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).

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!  

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