250. Nepal--final post

Last round of pix from Nepal mission: two from recovery, one from postop rounds; tattoo on preop pt.

Ciao

249. Nepal Day 16

Wednesday Morning 3 AM.  Actually it's Thursday and 4 AM; I'm awake as usual (never really accommodated to time changes); can't turn on light with roommate asleep and nowhere else to go (the strip motel we're staying in has no lobby to speak of). 

Staring at the ceiling, I'm thinking what am I going to do the next two days until the group packs up and returns to Kathmandu? With no gyn surgery scheduled and just a handful of postop patients for six gynecologists to round on, not much to do.  I know because yesterday there was just one surgery; spent a lot of time wandering the halls.

Well, what about returning to Kathmandu early (where my wife has been hanging out, sampling the Buddhist culture? I'd have to arrange a car to the airport (90+ min away); once there change my flight; then grab a cab from KTM to her hotel.  Everything falls into place, including dropping off an older laptop (that I use for travel and don't really need anymore) to a school that I pass by every morning (these three pics are all from this school with its open air, crowded classrooms).

Problem is that though I try to let people know and say nice goodbyes, I don't actually ask permission and thereby engender some significant ill will.  I have a good time with the extra days in Kathmandu but all things considered, probably should have stayed.

248: Nepal Day 15

Another postop patient returns, dehydrated with watery diarrhea.  She responds well to intravenous fluid hydration but we do worry about clostridium (see day 12 post).  Or it could be cholera which is endemic in Nepal (Nepalese soldiers transmitted cholera to Haiti)? Or non-clostridium bacteria taking advantage of the elimination of normal (”good”) bacteria by preop or postop antibiotics? Or just a common viral or bacterial gastroenteritis, the same thing that's been affecting members of our group? We encourage extra hydration, which once home may mean more unsafe water than the usual safe tea. Then two more patients arrive, also with gastroenteritis. All did well with fluid hydration.

Performed my final vaginal hysterectomy today; we decided not to do any gynecologic surgery on Thursday or Friday given the number of re-admissions and our departure set for Saturday morning. General surgery continues to do simpler procedures such as hernia repairs and hemorrhoid banding, both less likely to have the kind of postop complications that we have been seeing.  They and the dentists will all stop work noon Friday.

solar "suitcase" closed

solar "suitcase" open
showing converter and battery

The mission is more than just surgery. We brought 100 pounds of prosthetic hands and “solar suitcases,” which includes a solar panel hooked to battery for two LED lights for an operating room when the power fails. One was installed in the hospital last year and another couple were placed in villages a few hours drive away.

solar powered LED ceiling light 

And there is a team from another organization that provides water filters. We help provide logistical support.

247. Nepal Day 14

Difficult day on the postop ward. One young patient with a simple tightening of the posterior vagina (the vaginal floor) reported postoperative abdominal pain, back pain and and/or headache. No vaginal pain was reported. All of my previous U.S. patients with this procedure go home after a few hours, many reporting report zero pain.  

Concerned about a “white” vaginal discharge she was reassured, with the caution that a vaginal discharge becomes a concern only if associated with pain or itching or malodor. Yes she promptly reported, she was experiencing all three. But an exam showed only a slight blood-tinged discharge that one would expect in this postop setting. 

Nepalese nurses and doctors spent much time with her, eventually discovering that she hadn't taken thyroid medications for four days—but it turned out that it was such a low dose that even four days missed should not elicit the symptoms she reported immediately postop. Questionable use of thyroid supplements for fatigue and weight gain among other complaints has a long history in the U.S., and it would be not unexpected to find the similar prescription patterns here. She ended up staying three days.

"They all want medications" I was told by a local nurse using “antibiotics” as the generic term for any pharmacologic cure. But then again, so do I with my tumeric, vitamin D ibuprofen for arthritis, along with thyroid and HCTZ, which is another story (osteodude.blogspot.com).

246: Nepal Day 13

Still doing 30-45 minute vaginal hysterectomies (in the pic I'm the primary surgeon) then assisting complicated 1-2 hour vaginal suspensions for the same patient—bent over, holding a retracter, no opportunity to stretch or change position, operating room at least 75-80 degrees—inside my impermeable gown probably 80-85. Plus my headlight is pressing into my forehead—okay for a few hours but after that it just adds to the general discomfort. Not what I signed up for I think until it's over and I can take the headlamp off (as an assist, I don't really need it but it would be awkward to remove it during the transition from primary to assistant surgeon).

Walking home, a guy came up and initiated a conversation.  He first encouraged us to change sides of the street, walking on the left following
English-pattern driving (I didn't point out the safety of walking facing oncoming traffic). He's a math teacher with a son who wants to be a doctor because doctors earn more than the $200/month teacher's salary of his father, which “isn't enough to live on” (current minimal monthly income is $92)). The son wants to study medicine in India, which offers medical school scholarships to Nepalese students. (I met one of the recipients of these scholarships who is spending a government-required two years practice in Lahan before returning to Kathmandu). He also commenting on the tug of war between China and India over Nepal.  City people, he said, usually have Indian connections but “hill people” favor China.

245. Nepal Day 12

Surgery today uneventful, but in the evening a patient from the first day returned after not feeling well for several days. Low blood pressure, no significant urine output, rapid heart rate, and rapid respiratory rate. No fever. Appeared in considerable distress.

Severe dehydration? Internal bleeding? Septic shock (systemic infection; see post #)?  

A "stock" image showing healthy pink bowel
and necotic dark bowel segment

Deteriorating vitals signs prompted surgery which showed a necrotic bowel. The necrotic areas of the bowel were removed, and the patient transported to the nearest hospital with an ICU, about two hours away, where several hours later she was reported as stable. 

Which came first, an infected bowel (say from accidental surgical injury) or necrosis from inadequate blood supply which then led to infection? The surgeons “ran the bowel” (that is, inspected the bowel from top to bottom) and found no evidence of perforation.  

Regarding the latter, at her age (71 it appears now though in the clinic she said she was 60, perhaps translation error or concern that she would be rejected because of age), there could be poor bowel vascularity—not enough blood going to bowels means not enough oxygen which increases risk of tissue death and widespread necrosis.

A final possibility is the antibiotic that a Nepalese doctor gave her at discharge (we would not routinely give antibiotics for a postop patient).  A not uncommon bowel bacteria call
clostridium is not covered by these drugs and could take advantage of the open field provided as normal bacteria were eliminated by the antibiotics. But clostridium infection
is usually associated with severe diarrhea. 

Lesson learned? Better attempts at screening for age or age-related conditions--easer said than done. Longer post-op stays: 2-3 nights after surgery instead of 1-2. Low threshold for use of metronidazole, the one antibiotic that covers clostridium. And a tweak of the method used to clean the vaginal wall.

244. Nepal Day 11

Back to work today. Concluding that during the previous week too many cases went too far into the evening, the decision was made to cut back surgeries: 4 operating room tables instead of 5.  

An anesthesiologist from Kathmandu helped today and hearing our stories of unexpected blood loss said that in his practice the expectation is that almost all hysterectomies will have sufficient blood loss to require transfusion.  We think maybe some dietary deficiency--some missing mineral vital to the blood clotting mechanism.  Dietary yes, but not deficiency.  Garlic, for example, is an anticoagulant, perhaps ginger as well, both common ingredients in local cooking.

Several providers ill with gastroenteritis.  I estimate that with each mission, 10-15% of participants at some point become incapacitated, though usually for just 1-2 days. Rest, fluids (sometimes intravenous), and antibiotics for travelers' gastroenteritis usually are sufficient.  I'm lucky, I remember just one afternoon in Malawi, when I returned to my room, just feeling poorly, perhaps lingering jet lag/sleep deprivaton, since I felt better after several hours sleep).  True GI illness did get me a couple of times, but on the way home so didn't disruption mission activities.

243. Nepal Day 10

Sacred cow wandering on main street

Day off (Saturday is the traditional day off in Nepal); some of us went to a wildlife sanctuary, by chance sitting in the bus ( a 90 minute ride) next to a nurse who shared “office politics” with me—the mission's chosen (but in situ unqualified) lead OR nurse picked because she was office nurse for the lead surgeon. After a verbal duel with a "take charge" nurse, the former ceded her position to the latter. My confidant works at the same hospital as the original lead nurse, with grievances that appear to predate the mission by some time. I was oblivious to all this until the bus ride, and never noticed any dysfunctional relationships (to which I also could have been oblivious). 

The ride took us within a few miles of the border with India, a reminder that Nepal is 80% hindi, probably more in the east.  India is known for it's skin-whitening creams. This picture of a woman about to receive a spinal anesthesia provides a partial explanation. Traditional clothing (sari) exposes her lower back as she bends over planting/harvesting rice, thus the deep pigmentation. Darker skin = common laborer.

242. Nepal Day 9

Without the pressure of a fee-for-service or a strong continuity of care theme give the see-one-day, operate-the-next, and home-the third (or fourth), the lead gynecologists scheduled patients without feeling this need to have the doctor who made the initial recommendation actually do the surgery. 

The concern is what if I am scheduled to operate when if I had first seen the pt I would have chosen a different procedure or non-surgical management. 

And that's what happened. While I was finishing rounds, I patient I had scheduled for a vaginal hysterectomy was instead prepared for an abdominal approach, based on    findings from an exam under anesthesia, an admittedly more informative exam. Scarring was suggested which would make the vaginal approach at risk for significant complications. However, an abdominal has a higher risk of complications and certainly a longer recovery. No scarring was found and the patient experienced more bleeding. 
But who knows, even more bleeding may have occurred with the exposure-challenged vaginal procedure. At some point, you take your colleagues' decisions at face value, stop the second-guessing, and move on.

241. Nepal Day 8

More of the same: vaginal hysterectomies followed by vaginal suspension or closure

Our hotel is two miles up the road—the country's main highway, dusty with cars, busses, motorcycles, bicycles, and lots of trucks, all weaving in and out with constant horns. Most motorcyclists wear helmets but their passengers don't. Cyclists have no helmets and no lights, which is tricky at night. Some of us walk the four miles daily; others take the three-wheeled electric taxis that seat a tight four--”tuk-tuks” in other countries.

The nurses work the hardest, arriving early to prepare instruments, rooms, and patients for surgery; many stay until the last patient has made it though recovery and to the ward.  Local nurses are hired to take care of patients at night.  

No elevators so a long ramp allows gurneys access to the second floor postop ward.

240. Nepal Day 7 part 2

Three cases today:
1. 60 year old with complete uterine prolapse (the ligaments that suspend the uterus are so stretched that the uterus has fallen first into and then outside the vagina. During surgery the small atrophic uterus is removed (my part) and then the gyn urologist does her part, elevating the vagina and tying it to a ligament near the spine .  A tedious procedure (because many sutures are required in hard-to-see spaces) for the the surgeon and for the assistant as well (that be me).

2. 38 year old with a weak rectal-vaginal septum (wall) that protrudes into the vagina and interferes with normal bowel function. Like a seamstress's dart, skin is brought together and redundant tissue removed.

3. 65 year old also with complete prolapse but in this non-sexually active (and never expecting to be) woman, removal of the uterus then closure of the vaginal opening is the safest route.  First the surface skin layer is removed from the vaginal ceiling and the vaginal floor. These exposed areas brought together with suture.  When healed they will form a strong wall that essentially closes the vaginal opening.

One would think that complete prolapse would make for easy hysterectomies since the primary target of the procedure--the uterus--is right there, easy to see and manipulate. But not so; the descent distorts normal anatomy (so blood vessels and other structures are not exactly where you think they should be). And the many year exposure to the outside environment toughens and thickens the vaginal skin.  Compare the peeling of a naval orange (normal anatomy) to a juice orange.

239. Nepal Day 7 part one

First surgery today. We have two operating rooms, one with an single overhead light (doesn't make much difference; we all have headlights—some from Costco or REI, others medical grade and several hundred dollars; you get what you pay for), two operating tables and working air conditioning.  The other room has no overhead light, no air conditioner, and three operating tables. That's the room I'm in, center table with patient receiving spinal anesthesia.


Other missions have also used a single OR for two simultaneous operations (which makes it easier to share personnel and equipment) but this will be the first hat trick OR. 



Our “dress code” may raise eyebrows but the sterile integrity of the OR hasn't been breached tho the personnel (in this case an anesthesiologist) may not be as protected against spills and falling objects.

238. Nepal Day 6

More screening today, starting in pm though patients have been liningup since early morning. As in the Philippines and Ecuador, we often need two translators: one to translate local dialect to standard Nepalese and the second to go from standard Nepalese to English.  Obtaining an useful medical history is a real challenge.  Ages, for example, invariably end in 0 or 5, not surpising given low education levels (most “sign” consent forms with a thumbprint). These are women who have lived their lives as substinence farmers, bending over in rice fields, carrying heavy loads everywhere. I saw plenty of tractors but I suspect a recent development.


The word that went out among local medical providers that we were looking for patients with uterine prolapse (the vagina turns inside out, extending outside the vaginal opening in a complete prolapse). So that's what we saw, no problem since the mission came with three specialists (urogynelogists who have expertise with the fixing of prolapse—essentially removing the uterus then attaching the vagina to a higher structure, such as the ligaments that hold the spine together. 

237. Nepal Day 5

I think the hospital is private but looks like it was built with public funds.There doesn't appear to be any active public hospital in this city of about 40,000. The two operating “theatres” and now empty pre-op/postop wards look like they haven't been used in weeks or months (but there is another OR upstairs next to an active labor and delivery ward which is used for cesarean deliveries), so the first task is a thorough cleaning and the unpacking of supplies. I personally brought about 100 pounds of sterile drapes, gowns and other medical items, and 50 lbs of prosthetic hands supplied by an LA foundation.

We also started some screening.  Lines didn't go around the block like in Cambodia, but there were always some women waiting to be seen.

236. Nepal Mission days 1 through 4

View from plane: Everest?  Maybe

A surgical mission to Nepal.  Treking to a mountain clinic with mountain goats carrying surgical instruments and IV bags? No, we're going to the agricultural lowlands (rice, dairy, sugar cane), near the border with India. A Nepalese ex-pat physician now working in U.S., grew up here.  His wife, also a physician, is from another area in Nepal and in alternate years the team travels there.  This is a large surgical team —six gynecologists, five general surgeons, and 5 anesthesiologists. Add nursing and other support personnel and the team adds up to 50 or so.

Marshlands and Water Buffalo

The real beginning of an overseas surgical mission begins months or even years in advance. Visas, governmental approval, lodging, ground transportation, and supplies, supplies, and supplies.

I left Wed at 2pm with an 11 hr flight to Seoul. Overnight airport hotel (part of the airfare package). Day two a six hour flight to Kathmandu, a six million urban sprawl.  Day three acclimatize, then on day four a 7 hour combination air/bus to destination. Whew. Waiting for the last flight, met a young Chinese businessman who was both surprised and impressed that our group was not sponsored by the government or a Red Cross type of organization—we travel, lodge and eat all at our own expense I explained. 

235. Sophie's Choice

Annie is 34, the primary breadwinner and probably primary caregiver for her two children given the nature of our culture. Not saying that her partner is a slacker, but that's how it is. 

Now comes an unplanned pregnancy with that type of morning sickness that leaves the mother feeling really nauseated without actually throwing up. She can't afford to miss work--she can't afford this pregnancy, period.

And she feels guilty because she doesn't want the pregnancy.  Have you considered termination I ask; I could never do that she replies but you know she has thought about it, which only increases her guilt.

234. Tamoxifen again

Remember tamoxifen (post #221)?  In some organs (e.g., breasts) it blocks the effect of natural estrogen, in others (e.g. uterus), it acts like an estrogen. 

First chemotherapy for Eve's early-40's breast cancer, followed by a standard 5-year course of tamoxifen, since her cancer was estrogen-sensitive. Periods which had stopped during the chemo resumed for a few years then no periods for several months. A new episode of bleeding prompted her first consult.

Is this postmenopausal bleeding requiring further testing for uterine cancer, or does it reflect non-threatening hormonal variations not unexpected in this setting?

An endometrial biopsy was obtained showing no sign of cancer; then a ultrasound, showing a thin uterine lining (cancer or a pre-malignant condition called hyperplasia) invariably lead to a thick lining. 

7 months later she presents to me with another episode of light bleeding.

We discussed repeating the endometrial biopsy or ultrasound, or scheduling a hysteroscopy, allows direct visualization of the uterine lining while patient is under general anesthesia or sedation (for example, valium and ibuprofen).

Eve seemed inclined to go with the hysteroscopy, then decided to wait and repeat the ultraosound in six months--when she found out she would need a ride home after the hysteroscopy! As good a reason as any, I guess. Any approach has a 2-5% false negative rate with low but not zero health risks.

233. It's All Relative

Comment from a 20-something nurse:

"...for 38 she's pretty healthy..."

232. Why , Doctor, Why?

"What was all the other tests you ran. You said a urine infection test when there was no reason for one and then you ran a list of tests that you did even say you were doing.  Just because I have State Insurance don't meen I'm going to put up with un nessasary and un warrentted test. This is going to stop right now from evey doctor there. Now I want an understandable breakdown of the tests you did Why and what they all ment and were for, that I can understand."

Though directed at one of my colleagues, I could well have been the subject since I frequently order tests without explanations--just a general "screening for infections," or "looking for problems with your kidney or level."  I could do more.

231. Thirty-Five

My son and his son

35 years ago today, I delivered my son, and a VBAC at that (post #128)!  Or I should say, I attended the delivery, because of course his mother delivered him. It was a month after my internship so I was a fully fledged MD though still three years shy of being an obstetrician-gynecologist.

So if any one one asks how long I've been delivering babies, I just respond with my son's age.

230. Privacy

You wouldn't think that a few days after you visit a doctor you see your story show up on a blog, such that you neighbor calls up and says she's sorry to hear about your abnormal Pap smear.

So what do I do to protect the privacy of the patients whose stories are the seeds of my posts?


1. I change the name, age and other demographic details.
2. I tweak the stories, changing details that don't impact the nature of the observations being made. 
3. Though I will write a draft soon after an encounter, the final post may be delayed for weeks or months.
4. Many stories are a composite of several patients with similar medical histories.
5. Just a handful of people know my identity.

In other words no one reading my posts would be able to identify the patient unless he had access to all of my daily clinic and hospital records, and lots of time to sort things out. If there is any concern about privacy, it should be directed at that person who has such access and uses it in that manner.

229. $10,000

Kali, now 24 weeks pregnant, and her boyfriend maintain separate homes, something about commuting or such, but she says he comes down on weekends, helping with shopping and cleaning. Must have been a planned pregnancy because she has saved $10,000 to support herself after giving birth.

Unfortunately, a weak ("incompetent") cervix means she can't work. Her $800 month rent, is going to eat up a good part of her savings, and add to that groceries and other day to day expenses.

I'm impressed that she has been able to save that much; she's way ahead of the curve.

228. In Tune

Marsh's urinalysis shows bacteria in the submitted sample, but no harmful bacteria in the culture, just common skin bacteria; i.e., a contaminated sample.  Her symptoms (mainly frequency of urination) continue so another sample is obtained--same results.

But "I'm in tune with my body," she responds, in support of her certainty that she has a bladder infection because these symptoms in the past have been associated with the same. "Just give me a mild antibiotic."

Problem is, it's one thing to tune a six string guitar; it's another to tune a twelve string guitar. She's pregnant: another six strings to figure out.

So I suggested she come in for a catheter specimen--we insert a small sterile tube into the bladder to obtain a non-contaminated sample. 

227. Friends

The operating room has strict rules to maintain a sterile environment.  Duh.

Which includes no apparel other than that supplied by the OR (only their scrubs, not ones I've washed at home).  Disposable hats and masks are mandatory; disposable shoe covers optional (apparently less concern about bacteria tracked in from OR area floors. Shoe covers seem more used for shoe protection than for patient protection.

I use earphones on my bike commute, and when entering the office leave them dangling on my neck (mornings are still cold so I'm using the warmer external earphones instead of earbuds) as a I walk from the bike rack to the locker room.

Well, a couple of days ago, I forget to remove them when I changed into scrubs.  I saw a few patients in the office then went to the OR, scrubbed, entered the room and was about to begin the planned procedure when a nurse gently lifted the earphones off my neck.

You know the line, "friends don't let friends drive drunk,?"  How about "friends don't let friends walk around the office and OR with earphones hanging around their neck?"

226. Sorcerer's Apprentice, part 2

Though septic shock seemed the most likely scenario, her distended belly raised other possibilities. Cytokines are increase blood vessel permeability. The liquid part of blood--serum, can now leak out of vessels and cause swelling.  Accumulation of this or similar fluid in the abdominal cavity is called ascites.  So her distended abdomen can fit the septic shock scenario

But internal bleeding--perhaps from a ruptured uterus--coiuld also cause this distension. Now that's something we could/should address. So once the BP stabilized, an immediate laparoscopy (camera inserted through a half-inch umbilical incision) showed that the fluid was ascites not blood; a quart and a half were removed to take pressure off the lungs (more could have been removed, but we wanted the laparoscopy to be as quick and atraumatic as possible).  

She was taken to the ICU, who found her condition so perilous that transfer by helicoptor to the local county hospital/medical school training site/multi-state trauma center was recommended.

There massive antibiotics were administered and a hysterectomy performed (to remove the most likely source of continuing infection.  She improved slowly, discharged after three weeks.  The mortality of septic shock can be as high as 50%.  She did well.

225. The Sorcerer's Apprentice, part 1

Laney's first pregnancy was uncomplicated. At 26 and healthy her delivery should have been uncomplicated, and it was. Well, a little more than average bleeding, but no need for a transfusion.  For several days she didn't feel well ("must be the low blood count"), but on the fifth day postpartum, she came in to urgent care , having not been able to empty her bladder for several hours.  The bladder is stretched and pushed during labor, so not uncommon to experience urinary retention. A catheter was placed, more than a quart of urine drained, and she was told to return in three days for its removal--three days being enough to swelling and inflammation to subside and normal bladder function return.

On that day her mother called saying Laney was "hot" so she was told to go to urgent care. There her blood pressure was low, labs abnormal; sent to the ER thinking she was in septic shock.  At the ER, her blood pressure continued to drop, and blood oxygen levels were dangerously low. She was immediately intubated and given oxygen and "vasopressors"--medicines that keep the blood pressure up by causing blood vessels to constrict, thus promoting blood flow and oxygen to her brain and other vital organs.  

But what caused the blood vessels to dilate in the first place? Probably cytokines--small proteins released by bacteria or the overwhelmed immune system.

Consider the sorcerer's apprentice, who tasked with cleaning the dungeon, animated some brooms, mops and buckets to do his work. While he slept, the animated objects reproduced themselves and soon there was a stick army and a flood.

In septic shock, cytokines act as the apprentice's spell, causing blood vessels to dilate, which lowers the blood pressure, depriving vital organs of oxygen.

224. Darian III

No, not an 18th century Romanian King, but the name given to a baby boy born this morning around 5am.  A strong-willed mother who said she didn't want anything for pain and stood by that.  A soft-spoken father, who hovered closely, not as in a  "I'm-in-charge, macho, territorial" mode, but as in "I care; I'm here when you need me."

I don't see many namesakes let along juniors, in fact can't remember the last one, and "the third" has to be very rare.  But I'll bet that Darian III will be proud to be a Darian.

223. Is Health Care a Right?

Not a subject of debate, that having been decided with the first laws preventing emergency rooms from denying service, and confirmed by republicans who now say, "repeal and replace," instead of the previous, "repeal."

But how far, if at all, does that right go beyond the ER?

Amber is 24 weeks pregnant.  With each visit she requests an ultrasound. She also has regular massages for pregnancy-related back pain and weekly sees an "obstetric chiropractor," all covered by her work-based health insurance. 

Is health care a limited resource, a health care pie as it were? Does Amber's bigger piece mean a smaller piece for someone else? Obamacare gives (I almost said "gave" but we're not there yet) a piece of the health care pie to millions who never had pie. Detractors feel their pieces are thereby diminished. 


Somehow, in this squabble for the imagined last piece of pie, the humanity of it all has been lost.

222. Maria Update

Maria's ultrasound showed a very thin uterine lining; no cancer has been associated with such a thin lining. With this news, I hoped she'd be comfortable with not pursuing a hysterectomy, but after I emailed her with the positive news from the ultrasound, she did not reply. Maybe signaling a persistent uneasiness.

221. Sign of the Times

Not an uncommon request: "Can I have [procedure x] done before I lose insurance at the end of the month?"  The frequency (and emotional urgency) of such requests will surely increase.

Last week Maria asked for a hysterectomy.  She had breast cancer several years ago, her treatment including surgery and chemotherapy.  She received a standard 5 year course of tamoxifen, a drug that blocks estrogen receptors in the breast (her cancer was accelerated by estrogen) but paradoxically stimulates estrogen receptors in the uterine lining, increasing the risk of uterine cancer.

So, she asks, why not just take out the uterus, an organ that now serves no health purpose and carries the risk of cancer?  I acknowledged that although a hysterectomy would remove the threat of uterine cancer, the risk of uterine cancer is low even with taxoxifen, and usually easy to detect--bleeding occurs at pre-cancer stage and she has experienced no bleeding. Furthermore, she is now a couple of years beyond the final tamoxifen dose.

Then consider the potential complications of a hysterectomy such as injury to the bladder or bowel, infection life-threatening blood loss.

Maria returns to her original concern:  "I may not have insurance when and if I experience signs of cancer.

We end up planning an ultrasound (assuming it can be performed in the two weeks remaining on her insurance), which can show signs of hyperplasia (the pre-cancer stage).

220: Child's Play

In response to the regular survey that most of our patient's receive, a patient said that she felt like she had been treated like a child. As a brief written note, I couldn't tell whether this comment came out of anger, frustration, humiliation or resignation, but it sure wasn't a compliment. Too much time had elapsed between the encounter and the feedback, and I could't remember the specifics of the visit; I just had to leave it as an unknown.

Unknown until last week when I experienced a very unsatisfactory exchange with my (now ex-) dermatologist. I was at first annoyed, then frustrated, then unhappy but I couldn't pin down exactly what it was that bothered me until after a couple of days I connected the two. I felt treated like a child.

If a 4-5 year old came to me with a scratched arm or broken toy (or more likely, a crashed iPad ap), I would exaggerate my concern and sympathy wanting to make sure that I would be heard through the tears.  "Oh that's just terrible," I might say, or "you must feel really upset; let me make it better"  A knowing parent might want to add a reality check: the scratch is minor, the toy fixable, the pad just has to be rebooted. But I think (wrongly?) my relationship with the child would suffer if I reacted that same way as I would to a friend.

The dermatologist brought her chair close to me, tilted her head just so, maintained steady eye contact, and expressed much concern even though I hadn't really complained--I just came in for a refill. Her manner would have been lauded at a doctor-patient communication workshop. But it didn't work for me any more than my condescending manner worked for my patient a few months ago.

219. Pancakes

At 34 weeks Rosie was hospitalized with “intrauterine growth retardation” and poorly controlled diabetes. Are the two complications related? One causing the other? Both caused by an unknown factor? Coincidental?  

Anyway, I walk in for morning rounds and find her eating pancakes.  I go ballistic!  Who allowed that? Then I found out that pancakes are indeed on the hospital’s diabetic diet because the venerable American Diabetes Association wants to make sure that diabetic patients get enough carbs so that they don’t crash from hypoglycemia (low sugar).  That’s fine and good for type 1 diabetics whose blood glucose levels vary widely.

But for type 2 diabetes, carbs are the problem, not the solution.  Many type 2 diabetes will resolve with low carb diets.  So no white bread, no white rice, no potatoes, no pasta, NEVER; and rarely whole grain breads and pasta, brown rice.  As for pancakes?  Give me a break.

218. Heroin part two

A month later, with negative urine screens for any opioids--not even the narcotics (Percocet) that I thought she took regularly, Carolyn returns to preop.  With no unexpected confessions, and a more flexible anesthesiologist, her hysterectomy proceeds without complications. At the eyesight level, the uterus, fallopian tubes, and ovaries appear normal, including no evidence of endometriosis (I wouldn't expect to see adenomyosis).

The pathology report not only confirms the presence of adenomyosis but also notes the presence of small fibroids, which can also cause pain. 

Carolyn went home the morning after as planned.  She did not need more than the usual postop pain medications.  I provided a prescription for 40 Percocet instead of my usual 30 since her history suggests narcotic tolerance--more will be needed for the same pain control.  

It's now been almost a week--I expected a call requesting a refill (at 2 Percocet three times a day, she would have run out by now), but have heard anything.  No news is good news.

217. Heroin part one

Hardly a day goes by without a news headline about the nation's opioid epidemic.  So no surprise when a patient's history reveals a history of substance abuse, including heroin. 

47 year old Carolyn was referred to me by a partner who didn't have time on her schedule for a hysterectomy.  Carolyn experiences chronic pain, especially with menses, which some providers attribute to endometriosis, others to adenomyosis. 

Adenomyosis occurs when the active cells of the inner uterine lining expand into the more sedate muscle fibers that comprise the uterine wall (which they are not supposed to do), Hysterectomy is the only effective treatment.  Remove the uterus--remove the adenomyosis.

Hysterectomy for pain can create more problems than it solves, but I reviewed the chart and said okay. 

The morning of surgery, Carolyn tells the admitting nurse that she used heroin the day before (just a little bit she said; "I didn't really feel anything").  The anesthesiologist promptly cancelled the surgery, saying he wouldn't do it unless he could confirm that she had been off heroin for six months.

But taken at face value, she does have a reason for pain; she takes narcotics for pain; trying to take her off of all narcotics and similar drugs for six months, is not realistic.

So we're going to try again, monitor her urine for a couple of weeks and try again after labor day.

216. Natural Birth

Sounds patronizing but when I have a laboring patient who I think is trying too hard to have a "natural birth" I make the observation that a woman wanting a really natural birth would forego the hospital and even the comforts of a king size Sealy mattress and find some wilder place for the delivery (and then eat the placenta afterwards--though I usually don't add that). The point I'm trying to make, probably not very successfully with the image I have chosen, is that "natural" is an imprecise concept, not helpful for labor decisions

Pain can cause muscles to contract (tighten), which in turn increases blood pressure, which decreases blood flow to the uterus (when muscles encircling blood vessels contract, the vessels are smaller, meaning less blood flow to the uterus and other organs).  There may be evolutionary explanations for this sequence, but none are helpful in modern childbirth.

That was my approach with Nelli, having her first baby at age 24.  To which her mother-in-law promptly proclaimed that she had delivered three babies all natural.  Thanks, mom.

After about 10 hours of labor (4 hours of hard labor), she requested an epidural and went on to deliver vaginally about 6 hours after that.