I tried to draw out what I had found so I could understand it better. This is what had happened:

The shaded part represents the dead bowel. 

another view

The few articles I read said that the mortality rate after operating on an ileosigmoid knot is very high. Forty to fifty percent of people die soon after the operation, especially when the bowel is dead (this man's bowel was very dead). Happily, he is doing very well and has started drinking liquids 3 days after the operation!

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.

back logged

When I looked at the OR board Friday morning I had to laugh. It was a are-you-kidding-me-that's-not-going-to happen kind of laugh. You see, we had planned to have all three of us surgeons here this week so we booked about 4-5 elective cases for each day. Then, Dr. S. had to leave unexpectedly for a few days and we were down to two surgeons. As per usual, this week we've had enough emergency operations every day to keep at least one surgeon busy, enough clinic patients for two surgeons, and enough elective operations for another couple of surgeons!  This is what I saw scheduled for the day:

1. Reprise (a typhoid patient scheduled for a second look operation)

2. Hysterectomy

3. Another reprise 

4. Left inguinal hernia

5. Epigastric hernia

6. Fistula-in-ano

7. Inguinal lymph node dissection for cancer

8. Right hydrocele

9. Left inguinal hernia

10. Urgent laparotomy for peritonitis

11. Laparotomy for cystic abdominal mass

12. Below knee amputation

13. Prostatectomy

14. Thyroidectomy

15. Sequestrectomy

16. Reprise (another typhoid patient scheduled for a second look operation)

17. Skin graft

18. Epigastric hernia

Those 18 cases would usually take at least 25 hours of operating. Many of the patient's operations had already been delayed several days. To make matters worse, what you don't see on the board is the emergency C-section, D&C, two more emergency laparotomies, and multiple day cases that were added on throughout the day.

I knew it was impossible. There is an impossible amount of work to be done here every day. So we just do what we can. We did all of the emergency cases, a few of the elective cases. Then we learned that the washing machine was broken again and we were running low on surgical drapes and gowns. By then it was the end of the day so we finished up the last two urgent operations and everyone else will have to wait. Sai hankuri (have patience) as they say around here.

what typhoid can do to the bowel...

its on

Typhoid season seems to be in full swing again now that rainy season has come to an end. My first patient of my first call weekend after vacation was a nine-year-old boy with high fevers and severe abdominal pain. He was very sick. In fact, he had been very sick for over a week before finally coming to the hospital. His story was typical for a typhoid perforation

We gave antibiotics and fluids and got him stabilized before taking him to the operating room. As soon as I opened his belly, pus and stool poured out. Often that release of abdominal pressure helps with breathing. But this time, he stopped breathing and his heart stopped beating. A surgeon's worst nightmare...

We fought for his life. We breathed for him. We gave medicine. We did chest compressions. He pulse came back. A few seconds later we found the hole in his intestine...typhoid perforation. But before we could fix it, his heart stopped again. For many agonizing minutes we fought to revive him. We couldn't. He was gone. We closed his abdomen, covered him with a sheet, and went to find his father.

After that, I just wanted to go home. To process. Looking back, there was nothing more we could have done.  I told myself we had done everything we could. That didn't make covering my patient with a white sheet any easier. It didn't make telling the father easier. It certainly didn't make preparing to operate on my next patient, another little girl with exactly the same diagnosis, any easier. She was so sick that the anesthesiologist insisted that I go tell her family again that she was very sick and could die. I did.

As I made the incision, I thought, "Dear God, please don't let this little girl die too. Please don't let her die."

Thankfully, she didn't die. She made it through.  So far, so have my other six patients with typhoid perforations this week. Many of them just barely. None of them without a fight. It has been emotionally exhausting, hoping with each incision that the child will live through the operation. Knowing that tomorrow morning when I go to the hospital, there may be an empty bed from a child who didn't make it through the night.

One hundred and twenty years ago, the typhoid fever mortality rate in Chicago averaged about 65 per 100,000 people per year. Now it is perhaps 5 per 1,000,000.  I hope someday we'll have the same progress here.

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)

guess that mass

The uterus...its an organ that I didn't operate on much during general surgery residency. It fell under the realm of the gynecologists. In fact, the gynecologists usually took care of anything involving the "female organs" (and, in turn, they would call us for almost anything involving the bowel).

Right now, there are no gynecologists here. Hence, I now operate on the uterus, tubes, and ovaries.  Turns out, as long as you know the anatomy and have an experienced surgeon to consult when things are unusual (as they often are here), its not that complicated.

In addition to the 105 (!) C-sections  I've done so far, I've also removed a few uteri and ovaries. Here are a couple pics:

this was the second elective hysterectomy I've done here (uterus is on bottom right). For reference, the scalpel is 14 cm long (about 5 1/2 inches). I'm not sure what this mass is...but it was big.

This is the inside of a 15cm ovarian cyst that had twisted on itself (torsed). After removing it, I cut it open and found a tooth inside!  Although it seems bizarre, having a tooth growing inside an ovarian mass is a kind of a good thing because it means it was a benign tumor called a dermoid cyst. Those cysts can have anything from hair, teeth, eyes, bone, etc. in them. Fascinating, huh?

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)

eleven

When I was a surgical resident, we used to have Morbidity and Mortality conference every Tuesday. We would each stand up in front of our colleagues ready to discuss/defend every operation and/or complication we had been a part of in the past two weeks. It was relatively uncommon to have any patients who had died, usually there was one or two complications (most often minor), but, best case scenario was having "No deaths, no complications, and an interesting case to present."  Usually something relatively interesting had occurred in the past two weeks of operating. Some unusual pathology or presentation of a disease that we could talk about. Occasionally, it was hard to find something interesting to talk about. Boy, are things different now. In one day at Galmi hospital, we can see and operate on enough interesting and unusual pathology for many, many morbidity and mortality conferences.

Take last Wednesday, for example....one of our surgeons was gone traveling, the other was busy with meetings and preparations for our site inspection (to become an officially certified site for training surgical residents). I was in the operating room.

All the elective cases from Tuesday had been moved to Wednesday because we had  five emergency laparotomies come in on Tuesday.  So, the operating room board had a very long list of patients needing operations. And, we had a Head and Neck surgeon visiting. It was her first day. We were so happy to have her here to help with some very difficult cases. In just the few weeks before she came, several patients with head and neck masses came in to clinic.

recurrent central mandibular mass

parotid mass

big mass of unknown variety

Dr. S had never been to a mission hospital before. She was only going to be here a week. She needed help getting acclimated to the OR here…and figuring out what cases to do (we had scheduled several for her).  I was supposed to be doing five things at once: show her the changing room and where to find water and a bathroom, introduce her to the patients that she was going to operate on that day, show her a few more patients that needed exams and possible operations later that week, figure out which patient I wanted to operate on first and which ones she was going to operate on, read the charts of the patients I was going to operate on, and, of course, in the middle of all this we had an emergency C-section. That C-section was a harbinger of things to come...a long day of interesting, difficult cases.

1. Emergency C-section. Indication:  “malpresentation.” Ok, how hard could that be? Answer: Really hard. I made the standard lower uterine segment incision, entered the amniotic sac and out came some meconium stained fluid…then, where I would have like to see a head or even feet or a butt,  I was looking at a shoulder and the baby's back. I stuck a couple fingers in and out popped an arm. But nothing else. The baby was wedged in the uterus. His head was angled up in the fundus, the other arm was up there too, out of reach. I could get my hand around his head, but there wasn’t enough space to turn the body to get the head out. I tried to shove his arm back in so I could turn him but the arm wouldn’t go back in.

Now, C-sections are intense because it’s not as if you have all day to figure out how to get a stuck baby out. You only have a few minutes until you have to worry about enough oxygen getting to the baby. And I couldn’t get this baby out through my lower uterine segment incision. I tried reaching for his legs/bottom…but with one arm already out I couldn’t turn him that way either. With sweat rolling down my forehead, I tried hard not to feel panicked and quickly weighed the options. I couldn’t see any way I was going to get that baby out without making a bigger incision on the uterus. I couldn’t go any further laterally on the uterus without getting into the uterine vessels, so I did what I had learned about in a lecture 2 years ago at an international surgical skills course. I extended the incision vertically to make an inverted “T” shape. Thankfully, that extension allowed me to reach up and pull the baby’s legs and bottom out and the rest of him soon followed…and he was alive. Whew. I breathed a sigh of relief and a prayer of thanks, and closed the uterus. 

You might be  thinking “what’s the big deal” you just made a different incision. Well, a vertical incision on the uterus increases the risk of the uterus rupturing during the next delivery/pregnancy and that is a catastrophic occurrence, especially if it happens in a village far from any hospital. So, now that this baby (her first) was out and alive she may need a tubal ligation to prevent any more pregnancies and perhaps save the mom’s life if she won't be near a hospital to deliver next time We closed her skin with a non-absorbable suture so she would have to come back to have the stitches removed and to talk about the importance of all future deliveries occurring in the hospital or of getting a tubal ligation. 

2. That C-section was enough excitement for one day…but it didn’t stop there. Next I did an exploratory laparotomy for peritonitis and  what ended up being typhoid perforation. This was a fairly typical Galmi operation. He was seven years old. He was very sick. I found one complete perforation at the terminal ileum and 5 near-perforations. I sutured the perforation, oversewed the near-perforations, and closed him with a Bogota bag. 

3. Next was a 60-year old woman with a huge, necrotic (rotting), mobile breast tumor and possible evidence of metastasis on her chest x-ray.  Sounds relatively straightforward, right? Except she  wasn't quite healthy enough for general anesthesia. One of my partners had scheduled her for a mastectomy under local anesthesia…and then didn’t have time to do it. She had been waiting a few days. So I did it. Lets just say that relatively big operations under local anesthesia are not  fun.  Why? Big tumors bleed, you can only use so much local anesthesia, and electrocautery is painful...so I went quickly with a knife and the whole operation took about 30 minutes. At least she should have a much better quality of life with the tumor gone.

4.  Number four, 20 year old, thin-as-a-skeleton, man with two years of abdominal pain that "comes and goes" and a huge (soccer ball sized), painful right flank mass that had been growing for the past 3 months. I aspirated his flank and found pus, then made an incision through with we drained over 1.5 liters of pus. What caused it? TB? Appendicitis? I don't know.

5. A diabetic woman who came in with a neglected leg infection (unfortunately, very neglected infections are pretty common around here). Her hematocrit (not hemoglobin) was 12%. And she was awake and talking. We gave her some blood and I debrided it. I will spare you the gory details...but it was a terrible infection and she will likely lose her leg.

6. 8 year old child with peritonitis… He had purulent fluid, every surface I touched bled, lots of adhesions, no obvious feculant soiling…and a the top of his gallbladder had eroded away. Weird. Probably was from typhoid…but still odd to have an isolated gallbladder perforation. He was septic and bleeding too much for me to take his gallbladder out right then. I put a tube in it, washed out all of the pus, and closed his abdomen with a Bogota bag (a plastic bag over his intestine and sutured to his skin). [I took him back to the OR yesterday and took his gallbladder out when he was more stable].

7. 15 year old boy with peritonitis, purulent free fluid,  a mass in his small bowel that was invading into the bladder wall, and, bulky, hard lymphadenopathy all the way up the SMA to around the aorta. Well, we don’t have frozen section pathology here, so I don’t know what it is. But, I took out the small bowel that had perforated and reconnected it. Weird. Lymphoma? Carcinoma? We’ll see what the pathology shows…eventually.

8. Next was a  call from OB for a woman with a retained placenta that the midwives couldn’t get out. Great. I’ve never seen or dealt with a retained placenta before. Why is a placenta retained? Do you just pull it out? The surgical assistant said that usually, once the spinal is given and the woman relaxes, the placenta comes out fairly easily. So, I put on some gloves…and pulled on the umblical cord. Nothing. I put my hand up into the uterus and twisted and pulled. Nothing. The placenta was hard and stuck. It wasn’t coming out. Then I took off my gloves and called my surgical partner. He said…you just have to put you hands up into the uterus and peel the placenta off. But, if it won’t come out it could be placenta accreta. If you can’t get it out or she won’t stop bleeding, you will have to do a hysterectomy. So, I put a gown and gloves back on, got up to my elbows into her uterus, huffed, and puffed and pulled and grunted while standing in the pool of blood that was forming. After much effort and with blood up to my elbows, I eventually scraped the placenta out. The bleeding slowed down, except for the bleeding from a small cervical tear.. So, I repaired the cervical tear and packed the uterus. [The packing was removed the next day and she did fine.]

9, 10, 11.

Now, it was after 9pm. I had been operating for 12 hours. I was on call alone. The residents and other surgeon had gone home...and the midwives called with the news that there were three C-sections waiting. Unfortunately, all three C-sections were for babies that had died before the mom made it to the hospital. Sad. At least we saved the mom’s lives…and, perhaps, helped keep their other children alive. But still.:(

At the end of the third C-section, the anesthesiologist looked at me and said…”There is one more C-section.”  But, he was just joking. So, I walked home in the pouring rain. Glorious rain for Niger…without it the food won’t grow. With it comes malaria. I got home at midnight. Exhausted.

Congratulations if you actually read to the end of this post. I know it was too long...but so was my day. ;)