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.