111. Throw the Bum Out

Commenting on her current status, 78 yr old Mildred noted that she was "not sexually active, got rid of him 7 years ago, no need for men, especially cheating ones."

110. Community Call

I think I've posted before about community call: the rotating system used to provide care for ER patients with no established doctor (they may or may not have insurance).  ER docs provide immediate care to stabilize patients but do not perform surgery or provide ongoing in-hospital care; patients that need either of these services are referred to the appropriate specialist on call.

Recently I overheard a colleague make the following comment:

"Makes me even less willing to do community call."

And what prompted this statement?   ... the several week delay in receiving reimbursement.

Dr. Zorba would not approve (or for that matter, Hippocrates either).

109. Glass of Wine?

Question from antepartum clinic:  "Can I have a glass of wine with Easter dinner?"

I'm supposed to say, "no, never."  One of my partners defers the question by noting that "there is no evidence that it is safe to do so."

My answer: It's probably okay (for first trimester patients I would say no).

But I'd probably be more scientifically (and politically) correct if I copied my partner.

108: "I Don't Like Needles"

Pertussis (whooping cough) is now an epidemic in this part of the world.  Too many parents have not vaccinated their children, allowing the virus to take hold.

Meanwhile my organization of several thousand employees has decided that employees who have direct contact with patients must either receive the flu vaccine or wear a face mask.  One of our receptionists has selected the latter.  After a few days of stuffy breathing and difficulty making herself understand, she has allowed the mask to slip; it now just covers her chin. Her rebellion stands unchallenged.

Sure, I understand true needle phobia, and initial parental concerns about the many vaccines kids are subjected to.  But shouldn't rational decision-making also play a role?

107. Pelvic Relaxation

Think of a hammock that's been outside for a number of years and subject to a lot of kids jumping in and out.  The hammock and the ropes that hold it up will stretch with time and sag.

Now take that image to the pelvic opening.  The connective tissue across that opening keep the bladder and the uterus where they are supposed to be, despite lots of kids and lots of jumping (the jumping can be lifting, chronic cough, constipation; you get the idea).  We call the subsequent sagging pelvic relaxation.

Last night a woman presented to the ER worried that everything was going to "fall out, just like a baby."
No question but that it feels that way.  Too bad that the urologist that she had seen the day hadn't spent a few minutes explaining that though very uncomfortable, this conditioning is not life threatening.

We complain about patients filling up the ER with non-urgent problems, but a proactive minute of teaching would prevent a lot of it.

106. Law and Order

A patient recounts her 90-yr old mother's exchange with her cardiologist who was proposing to place a cardiac stent.  "I know I have to be careful," he told her, "since your daughter is a cardiologist."
Not missing a beat, she replied, "She's not the one you should be worried about, it's my three daughters who are lawyers."

This story was told while I was preparing this patient (one of the lawyer daughters) for major surgery.

Yes,  I got the message.

105. San Lucas: Resolution

Locked out of the OR, I instead went to the regional government hospital in Solola, about 1- 2 hours from San Lucas (depending on public or private transportation).  Talked to the second in command and to the head of Gyn, who confirmed their reluctance (even refusal?) to care for postop complications from surgery done at San Lucas.  But then the gyn guy went on to tell me I could bring patients from San Lucas and operate at Solola, provided that I bring my own supplies, and anesthesiologist as well.  Transfusion availability and back-up would be part of the deal.

I figure day one: unpack, visit Solola, lay of the land.
day two: general ob/gyn clinic; interview pre-screened patients
day three and four: gyn surgery at Solola
day five: postop care and minor surgery at San Lucas
day six. final post op care.

I need a sponsoring organization from U.S., help from the San Lucas parish (have already started on this), final go-ahead from Solola once dates are settled on, maybe March 2013?

104. San Lucas: Anesthesia

No problem with having anesthesia able to cancel any surgery any time.  Surgeons, with their "chance to cut, chance to cure" mind-set may schedule surgery for someone with a concurrent illness (upper respiratory illness, uncontrolled diabetes, heart disease, anemia, etc.) that increases surgical risks to unacceptable levels.  So put a hold on, let the patient recover, stabilize, benefit from further evaluation.

So when anesthesia asks to talk about my planned San Lucas surgery, it seemed routine.
"Do you have access to blood if a transfusion is needed?
"Do you have a specific (i.e., name and phone number) back-up for delayed postop complications?
"Do the sponsoring organizations know what you're doing?

These are valid issues for overseas medical missions and always play a role in patient selection, but I felt that I might as well have been asked, "Do you have a silver stake for the vampire?"

Bottom line: no gyn surgery.  I think the real issue was not wanting a gyn patient to bump a podiatry patient.  After all, this was podiatry mission, with four podiatrists and a team organized to support them; I was just an self-invited guest.  I'm okay with that. Just be open about it.

103. San Lucas: Fibroids

Fibroids, or leiomyomas, a common subject here.  Benign muscular tumors of the uterus. Ana, 36, Aura, 47, and Irma, 43, all have symptomatic fibroids.  Symptomatic means pain or abnormal bleeding.  No medical treatment for fibroids, just surgery, usually hysterectomy, which is usually not difficult but does have increased risk of bleeding (see previous post).  Ana and Aura have low blood count, so probably would do best taking iron supplements for a few months before any surgery.  But that leaves Irma (whose fibroid seems to be a pain issue), and Leticia, who has abnormal bleeding and an enlarged though non-fibroid uterus, as surgical candidates.  Two out of five, not bad, all things considered.

Enter anesthesia.

102. San Lucas: the Logistics of Care

Dr Tun had five San Lucas patients screened for possible gyn surgery:

Valeria, 67 has apparent cervical cancer with zero chance of getting the type of radiation, chemo and/or surgical treatment that would be standard in first world countries.  Would a "debunking" (i.e. removing as much of the cancer as possible, knowing that microscopic remnants would probably remain?) hysterectomy help?

But malignancy makes surgery more risky: life-threatening bleeding, pulmonary embolism, and injury to the urinary system, and so on. So I said I could not offer surgery, though the government hospital about 2 hours away by public transportation, might help her.  That would require multiple trips and blood donors.

Surgical patients at the government hospital are supposed to bring two blood donors (of the same blood type) in case they need a blood transfusion. Even if the surgery is unlikely to be associated with heavy blood loss--therefore the blood not needed--these donors will help replenish the hospital's blood bank. Apparently there are local biases against blood donation, such that many prospective surgical patients have to pay donors.

Chances are that the logistics of care away from San Lucas will prevent Valeria finding any care, unless symptoms such as bleeding increase, at which point any therapy would be less likely to help.

101. San Lucas: Tips for the Airport

Preparing for another overseas medical project (#10), to San Lucas, Guatemala, I was given advice that seems to go a bit more than the 3 ounce rule.  I've not had problem on previous trips, but on any particular day, a customs official can make life difficult.

"If you are carrying any medications, bury them at the bottom of the bags and keep a list with you.  If they find them, say that they are OTC [over the counter; i.e., nonprescription] meds and vitamins.  They are being very sticky about meds and anything out-of-date [i.e., "expired"].

The best thing to do when you get to the airport is to load our bags onto a card and walk toward the exit nonchalantly, looking straight ahead, walking out immediately.  Do not stand around waiting for someone to give you permission to leave.  Just keep walking out.

If they ask to see your bags, get your manifests and support letters and team roster list out and be prepared to answer their questions."

100. The Iron Lady

At 48, Vanessa continues satisfied with her decision to remain childless, but seeing friends unable to conceive, she wonders if she could be of help.  She reasons that a surrogate pregnancy with an implanted embryo, using either donated or anonymous sperm and ovum, would not only help friends, but would also provide her with a family of sorts.  Now caring for an aging mother, she is worried about becoming older without a family.

I told her that an IVF clinic would give her a better answer, but cautioned that she probably would not be accepted as a surrogate mother even with donated embryos.  There's too much at stake to risk the uncertainty of a 48-yr old uterus.

The film "Iron Lady" suggested to me that children or not, successful career or not, aging and loneliness are inextricably intertwined.

99. Hot Flashes

There's a connection between changing hormone levels and the body's heat regulation system.  So when there is a sharp decrease in estrogen level, the body's thermostat thinks that body is overheating, triggering perspiration and dilatation of superficial blood vessels.  The latter shunts blood to the skin, allowing heat to escape.  A perception of increased body temperature follows (though the core temperature has remained normal)--the classic menopausal hot flash (or a hot "flush," recognizing the skin's redness due extra blood near the surface).

48-year old Leeann tells me that she only experiences hot flashes when she's near her husband.  Apparently, there can be more to a hot flash than a malfunctioning thermostat.

98. Turf Wars

Medical turf wars usually involve stent-placing cardiologists up against bypass cardiac surgeons.  Or family practice docs performing colonoscopies that gastroenterologists want to keep as their own.  Or optometrists v ophthalmologists.  But here at StJ's we also fight over call rooms.  Call rooms are for hospital docs who don't need to be up all night but still want to be in the hospital for urgent calls.  Usually we think obstetricians and midwives, but others are involved, too.

StJ has 8 or so call rooms, with advance sign up sheets taped to each door.  Apparently someone has been  playing around with these sheets, to the ire of one doc who found his reservation crossed out.

So he posted this sign, naming the alleged offenders (before taking this pic, I blocked out the names) and this message: "Don't be DICKS and move out people who signed up for call rooms.  Our sleep is just as important as yours." Surprisingly this sign has stayed up for a couple of weeks.


It's a jungle out there.

97. My Husband Won't Let Me

Sandy is 25 with chronic pelvic pain and four kids.  Repeat evaluation over the years has not revealed any cause.  Last week she came in and asked for a hysterectomy; I hesitated because without diagnosed uterine pathology, the pain will likely continue after the surgery.

"Healthy Life Style"  That's what we propose for patients with chronic pain.  Sleep, nutrition, exercise.  Just a daily 20-30 walk outside can combine exercise and a meditation-like mind clearing.

"Do you have time for yourself?" I asked, hoping this would trigger a useful conversation.  Finding time (alone! --an exercise DVD won't work with a house full of kids) is the deal-breaker for many would-be home athletes.

Her reply:  "My husband won't let me."

With some prompting, she explained that he doesn't literally stand in the doorway keeping her homebound, but he refuses to take care of the kids. With no money for babysitters, he has effectively prevented her attempts to gain control of her health.  And I suspect that when someone has to be up at night with the kids, she's the one who loses sleep. Or she stays up late with laundry and other chores.

There's abuse and then there's abuse.

96. La Familia

Though childless at 51, Inez is not without family.  She came to the hospital with heavy bleeding, abdominal pain and just plain feeling terrible.  I've seen her several times--she's never been without family. There were six in the tiny ER exam room.  Two women sleep in her room.  This evening, I counted at least eight, of all ages.  You read a lot about the extended Hispanic family. It's one thing to read about it, another to see it in action.

95. Fate

At 90 Mildred is alert and independent.  She's in the hospital for complications of congestive heart failure: the heart doesn't pump as well as it should, blood and fluid back up in the circulatory system, leading to swelling in limbs and fluid in the lungs.  She needs meds (e.g., digitalis) to strengthen the heart, which should clear up her lungs, allowing for a discharge in a few days.

An abdominal CT scan (not too sure why that was obtained, but it's almost routine), incidentally showed an abnormal uterus, suspicious for cancer.  I recommended a uterine biopsy, to be done in the office after her discharge.  If it showed cancer, surgery might be recommended, or for a precancerous condition called hyperplasia, easy to take suppressive hormones (progesterone) could be recommended.  She said no thanks.

Her son was present and clearly wanted her to accept the biopsy.  A common theme. The kids want everything done for their parents, who often are satisfied to "let nature takes its course."  I argued for a middle ground:  do the biopsy (uncomfortable for a few minutes but no risk to health), then rethink.  She said she would consider but was inclined not to.

94. "Partner" part 2

Beth, 24, came in a few days before New Years' with a couple of issues, including refill of her birth control pills.  She mentioned that she would be leaving for California on Sunday but would be back in the spring. "Going back to school?" I asked.  "No, but my boyfriend is in divinity school there."

93. "Partner" part one

I'm rounding on a recently delivered 34 year I had not yet met.  The father asks if I will write a note excusing him from work for another week since she had an unanticipated cesarean delivery.  Sure, I said, and returned to the nursing station to write a note (most companies don't mind a hand-written note for this purpose; as long as there is some paper trail).

Then I realized I forgot his name--no problem, I'll just check the admission record; his name should be on it.  But no, for emergency contact, just her mother was listed.  Too bad because I had already started a note: "Please excuse [blank] from work until Jan 9th because his wife underwent an unexpected operative delivery."  When I wrote "wife" I had a fleeting thought--"maybe I should write 'partner.'" But that didn't seem right in this setting.  During that brief encounter, they seemed... well, like a married couple.

A recent analysis of census data shows that 51% of all adult Americans are married, an all-time low.   In my state about half of all deliveries are to unmarried women.  My own records over the past 15 years show that 70% of the woman whose deliveries I have attended are married.  That number will probably decline.

Anyway, I left the note as written, asking for and adding his name when I returned to give it to him.  I doubt that he or anyone reading it will give a second thought to my outdated social prejudices.

92. Quick, Boil Water

Remember those movies with an impending birth and a subsequent command to "boil water?" Most of us thought that had something to do with sterile technique. And that's the answer given in most Google responses to the question (either that or as an excuse to send away a nervous father to be)

But the practice existed long before germ theory. Hot compresses accelerate the normal labor processes in which the skin becomes more elastic, which makes deliveries faster and easier for both baby and mom.

Recent research concluded that "the use of warm compresses on the perineum duiring the second stage of labor [the "pushing" stage] is associated with a decreased incidence of perineal trauma," which of course confirms what midwives have been doing for eons.

But in classic "unintended consequences" fashion, the sinks in our delivery rooms don't have bacteria-laden hot/cold controls, it's all motion activated, so never has a chance to warm up. We'd have to go down the hall, around the corner, to get hot water (which is not that hot anyway, again for safety reasons), so evidence and tradition notwithstanding, one rarely sees hot compresses used.

91. Confession

An abnormal Pap smear prompts further evaluation, which often includes a cervical biopsy. Most women experience some anxiety during the 3-4 day wait for biopsy results but few as much as sixty-year old Marlene.  She called in tears after several days had passed without hearing anything (her doctor was out of town and had failed to contact her before leaving).  As the on-call doc, I was asked to talk with her.

We talked about the result of the biopsy, which confirmed the Pap smear--abnormal but a low level that requires monitoring but no immediate intervention.  And we talked about the cause of abnormal Paps: the sexually-transmitted human papillomavirus (HPV).  This again brought Marlene to tears as she confessed that she recently had a brief affair (her 80+ year old husband cannot meet her needs she said in so many words). I'll never do that again, she promised and then asked if she should tell either her husband or her ex-lover about the diagnosis of an STD.

Under the guidance of the "keep it simple, stupid" doctrine, I just said no.  A difference answer for chlamydia or other STDs, but for the ubiquitous, untreatable and mainly female-problematic HPV, no need to stir up trouble. Just don't ask me how I would feel if the ex's next sexual partner ends up with cervical cancer

90. Scent of a Man

"When you've been married 40 years," explained Marley, "you know what he smells like, so I knew something was wrong, even before he was diagnosed with prostate cancer.  Now after radiation therapy he just smells like char."

I'm not too sure how we got on this subject during an annual exam, but I did find it enlightening.

89. Los traductores

Can't return to routine clinic without acknowledging my translators.  Sarah is a young ex-pat who studied Spanish in Argentina (one day she decided to learn Spanish and travelled there to do so), then ended up in Bogata, working with the export business of the brother of one of the Ecuador team's founding physicians.  She not only paid her way but because she gets paid by the hour, gave up a week's pay by coming here.  In listening to her translations (I understand a whole lot more than I can express), I appreciated that her explanations in Spanish were often better than my original English comments.  And she kindly helped me with my Spanish, as I tried to move beyond, "Donde se duele?" And she made the front page!

Two translators in Monterrico: Diana, Guatemalan by birth, but for several years has lived in U.S.  Her English is excellent as is her persistently positive attitude.  I think, however,  the midwife must have been frustrated by one abbreviated translation.  L. was asking the comadrones to comment on their experience with postpartum hemorrhage.  "Do you every have bleeding," she asked, "that flows like a river?"  Diana essentially translated this evocative image as "mucho sangrante"-- a lot of bleeding.

And Florina, a Montericcan, who has just picked up English by being around the traveling medical teams.
She did a fine job.

And me?  I think I'm getting better.  Towards the end, I was able to evaluate, diagnose, treat and explain all without a translator's help.

88. OP #10 Monterrico's Comadrones

Taking the opposite approach of Malawi, Guatemala encourages lay midwives--comadrones--offering support such as periodic training sessions (Malawi, to remind you, basically outlawed lay midwives, claiming that they were "unteachable").







We invited Monterrico midwives to meet with L., the midwife who was a member of our team; four came.  L. asked them why they became midwives.  The strongest reply came from a midwife of some 15 years who related her story of being ignored by the medical establishment when she delivered in hospital.

Several years ago I asked a group of medical students in Hue, Viet Nam why they decided to study medicine.  Several answered in a similar manner:  they had witness family members who had not been well treated by physicians.  But a greater number answered that they were meeting family expectations.    For several years I've worked with a second-generation Chinese-American surgeon, who quite frankly admits that he became a doctor just because that's what his father wanted. So he did it.  Fifty years later, he is an accomplished surgeon and continues to operate part time--he really enjoys it.

87. OverseasProject #10: Monterrico

Monterrico About three hours away from Guatamala City on the Pacific coast, Monterrico (aka Monte Rico) is the largest (and therefore the commercial  trading center) of a cluster of villages that also includes Agua Dulce (a system of esturaries—reminding me of Louisianan bayous) in which each family has its own small island, Curvina, and Hawaii.  Catchment population about 20,000, I’ve been told, certainly an overestimate.  The closest local doctor is about a 90 minute drive away, with no guarantee of being seen on the same day, a real deal-breaker. Sharing the black sand beach are weekend homes for the wealthy of Guatamala City, a couple of  2 or  3 star hotels, and the two buildings of the CCCG retreat. One building holds the kitchen and store room; the other has two stories of dormitories, each with 30 or so bunk beds. The palm-leaf covered but otherwise open-air areas above each building  were converted into a clinic for the week, with folding tables for registration, lab, pharmacy, and 3 clinician stations in the larger room.  Draped sheets provided some exam room privacy.  The smaller room was divided into two areas for me and the midwife.  Altogether, 16 volunteers:  3 docs (two family practice and me), one midwife, two nurse practitioners, one NP student, one FP resident, one med student, one lab tech, two nurses, two med admin students, and two non-medical volunteers. Knowing that there were no facilities or an OR team for surgery, I expected just outpatient care. Over three days I saw 24 patients, equally divided among: cervical cancer screening pelvic pain, bladder problems, abnormal vaginal discharge, and reproductive issues. A long ways to travel for 24 patients, but I was also scouting the potential for future surgical trips. I'll have to think more, but I don't think I'll ever being doing much major surgery in Monterrico. Tubal ligations maybe, repairing vaginal prolapse and superficial skin tumors, but not much more. Which is okay; I think I'll go back.

86: Hurricane Mitch

David, Samuel, and Roberto Alvarez are evangelists, community activists, and entrepreneurs. In 1982 David started his ministry (Centro Cristiano Cultural de Guatemala:  cccguatemala.com) in his garage as a young man and hasn’t looked back.   He has worked a number of jobs to support CCCG, most recently an advertising business, but along the way he worked as a bombadero (firefighter).  He built a church in the middle of a gang-ridden neighborhood and feeds children breakfast if they agree to go to school that day.  He developed an Oceanside retreat near Monterrico so these same kids could escape the city for a few weeks every summer. Photo: Roberto (right) working with his David's son Eric inside the clinic.

 

Enter a Puyallup firefighter who came to Guatemala to teach bomberos paramedic skills.  When his translator didn’t show he asked if anyone knew English;  David raised his hand and said he spoke a little. They've been friends since. Photo: Front entrance to the clinic. Under construction on right will be open air waiting area.

Enter Donald Van Nimwegen, a Seattle anesthesiologist who has a long history of overseas volunteer work that did not end with retirement--many of his days now spent in a large basement room donated by Group Health where he collects, sorts, and packs donated medical supplies for various volunteer groups including Healing The Children and Amigos de Salud. Firefighter introduced Don to David during a paramedic training mission that turned into a Hurricane Mitch rescue mission.  Don then introduced David to Jennifer Hooch during an ENT trip.  Jennifer is a family practice doctor with an interest in public health and lots of energy.

Photo: Work progressing on the clinic's outdoor waiting area.  I suspect it will also be a thatched roof.

Add about $40,000 from Rotary groups in the Puget Sound and the result is a new clinic in Monterrico, the site of my overseas project #10.

85. OP #9: Riobamba II

Summary: Final post for this trip.

10 surgerical cases, short of the 12 from Guayaquil two years ago, but still impressive for 5 days.

82 outpatients, with the primary goal being to screen for surgery, so that means that for about every 8 patients I was able to schedule one surgery.  The secondary goal was to provide non-surgical outpatient care.  Except for most of the 13 "bladder" patients who expected to have surgery, I think they felt the visits were worthwhile. Anyway, here are the data, with a comparison from 82 random referral patients from my home practice:

category             Home Total    Home %     Riobamba Total     Riobamba %

abn bleeding       26                  32               4                             5
reproductive       14                  17               6                             7
abnormal Pap     11                  14               2                             2
abd pain/mass     12                  15             31                           38
prolapse               6                    7                5                             5
vag/vulvar             9                  11               8                           10
breast                   2                    1               2                             2
menopause           1                    1                3                            4
bladder                 1                    1              13                           16
worried well          0                    0               8                            10

Comments:
1.  Abnormal bleeding: in the U.S., thresholds may be lower; i.e., the level of bleeding that becomes an issue for Americans may be acceptive by Ecuadorans as, "that's life."  Or, there may be more pathology among Americans: external hormones, obesity, stress can all contribute to abnormal bleeding.
2.  Ecuadorans seemed sophisticated regarding reproductive/contraceptive issues and didn't feel they needed a consult.  Also, the average age was higher in Riobamba, so reproductive/contraceptive issues would be less common (maybe if we had advertised on Twitter or Facebooks instead of on the radio....)
3.  Finally, the radio announcement apparently mentioned that incontinence surgery would be available, unfortunately, that is not something I do, so I had to turn many away, some having travelled 5 hours to come to Riobamba.  Lo siento. Maybe that's a procedure I should adopt, though current methods require expensive supplies.

All told, a good trip, though I may not return, preferring joint local-community projects over the independent, self-contained work accomplished by Amigos de Salud.

84. OP #9: Riobamba II

Day 6

Carmita, a 39 year old primigravid, presented with 2 months of progressive left abdominal pain. An exam confirmed the ultrasound diagnosis of a 7cm simple cyst. No worry about cancer here, but a cyst that size can twist and pull and be the source of significant pain. At home, a laparoscopic approach would have meant a faster recovery (because of a smaller incision), but she did well and the operative findings confirmed a benign cyst. The tube was wrapped around the cyst and had to be carefully dissected away from the cyst, which was removed intact after about 180mL (about 3/4 a cup) of clear fluid had been aspirated. A damaged tube can increase risk of an ectopic pregnancy (a pregnancy fatally stuck in the fallopian tube), but though removing the tube (to eliminate this risk), it also decreases chances of conception. The ovary without a fallopian tube would still takes turns ovulating, but the egg would have to travel to the other fallopian tube. Possible, but unlikely.

The other post-op patients have done well, more pain than expected, partly because it is hard for a surgically naive patient to anticipate the extent of postop pain, and partly because the patients receive significantly less narcotics than they would in the EE.UU.

23 outpatients seen, two surgical candidates, but today was the last day of surgery, so they couldn't be scheduled. The others were mostly a mix of chronic pelvic pain and patients seeking reassurance about treatment programs from local doc's.

At night a closing party; using a non-commissioned officers club with a military band. Too loud and food that looked liked it was catered by Safeway, so I left early, caught a cab home, and packed. My roomate for the week didn't go at all: "I'm 11 years AA and plan to keep it that way."

83. OP#9: Riobamba II

Day 5

Peak day: three major cases.

Two vaginal hysterectomies for complete uterine prolapse (the uterus literally descending beyond the vaginal introitus).  Marie, in her 80´s, has high blood pressure (non-compliant with recommeznded meds) but otherwise a good surgical candidate.  A combination of age, life-long straining (heavy lifting, multiple and difficult deliveries), malnutrition, and perhaps genetic factors combine to cause the prolapse. Marie Dina (on the left with her husband and my ever faithful translator Sarah) is only 51 but with 8 vaginal deliveries...

In her early menopause, Judith received "injeciones," presumably estrogen, not uncommon anywhere in the world at that time.  She does not remember taking progesterone which protects the uterus from uterine cancer, a standard approach in the past 30+ years.  At sixty she experienced an episode of bleeding but was told not to worry about it. Now 62 she presented with persistent bleeding and in our clinic a markedly abnormal ultrasound. Surgical findings showed multiple fibroids (the white mass at top and the egg-shaped mass that was removed early in the case to make it easier o access critical ligaments) and malignant tissue extruding through the uterine wall, making her a candidate for chemotherapy without need for staging.  I did not do a omentectomy (removal of a layer of intraabdominal adipose tissue) which is usually performed since the omentum frequently is an early locus of metastasis.  But her omentum was normal by palpation and wanting to keep the operation as simple as possible, I left the omentum in place.  A difficult decision.

My translator Sarah noted her carrying a set of car keys with an electronic opener, so it is reasonable to assume that she can afford chemotherapy.... (more to follow)

82. OP#9: Riobamba II

Day 4

Two major cases in the OR today:

Both were potential cancer, which raises a critical issue. The intraoperative diagnosis of cancer requires first a preliminary pathology report and then a decision whether to proceed with a "staging" procedure, basically the removal of lymph nodes, where cancer often spreads first. The absence of cancer in any of these analyses may mean no need for chemotheray. If the staging procedure is not done, the patient and her oncologsit is faced with the difficult decision whether to proceed with potentially life-threatening postop treatments.

Since I do not do these staging procedures, shoud I not do overseas surgery with no pathology on surgical oncologist back-up? But if I don´t do the surgery for these patients, they may not have it done until syptoms increase, whicy usually means that the cancer has spread and chemotherapy less likely to be successful.

Postmenopausal bleeding is often an early sign of uterine cancer. Martha presented with a single episode of such bleeding. Our ultrasound showed a markedly abnormal uterus, increasing the suspicion of cancer. The excised uterus showed a thumb-sized polyp, which is unlikely to be malignant, so she should do okay. I did request that the polyp be sent to a pathologist, but don´t know if that will happen.

Edelma presented with pain and a right ovarian cyst that had doubled in size over two years. This increase and the nature ("septated") of the cyst again suggested a risk for cancer. But operative findings were unequivocal for a benign growth. At the near-menopause age of 48 we had discussed the removal of the other ovary and she so requested. But it was adherent to the bowel, a consequence of her hysterectomy 15 years previously. Thw risks of injury to the bowel during attepted removal of the ovary was judged more of a risk than future ovarian cancer.

Just ten patients seen in clinic but three scheduled for surgery, an efficiency the reflects the the assistance of a nurse midwife who was part of the team and performed invaluable screening as well as excellent care of non-surgical patients. Nurse midwives are trained manage gynecologic conditions.

81: OP#9: Riobamba II

Day 3

Two surgeries, abdominal hystectomy for chronic pelvic pain for 49 year old Mario with chronic pelvic pain since her tubal ligation 20 years before. Hysterectomy for pelvic pain is always an iffy measure. Many women continue to have pain postop, suggesting other sources of pain (gastrointestinal, or muscular for example) or an esceptionally low threshold for pain. But studies have shown that most women who undergo hysterectomy for his reason (assuming that other sources have been investigated and exluded) end up having a better quality of life postop. 

Maria's hematocrit (the percentage of blood that is red blood cells) was 51, reflecting her high altitude adaption.  Normal range for U.S. is 36-45; for Riobamba 45-55.

The second case was bilateral removal of ovaries for a postmenopausal woman with a “complex” ovarian cyst. Simple cysts are like water balloons—thin walls and clear fluid contents. Complex cysts are everything else—thick walls, solid components. Simple cysts are benign; complex can be malignant. Martha's cyst appeared complex on ultrasound but intraoperatively was clearly benign.

A busy clinic showed just about the same grouping of presenting problems that I might find at home, with one exception: parasites. The other 19 included:

urinary tract problems: 2

reproductive counseling: 2

annual exams: 2

menopausal issues: 3

abnormal bleeding: 2

pelvic mass: 1

chronic pelvic pain: 7

80: OP #9/Riobamba II

Day 2:

Clinic: 14 patients

Surgery: With time and the effects of increased abdominal pressure (e.g., heavy lifting or chronic cough), vaginal supporting structures stretch and relax allowing the rectum and/or bladder to bulge into the vagina. Harmful, no; uncomfortable, even painful, yes. Anterior vaginal repairs (anterior colpopexy) begin with an incision in the vaginal roof that runs from the back to within about a half-inch of the urethra, and as it progresses, the underlying connective tissue is dissected away from the vaginal skin, extending one-half to one inch from the center. The freed vaginal skin is excised and the new edges are sewn together, thus eliminating the stretched, redundant vaginal skin that has allowed the bladder to drop. Two anterior repairs went well today, with one predictable complication.

At 46 and in good health Atienia should have recovered easily from this relatively simple procedure. But several hours postop, nurses found her weak, nauseated, syncopal. Her oxygen saturation level measured at 70%. Oxygen saturation is the percentage of hemoglobin binding sites filled with oxygen. Levels below 90% define hypoxia, the point at which organs don't function normally.

At Riobamba's 9035 feet, the atmosphere is still about 20% oxygen, but less gravity at higher altitudes means decreased air pressure, which makes it more difficult for oxygen to enter blood vessels. A number of physiologic changes help Riobambians maintain O2 sats above 95. But Atienia is from Guayaquil, a coastal city and arrived only yesterday to be seen by our team. By giving 100% O2 with a face mask, she did well.

At this level, 4 days is usually cited time required for altitude adjusment. On my first night in Quito (also 9000 feet), I ran 5km in the hotel gym and felt fine (tho at an admittedly wimpy 7km/hr).

79. Overseas Project 9: Riobamba II

Day 1

Arrived in Riobamba (aka friobamba) around 2pm, after a 5hr bus ride from Quito. Lunch, then to hospital to unpack (most of the 46 participants had two 30-50lb bags of equipment) and to hold clinic. Had time for 8 patients, with a thirty-something American expat translator living in Bogota with no medical background but a Spanish for health providers book, and eyes wide open as we delved into gynecologic issues.  Every one presented with incontinence.  I haven't done vaginal incontinence surgery in too many years, so turned most away (and felt bad about it since some had travelled from Guayaquil, a 5-6 hr bus ride away.  However, two also had symptomatic bladder prolapse and I scheduled them for surgery tomorrow. I'll have to think about resuming incontinence surgery for future overseas projects.

Chimborazoso from downtown Riobamba.  This is earth's tallest mountain as measured from the center of the earth, given the earth's equatorial bulge. In other words, the closest you can get to the sun, while still standing on earth.  20,565 feet above sea level (compare Everest's 29,029 and Mt Rainier's 14,411).

78. Hair, part two

Mildred's surgery showed an aggressive form of uterine cancer with biopsies showing the presence of this cancer in the omentum (intra-abdominal fat storage) and the abdominal surface of the diaphragm (the muscle that moves the lungs up and down).  In other words, metastatic disease.


She did well postpartum, and consulted with the oncologist who "explained risks and benefits of treatment, what would the advantages of treatment.  I also reiterated that treatment will not be curative and that she probably has to go on and off treatment in the years to come"

77. Lonely

I'm not sure why Beth came in today.

Something about medications and supplements; unwanted facial hair and weight gain.  By appearance today she has no excess hair or weight. She takes birth control pills because they suppress testosterone production, testosterone being blamed for the mentioned excesses, and herbal supplements to suppress what used to be called premenstrual syndrome but now goes by the name of premenstrual dysphoric disorder.

I was in the middle of expressing caution about combining multiple prescription and herbal medications when she interrupted me with, "Do you think I can get pregnant?... I'm childless by choice, but all I have is my mother, and I see some of my friends who are unable to get pregnant, and think I could be pregnant for them.  That way I would have a family for when I get older, and they would have children..."

I didn't particularly want to play the role of a ballon-breaking realist, but I did point out that at the age of 48, she'd be unlikely to naturally conceive, and would probably not be accepted by any fertility specialist as a surrogate mother or womb.

She seemed to accept my explanation, I'm guessing that she knew the answer but would always regret if she didn't at least ask.

76. Boy's Day

Just off a 24-hr shift with four baby boys:

1:14pm, Aiden Quinn, 9lb 7oz, vaginal birth

2:11pm, Leolani David, 8lb 4oz, vaginal birth

10:09pm, Cooper Davies, 7lb 12oz, cesarean, and

4:17am, Bennett Rosario, 9lb 12oz, vaginal

Moms and babies all doing well.

75. Paper or plastic; Percocet or Dilaudid

In Her wisdom, Mother Nature boosts a pregnant woman's self-clotting mechanisms.  After all, when the placenta separates (or perhaps better said, tears off) from the uterine lining, a lot of big blood vessels suddenly open up and bleed.  So stronger clotting means less risk of postpartum hemorrhage (in the developing world the most common cause of maternal mortality).

But the clotting mechanism is a delicate balance.  Too much causes larger clots to form in veins, some breaking off and traveling to the heart, lungs and/or brain, where they can wreck havoc.  Beth is about 10 days postpartum (a cesarean--surgery and anesthetic agents also increase clotting) with a pulmonary embolus (PE)--several of those clots are plugging parts of both lungs.  So she gets heparin and other blood thinners to dissolve those clots, or at least keep new ones from forming.

PE hurts, but Beth tells us that Percocet helps that pain, though does not help the pain associated with her abdominal pain, unlike Dilaudid, which helps the incisional pain but not the chest pain.  Both are equally strong narcotics.  Go figure.

74: Hair

Mildred is 63 with a new diagnosis of uterine cancer. Uterine cancer shows early and more often than not surgical removal of the uterus is a total cure. Based on early evaluation her appears that it may be more advanced, requiring postoperative treatment, chemotherapy and/or radiation therapy.

She immediately expressed concerned about her hair: "I don't want to lose my hair.  My husband's taking blood pressure medicine so we don't do it anymore, but I still like to be his girl.  I can't lose my hair."

73. Follow-Up

At 26 Gwen's Pap smear shows “severe dysplasia” (which means the presence of cellular changes that carry a 10-15% risk of progressing to cancer). She was referred for a gynecologic consult to confirm the diagnosis and to make recommendations for management (usually a simple office procedure that removes a button-size segment from the tip of the cervix).  She did not make an appointment.

3 months later: patient encouraged by phone to make gyn appointment. She replied that she was waiting for the new year because she had used up her deductable for the current year.

Over the course of the next 3 years, 8 more telephone calls were made from the family practice office, and three letters sent, all reminders of the importance of follow-up.  

She finally comes in for STD screening because of an abnormal discharge.  These screening tests were negative, but a Pap smear obtained at the same time diagnoses cervical cancer

Next week she  will start radiation therapy, then a radical (i.e. extensive) hysterectomy.  She may survive the cancer, but the effects of radiation and surgery will be permanent and potentially disabling

72. IUFD

Around 30 weeks, Tess hadn't felt much movement for a few days, so she came in.  No heart tones with the doppler; ultrasound confirmed IntraUterine Fetal Demise.  Labor was induced and in just a few hours she delivered a lifeless but otherwise normal appearing baby.

Now two weeks later she comes in as recommended, though "I really didn't want to come in."  I shared with her test results: no evidence of infection, a "less than 10% placental infarct," and a "true knot" in the cord but without sign of ischemia--lack of blood flow--on either side of the knot.  So we really don't know; we rarely do in this setting.

I asked her if she though she was coping okay (she shrugs), if she had people she could talk with (yes), if she wanted to talk with a counselor (no), if she was sleeping (not at all, "I keep seeing tiny coffins.")

I gave her some ambien and contraception.

71. SSKI

As an essential component of the thyroid hormone, most ingested iodide concentrates in the thyroid gland.  The same happens with inhaled iodide, as in radioactive iodide, a common by-product of nuclear fission (see nuclear bombs and nuclear plant accidents).  Anyone downwind from Japan should think about this.

One of my patients has thought about it and today asked whether she should start taking SSKI, a potassium iodide supplement.  It turns out that saturating (more or less) our bodies with SSKI makes it likely that any inhaled radioactive iodide will be excreted rather than concentrated in the thyroid gland where it can cause cancer.

I politely reassured the patient: any radiation released from the earthquake-damaged reactors in Japan would be at very low levels by the time they reached the American west coast, so no need for preventative measures such as SSKI.

That was this morning.  Tonight, I'm reconsidering my advice.

p.s. SSKI does not protect against any other radioactive danger but can mess up the body's endocrine system.

70: It's In the Air

In post 34 I described the resumption of menses 2-3 years after a natural menopause, associated with the extended stay of daughter and family.  After several months later, the daughter has moved out as planned, but menses continued.

Initially I presented evidence that pheromones (olfactory signals) may influence the timing of menses in young women.  I asked, could the same mechanism cause the return of monthly periods after menopause?

But this most unusual event may also have reflected the interplay of reproductive and stress hormones, the latter increased with the stress of a crowded house.  Another possible cause of postmenopausal bleeding is cancer.  We tested for that: negative.

After the daughter moved out, menses continued, which neither confirms or disproves my speculations.

69. Everything

Pelvic pain, the nemesis of a gyn clinic.

We all recognize stress as both a cause of and an additive factor to pain, but try to look for "physical" sources first. However, Tammy's words and body language shouted, "stress," so early on I asked, "what is going on around you?"

"Everything," she answered.  Daughter leaving home; "had it out with my partner;" no pay when not working (because of the pain), no sleep ("since my daughter was born 18 years ago").  

She knows the effect of stress; her assessment is spot-on; she just feels overwhelmed.

The medical profession with its time constraints and the insurance industry's with its limits on mental health coverage have conspired to add to her list: narcotic addiction.

68. Bedside Manner

Experts tell us that sharing personal experiences improves our "bedside manner."   My recent experience with this advice:

Sheila talked about her addiction to peanut butter: "I start out thinking I'll have just a half-sandwhich, then before I realize it, I have finished one and started another."  I said the same thing happens to me and then added, "It has be crunchy of course."  "Of course." I then said something about how peanut butter has probably been a major factor in her remarkably good health at age 74.

Teresa mentioned how much she likes Dr. Pepper: "When I want a shot of caffeine, I grab a diet Dr. Pepper; that seems to do the trick. "Without doubt," I said, "the best diet soda." Then a description of how she lobbied to have DDP in the office coke machine.  One line was allotted, always the first to empty.  Later I went down to the clinic's employee lounge.  The two rows reserved for DDP were empty.  All the other rows in the machine were full.

Is anyone out there paying attention?

67. Drugs, Pain and Death

FDA approval means that a drug has demonstrated safety and efficacy.  Recently The FDA pulled Darvon, aka propoxyphene, from the market.  Studies 30+ years ago demonstrated that Darvon provided no more pain relief than placebo, but safety issues have been more controversial.  Now with 10,000 deaths atributed to its use, the FDA decided to remove it.  No tears shed.

A leading pain expert wants the same judgement on Demerol, aka meperidine: "It's toxic and sedating." Toxic as in seizures, etc.

When I was working at small hospitals without anesthesia support (i.e., no epidurals), we offered Demerol, with many takers.  Efficacy is not questioned here as was the case with Darvon, and safety concerns are complicated.  Metabolites (compounds produced as the body breaks down Demerol) are long-lasting, something you don't want in a pain killer because of the temptation for both provider and patient to keep increasing the dose for episodes of acute pain, unaware that several hours later the additive effects of Demerol and its metabolites can be life-threatening.  My currently hospital/clinic don't allow its use.

Demerol may have been the final (though certainly not the only) cause of Michael Jackson's death.

66: Getting Old Is No Fun

Just about as close to verbatim as my memory allows:


"I'm 70 but don't look it, except I use a walker.  Now don't get me wrong; I'm not going to go out and kill myself, but I wish the good Lord would take me.  I feel and act like a 60 year old... I don't feel old"   


Medical problems include seizures, emphysema, incontinence, bipolar disorder, breast cancer.