65: OP#8/Malawi: day 14 continued

My final task was to leave my written recommendations for the molar pregnancy with Dr Te Haal.  He was home and accepted them without comment, then asked if I had a few minutes.  Rainier explained that Dr. M. who had diagnosed the molar pregnancy probably would not be staying long in Nkhoma because better opportunities existed elsewhere in the country (my impression is that newly graduated physicians were required to spend a few years in rural areas).  He further explained that Dr. M. had expressed an interest in Ob-Gyn and might be accepted in a South African residency whose director was a friend of Dr Te Haal.   Dr M then might be enticed to return to Nkhoma if there were funds to supplement his government salary of about $700 per month.  $700 is fine for food and housing, but for cars, gas, computers, etc., it doesn't go very far.

We all know where Rainier was headed.  Could I talk with colleagues who together might collect funds to make all this happen?  I appreciate how difficult it is to ask for money.  If I hadn't come over with my notes, this conversation wouldn't have happened. It's obviously something he had thought about, but the opportunity just hadn't arisen.  It may have been just taking the happenstance of my coming over and the impending departure, or perhaps my interest in follow-up may have suggested that I would be a good candidate for this request.  In an event, I said I would think it over.  And I have.

To do this right, I would have to link with an existing non-profit (to make sure any donations were tax deductable), or even form my own foundation.  A friend of my neighbor was traveling in Vietnam and started a conversation with a cab driver who was an unemployed teacher.  One thing led to another, and now this friend returns regularly to VN to drill wells for villages without close and safe water supplies, using the driver as his local connection.  He started a non-profit to support this work.  Am I up to anything like this?

64: OP#8/Malawi: day 14

Part One

This is the most difficult day to write about.  I had a 9:30 deadline for the airport bus, but before that I planned on some rounding and data collection and follow-up notes for the molar pregnancy.  I left early and saw a few patients then passed by L&D because I wanted to look at the delivery log.  The C.O. on call asked me about a woman in her first labor, pushing for about 30 minutes.  He asked about a C/S.  My exam showed more descent than one would expect after just 30 minutes--almost crowning (many unmedicated first labors push for 2 hours), so I said I thought she would be okay, but I would finish up some other business and return in half an hour.  I asked whether the baby was doing okay and was reassured that there were no problems, though I didn't personally listen to the fetal heart.  I finished rounding and returned to find that some progress had been made, but not much. After 15 minutes, there was sufficient descent to allow a vacuum delivery, which I felt justified because of uncertainty regarding the baby's status.  The delivery was quick and uncomplicted but the baby was limp at birth, in need of resuscitation.  Vigorous tactile stimulation did not help--no breathing and no movement or tone, so I took him to the warmer and prepared for bag oxygen (meaning that I'm squeezing a bag of oxygen into a face mask).  A nursing student listened for the heart beat and confirmed its presence.  After a few minutes of oxygen, first by me then more competently by a second C.O. who happened by, spontaneous respirations appeared.  But still no tone, no movement.

I had to leave, so left the baby under the care of the staff.  On the way back to my room I passed the American pediatrician and explained the situation.  She said she would call the C.O. and encourage him to proceed with the neonatal resuscitation protocol.  In this case, it would mean intravenous fluid and antibiotics and if blood tests showed anemia, then a blood transfusion, nothing complicated or new to the staff.  I don't know whether any of that happened, but a few days later the pediatrician e-mailed to say the baby had died.

[nb: all my other pictures are from Nkhoma, this one is from the net]

63: OP#8/Malawi: day 13

Word travels.  Sister Christina was so happy with her vaginal hysterectomy that Sister Elizabeth showed up wanting one too.  But her fibroids were too large for a vaginal hysterectomy, so she underwent an abdominal procedure.   A more difficult operation than anticipated, losing about 4 times as much blood as an average hysterectomy (as is common with large fibroids). Would have been a difficult vaginal hyst.  Also, Sister Christina has a post-op infection.  For all their advantages, vaginal hysterectomies have higher rates of infection.  I brought antibiotics with me that I gave her by injection (more effective than pills)..  

The second major operation today was another dermoid, this one straightforward.

Meanwhile, the vaginal hysterectomy from two days ago ran a high fever.  I thought bacterial infection; the nurses shook their heads and suggested a malaria screen.  Positive.  She did well with medications recommended by a C.O. (I'd have no idea how to treat her). She also received 2 units of blood for a hemoglobin level of 6.6 (very low, normal range 12-14).  It wasn't intraoperative blood loss--she started with a level of 7.3.  So this may have been a malarial relapse (prior malaria would explain her chronic anemia) or a new infection.  Hospital beds have nets, but I'm not sure how often they are actually used.

62: OP#8/Malawi: day 12

Postmenopausal bleeding can be a sign of uterine cancer or a precancer condition called hyperplasia.  At 71, the concern increases, so a hysterectomy was planned and accomplished.  In the U.S. a pathologist would perform a microscopic examination of the uterus and any lymph nodes that we might have removed (cancer cells found in the lymph nodes would prompt chemotherapy).  But pathology (and for that matter chemotherapy) is not available, so we'll just hope either that there was no cancer or that any cancer present had not extended beyond the uterus, making the hysterectomy definitive therapy.

A 31-year old in her first pregnancy underwent a cesarean delivery for severe preeclampsia, a pregnancy condition that probably has it roots in the very beginning of pregnancy when the placenta fails to adequately penetrate the uterine lining.  Found worldwide, the only cure is delivery.

And then a 30-yr old who had a cesarean delivery, with neonatal demise and then a serious wound infection.  For the next several days, I will removing the packing, clean the wound and repack.  She's on the open postpartum ward with healthy newborns all around her.

61: OP#8/Malawi: day 11

One of the young Malawan doctors came to me a few days ago with an ultrasound image that he had obtained a few minutes earlier from a woman 4 months pregnant. He asked me if I agreed that it looked like a molar pregnancy. Instead of a fetus within a fluid-filled gestational (amniotic) sac, the scan showed the classic “cluster of grapes” described in books that he had remembered from medical school.

A molar pregnancy is essentially a cancer of the placenta, usually managed with a “D&C” (dilatation and curettage), a gentle suctioning of the uterine lining.  This is followed by serial measurements of human chorionic gonadotropin (HCG, now of diet fad fame), which is only produced by a placenta.  If there is any of the “mole” left, HCG will show up on the blood tests, prompting effective and well-tolerated chemotherapy (methotrexate).  No HCG means the molar pregnancy was completely removed; no further treatment indicated

Worried that with this advanced gestational sac, the D&C might not entirely remove the molar pregnancy, I recommended hysterectomy.  This was an unplanned pregnancy; she's 42; an easy decision for both of us.

Surgery went well, but follow-up will be difficult.  The hospital has no HCG blood test and no readily available methotrexate.  I recommended weekly urine pregnancy tests, a less sensitive measure of HCG; if repeatedly negative, she's ok, if positive, someone needs to find MTX for her.

The surgical day continued with a repeat C/S and a vaginal hysterectomy for chronic heavy bleeding.

60: OP#8/Malawi: day 10

Sunday: early rounds, everyone is doing okay.

Looking over the surgical log June though September, with some notable absences:

No cholecystectomies (removal of gall bladder), which must reflect the low fat diet of sustenance farmers.

And just one hysterectomy, more difficult to understand.  Hysterectomy is one of the most common procedures in the U.S., and though granted that many may have marginal indications, the severe anemia and pain that can accompany uterine tumors (fibroids) should show up in the surgical log.  I don't think it's diet or genetic, plenty of fibroids in my other trips, and by the end of the trip I will have performed 4 surgeries for fibroids.  Don't know.

59: OP#8/Malawi: day 9

Up at 5 for a 4+ hr ride to bland, the "commercial" center of Malawi, for the annual medical conference sponsored by the country's only medical school. There was some concern that we would have problems with the nation's chronic gas shortage (due to low foreign reserves), but we were okay.  


Some of the topics:

1.  in a survey of Malawan doctors, 65% expressed "general satisfaction" with their work. A recent survey of American doctors found 80% agreeing with the statement, "I like being a physician," but the same survey showed that 30% would like to change jobs or professions.

2.  Current HIV treatment recommends triple drug therapy, Malawi can afford only one.

58: OP #8, Malawi, day 8

Another morning in the antepartum clinic.   Malawi has decided to discourage traditional birth attendants (lay midwives), even to the point of criminalizing their activities, because attempts to bring them into mainstream medical practice failed.  With 90% having only a primary level education and with increasing age, they apparently were unable to assimilate the public health information and practice changes promoted by the Ministry of Health.  At least that's the government line.

57: Overseas Project #8, Malawi, day 7

First, a vaginal hysterectomy today for a 33-yr old nun (self-pay and able to afford a room on the "private" ward--two beds to a room in contrast with the open wards elsewhere, and a higher nurse to pt ratio).

Then, a  myomectomy (removing 12 marble-size fibroid tumors, leaving the uterus in place).  She is 34, never been pregnant but wants to be.  She lives in South Africa but couldn't afford this procedure there, so she came home to Malawi for the procedure.

Finally, the excision of an ovarian dermoid cyst.  A dermoid cyst follows an ovary's attempt to clone itself. It gets as far as some hair, cartilage, sebacious goo, sometimes a tooth or nerve tissue but nothing organized or complicated.  

This young woman presented with an abdomen distended with ascitic fluid, usually associated with liver disease or cancer.  

When an ultrasound showed on ovarian cyst, we were concerned about cancer, but after surgical drainage of 12 liters of ascites we removed a benign ovarian cyst.  There was no consistent lab evidence of liver disease, and I later found no reports of dermoids associated with ascites, so this remained a puzzle.