sharing the load

For the next two weeks we have a head-and-neck surgeon visiting! I'm excited, because I don't even know where to start with patients like this:

It is such a relief and encouragement to have an expert come alongside and help out.

This is one of the "I've never seen anything like it" cases today.  A teenage girl comes in with an umbilical wound present for 4 days, vomited once, normal bowel movements. On further questioning, her family tells me she delivered a baby 2 weeks ago.

On exam:

Malnourished girl with very distended abdomen, mild tenderness, something eroding from the umbilicus with surrounding cellulitis.

Her ultrasound looked kind of like this...her abdomen was filled with a multicystic mass with thin walls, uterus looked normal.

 What is it? I don't know. Ovarian tumor? Mucinous cystadenoma? Omentum eroding from an umbilical hernia...or a Sister Mary Joseph node.

Mystery. I'm not sure if I love it or hate it. I suppose its a little of both. I wish I were the type of person that just loved an endless supply of the mysterious and unknown. But I'm not. Unless there is a way to find the answer. Than its fun. Otherwise, it can be stressful and hard. Especially when another person's health/life is involved.
 
Here was the rest of my day...notice that less than half of the patients have problems that a general surgeon would take care of in the states. Its helpful to remind myself of that- there are good reasons to feel a bit frustrated and exhausted after clinic here!

1. Man 3 months post orchiectomy with a non-healing scrotal wound.
2. follow up after tibial sequestrectomy
3. follow up after Graham patch for perforated ulcer
4. Chronic draining sinus of left thigh
5. Chronic left leg wounds
6. Left thigh abscess
7. Nonspecific abdominal and leg pain
8. Child with 12cm incisional hernia several months after laparotomy
9. Resolved abdominal pain
10. Left hip abscess
11. Urethral stricture
12. Vesicocutaneous fistula, ultrasound for possible foreign body
13. Gangrenous toes in a diabetic
14. Peritonitis
15. Follow up chest contusion
16. Palatal mass and malaria
17. Finger infection
18. Large breast mass in young woman
19. Follow up shoulder dislocation
20. Follow up 20% body burn
21. Impacted bladder stone
22. Follow up toe mass removal in a child
23. Follow up chest burn
24. Peritonitis
25. Severe leg cellulitis
26. Urinary concerns in a man- stricture versus prostate
27. Left knee pain
28. Huge abdominal mass in young woman
29. Stage III breast cancer
30. 3 week old foot fracture
31, 32, 33. Young men in a motorcycle crash with various arm/leg fractures and lacerations
34. Young man pelvic fracture
35. De-gloving injury to fingers four days ago

36. Mastitis
37. Young man with testicular/epididymal mass 
38. Boy with ankle abscess after an iron fell on it four days ago

and a few I forgot...there were still more people to see, but we stopped letting patients in at 6pm. There is an ocean of need here and I can only do so much. It just never seems like enough.  Perhaps I just need to change my attitude...relax a bit more and try to enjoy the mysterious and stop trying to solve every mystery and treat every disease.  Perhaps then I won't wear myself out. *sigh*  I'm ready for the weekend.

chiefs' office

You know what? I miss having a a group of residents, attendings, and *gasp* sometimes I even miss having multidisciplinary tumor board. There is something nice about have a group of experts and, especially, friends that can help you find an answer to a difficult problem or diagnosis...or are just interested in hearing about what you did that day...or the interesting/difficult/exciting/terrible/wonderful operative case you performed. Since I don't have a "chief resident office" anymore,  this blog will have to suffice as an outlet for occasional 'venting'. I know at least a couple of you read it, anyway. :)

I have a mystifying patient that was sent over from clinic today at 5pm for "evisceration." He is one-year-old. He is very malnourished with ribs protruding and legs like toothpicks. He doesn't cry, he just lies still on the stretcher and looks around a little bit. His mom says he has never had an operation. She says he had an abdominal wound for four weeks and then the wound opened and his intestine has been out for 2-4 days (the story changed a few times, I think).

I took down the gauze that had been wrapped around his lower abdomen and I saw  4 inches of intestine....inside-out.  And, the weirdest part is, the intestine is not continuous. It has an end (like an very prolapsed ileostomy). It is coming out of a 3 cm, round, abdominal wall defect below the umbilicus (so it was not an umbilical hernia that eroded). Also coming out of the abdomen, adjacent to the intestine,  is green stool and gas.  To top it off, he has macerated wounds on his thighs and scrotum that look like they been there awhile...definitely longer than 2 days.

What is it? I don't know. I've never or heard of anything like it (in a textbook or in training). I have a theory. I'll let you know what I find.


Update:  So, this morning the little boy's mom changed her story and told the residents that he did have an operation one month ago. Diagnosis- prolapsed/necrotic ileostomy (probably done for a typhoid perforation), abdominal wall infection/necrosis, enterocutaneous fistula and severe malnutrition.



Here is something I saw in textbooks and on tests. Young man in his 20's, fell into a fire as a child. Has had a growing ulcer at the wound site for the past 1 1/2 years. He came for some medication, dressings...I told him he needed an amputation for the cancer. Sad.

Marjolin's ulcer

Images of the week

Can you see the fracture?

A bladder stone bigger than a chicken egg!  (don't forget to drink lots of water)

Barrel chest

Another reason to be very careful when riding a motorcycle. I'd show you a picture of the foot, but it is a probably a bit too gruesome for the blog. We spent a couple of hours amputating part of his foot while trying to save as much as we could. Unfortunately, it is very difficult (almost impossible) for patients to get prosthetic limbs here after amputation.

Just in case you didn't see it. I am glad we have a dentist here that can wire jaws. I don't enjoy putting wire through people's gums- it seems so painful.