182. Pardon me for asking

Randy has scheduled a vasectomy 3 days before his wife's scheduled cesarean delivery.  When a prior provider suggested that the time may be not be optimal, Randy, a trial lawyer, said he had a six week trial starting in January and just couldn't take time off.

But I'll have to give him credit: in the same setting, most dudes would tell their wives, you're having surgery anyway, you do it.  Which attitude aside, does have it's point, a cesarean tubal ligation has fewer complications than a vasectomy, and does not make the cesarean recovery any more difficult.

181. Proactive

52 year old Lisa, on the other hand, has decided to learn from history, so as not to repeat it, as they say. During a recent exam, I thought I felt an abdominal mass, until I realized I was just feeling her abs.  I noted my observations and she said, yeah, I do core exercises all the time.  My mother had ovarian cancer, and she broke her hips just getting out of her chair. She just sat in the chair all the time. Go Lisa.

180. Fate

Theresa is 38 years old, never pregnant and not sexually active.  She is overweight, hypertensive, and pre-diabetic, without much evidence from the clinical records of much progress in managing these issues, but she did come in for cervical cancer screening ("Pap smear"), which was abnormal, prompting an office procedure called colposcopy--that's where I come in.

Pap smears screen; colposcopies confirm. 

The colposcopy begins with application of acetic acid (aka vinegar), which causes proteins to denature/precipitate, forming small particles that reflect light straight back to its source instead of scattering the light.  The examiner thus sees white, which is biopsied (a small--about 1/16th inch--sample is removed for microscopic evaluation). This contains more cells than the brushings of a Pap smear.  More cells = more information = more accurate diagnosis.

Theresa's biopsy showed cancer, early enough for successful treatment--she will do well. I was struck by her attitude with the news; as if she totally expected cancer; just one more health problem that fate has decreed for her.

179. Please, Mommy?

When I came on call Friday I looked at my schedule and saw a D&C (dilation and curettage) added to my schedule for 1:30, a miscarriage.  I looked up the chart and saw that Emilia also underwent D&Cs for miscarriages in 2013 and 2011.  

All told she has experienced 6 miscarriages and one life birth. The most recent miscarriages may be related to her age, 42, but there may be some other factors to explain so many.

She tells me that she didn't really want to try another pregnancy, but her daughter keeps pleading for a brother or sister. But this is it, she tells me, not again. I want to believe her.

178. Dead Poets Society

28 year old Samantha is about two thirds the way through her first pregnancy.  I always ask about work issues that may impact antepartum care; she told me she loves her job as a high school language arts/creative writing teacher, a career she attributes to an inspirational high school teacher.  

We also talk about two other issues noted on her problem list. She has had problems with "substance abuse" in the past, but is not shy to tell me that she will be two years sober in October.

And there is a history of depression, a subject which when raised brings tears and a choked admission that, "I'm having a real hard time with Robin William's death."  She's not alone.

177. Mission Accomplished

I like to know something about patients, more than just the "what can I do for you today." I asked Yolanda, age 39, about her family. She said she had two teenagers and a 20 year old.  Is the 20 yr old still at home?  No, he’s serving a mission for our church in Florida.  Well, I replied, that’s what I did many years ago in Brazil.  

She had come to the office after experiencing some abnormal bleeding for about 9 months; I assumed hormonal imbalance, but to exclude the much less likely uterine cancer recommended a routine endometrial (uterine) biopsy.  But the exam expectedly suggested cervical cancer. She’s not had a Pap smear in 10 years--no insurance. Regular Pap smears would have picked up an earlier and easily treatable “pre-cancer.”

Two days later I have the results: cervical cancer confirmed. I don’t normally have patients return for just a discussion of results ($20+ copay and a half day missing work just to be told, “everything is normal”).  So I call her with the news; silence then some crying as I explain and try to reassure.

So whenever an anti-Obamacare guy starts complaining about the surfer who expects free health care for his chronic ear infection, I’d like to direct the conversation back to Yolanda and her missed Pap smears.

176. Decision-Maker

Several years ago Myra delivered a healthy 7 pound girl; a couple of days ago she presented at one week after her due date with spontaneous rupture of membranes.  Labor progressed slowly, augmented by the contraction-stimulating hormone oxytocin (Pitocin).  Fetal heart monitoring was abnormal with several episodes of bradycardia (heart rate less than 110 for more than three minutes). Bradycardia prevents inhibits normal delivery of oxygen to vital organs.

Each episode resolved spontaneously, but the concern remained that the next bradycardia might persist, causing permanent damage.  Severe bradycardia (less than 60) cannot be tolerated for long; even a fetal heart of 100 or so can result in fetal harm if continues more than 30 minutes. So we faced the decision whether to interrupt labor by performing a cesarean delivery.

We hesitated because between the bradycardia episodes the heart monitoring was reassuring (no subtle signs of fetal distress) and because labor was progressing. We became hopeful when she made it to complete dilation but the first push triggered another bradycardia. At about 8 minutes into this episode, we recommended and Myra accepted cesarean delivery.  The baby was vigorous at birth, with no explanation for the bradycardia. 

Based on the exam (the baby’s heady was well descended into the birth canal), and her prior delivery (proving an adequate birth canal), I estimated that a vaginal delivery was only 10-20 minutes away. If she had requested a continued trial of labor, I would not have objected.  But she didn’t. It’s a joint decision--in the current parlance, “shared decision-making," and that 10-20 minutes could be devastating.

175. No Doc Call

Amy’s new partner not only donated sperm but also herpes virus, which became manifest when she entered labor, requiring a cesarean delivery (by a covering doctor she’d never met) to protect the newborn--neonatal herpetic encephalitis can be devastating if not deadly.  Too bad after 6 prior vaginal births.  But that was just the start of her problems.

First, postpartum hemorrhage, requiring a return to OR to control bleeding. Six units of blood transfused.  Then a blood clot in her ovarian vein, extending into the inferior vena cava. Hospitalized 10 days for anti-coagulation (blood thinners).  Sent home still bleeding.  Returned in two days when bleeding increased.

This is where I come in.  The same doctor who delivered her is again covering for her doctor, but she refuses to see him, so the ER calls me as the doc assigned to see patients without local doctors (aka community call, aka “no doc” call).  

She receives another two units of blood and responds to “uterotonics” (drugs that make the uterus contract; her overused uterus just can’t do the job on its own), meaning we don’t have to take her off the blood thinners, which would be a risky venture. Nor does she have to return to the OR for a hysterectomy, another risky option.

And yes, she did get a tubal ligation at the cesarean delivery. 

174. Primum Non Nocere, Part Two

Well, we made it to Singapore.  By arrival, his blood pressure had decreased slightly, to about 219/118, and his oxygen saturation level remained at 100%.

A medical team was waiting for us, but initially couldn't even make it up the aisle because the minute the plane stopped, passengers filled the aisle, pulling down suitcases, ignoring the flight attendant's timid request to remain seated.  So I stood up and very loudly (but not to the yelling state) said, "Everyone please sit down to make room for the medical team. This is a medical emergency."  That did the trick.

The medical team had three people, with a stretcher and a medical bag. A young man in an impressively neat, tailored white shirt and tie, presumably the equivalent of a paramedic, was clearly in charge.  I told him what I knew, and he proceeded with an initial assessment of heart and lungs then quickly inserted an IV (just like in the movies). 

Then he opened up the defibrillator kit (which can provide an electric shock to convert arrhythmic heart patterns to normal rhythms, arrhythmia a common consequence and/or cause of cardiac arrest).  But wait: he has a normal pulse, is breathing regularly, and is fully oxygenated (so clearly the heart and lungs are doing their jobs).  So why the defib? The defib routine begins with electrodes that are placed on the chest to provide an analysis of the heart's rhythm. Though skeptical of the need for this (why delay the transport?), I grant that uncommonly an arrhythmia might be present but undetected by a stethoscope exam (not that he asked for my opinion).

If the defib machine were to pick up an arrhythmia, it would verbally prompt the medical attendant to push a button to administer a shock.  In this case, with a normal heart rhythm demonstrated, the verbal prompt instead said, "begin chest compressions." Having just confirmed a normal heart beat, why would the machine's algorithm do that? Anyway, the paramedic knew more than the machine--that the patient's oxygen levels were normal. But he followed the machine's instructions and started chest compressions. Chest compressions are not harmless since ribs can be broken, and of course the continued delay.

Fortunately, he soon gave up on this and the patient was put on a stretcher and taken to a hospital, where he probably received a head MRI--when I later talked to an ER doc in my clinic, asking what he would have done, he just said, a head MRI, as soon as possible.

I headed for the terminal, wondering, as is my nature, if I could have done anything different.

173. Primum Non Nocere, Part One

First work, then play, right? Maybe not. 

We thought play as we left Bagio for Bali, flying over the South China Sea, with anticipation of tropical waterfalls and coral reef snorkeling, when the an overhead announcement asked if there were any medical personnel on board. Though not eager to volunteer--unless of course a baby has decided that time's up--I did catch the eye of an attendant.  A Filipino nurse also raised her hand. No one else.

An elderly Filipino man had become unconscious.  I noted normal respirations and a strong, steady pulse in the 80's.  Family members thought he took medicine for high blood pressure, but did not think he was diabetic.  He was already being given oxygen through nasal tubes.  The plane's medical kit produced a pulse oximeter which attaches to a finger and measures oxygen levels (anything over 90% is okay).  His level was 100%. 

We also found a wrist blood pressure cuff: 220/119, suggesting an hypertensive crisis which could cause a rupture of cerebral blood vessels, aka hemorrhagic stroke, leading to unconsciousness. Concerned about the accuracy of the blood pressure, I measured my own: 140/90, more than my usual, but considering the stress of the moment, it seemed to confirm the accuracy of the device.  I remeasured his BP: 228/122.  A normal variation or an accelerating, possibly deadly hypertensive crisis?


Other common causes of unconsciousness: drug overdose, seizure, cardiac arrest, and either hyper- or hypoglycemia.  Hyperglycemia from uncontrolled diabetes, hypoglycemia from accidental insulin overdose.  The history, setting, and elevated BP all point to stroke. 

The nurse knew how to use the glucometer also found in the medical kit; it showed a normal blood sugar level. I didn't really think he had blood sugar issues, either extreme value would not likely be associated with increased BP.

The kit also contained a number of medications, including some that could be used for hypertension; many with unfamiliar (non-American) names, but I did recognized one: nifedipine, occasionally used for gestational hypertension.  He can't swallow and I didn't have the resources to monitor intravenous medications, but nifedipine can be given sublingually

We were 90 minutes from the nearest airport: Singapore, which was the destination of the flight. Attempts were being made to contact an ER in Singapore, but no immediate response.

Should I give him an hypertensive agent, possibly preventing further stroke damage, but risking a sudden drop in BP which could lead to cardiac and cerebral ischemia as the body becomes unable to deliver oxygen to vital organs?  

First do no harm.

172. Final Baguio Post

Most fibroids grow within the wall of the uterus.
This "pedunculated" fibroid grew from the top,
 attached to the uterus by a narrow stalk

The dense, gnarled nature of a fibroid
appreciated when it is bisected.

That's the cervix underneath the bulky uterus fundus,
which had to be removed first to gain access to the cervix

Inside, it looks like multiple, not a single, fibroids

Again, multiple fibroids, this time apparent from the outside

That's just $13.50 per day for hospital room, but a hospital and doctor costs for a hysterectomy would add up to P60,000, or over $1300, we were told.  That's over $30,000 of gynecologic surgical care.
Assume an equal amount or more for the general surgeons and $2500 expenses for each of the 25 volunteers.
The result: an investment of $60,000+ for $60,000+ medical care plus some teaching along the way.
All in all, a pretty good return on that investment

171. Baguio Stats

9 -Day of Surgery:

large fibroid uterus

Twenty-four major gynecologic procedures.

• 10 abdominal hyst (8 fibroids, one unanticipated cancer, one ovarian cyst)

• 11 vaginal hyst (8 prolapse, two fibroid, and one hyperplasia with atypia (“pre- cancer”)
• and three exploratory surgeries, one for the removal of just the fibroid and one for a suspected cyst.

And two minor procedures, both tubal ligations (one open, one laparoscopic)

Multiple fibroids totally distort anatomy

It would take me about a year at home to do as many hysterectomies; more than double what I’ve done on any other mission.

The two general surgeons had a few more cases (one only could stay a week), mostly gall bladder, hernias with a few thyroidectomies and one breast lumpectomy.

170. Baguio Day 10: Wipeout

On day ten we started the first case shortly after the start of the Superbowl, time zones and international datelines being what they are.  Four team members live in the Puget Sound area, ranging from lukewarm to energetic Seahawks supporters.  One of the latter tried and failed to find online Superbowl streaming, but did manage to pick up running commentaries.  He kept the operating room staff informed by periodically appearing in the glass OR door with an updated score.  

169. Baguio Days 6, 7, 8, 10: Ovarian "Accidents"

Ovaries produce and secrete (release) hormones and fluids that help prepare an immature ovum (egg cell) for its big meeting with Mr Sperm;  the same hormones have systemic effects as well, including but not limited to skin, joints, gastrointestinal, central nervous system.  Most of these secretions take place within the monthly ovulatory (aka follicular) cyst. But there are also abnormal cysts, what we used to call ovarian accidents.

Sometimes the ovary thinks it can reproduce without the help of a sperm, resulting in a dermoid cyst, which does grow and differentiate—mainly into nerve, cartilage, hair, and fat cells. But that’s about it; no virgin birth here. These cysts can become quite large and can rupture (very painful as the contents irritate the lining of the abdominal cavity), twist (also painful), or mask cancer.  So totally worthy of surgical excision.

endometrioma on left with swollen left fallopian tube;
uterus is normal as is the opposite ovary and tube.

Less dramatic are the cysts that just secrete fluids, such as Remerlita’s, or the almost as large cyst of 31 year old Ailyn.  Though suspicious for malignancy because of nodules on the lining of the cyst, her age, and normal screening blood tests suggested otherwise, so we proceeded with removal without assistance of a gynecologic  oncologist.  Lolita’s “ovarian accident” was an endometrioma, where cells from the uterine lining migrate from the uterus and form an ovarian cyst.  These "endometrioma" cysts are vascular and bleed, forming blood-filled cysts. 

Then came an ER consult: 33 yr old Emma with acute pain and an ultrasound showing an ovarian cyst, possible torsion (twisting, which would explain the sudden onset of pain), and also a fibroid.  She wanted to maintain fertility so our goal was to remove the cyst and the fibroid.  As soon as we entered the abdominal cavity we encountered adhesions between the uterus and bowels.  These were carefully dissected, separating the two organs.  Then a relatively simple removal of an anterior fibroid (about 2 x 3 inches).

But no cyst and no visible ovaries (obscured by adhesions which were left in place; the risk of removing greater than any benefit.  Best explanation: the ultrasound mistook an immobile segment of bowel for a cyst. The usually constant moving bowels are easy to differentiate from immobile ovarian cysts, but when part of the bowel  is stuck to the uterus, it can look like a cyst.

168. Baguio Day 6: Pain

In America, post-op hysterectomy patients are started on intravenous narcotics from just about the minute they reach the recovery room, the goal being to “stay ahead” of the pain. Narcotics are difficult to purchase, manage, and distribute on these missions. So most patients just received an acetaminophen suppository at the end of the surgery, then 1000mg acetominophen (two extra-strength Tylenol) and 400mg ibuprofen (two Advil) every 6 hours.  In Cambodia we added ice packs, but in the temperate climate of 5000ft Baguio, I didn't seen that approach.

Most postop patients cope well.  Except for Olivia, who couldn’t tolerate even the brush of a finger on her abdomen.  So she got some Vicodin, a moderate narcotic that I brought and was much appreciated. Out of 26 patients just 4 (two of whom had ibuprofen allergies) needed narcotics, each receiving 4-8 Vicodin tablets.

No privacy on an open ward, with beds only 12-18 inches apart, but observing others manage postop issues may benefit all.

167. Baguio Day 5: There's a Cyst in Your Bucket

Being prepped for abdominal surgery, Remerlita looks like she’s about to undergo a cesarean, but at 51 that seems unlikely, and in fact, she’s never been pregnant. She has a huge ovarian cyst that we were able to remove without rupture, important since if it were cancer, such rupture within the abdominal cavity could spead the cancer.  Too big for any specimen container, this 6 x 9 inch cyst had to be carried out in a utility bucket.  By pre-op testing, probably not malignant, final path report pending, won’t be available before we leave

 

166. Baguio Day 4: TVH

top: me, flanked by residents; bottom: student nurses 

Nancy, 48, was scheduled for an abdominal hysterectomy (TAH) because of a fibroid that had prolapsed (think “deli vered”) though the cer vix and into the vagina, still attached to the uterine lining by a half-inch diameter stalk.  With four vaginal deliveries and an otherwise normal uterus, I rescheduled her for a vaginal hysterectomy (TVH).

This is a teaching hospital, student nurses everywhere, and 12 ob-gyn residents--all women; the last male was 2 years ago. When I asked why there are no male residents and answer was predictable: “women want women for their doctors.”  So I’m working with 3^rd and 4^th year residents, who are quite competent with TAH, but have little experience with a vaginal approach.  One told me that the preop diagnosis of a fibroid automatically excludes a TVH. Most of them have assisted a couple but never performed a TVH.

So while I may be demonstrating just alternative techniques or short-cuts TAH, with Nancy the residents are learning a new procedure.  Is one experience enough to make for a long-term learning experience?  I’ve adopted new techniques from single observations (I’m taking home a few things I picked up here); I trust they can also.

165. Baguio Day 3: Thirty Thousand Pesos

49 year old Virginia presented to an outlying clinic with an abdominal mass that she had first noted about three months ago. A local ultrasound showed an enlarged uterus due to a 6-7cm fibroid and she was referred to Baguio General Hospital, and scheduled as my first patient. Had we not been here, she still would have had surgery, but perhaps weeks or months later.

After securing the upper uterine blood supply I decided to cut into the uterus to remove the bulky fibroid from the uterus, the better to see surrounding anatomy. But it was cancer we found, not a benign fibroid.  Endometrial cancer starts at the inner endometrial lining and then invades the uterine wall, eventually encountering blood vessels, which allows spread anywhere, and then through the surface of the uterus (as with the Riobamba patient in previous post). This tumor had not yet broken through, though so close that metastasis is presumed and chemotherapy recommended.

Our free care stops once she leaves the hospital; if she cannot she come up with the 30,000 pesos ($650) needed for minimal chemotherapy, her prognosis is dismal.

164. Baguio Day 2: Go-Med

Magandang Umaga.

One of my call day routines takes me to recycling bins on L&D, and occasionally the main OR.  Once a sterile pack has been opened, the contents can no longer be used, even if not contaminated,the hospital figuring that it is cheaper to buy new than to re-pack and re-sterilize. But these supplies are not trashed, instead they are saved for overseas missions.

Last October I stopped by the OR on a Saturday morning, and seeing me, someone asked, hey Dr H. do you have [an emergency] case for us? No I said, just looking for supplies to take overseas.  Hearing this, RN S.M. said, do you want to go to the Philippines? When? Late January. Sure, I said. And here I am, a member of the Go-Med surgical team to Baguio City, Philippines.

Arrived Manilla Saturday, then 6 hr drive to Baguio City, over 300,000 at 5,000 ft, spread over several mountain ridges; today, Sunday interviewed and examined pre-op patients for Monday.

note: all patients gave explicit, written consent to be photographed before, during and after surgery.

163. Victory!

Remember Ronda, from a month ago (post #161)--gestational diabetic, nutritional contrarian?  She was admitted to the hospital a few days ago for a medical tune-up, her blood pressure and blood glucose levels both needing attention.  Well, at some point she pointed out to a nurse that she was drinking a diet soda, even though it "doesn't taste very good," because "some doctor told me to."

Okay, so I didn't get personal credit; it still counts.