162. Grumpy

From 59-yr old Teresa, when asked the usual screening questions about depression and safety at home: "I feel safe at home and I don't feel in any danger.  I know that he's not in good health, and he's just getting grumpier and becoming more stubborn as he gets older."

Old age?  His depression perhaps secondary to illness? Early Alzheimer's?  Or perhaps not a change at all, but rather the continued manifestation of a lifelong personality disorder that Teresa is just tired of putting up with.

161. Faaast Food

At over 6ft, Ronda carries her 240 pounds reasonably well, but still not surprising that in this fourth pregnancy, she screens positive for diabetes.  Her other pregnancies have gone well, so she finds it hard to get serious about this.  Not well controlled on a moderate dose of insulin, I ask her to keep a diet diary--everything she eats over three days.

She must have found a smart phone ap because she brings in a computer print-out, initially impressive though short on details (more of what she ate than how much):

1. Fast food ("I don't have time, I work, I take care of my family, I get up at 4 to drive my boyfriend to work.").  Okay, grant a hectic schedule. leaving  little time for food preparation.

2. No fruits or vegetables ("I don't like salads; maybe broccoli with cheese; or if I have my thousand island dressing").


3. Sugar soda ("I hate diet drinks--all of them").

Any suggestion I made was immediately countered--she's been through this discussion before.  Best I could do was an agreement to mix regular with diet soda, slowly increasing the ratio of diet to regular.

160. Cancer Phobia

A few months ago Helen's mother passed away from ovarian cancer; several years ago the mother had undergone surgery for breast cancer.  Most breast cancer is not hereditary, but the BRCA1 and BRCA2 mutations dramatically increase the risk of breast cancer, hence Angelina Jolee's decision to undergo bilateral mastectomy.  That Helen's mother tested negative for BRCA1/2 provided little reassurance: "There's breast cancer in my father's family as well."

So she wants to "take it all out," meaning removal of uterus, ovaries, and fallopian tubes.  Our offer to frequently screen with ultrasounds and not-that-accurate blood tests.  For now she's satisfied with waiting for the BRCA1/2 testing that her family practice doctor agreed to order (pending approval by a genetic counselor or will talk with her in a few weeks).

Even if this test is negative, I expect Helen to return with her request.  I don't think I could justify a hysterectomy, or even the safer laparoscopic removal of ovaries.  But first there needs to be more time between her mother's death and a final decision about surgery.

159. To BF or not to BF, that is the Question.

Breastfeeding--either directly or by pumping ("induced lactation")--has a list of benefits that grow with every review.  Breast milk components change as the baby's nutritional needs evolve; it contains antibodies that enhance the newborn immune system. It's easier to digest, and breast-fed babies are less likely to develop asthma and diabetes, or become obese.  And they have a decreased risk of Sudden Infant Death Syndrome.

But some babies just do better with a bottle, and filling a bottle with pumped milk is easier said than done for some women. Forget the psychological second-guessing; formula just works better for both Mom and baby
.

Kelly tried nursing, then the pump, but now just wants to formula feed. She denies depression, but feels stressed out by the pressure exerted by her family who want her to continue pumping. Do these people not know what it means to support a new mom? The difference between encouragement and badgering? Apparently not.

158. Stream of Consciousness

40-something Cynthia came in to talk about pelvic pain, but the usual questions about pain (exactly where, what triggers, how long, how disruptive) were soon sidelined by the following:

I'm unemployed... I just found out he's addicted to pain killers... I'm impatient with my daughter... He's kind of abusive... I don't want to go to hell.

157. Update on Helena: a tough call.

Looked good for a few days, with baby now head first, mom could look forward to a vaginal delivery (she has enough problems without having to recover from an operation).  But the baby turned around, and the doctor on call that day was concerned that another "external cephalic version" (the process of apply gentle pressure on the abdomen to turn the baby) could disrupt some uterine-placental vessels, allowing mom's HIV to transfer to the baby.  Helena's viral load (the technical term for the amount of HIV in her blood) was very low, her HIV well controlled by medications.  Low but not zero, so the doc's concern was justified.  So he recommended and performed a cesarean.  A tough call.

156. Tour de France

What do you think when you see a cyclist, football player or other athlete with an oxygen mask (not illegal since oxygen is natural, though some may object that 21% atmospheric oxygen is natural but 100% tank oxygen is not natural)?  The more the better, right?

Well, that's what neonatologists thought a few decades ago who gave premature babies continuous 100% oxygen. It turns out though, that high oxygen levels stimulate blood vessel formation--normally a good thing, but not in the retina, which such proliferation can cause blindness.

Enter Helena, who was born premature 34 years ago, given 100% oxygen and blood transfusions as well (premature babies are often severely anemic).  Fast forward: Helena is blind, HIV positive, and pregnant.  Oh, and as another consequence of prematurity, her cerebrospinal fluid doesn't circulate so she has a plastic shunt draining excess fluid away from her brain into the regular vascular system.  A couple of hours hard pushing could disrupt the shunt.  And did I mention she's breech?

Well, the baby was turned by one of my colleagues, and we are now waiting for spontaneous labor.

155. Mary Jane

58 year old Margaret has lost 25 pounds in the past 4 months.  Just don't have an appetite she explains, I prepare meals for my husband and start to eat, but then feel nauseated and can't continue.  She never vomits and has no history of recent trauma or depression, though today she appears depression (but of course what part is antecedent depression, or depression from uncertainty about her weight loss, or simply weakness from malnutrition?)

In the midst of an extensive work-up for this, I was consulted because of an incidental finding on an abdominal CT--the uterus looked a little funny.  The  uterus was fine, I decided, so my services were no longer needed.

But I thought I'd throw in my two bits: for example, protein shakes, sipped every hour or so throughout the day, with no expectations of sitting down and eating a full meal.  I thought about, but decided against discussing marijuana, known for it's anti-nausea effects for patients with chronic illnesses such as AIDs or cancer or who are undergoing chemotherapy.  

Her evaluation needs to be completed first, and then such a suggestion should come from her primary care team who knows her best and has her trust and confidence.  Still, though, what if no one else suggests what could be a significant, even life-changing treatment?

154. Time to Move On

The recent quarterly report of actions taken by the state medical license commission noted the license revocation for a doctor under whose care a mother and her twin babies all died from complications of preeclampsia (the same condition that led to the death of Lady Whatshername in Downton Abbey).  License numbers are issued sequentially so seeing that his license number is lower than mine, I can assume that his license was first issued well before 1982 when I first became licensed in this state.

Cut to the chase: did his age (60 or more) contribute to the mistakes he made in not preventing this tragedy, or did he just not know what to do (seems unlikely, this not being a rare condition) or was it unavoidable?  The commission did not go into details but clearly thought it was time for him to move on.

At a recent meeting, a 64 yr old colleague expressed uncertainty with a chart note, "patient needs TOC for CT."  Everyone else in the room knew that it meant Test Of Cure for Chlamdyia Trachomatis, i.e., the patient needs a follow-up test to see if her chlamydia infection was adequately treated.  I think this guy focussed on "CT" as in the xray procedure computerized tomography and was trying to figure out why someone need to be retested for an xray.

Does this cognitive inflexibility suggest an aging process, or just an off moment?  When I forget a scheduled meeting, I think, is this early dementia? When a younger colleague doesn't show, we say, oh that's just Bob again.

How do I know when it will be time to stop working, time to move on?  Hopefully before I tell a woman carrying twins, oh, your blood pressure's a little high, rest more and see me back in a week.

153. Breech

Worried about an after-coming entrapped head, we generally don't recommend breech (butt or feet first) deliveries. The head can be the biggest part of the newborn, and if it gets stuck with legs and trunk already outside, the results can be catastrophic.

Sandy is near term with breech presentation, being seen by a lay midwife (which means a home or other non-hospital delivery).  The latter recommended that she see us to discuss possible version (trying to turn the baby around before labor) and/or a CS.  

She failed to answer our attempts to call to make an appointment, and when I called the midwife to find out her current status, was informed that Sandy now may be seeing an unlicensed lay midwife known to attempt home breech deliveries.  The new lay midwife once had a license, but it was withdrawn after a couple of deliveries with negative outcomes and serious questions about her ability to provide appropriate care.

152. Floodgates

Early in his career, one my colleagues remembers greeting with mother-in-law with the standard, Hello, how are doing,"  expecting a return, fine, and how are you?

Instead, she replied, "the floodgates have opened," leaving him a little confused.  He later realized--perhaps with the help of his wife, that she was referring to the onset of a heavy period.

Like most phenomenon, menses follows a bell curve.  So though most women may describe a 4-5 day flow, a small group may experience 2 days of light bleeding, and an equal group on the other end of the curve may have 7 days of heavy flow, enough sometimes to keep them home for a day or so.

Lindsay has been bleeding for three weeks, never like this before and with no apparent reason.  She has lost about half of her blood supply. As a healthy 23 year old, she is able to tolerate this loss to a degree.  She can walk around but has a strong headache and could not deal with her job where she stands most of the day

If the bleeding stops and she tolerates iron supplements, her level could be back to normal within a couple of weeks.  But she has been offered a blood transfusion because another few days of heavy bleeding could lead to a life-threatening level. That would allow her to return to work. A temp worker now, she wants a full-time position and is worried that taking time off now (which she would have to do for a several days if she does not received a transfusion) would jeopardize this advancement. She says yes to a transfusion.

So we stopped the bleeding with intravenous estrogen and gave her two units pints of blood. The average adult has 10-12 pints of blood, so while two units will not put her pack to normal, it will take her out of the danger zone.

151. Judge Not

Cathy has been pregnant nine times: one child and 7 abortions.  Today she is in tears because she is pregnant again and an early ultrasound showed a small fibroid which she misinterpreted as meaning an inevitable miscarriage.  She really wants a second child.

150. Sticks and Stones

At 19, Ericka did not plan this pregnancy with her live-in, unemployed boyfriend, but she says she is okay with it.  At least until she became ill at six weeks (just a month after conception), with nausea, vomiting, diarrhea, and abdominal pain.  A little early for morning sickness, perhaps just a prolonged viral gastroenteritis ("stomach flu"). Or a combination of the two.

I met her for the first time this morning, her 4th day in the hospital.  Talking with a couple of the nurses, it appears that she has not had any visitors during these four days. With a couple of intravenous anti-emetics (she refuses to take pills), she was able to eat for the first time this morning. She wanted a burrito but a nurse limited her to some applesauce and similar soft foods.  A few hours later, she was throwing up again.  

I need to talk with her, but she hides her face in the pillow and complains about the light when I open the door to her room.  I don't want to talk, she says, I just want to sleep.  I tell her that I need to have a serious discussion about other treatments. Because she talks so softly, I bend on my knees (no chair available) to get close enough to hear her responses.

"You're creepy, staring at me like that." 

Accepting my dismissal, I told her I'd be back in a few hours when she might be feeling better.  As I left I could hear dry heaving in the background.

149. Insurance

Usually when we consider the non-insured, the non- or under-employed come to mind.  But not always.

At 37, Trish and her husband have no insurance for delivery and only high-deductable for non-pregnancy care. She is an attorney and her husband a family practice doctor.  If they were employed by a large system, say a hospital or a large legal firm, they'd have insurance, but as solo providers, they have opted for a high-deductable individual plan.  

Anything else would be very expensive even for this double-employed couple.  Remember that not all lawyers are millionaires and family doctors are at the low end of doctors income scales.

"She is very concerned about the cost of everything," notes the midwife she sees, explaining why she is having blood drawn at her husband's office.  She will not ask for extra (but not necessarily indicated) ultrasounds and she's hoping for a less expensie vaginal delivery (first child was cesarean).  

We feel uncomfortable with patients or doctors making decisions based on financial reasons, but maybe that's the only way to control medical costs.

148. Mother and Child

At 79, Ellen has a prolapsed bladder (see post 107).  Won't shorten her life, but uncomfortable, irritating her bladder, preventing normal activity.

There is a surgical fix and a pessary, the latter a silicone ring placed in the vagina, acting as a dam holding back the bladder and/or uterus.

Size is important.  A pessary too small falls out; too big and it becomes more uncomfortable than the prolapse.  Sometimes we just can't find the right size and turn to surgery.  And so it is with Ellen.

We plan surgery, and in the course of discussing postop care, I told her that for a month or so, she will have to avoid heavy lifting.  That may be difficult she replied. My 60 yr old son lives with me; he has mental problems and sometimes puts the recycling in the regular can and the other way around, so I have to go and make it right, which means bending and lifting

147. Momentum

In the final month of her pregnancy, 26-yr old Dolly experienced a "loss of vision" while driving. She managed to pull over and call the consulting nurse who told her to go to the urgent care clinic (instead of labor and delivery?). Urgent care called me, noting normal vision and normal blood pressure (one of the complications of the auto-immune disease involves hypertension). Send to L&D, I recommended, which they did.

I opened her chart: 4 prior pregnancies, all uncomplicated, moderate anemia (low blood count), and a recent diagnosis of an auto-immune disease, based on lab tests but not on actual symptoms.  Symptomatic auto-immune conditions increase risks of pregnancy complications.

L&D called me in my office, said the baby looked fine, normal blood pressure; OK, I’ll be there in about 15 minutes. Five minutes later, I got a call saying we need you right away, the baby’s heart rate has dropped. I was there in ten and found Dolly in the OR being prepared for an emergency cesarean, a decision made by another obstetrician who had been consulted in my brief absence.  He thought there might be a placental abruption (premature separation of the placenta, which leaves the baby without oxygen).

The baby’s heart rate was 80-100.  Normal is 110 or above, with rates in the 90-110 range considered tolerable for the short-term.  So no immediate crisis.  I put a hold on the proceeding, waiting for her to receive a full liter of intravenous fluid, which can revive a compromised baby. Waiting with me in the OR were two neonatal intensive care nurses, the anesthesiologist, two labor and delivery nurses, the OR technician, and the midwife who assists me with cesarean deliveries.  And of course the patient, who is freaking out. With the baby’s heart remaining low, but not critical, I decided to proceed with operative delivery. Too many unknowns--the visual thing, the prior diagnoses, the uncertain meaning of the fetal heart rate--and of course the momentum of a process set in motion 10-15 minutes earlier.

A vigorous baby with no sign of placental abruption or other problem, but over the next hour was noted to have a resting heart rate of 90-110 instead of the expected newborn rate of 110+. Add hypoglycemia (the patient had not eaten for about 10 hours at the time of the surgery) and her even lower blood count (blood drawn at arrival to L&D but not available until after the surgery).

So a combination of hypoglycemia, low blood level, and the baby’s naturally but not abnormal low resting heart rate contributed to what seemed like an emergency.  An unnecessary cesarean?  Maybe, maybe not.  But given the uncertainty and the momentum, pretty much unavoidable.

146. Second Sleep

At the end of the visit, Tim nudged Svetlana.  Go ahead, he said, ask about it. Fatigue, she said, I'm tired all day.

Okay, good question.  Experts tell us that 35% of the US population sleep less than 7 hours per night, and that falling asleep at the wheel accounts for up to 20% of all traffic accidents.

So I ask, how many hours do you sleep at night. 

"5-6"

Tim works swing shift, getting home around midnight.  She stays up for him; they have a meal, the she sleeps from about 1-6am, getting up at 6 because, basically she's a morning person.

5 to 6 hours sleep per night is not enough.  Forget about this celebrity or that who thrives on 4 hours per night. Most of us need at least 7, probably would do better with 8.

It's okay to break up sleep, I said; sleep from 10 to midnight, or nap during the day.  Find what's best for you.  Before electricity many societies pracrticed a second sleep: going to bed with dark, then waking again for a few hours around midnight before returning to sleep.

145. Oh, Yeah

Svetlana and Tim came in to talk about infertility.  They have both had children from prior relationships; sexually active without contraception; she has regular menses suggesting ovulation; no history of pelvic infection that would block fallopian tubes. So far so good. Anything else, I ask?

Oh, yeah, Tim just had a vasectomy reversal.

What?

The average couple, with no health problems, takes about 7 months to conceive.  If seven is the average, then even a year or so of trying without conception does not imply an infertility problem. Umm, come back in a year, I suggest.

But not a wasted visit.  We talked about timing of intercourse.  Generally, a woman is fertile three days a month (since both sperm and egg are viable for about a day; do the math), so a worthwhile discussion.

Although there are various ways to determine ovulation, it's not exact. So assuming a 28-30 day cycle, I recommend that starting on day 10 of cycle (first day of bleeding is day #1), have sex every 2-3 days for 10 days. Every day would be depleting; four days of abstinence might miss the three day window.  Actually to keep it simple, I usually just say, every other day. At which point Svetlana winced.

144. Not in My Lifetime

At a conference the other day, an expert (he's written a book!!) on medical economics, was asked what he thought about the potential for a single-payer medical system for the United States.

His reply, "Not in my lifetime," appears on the surface a dramatic but safe prediction, though on further reflection might ought to be avoided especially given its association with predictions about integration, marriage equality, and the election of a black president. In general, one ought to be careful with predictions about health care.

The largest medical plan in the country (Medicare/Medicaid) is already single-payer.

The country most like us (Canada) is single-payer.

And one state (Vermont) has made major steps towards a single-payer plan.

Is this dude planning an early departure from the world?

143. Burnout

So... you're in a doctor's waiting room reading a handout introducing you to the practice, where the doctor went to medical school, his or her special interests, and finally the observation that the doctor has lost his/her enthusiasm for medicine, feeling cynical and unaccomplished. How would you feel? Like leaving and finding another doctor?

If your visit is in an ER, an ICU, or a family practice or ob/gyn office, chances are about 50/50 that your doctor would report at least one of these signs of burnout. These four specialties top the list; least likely to have burnout are pathologists and psychiatrists (though still over 30%).

We know the effects of burnout on the doctor: increased rates of suicide and divorce, for example, but what about the effects on the care that they provide? Worse because they just don't care enough to go the extra mile; or better because they are better able to empathize with patient who are experiencing similar feelings?

Many experts fear the former, as the American health care system is strained by increasing patient loads with Obamacare and the difficulty that medical schools face in replacing retiring physicians

142. Cybermedicine

"I didn't go to school until 30 to be a typist."

"I spend an extra hour every night because of EPIC."

"The only people who like electronic medical records are those who sell them."

Luddites notwithstanding, electronic records such as EPIC promote better care for a number of reasons. Hand written records are easy to lose or are unintelligible. Computer systems allow for data collection and alerts (if a provider attempts to prescribe a medicine to an elderly patient whose age places her at higher risk for side effects, the screen flashes, "Are you sure....?")

Yesterday: a patient has an X-ray, the radiologists dictates the report, which takes a few days to transcribe, and a few more days to make it to the patient chart.  

Today, the radiologist uses voice recognition software, so that by the time the patient has walked from the xray room into my exam room, I have already read the report.

the legend is fuzzy, but the states in dark blue (Hawaii, Washington, Oregon, Utah, etc), have a "significantly higher" use of electronic medical records; as for Florida, Louisiana, Kentucky--well, what can I say?

141. Papal Influence, part 2

And....     the hospital pharmacy will now carry drugs and devices (birth control pills and IUDs) generally prescribed for contraception but having other uses as well (e.g., alleviate abnormal uterine bleeding).

Of course the assumption is that such prescriptions will cite these other uses.  But another loophole to be sure.

140. Fast Work, Frank

Pope Francis has been in office for only a few days, but already his influence has reached the shores of the Pacific.  The local Catholic hospital is easing up its rules on elective sterilizations, a Catholic no-no (perhaps not quite the "machination of the Father of Lies" as the new Pope has characterized gay marriage, but still verboten).

Routine (i.e., no advance approval required) tubal ligations have been allowed at this institution only if performed in conjunction with a cesarean delivery.  In my limited experience, this has been the case in other Catholic hospitals run by nuns; in those under the direction of priests, no tubal ligations under any circumstances. The principle is that if the woman were to have a tubal ligation as a separate procedure in the future, that additional procedure would carry more (albeit negligible) risk to her health than by doing it at the same time as a cesarean delivery.

Now any procedure can be included under the same generalized exception: "surgical sterilizations not needing prior approval... existing medical condition requiring surgery and/or treatment modality that increases health risk should the patient become pregnant the tubal ligation becomes medically necessary [sic]."

Two loopholes here (yes, you can drive a truck through them).  First, the phrase "increases health risk" as opposed to the "risk to life" that is the usual exception to Catholic health directives.  Second, before just cesareans, now, you name it, as in, "while we're removing your ingrown toenail, would you like your tubes tied?"

139. Takeo Eight: Wrap Up

So, about a hundred cases.  Four general surgeons did mostly hernia repairs, with some partial thyroidectomies, and one mastectomy (which may or may not be curative for a large tumor present for a year and with no options of chemotherapy).  

The two gynecologists saw mostly prolapsed uteri, a combination of poor nutrition (weak ligaments), heavy work in the fields (heavy lifting), and for some many births (though the average operative patient had just two or three births, again poor nutrition's effects on fertility or perhaps many war widows).  Also, a couple of uterine fibroids, ovarian cysts and an exploratory surgery for an ectopic pregnancy based on external ultrasound, which "strongly," but in the end mistakenly suggested ectopic pregnancy. 

I did 10 cases over 5 days, which is about what I had planned for (I brought ten pre-sterilized surgical packs with drapes, gowns and "lap tapes"--think small wash cloths).  We had more than enough supplies and medications and in fact left much behind for hospital use.

The only organizational disappointment was lack of pre-screening, which put us behind a day, but not more than that.  On other trips lack of pre-screening has had a much more negative impact. Within the surgical team, many working together for the first time, communication among the staff couldn't have been better; I'd work again with any of them, docs or nurses, anytime, anywhere.

Finally, we used almost no narcotics for postop pain.  Other missions have had limited amounts of narcotics.  We just provided ibuprofen and.... ice.  Families would go out and buy block of ice which would be wrapped and placed on the patient's abdomen. Just based on my visual observations, I don't think these patients experienced any more pain that what I see with patients who have immediate access to various narcotics.

138. Takeo Seven: Pride

Given that Americans have made such incredible blunders under the banner of pride, let's give some slack to our hosts.  Often unwilling hosts.  Sure, local political and ecclesiastical leaders may ask us to come (well, maybe better said responded favorably to our requests to come), and perhaps hospital administrators as well, but the front line staff seem less eager to see us. Some may view us as adding to their already busy, poorly paid days.  More rooms to clean, instruments to sterilize, crowds to handle.  

And medical staff: do they ask our opinions on difficult cases, request lectures, or ask to watch surgery, to learn new techniques?  By and large, nope. At the end of the week, we heard (warning: second hand info here) that in a new wing of the hospital, there were new and better equipped operating rooms. That's okay, why should they suspend their schedules to give us free rein? The staff doctors didn't even know we were coming, the hospital administrators curiously keeping that to themselves.  Or maybe they did know, but said they didn't to justify their wariness.

And then there's Halothane.  Since Queen Victoria used ether during childbirth, anesthetic gasses have come a long way. Introduced in the 1950s, Halothane is cheap and has a positive side effect as a bronchodilator (relaxes airway muscles), but because it's slower (slower to sleep, slower to wake up), and because of rare cardiac complications, it is not even available in U.S. Cambodia, on the other hand prohibits the use of any anesthetic agent other than Halothane. This could be a pride issue--rather than admit it can't afford the other agents, the latter are simply outlawed--or it could be a reasonable attempt at cost control. Maybe something we could learn from. Darn it, there's that pride thing again.

137. Takeo Six: For Me?

Left: student Botha; Right: team RN

As happened in Mozambique (there fortuitious, here planned well in advance), medical students served as translators. I think they learned a lot, their studies not having yet exposed them to patients. I was explaining preeclampsia to one and drew some diagrams. Finished, I handed him the drawings; he looked surprised and asked, "For me?"

Three medical schools, two private schools teaching in English and the French-speaking government school, serve Cambodia's 14.8 million population. Private school tuition $1000 per year, going up to $2500 next year, they tell us. Combined, the three schools graduate about 150 new doctors per year every year, so one per 99,000. Compare that with America's yearly class of over 17,000, or one new doctor per 18,000.

Medical economists don't think that's enough to replace physicians who are retiring earlier than predicted, or who have cut back their hours. 

That retiring issue--not so much a problem in Cambodia, since many (most?) of retiring age physicians did not survive the Khmer Rouge brutality.

136. Takeo Five: Local Support

We try to bring our own supplies, personnel and meds, but are still rely on local facilities for OR rooms postop beds, and night nurses (I haven't seen any teams bring their own nurses for care of postop patients at night).

This hospital had the best night nurses I have worked with: reliable, knowledgeable, and good at documenting their care. The ORs have relatively new anesthesia machines (which means ability to monitor heart rate, oxygenation, and flow of anesthesia gasses). Overall, better facilities and support than I have seen elsewhere.

Interesting bed, you're thinking, but where's the mattress?  See the straw mat--that's it. And note the stacked porcelin dishes under the bed--families bring food.  Finally, the red pail? A chamber pot.  Yes, a chamber pot; patients stand up and pee at the side of the beds, which are of course in open wards. There is a squat toilet down the hall, but for postop patients not yet able to walk that far, if they can just stand at the side of the bed, they use the pot. When you think about it, not that much different from the bed side commode we use in the States.  Sit or squat, behind a curtain, or not, it's all relative.

135. Takeo Four: In the Spotlight

Two scrub assists, each ready to go

Yesterday we had two tables set up in the same room (a common practice for overseas teams); it's a large room and although sometimes a bit noisy and hectic, works out.  Infection control freaks will object but for the low risk (infection-wise) procedures that we are doing, this is not a deal-breaker.

The room has just one overhead spotlight, but otherwise well lit, and I have my head spotlight--an item researched and bought for me by my son.  Similar spotlights are found from Costco to REI, for night bikers, hikers or campers, but adaptable to the OR, though my light has the advantage of being more focussed. So I didn't mind the overhead light being used by the other table. I was overoptimistic: the first case (see yesterday), didn't have the best lighting and I initially thought just wasn't up to the task at hand.

Then a "duh" moment.  My batteries! Almost dead. So I waited for the other table to finish (just a few minutes) and had the overhead light moved over.

Later I replaced the batteries and noted that the dead batteries were the original, now a couple of years old; with new batteries I had all the light I needed.

Lesson: start trips with new batteries or newly charged batteries in spotlights, cameras, whatever.

134. Takeo Three: Blood

Last year I posted on the difficulty I had in Guatemala because the anesthesiologists were reluctant to do hysterectomies without a blood bank immediately available. I've heard  this debate in conferences. For elective (non-life threatening) surgery, why take the risk of a dying because of blood loss?  But "elective" is a relative term; a day to day functional disability may not be life threatening but still makes a reasonable candidate for surgery.

Haun is a 51 year old who presented with uterine prolapse: the uterus has pushed down into the vagina, turning the latter inside out.  So part (or rarely all) of the uterus is hanging outside the vagina.  Uncomfortable as tendons stretch and the vaginal skin--not made for such exposure--is raw and susceptible to bleeding and superficial infection.  A vaginal hysterectomy for prolapse is not difficult and rarely presents with bleeding complications.  

But this hysterectomy was problematic from the beginning.  It was difficult to separate the uterus from adjacent tissues, I had inadequate lighting at the end of the case, when it's most important.
An hour postop I was called to see the patient in recovery for bleeding.  Light bleeding is okay after this type of surgery, but this exceeded normal expectations, so I placed some packing in side the vagina.  Apply pressure to stop bleeding, right?

Well, not in this case; bleeding continued and we returned to the OR, reopened the vaginal incision and immediately found a small artery bleeding.  Not much, but like a leaking faucet, builds up overtime.  A single suture easily stopped the bleeding, the vagina was reclosed.
We had checked her blood level before returning her to the OR; it was low so she received a unit of blood.  The next morning there was no further bleeding but a recheck of the blood level suggested another unit would help her recovery and so received a second unit of blood.

Lessons?
1.  Blood bank or not; always proceed with extra caution; the first time bleeding was noticed, she might have been returned to the OR
2.  Check blood level before surgery; she may have been low at the beginning and therefore not a good candidate for surgery
3.  No surgery without an immediately available blood bank?  Not so sure about this but certainly this case is an argument for this conclusion.  However, some remote areas will never have available blood.  Does that mean those areas can never receive gyn surgical teams? "First do no harm" says no surgery in these areas. Reality says, think about it.

133. Takeo Two: Baby David

Within a few days of conception the placenta invades the uterine wall.  Maternal and fetal blood vessels don't directly connect,  but as tiny capillaries from each system develop side to side, oxygen, water, nutrients and (from the fetus) waste products easily pass back and forth through thin vessel walls. 

It appears that early malfunction of this process may be the root cause of preeclampsia, the major cause of maternal mortality in the U.S. and second in the developing world (after hemorrhage). Symptoms usually don't appear until the increasing demands of late pregnancy stress the system.  The disease process can involve different organs: brain (seizures), liver (bleeding disorders), kidney (swelling, high blood pressure), and placenta (poor fetal growth).

So when 27 year old Kaun arrived at the Takeo hospital at 36 weeks with high blood pressure (173/117), massive swelling (lower legs looking like elephant trunks), Kaun's diagnosis was easy and the treatment straightforward: immediate cesarean delivery. 

Linda in grandma's arms; David is with his mother

She had been experiencing the swelling for a couple of weeks, but hadn't come in, we think because of she couldn't afford to.  Perhaps she heard that our free clinic was in town, so she came on the first day.  She did have some prenatal care, enough to know she had twins and hypertension, but did not have access (for whatever the reason) that either diagnosis would warrant. The surgery went well with the delivery of a 2.5 pound girl and a 4 pound boy.

During the first night Kaun experienced seizures with no apparent harm.  In the U.S. intravenous magnesium protects against seizures, given continuously from diagnosis until 24 hours postpartum; she received all that we had in a single dose, only finding out later that the hospital itself had magnesium, which the local night nurses knew and used, though only in response to seizures, not as a preventative measure.

After the first night, Kaun's blood pressure stabilized, her urine output increased (necessary to get rid of the extra fluid before it ends up in the lungs). Lower leg swelling continued, but with the placement of compression stockings and truly elevated feet (not just propped up in bed but higher than the level of the heart), swelling dramatically decreased.

Dad and Auntie with Twins

The main issue for the kids is not prematurity (36 weeks is about average for twins), but growth. At 2.5 pounds, baby Nancy had severe intrauterine growth retardation (IUGR) --the placenta just wasn't delivering. Once born and no longer dependent on placenta, IUGR kids should do okay. But feeding can be a problem. It takes a lot of energy to suckle, and 2.5 pound babies don't always have the energy reserves. They consume more calories nursing then they take in so need to be feed with tubes, eye droppers or gravity fed bottles. But miracles (a word I don't use easily) happen, and a few days later Mom, Dad and babies went home, all doing well. 

Kaun asked one of the nurses to name the babies, the result being David and Nancy, after the doctor and midwife who performed the surgery.  She also asked how much they owed us.  Nothing we said, and to carry this point further gave her some money so the babies could be seen in follow-up in a few days, otherwise they would not be able to do so. What else can you do?

132. Takeo One: Full Circle

This blog began three and a half years ago with a story of a Cambodian woman who gave birth while fleeing the destruction of the Cambodian-Vietnamese War.  Initiated by the Khmer Rouge, they were soon overpowered by the Vietnamese army, who installed a puppet government. Decades would pass before Cambodia knew peace.

Two to three million Cambodians died during the 4 years of Khmer Rouge rule, including this young boy whose picture taken in the S-21 prison, where 28,000 prisoners were interrogated before taken to the "killing fields" where they were executed and dumped in mass graves. No one survived this particular prison.

Today our medical team arrived at the rural hospital in Takeo, not far from the Vietnamese border. No one mentions it, but I wonder if some of us are looking for an atonement of sorts, since it was American bombs that helped destabilized Cambodia, opening the way for Pol Pot and the Khmer Rough.

First day, over 1200 showed up for the free dental, eye, medical and surgery clinics.  Most too poor to avoid private care; and public care rarely accessible. The Bhuddist monk is there for crowd control. Police may provoke fear, but the tremendous respect shown to monks allows them to easily handle the large number of waiting patients.

131. Stroke

Alma's Her husband had a stroke in December and returned home after a 3-day hospitalization. Irritable and argumentative, he has blamed her for his stroke, though she thinkss it was because he stopped taking his blood pressure medicine years ago.

Stroke, also known as CVA, for cerebral vascular accident, occurs when small blood vessels in the brain either rupture (20%), leading to the death of adjacent nerve cells now deprived of oxygen and glucose.

We think of strokes as causing paralysis, usually one-sided, or speech impediments (pronounciation, word-finding difficulties, etc.), but for many, the damaged area involves emotional centers, with consequences that Alma is experiencing first hand.

130. Mandatory?

28 weeks gestation, just entering the last third (trimester) of pregnancy: time for a final set of blood tests, screening for anemia, bladder infections, and diabetes.

Now 31 weeks, Rhonda feels a little guilty about having failed to have this done, writing in an email:

"I apologize I forgot abouty lab work that you ordered.  Are those labs mandatory? Being that im scared of needles if the labs aren't mandatory, can I not do them?"

I replied, also by email,  that nothing is mandatory (was I a little condescending when I said that?), but there are reasons for the blood tests, looking for treatable conditions that pose a risk to mom and baby.

129. FDA

56 year old Jean considers herself knowledgeable in pharmacologic matters, with 9 daily prescriptions meds and who knows how many supplements. But I had forgotten this when I saw her for her six month follow-up of uterine cancer (an early pick-up, common for this cancer, makes recurrence highly unlikely) so I was unprepared for her response when I noted that the FDA has recently approved a new approach for her overactive bladder.

“The FDA“ she sniffed, “Don’t get me started on the FDA.”  Though curious, I felt duly warned and chose not to pursue this subject, nor did she offer more, and we moved on to another topic: her request for my opinion about green coffee bean extract for weight loss, an item brought to her attention by Dr Oz.

So if any one asks what Dr Oz and I have in common: we both rank above the FDA... at least for Jean.  

128. Sympathize, Offer Info, But Don't Argue

27 year old Beth and I spent about half an hour discussion her plan to delivery vaginally after a previous cesarean deliver (VBAC).  Her first labor was long, she pushed for a couple of hours, but in the end it appeared that the 8.5 lb baby was just too big.  Second babies are usually larger, and she has gained over 40lb, so what are the chances that this one will fit?

Current recommendations would have her schedule a repeat cesarean.  Most complications from a cesarean delivery occur when there has been a long labor preceding the delivery.  And a long labor increases the risk of the previous scar breaking open.  This uterine rupture, not surprisingly, can be catastrophic for mom and baby.

If she had a previous breech that required a cesarean, and this baby was head-first and appeared average weight, then a VBAC would not be discouraged.

So we talk, and she continues to express desire for VBAC, but did agree to reconsider (at least I think she agreed to reconsider).

Then I noticed that she had refused both flu vaccine (safe in pregnant and important since pregnant women experience higher rate of complications from the flu) and the Tdap (whooping cough, diptheria and tetanus) vaccine, which can be deadly if the newborn (who can't be vaccinated for several months) picks it up from a family member.

Had I noticed this earlier, would I have changed my approach?