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.