238. Nepal Day 6

More screening today, starting in pm though patients have been liningup since early morning. As in the Philippines and Ecuador, we often need two translators: one to translate local dialect to standard Nepalese and the second to go from standard Nepalese to English.  Obtaining an useful medical history is a real challenge.  Ages, for example, invariably end in 0 or 5, not surpising given low education levels (most “sign” consent forms with a thumbprint). These are women who have lived their lives as substinence farmers, bending over in rice fields, carrying heavy loads everywhere. I saw plenty of tractors but I suspect a recent development.


The word that went out among local medical providers that we were looking for patients with uterine prolapse (the vagina turns inside out, extending outside the vaginal opening in a complete prolapse). So that's what we saw, no problem since the mission came with three specialists (urogynelogists who have expertise with the fixing of prolapse—essentially removing the uterus then attaching the vagina to a higher structure, such as the ligaments that hold the spine together. 

237. Nepal Day 5

I think the hospital is private but looks like it was built with public funds.There doesn't appear to be any active public hospital in this city of about 40,000. The two operating “theatres” and now empty pre-op/postop wards look like they haven't been used in weeks or months (but there is another OR upstairs next to an active labor and delivery ward which is used for cesarean deliveries), so the first task is a thorough cleaning and the unpacking of supplies. I personally brought about 100 pounds of sterile drapes, gowns and other medical items, and 50 lbs of prosthetic hands supplied by an LA foundation.

We also started some screening.  Lines didn't go around the block like in Cambodia, but there were always some women waiting to be seen.

236. Nepal Mission days 1 through 4

View from plane: Everest?  Maybe

A surgical mission to Nepal.  Treking to a mountain clinic with mountain goats carrying surgical instruments and IV bags? No, we're going to the agricultural lowlands (rice, dairy, sugar cane), near the border with India. A Nepalese ex-pat physician now working in U.S., grew up here.  His wife, also a physician, is from another area in Nepal and in alternate years the team travels there.  This is a large surgical team —six gynecologists, five general surgeons, and 5 anesthesiologists. Add nursing and other support personnel and the team adds up to 50 or so.

Marshlands and Water Buffalo

The real beginning of an overseas surgical mission begins months or even years in advance. Visas, governmental approval, lodging, ground transportation, and supplies, supplies, and supplies.

I left Wed at 2pm with an 11 hr flight to Seoul. Overnight airport hotel (part of the airfare package). Day two a six hour flight to Kathmandu, a six million urban sprawl.  Day three acclimatize, then on day four a 7 hour combination air/bus to destination. Whew. Waiting for the last flight, met a young Chinese businessman who was both surprised and impressed that our group was not sponsored by the government or a Red Cross type of organization—we travel, lodge and eat all at our own expense I explained. 

235. Sophie's Choice

Annie is 34, the primary breadwinner and probably primary caregiver for her two children given the nature of our culture. Not saying that her partner is a slacker, but that's how it is. 

Now comes an unplanned pregnancy with that type of morning sickness that leaves the mother feeling really nauseated without actually throwing up. She can't afford to miss work--she can't afford this pregnancy, period.

And she feels guilty because she doesn't want the pregnancy.  Have you considered termination I ask; I could never do that she replies but you know she has thought about it, which only increases her guilt.

234. Tamoxifen again

Remember tamoxifen (post #221)?  In some organs (e.g., breasts) it blocks the effect of natural estrogen, in others (e.g. uterus), it acts like an estrogen. 

First chemotherapy for Eve's early-40's breast cancer, followed by a standard 5-year course of tamoxifen, since her cancer was estrogen-sensitive. Periods which had stopped during the chemo resumed for a few years then no periods for several months. A new episode of bleeding prompted her first consult.

Is this postmenopausal bleeding requiring further testing for uterine cancer, or does it reflect non-threatening hormonal variations not unexpected in this setting?

An endometrial biopsy was obtained showing no sign of cancer; then a ultrasound, showing a thin uterine lining (cancer or a pre-malignant condition called hyperplasia) invariably lead to a thick lining. 

7 months later she presents to me with another episode of light bleeding.

We discussed repeating the endometrial biopsy or ultrasound, or scheduling a hysteroscopy, allows direct visualization of the uterine lining while patient is under general anesthesia or sedation (for example, valium and ibuprofen).

Eve seemed inclined to go with the hysteroscopy, then decided to wait and repeat the ultraosound in six months--when she found out she would need a ride home after the hysteroscopy! As good a reason as any, I guess. Any approach has a 2-5% false negative rate with low but not zero health risks.

233. It's All Relative

Comment from a 20-something nurse:

"...for 38 she's pretty healthy..."

232. Why , Doctor, Why?

"What was all the other tests you ran. You said a urine infection test when there was no reason for one and then you ran a list of tests that you did even say you were doing.  Just because I have State Insurance don't meen I'm going to put up with un nessasary and un warrentted test. This is going to stop right now from evey doctor there. Now I want an understandable breakdown of the tests you did Why and what they all ment and were for, that I can understand."

Though directed at one of my colleagues, I could well have been the subject since I frequently order tests without explanations--just a general "screening for infections," or "looking for problems with your kidney or level."  I could do more.

231. Thirty-Five

My son and his son

35 years ago today, I delivered my son, and a VBAC at that (post #128)!  Or I should say, I attended the delivery, because of course his mother delivered him. It was a month after my internship so I was a fully fledged MD though still three years shy of being an obstetrician-gynecologist.

So if any one one asks how long I've been delivering babies, I just respond with my son's age.

230. Privacy

You wouldn't think that a few days after you visit a doctor you see your story show up on a blog, such that you neighbor calls up and says she's sorry to hear about your abnormal Pap smear.

So what do I do to protect the privacy of the patients whose stories are the seeds of my posts?


1. I change the name, age and other demographic details.
2. I tweak the stories, changing details that don't impact the nature of the observations being made. 
3. Though I will write a draft soon after an encounter, the final post may be delayed for weeks or months.
4. Many stories are a composite of several patients with similar medical histories.
5. Just a handful of people know my identity.

In other words no one reading my posts would be able to identify the patient unless he had access to all of my daily clinic and hospital records, and lots of time to sort things out. If there is any concern about privacy, it should be directed at that person who has such access and uses it in that manner.

229. $10,000

Kali, now 24 weeks pregnant, and her boyfriend maintain separate homes, something about commuting or such, but she says he comes down on weekends, helping with shopping and cleaning. Must have been a planned pregnancy because she has saved $10,000 to support herself after giving birth.

Unfortunately, a weak ("incompetent") cervix means she can't work. Her $800 month rent, is going to eat up a good part of her savings, and add to that groceries and other day to day expenses.

I'm impressed that she has been able to save that much; she's way ahead of the curve.

228. In Tune

Marsh's urinalysis shows bacteria in the submitted sample, but no harmful bacteria in the culture, just common skin bacteria; i.e., a contaminated sample.  Her symptoms (mainly frequency of urination) continue so another sample is obtained--same results.

But "I'm in tune with my body," she responds, in support of her certainty that she has a bladder infection because these symptoms in the past have been associated with the same. "Just give me a mild antibiotic."

Problem is, it's one thing to tune a six string guitar; it's another to tune a twelve string guitar. She's pregnant: another six strings to figure out.

So I suggested she come in for a catheter specimen--we insert a small sterile tube into the bladder to obtain a non-contaminated sample. 

227. Friends

The operating room has strict rules to maintain a sterile environment.  Duh.

Which includes no apparel other than that supplied by the OR (only their scrubs, not ones I've washed at home).  Disposable hats and masks are mandatory; disposable shoe covers optional (apparently less concern about bacteria tracked in from OR area floors. Shoe covers seem more used for shoe protection than for patient protection.

I use earphones on my bike commute, and when entering the office leave them dangling on my neck (mornings are still cold so I'm using the warmer external earphones instead of earbuds) as a I walk from the bike rack to the locker room.

Well, a couple of days ago, I forget to remove them when I changed into scrubs.  I saw a few patients in the office then went to the OR, scrubbed, entered the room and was about to begin the planned procedure when a nurse gently lifted the earphones off my neck.

You know the line, "friends don't let friends drive drunk,?"  How about "friends don't let friends walk around the office and OR with earphones hanging around their neck?"

226. Sorcerer's Apprentice, part 2

Though septic shock seemed the most likely scenario, her distended belly raised other possibilities. Cytokines are increase blood vessel permeability. The liquid part of blood--serum, can now leak out of vessels and cause swelling.  Accumulation of this or similar fluid in the abdominal cavity is called ascites.  So her distended abdomen can fit the septic shock scenario

But internal bleeding--perhaps from a ruptured uterus--coiuld also cause this distension. Now that's something we could/should address. So once the BP stabilized, an immediate laparoscopy (camera inserted through a half-inch umbilical incision) showed that the fluid was ascites not blood; a quart and a half were removed to take pressure off the lungs (more could have been removed, but we wanted the laparoscopy to be as quick and atraumatic as possible).  

She was taken to the ICU, who found her condition so perilous that transfer by helicoptor to the local county hospital/medical school training site/multi-state trauma center was recommended.

There massive antibiotics were administered and a hysterectomy performed (to remove the most likely source of continuing infection.  She improved slowly, discharged after three weeks.  The mortality of septic shock can be as high as 50%.  She did well.

225. The Sorcerer's Apprentice, part 1

Laney's first pregnancy was uncomplicated. At 26 and healthy her delivery should have been uncomplicated, and it was. Well, a little more than average bleeding, but no need for a transfusion.  For several days she didn't feel well ("must be the low blood count"), but on the fifth day postpartum, she came in to urgent care , having not been able to empty her bladder for several hours.  The bladder is stretched and pushed during labor, so not uncommon to experience urinary retention. A catheter was placed, more than a quart of urine drained, and she was told to return in three days for its removal--three days being enough to swelling and inflammation to subside and normal bladder function return.

On that day her mother called saying Laney was "hot" so she was told to go to urgent care. There her blood pressure was low, labs abnormal; sent to the ER thinking she was in septic shock.  At the ER, her blood pressure continued to drop, and blood oxygen levels were dangerously low. She was immediately intubated and given oxygen and "vasopressors"--medicines that keep the blood pressure up by causing blood vessels to constrict, thus promoting blood flow and oxygen to her brain and other vital organs.  

But what caused the blood vessels to dilate in the first place? Probably cytokines--small proteins released by bacteria or the overwhelmed immune system.

Consider the sorcerer's apprentice, who tasked with cleaning the dungeon, animated some brooms, mops and buckets to do his work. While he slept, the animated objects reproduced themselves and soon there was a stick army and a flood.

In septic shock, cytokines act as the apprentice's spell, causing blood vessels to dilate, which lowers the blood pressure, depriving vital organs of oxygen.

224. Darian III

No, not an 18th century Romanian King, but the name given to a baby boy born this morning around 5am.  A strong-willed mother who said she didn't want anything for pain and stood by that.  A soft-spoken father, who hovered closely, not as in a  "I'm-in-charge, macho, territorial" mode, but as in "I care; I'm here when you need me."

I don't see many namesakes let along juniors, in fact can't remember the last one, and "the third" has to be very rare.  But I'll bet that Darian III will be proud to be a Darian.

223. Is Health Care a Right?

Not a subject of debate, that having been decided with the first laws preventing emergency rooms from denying service, and confirmed by republicans who now say, "repeal and replace," instead of the previous, "repeal."

But how far, if at all, does that right go beyond the ER?

Amber is 24 weeks pregnant.  With each visit she requests an ultrasound. She also has regular massages for pregnancy-related back pain and weekly sees an "obstetric chiropractor," all covered by her work-based health insurance. 

Is health care a limited resource, a health care pie as it were? Does Amber's bigger piece mean a smaller piece for someone else? Obamacare gives (I almost said "gave" but we're not there yet) a piece of the health care pie to millions who never had pie. Detractors feel their pieces are thereby diminished. 


Somehow, in this squabble for the imagined last piece of pie, the humanity of it all has been lost.

222. Maria Update

Maria's ultrasound showed a very thin uterine lining; no cancer has been associated with such a thin lining. With this news, I hoped she'd be comfortable with not pursuing a hysterectomy, but after I emailed her with the positive news from the ultrasound, she did not reply. Maybe signaling a persistent uneasiness.

221. Sign of the Times

Not an uncommon request: "Can I have [procedure x] done before I lose insurance at the end of the month?"  The frequency (and emotional urgency) of such requests will surely increase.

Last week Maria asked for a hysterectomy.  She had breast cancer several years ago, her treatment including surgery and chemotherapy.  She received a standard 5 year course of tamoxifen, a drug that blocks estrogen receptors in the breast (her cancer was accelerated by estrogen) but paradoxically stimulates estrogen receptors in the uterine lining, increasing the risk of uterine cancer.

So, she asks, why not just take out the uterus, an organ that now serves no health purpose and carries the risk of cancer?  I acknowledged that although a hysterectomy would remove the threat of uterine cancer, the risk of uterine cancer is low even with taxoxifen, and usually easy to detect--bleeding occurs at pre-cancer stage and she has experienced no bleeding. Furthermore, she is now a couple of years beyond the final tamoxifen dose.

Then consider the potential complications of a hysterectomy such as injury to the bladder or bowel, infection life-threatening blood loss.

Maria returns to her original concern:  "I may not have insurance when and if I experience signs of cancer.

We end up planning an ultrasound (assuming it can be performed in the two weeks remaining on her insurance), which can show signs of hyperplasia (the pre-cancer stage).

220: Child's Play

In response to the regular survey that most of our patient's receive, a patient said that she felt like she had been treated like a child. As a brief written note, I couldn't tell whether this comment came out of anger, frustration, humiliation or resignation, but it sure wasn't a compliment. Too much time had elapsed between the encounter and the feedback, and I could't remember the specifics of the visit; I just had to leave it as an unknown.

Unknown until last week when I experienced a very unsatisfactory exchange with my (now ex-) dermatologist. I was at first annoyed, then frustrated, then unhappy but I couldn't pin down exactly what it was that bothered me until after a couple of days I connected the two. I felt treated like a child.

If a 4-5 year old came to me with a scratched arm or broken toy (or more likely, a crashed iPad ap), I would exaggerate my concern and sympathy wanting to make sure that I would be heard through the tears.  "Oh that's just terrible," I might say, or "you must feel really upset; let me make it better"  A knowing parent might want to add a reality check: the scratch is minor, the toy fixable, the pad just has to be rebooted. But I think (wrongly?) my relationship with the child would suffer if I reacted that same way as I would to a friend.

The dermatologist brought her chair close to me, tilted her head just so, maintained steady eye contact, and expressed much concern even though I hadn't really complained--I just came in for a refill. Her manner would have been lauded at a doctor-patient communication workshop. But it didn't work for me any more than my condescending manner worked for my patient a few months ago.