56: Overseas Project #8, Malawi, day 6

No cases today, so spent some time looking over facilities and reviewing the surgical log.

There are two operating rooms; this is the larger, plenty of lights from tall windows and skylights, an air conditioner which we didn't really need.  Our nurse anesthetist didn't trust the anesthesia machine (for inhalation anesthesia) so she relied on spinal anesthesia: pt is awake but numb from the upper abdomen down.

Home for the afternoon, a long nap prompted by a combination of fatigue/jet lag and mild gastroenteritis. Just what I needed; I was okay the rest of the trip.

55: Overseas Project #8, Malawi, day 5

I spent the morning in the antepartum clinic for high risk pregnancies.

Two women both had hemoglobin levels of 4.9 (approx equivalent of hematocrit of 15), a severity of anemia simply not seen in the U.S. There is a biochemical adaptation to chronic anemia that allows these women to function, though neonatal mortality is high.  The following week one of these women presented with fetal demise.  Malaria, malnutrition, parasites, or more likely a combination of the three.

In the afternoon a 17 year old who delivered 20week twins at home was brought in for retained placenta.
A curettage removed the placenta from what appeared to be a bicornuate (heart-shaped) uterus.  Then another C/S for failure to progress, again working with one of the "clinical officers" (CO's or clinicians), the approximate equivalent of physician assistants who regularly perform C/Ss and other surgeries.  Their technique and knowledge of anatomy were good, and they were interested in seeing my technique, unlike their counterparts in Mozambique.  One newly graduated CO had not previously assisted on a C/S let alone perform one, so was excited to throw some stitches a tie a few knots.

And then the difficult re-repair of a third degree laceration (meaning the rectal sphincter muscles were torn) that occurred during a 17 year old's delivery at a satellite clinic.  An initial repair had broken down so the patient was brought to Nkhoma.

54: Overseas Project #8: Malawi, Day 4

After OpenOffice for Ubuntu crashed its presentation program for the third time, I decided to go low tech, using chalk and chalkboard for a talk at the Monday hospital staff meeting.  I promoted the use of aspirin for women with a history of preeclampsia, given recent findings suggesting that early abnormalities in placental vasculature that lead to preeclamapsismay may be prevented by aspirin. And I encouraged the use of misoprostol for postpartum hemorrhage, which is in their protocols but not in their pharmacy--at least it wasn't until I gave the pharmacist the 100 I had brought with me.

After the meeting, I was introduced to Labor and Delivery, where I was asked about a woman making poor progress in labor--the staff suggested a C/S.  The hospital has C/S rate of about 20-25%, comparable to the U.S.  Higher than I would have expected prior to the Mozambique trip where I appreciated that it is better to perform a few extra C/S's than to have vaginal deliveries of babies in need of non-existent resscitation.  As in Mozambique, the nursery here consists of a single warmer where newborns stack up waiting for their mothers' recoveries.

Although augmentation of labor with pitocin would an option for slowly progress, given the long labor so far(unexpected for someone with prior deliveries) and her request for a tubal ligation, I agreed with the C/S.  The baby was 3700 grams (over 8 lb), a probably cause for the stall.  Afterward, when one of our nurses asked the mom what name she planned, she said, "you name it."  The nurse suggested David, and David it was.

53: Overseas Project #8, Malawi, Day 3

The adjacent Presbyterian church (Dutch Presbyterians founded the hospital, church, nursing school and theological seminary) has an 8:00 English service and a 10:00 Chichewan service.  English is the nation's official language, well-spoken by the educated, but most of the hospital's patients speak only the local Chichewa.  My camera caught a visiting choir.  Many mornings we were awaken by distant sounds of practicing choirs, and when the electricity was down at night, we again heard choirs.

The hospital struggles to stay solvent. Monthly hospital income: $31,000 patient fees (I have no idea where they get hard currency), $50,000 from the government for salaries, and about $15,000 donations, for a total of $96,000.  Expenses: $16,500 medications and supplies, $75,000 staff salaries, $7,300 maintenance, and $10,000 administrative costs, for a total of $109,000.  The government owes $24,000 based on prior agreements for capitated ob and peds, but that would cover just two months of the projected $12,000 monthly deficit.

By contrast my local hospital, St Joseph, has about the same bed capacity, but a billion dollar annual budget--that's over 83 million dollars a month.

52: Overseas Project #8, Malawi, Days 1-2

Two red-eyes dissected by a 9-hr layover in Healthrow pretty much destroys my credibility as a travel agent, but about 45 hours after leaving Seattle we did arrive at Nkhoma, Malawi for overseas project #8.

With a bed capacity of 200, Nkhoma Hospital and its 10 satellite clinics serves an area of about 30,000  subsistence farmers. Patients are on their own for food, bed linen, even IV fluids. Our anesthetist expressed concerns about postoperative patients being underhydrated (adequate hydration is a critical postop issue) because patients can't afford IV fluids.  But nursing neglect provides a better answer--no one walks around adding up supply costs for subsequent hospital bills.

For fourteen years Rainier Te Haal, a South African by birth but Dutch by heritage, temperament, and marriage, has been the hospital medical director. He is an all-purpose general surgeon and also takes call for anesthesia, providing spinals for cesarean deliveries. He has developed a specialty in vesicle-vaginal fistula repair, teaching the technique to Malawian colleagues. Rainier and Wilika have six children; the oldest son is in a boarding school in Nairobi, followed by three daughters and then two younger sons, both local adoptions. Four years ago he spent a Sabbatical in rural British Columbia and was tempted to stay, but “they need me here.”

51: No Age Limit

Usual story: 

Doris says her husband is controlling.

He grabs her, hard enough to cause bruising

He has directly hit her, but not often.

She can't leave because of financial considerations.




What's unusual, at least in my clinic:
Doris is 70.

50. Sangre

More than a burning fever or the loss of gastric contents up or down, more even I think than a seizure or loss of consciousness, the extravasation of blood remains the scariest and dramatic life-threatening sequellae of trauma or illness. Yet also very common (especially for those of us with inherited deviated septi for whom nose bleeds occur almost with provocation).

So no surprise when blood loss triggers either an over-reaction--perhaps because denial can be fatal-- or a careful descriptions of blood loss. Still, though, I had never before heard a clot described as a "slug."

49. Three Stories

Juanita is 17, pregnant with a second child, struggling as a single mother, working and trying to finish high school. I see her for an ultrasound to precisely date the pregnancy, important if she terminates.

Jane is 34; an 18 ultrasound showed a "Chiari II" syndrome, which means injury to the primitive brain due to a malformation of the skull (20% of these babies die in the first year because of respiratory failure; it's the primitve brain the controls breathing. There is also an injury to the spinal cord in the lower back; this child will never walk. She is hopeful that surgery within a few days after birth will release pressure on the brain.

Jasmine is 22, a life-long diabetic who experienced an epidode of diabetic keto-acidosis when she was a few weeks pregnant. Diabetes means that blood glucose can't enter cells; instead it stays in the blood, hence the high sugar levels of diabetes. The brain needs glucose but is the one organ that can't store it, so fats are broken down with ketones as a by-product. High levels of ketones are life-threatening. The risk of birth defects is high when DKA occurs in the first trimester.

Three women with extraordinarily difficult decision. Why should some old white guy from Ohio make this decision for them?

48. DV

From a chart note:

"Case worker called me back to say that [Anita] was admitted to [St Elsewhere] after a severe beating from her boyfriend. She was only recently discharged and case worker says she still is black and blue. FOB is currently in jail but she still has contact with him. She declines to initiate restraining orders. She told case worker that she occ uses cocaine."

Soap operas and learned commentaries both lament the difficulty that abused women have separating themselves from their abusive partner. It's counterintuitive and you wonder if it's an exaggeration of reality, useful for a plot twist or to create interest in a written report.

No, it's not.

47. Belly Dancer

L. is 42, divorced without children. She presented with abdominal pain. There was no associated gastrointestinal symptoms, no urologic issues, but her current menses, tho light, had been ongoing for 3 weeks. At our first visit, the exam and her membership in a belly-dancing troupe suggested a "soft-tissue" injury, that is, a problem associated with trauma to muscles, tendons or ligaments.

Over the next three weeks, we proceeded through a number of blood and radiology testing, the final an abdominal CT scan; all normal. At our last visit, I decided to start over with a history and exam.

When asked about stress factors, she describe multiple sources:
1. Work difficulties: called to task for being slow when from her perspective, she is just doing her job ("courtesy bagger" at Safeway). She worries that she is being set up to be fired so that she can be replaced by a lower wage (less senior) new employee.
2. Estrangement from family; her father died last year and her sisters didn't even tell her about it.
3. Financial difficulties.
She finally acknowedged that her current pain may be associated with one day when she had push a large number of grocery carts from the parking lot to the front of the store, a sudden stop jamming the cart handles against her abdomen. She has not returned, and has not answered by follow-up calls.

46. Intelligent Design

This morning around 3:30 while I was watching 9lb 6oz Gary trying to figure out an exit strategy with the help of a determined mother and a patient midwife, I decided that anyone who believes in "intelligent design" must never have witnessed a human childbirth, or if she/he has, it's been totally erased from conscious memory. I can understand how the pressures of natural selection could lead to such a strange means of reproduction, but as a thought-out, planned-in-advance design by a superior being? Nope.

45: Resistance Is Futile

From an office email I received last week (I'm not the one being addressed, I just happen to be on the mailing list):

"... good to run into you last night. You discussed with me that you were experiencing some resistance to standard deployment of the tools of [new program X] into your department as well as some concerns from some of your colleagues that movement upstream to primary care may cause problems…

As we discussed our job is to understand that resistance and work with our teams to move through it adjusting our strategy and work as appropriate based on their good thinking."

When I find myself in a room with these people, I don't know what to say, it's like I'm listening to a foreign language I learned in college. Sure, I recognize a lot of words, but I have no idea what is being said.

44:OK, I Believe You

T. presents with pelvic pain. The abdominal exam with its initial gentle palpation that tries to localize the pain and estimate its strength, was, frankly, unimpressive. T. must have sensed this; without warning she grabs my hand, pulling it deep into her abdomen. After a long 30 seconds, she lets go and assumes a semi-fetal position, tears streaming from pain. She explained that she just wanted to demonstrate the pain.

43: Thanks

received an email today:

"Thanks so much Dr. H. Enjoy your Easter Weekend."

Illness can make it hard to see a caregiver as a person, especially when we don't have much to offer (which happens more often than I want to admit), so when someone breaks through and says thanks, well... what can I say but thanks in return.

42. The C Word

from an email received March 23th:

"I have an appt. for the 15th of April - but I have to say - I think it's crazy you have to wait so long for an appt. when its something potentially as serious as this is. I'm having a hard time concentrating on anything else. My father was recently diagnosed with cancer so this is making me crazy. I think three weeks can make a huge difference in whether or not someone beats a disease... or not!"

Two possible replies:

1. Explain that an abnormal Pap smear usually diagnoses "precancer," (dysplasia) not cancer, and that the progression from dysplasia to cancer takes years, so a three week delay really is acceptible. Three months would be okay. Three years not okay.

2. Offer an appointment tomorrow, my call day so it may mean some extra shuffling back and forth from the hospital to the clinic, but usually doable.

Number two of course. The time to talk about the difference between dysplasia and cancer or about the natural progression of the disease is BEFORE not after the results are known. But I'm not the one who obtained the Pap smear.

p.s., biopsy obtained during the appointment; she has moderate dysplasia (maybe 10% chance of become cancer over a few years). She accepted a procedure that will remove a button-size segment of the cervix, almost always including all of the dysplasia)

41. Diversity

Apparently bored by my discussion about antepartum risk screening (the result being reviewed estimated that the risk of Downs Syndrome was 1:35 so not a trivial discussion), a father-to-be said, "Doctor, can I ask you a question?"
"Sure," I answered.
"Are you a mulatto?"
"Must be; my hair's from Bathsheba, eyes from Thor and my deviated septum from Genghis Khan. It's my genetic diversity that promises a long, healthy life."

[the question was real, the answer sadly, was really something along the line of, "Must be, if you go back far enough..."]

40. Macrosomia

Macrosomia, literally "big body;" in my world, babies over 9 lb at birth (greater than 90th %ile). B. delivered a "macrosomic" baby two years ago, 9 lb 15 oz. Uncomplicated vaginal birth. Concerned that a second child might be larger, an ultrasound was obtained yesterday, two weeks before her due date. Estimated fetal weight: 5000 grams, or about 11 lb. For most babies, the head is larger than the shoulders so once the head delivers, the baby slides out. But macrosomic babies may have larger shoulders that get stuck, an obstetrician's nightmare: injured nerves, fractured clavicle, paralyzed arms, stillbirth; I've seen them all.

So one of my partners, who herself underwent two uncomplicated Cesarean births, gave her the option of skipping labor, going straight that same day to the operating room for a Cesarean delivery. She said yes. I was on call and delivered a 10lb 5oz baby boy. Would this baby have safely made it through the birth canal? Probably. Would I have counseled her differently? Probably. Would she still have chosen an elective Cesarean? ... Probably.

39. In My Country, part V

The ultrasound demonstrated not one but several "echodense" (i.e., sound waves don't pass through so white area on ultrasound) areas, consistent with collections of silicone. Not something one wants to surgically remove (the cure possible worse than the disease) unless symptoms increase. So, we like to call, "watchful waiting."

38. In My Country, Part IV

I asked S to return, to discuss results of antepartum screening. Four pregnancy "hormones" are measured and in a complex equation compared with the results of other women whose outcome is known. The results: for every 71 women the same age and weight as S, with the exact same results, 70 had normal babies and one had a baby with Downs syndrome. So her risk of having a baby with Downs Syndrome estimated at one out of 71. Using age alone as the predictor, one would estimate her risk for Downs at about one out of 200. I offer her an amniocentesis--withdrawing fluid from the amniotic sac, containing cells sloughed off from the fetus, which can be nurtured, after a couple of weeks yielding enough DNA to give a definitive answer. Problem is that the procedure has a 1/400 risk of miscarriage. It's always a tough call. S immediately declines the amniocentesis, a decision entirely consistent with her earlier request for an elective cesarean delivery. Baby comes first.

37. In My Country, Part III

After our discussion about the Prenatal Risk Screen, S asked me to evaluate the recent onset of leg pain. It seems that several years ago in Peru she received an injection of silicone into her buttocks for cosmetic reasons. S has a normal weight and body shape; I'm not sure and didn't ask the exact location and rationale behind the injection. Anyway, she reports past episodes of this leg pain which her doctors attributed to the spread of the silicone into her thigh, with relief obtained by injections of steroids and/or antibiotics.

Today she has a 4 by 6cm firm, mildly tender swelling on the lateral right thigh, with just a blush of erythema (redness). There are no breaks in the surrounding skin that would suggest an infectious process. I have no idea what this is, but will obtain an ultrasound. Either that or tell her to take a couple of tylenol and see me next week.

36: Pheromes, part II

While we're on the subject, a recent study from Florida recruited young men to opinionate on t-shirts worn by women while sleeping on three consecutive nights. There were three groups of t-shirts, one set from around the time of ovulation (when there would be an evolutionary advantage to attract sexual partners), a second set from a time distant from ovulation, and a control set.

The men rated the ovulation t-shirts as most appealing. Testosterone levels were higher when the ovulation t-shirts were being evaluated.

An earlier study showed that exotic dancers received more tips around the time of ovulation. Many factors here, visual, auditory as well as olfactory, the t-shirt study being just olfactory, but the conclusion is the same: we can't entirely escape our evolutionary destiny, too much of it is unconscious.

35. "In My Country"

"In my country women of my age [36] always have Cesarean deliveries. They say it's safer for the baby." I told S that in our experience, women over 35 can delivery vaginally without putting the baby at risk. Then she explained that she is very anxious about labor and "just couldn't handle it."

It is not uncommon to receive and accept requests for scheduled Cesarean deliveries based on physical health issues other than a previous Cesarean, even though I often wonder if an underlying fear of labor may be the unspoken but stronger motivation. It's all out in the open with S: she acknowledges that it is all about anxiety and fear.

So is fear a valid reason for an elective Cesarean? Most of the health risks of Cesarean deliveries are for those performed after a long labor. There is not much evidence that a vaginal birth is safer than a scheduled Cesarean delivery. Easier recovery, yes; less expensive, yes; safer? perhaps not.

34. Pheromones

Women who live together may find that their menstural cycles synchronize, presumably due to pheromones (olfactory signals). This menstrual synchrony is generally accepted as real, though with many factors influencing menstrual timing, it may not be apparent for all groups of women living in proximity.

Now consider Mrs. H. who experienced a year without menses, which is the definition of menopause and totally expected for this 56-yr old. Then her daughter and family moved in with Mrs. H. and her husband. After a few months, Mrs. H's menses resumed, the timing synchronous with that of her daughter's menses. The daughter recently found a house to rent and may be moving out in a month or so. I'll be curious to see then what happens to Mrs. H's menses.

33. Grouchy

"Menopause makes me grouchy," she said.

Half-tongue in cheek I countered, "What makes your husband grouchy?"

"He's a guy, it comes naturally."

Actually the hormonal shifts of menopause do not increase depression or the irritability that is often the harbinger of depression.
Health issues that arise in the 50's (the knees, the back), kids leaving (or not leaving) home, careers of husband and wife at a plateau, and the earthly departure of friends and relatives--these are the triggers of acute depression. Along with existential angst as one considers, "is this as good as it gets?"

32. Breech

Near the end of the day I met K. for the first time. She is 38, about a month before her due date. Three years ago she adopted a Nepalese infant who suffered some brain trauma at birth (not sure whether or not K knew this at the time of adoption, I think yes, but not the extent). K thinks it may have been a vaginal breech delivery, a not uncommon source of birth injuries.

So of course she is worried whether this baby might be breech. My impression from an abdominal exam was that the baby was head first and I confirmed that with an ultrasound.

She was visibly relieved: "You've made my day."

"I wish it were always this easy," I noted. And we both laughed.

31: Pay Now or Pay Later

Eight states require insurance plans to cover in-vitro fertilization (IVF). Costly decision? Well, maybe not. Couples who pay per cycle (about $10,000) demand implantation of multiple embryos with each cycle, in order to lower total costs. While this may lesson the number of cycles necessary for a successful pregnancy, it also means more twins, triplets, etc., And that means millions more spent in neonatal intensive care units. The average cost of triplets is $300,000. These eight states have significantly fewer IVF multiple births.

30. Have You Thought About...

...going to Haiti? Yes, but my assumption has been that the need is for providers who have experience dealing with acute trauma, and that there have been more volunteers than the infrastructure can handle. To wit, the following comes from an email sent by a rehabilitation psychologist:

"Hi everyone. Just back from Haiti and I wanted to put forth a few thoughts to those of you who would like to volunteer… It is absolutely key and essential that ONLY people who have had large-scale and severe disaster experience go over at this point. Many of you know that I have been to Sichuan--have had many experiences with large hurricanes, Katrina, etc., but I cannot tell you how horrendous and very different this situation is right now… We were doing surgeries almost 24 hours a day....mostly amputations. Unfortunately many of the people who have had amputations have already become infected within a day or two of the surgery (remember essentially no aftercare)... The docs I flew back with came to the consensus that if 30% of the people they operated on survive, they will be lucky... Even the tsunami was in a country where you could find some infrastructure...somewhere. Here--there is nothing. For the first time in my life I truly had to consider [my own] survival …"

Other sources estimate tens of thousands of amputees, which will burden Haiti's health care for decades.

29. Foreign Bodies

T., a 29-yr old exotic dancer, doesn't want to have any more kids. She has three and thinks that's enough.

She tried an IUD, a T-shaped piece of plastic about an inch long that is placed inside the uterus. But then had it removed after several months because "it bugged me having something foreign like that inside of me." I restrain from making the observation that her breast implants aren't exactly natural.


So we decided on a tubal ligation, a day surgery.

"How long," she asks, "do I have to stay off of pot before the surgery?"
"Don't really know," I say, "how does 48 hours sound?."
"Good, that's what my boss says too"

Smart lady, getting lots of opinions before making a decision

28: Pulmonary Embolism

After several years of menopausal quiescence, Mrs. J's 60 yr old uterus erupted a few days before Christmas. What was the stimulant--stress hormones? More likely estrogen produced by adipose cells, of which Mrs. J has in excess. Whatever the source, too much stimulus can cause cancer, necessitating a biopsy, obtained last week.

Tonight I called her to explain the results: hyperplasia with atypia, just one stop short of cancer. I needed to tell her about my referral to a local gyn oncologist who will certainly recommend major surgery. Her husband answered, and I asked for Mrs. J. He paused and then slowly and quietly explained that she had gone to the ER last night, short of breath. And then died there. In the ER.

27. Zero-Sum Game

Ironic that tonight, while a sizable segment of America is salivating at the thought of defeat of health care reform, I'm on call for the ER. Two patients without insurance. One will have a shorter life because of delayed diagnosis of cancer. She couldn't afford a doctor despite telltale symptoms for several months. The other bleeds half of every month, receiving periodic transfusions in the ER, just enough to get her on her feet and out the door. Why does America think that health care is a zero-sum game: every benefit given to one means less benefit for another?

26: Ah, Now I Understand

Yes, I was annoyed when Dr. A called me on Sunday, asking me to come in to see a patient Monday morning (with the unspoken understanding that I would assume care for her). T. delivered six weeks ago (by Dr M), with a rare complication that required two subsequent minor procedures, one by Dr. M, the other by Dr L. She was later re-admitted by Dr J, and followed by Drs W., M, and A in the hospital. So why call me? Well, it seems that the patient made that request, having met me during antepartum visits. Well, of course--my unimpeachable bedside manner. But doesn't Dr A (or any of the others) have the communication skills to establish a relationship with patients in whatever setting? To make plans and carry them out? Whatever.

So we go to surgery, this time more of a final approach, gratefully not as difficult as predicted, and her uterus remains intact. Meeting her mother in the waiting room afterwards, I noticed a book peeking out of her handbag. Glenn Beck. Dr. A is black. It's not my bedside manner, it's the color of my skin.

25: the Token

Received an email last week advising me that I would shortly be receiving "The Token," and that I should carefully read the attached instructions.

Wow, am I being inducted into a secret society? Will it help me find the Holy Grail, or open the back door to Hogwarts?



No, it's just a security upgrade. My "remote access" allows me to review all of my organizations medical records, for its 500,000 current members plus several hundred thousand former members. So yeh, I understand the need for security. So when I log on, I'll need not only my personal password (which I have to change every 60 days or so) but also the token's 6-digit number, which I assume changes much more frequently.