142. Cybermedicine

"I didn't go to school until 30 to be a typist."

"I spend an extra hour every night because of EPIC."

"The only people who like electronic medical records are those who sell them."

Luddites notwithstanding, electronic records such as EPIC promote better care for a number of reasons. Hand written records are easy to lose or are unintelligible. Computer systems allow for data collection and alerts (if a provider attempts to prescribe a medicine to an elderly patient whose age places her at higher risk for side effects, the screen flashes, "Are you sure....?")

Yesterday: a patient has an X-ray, the radiologists dictates the report, which takes a few days to transcribe, and a few more days to make it to the patient chart.  

Today, the radiologist uses voice recognition software, so that by the time the patient has walked from the xray room into my exam room, I have already read the report.

the legend is fuzzy, but the states in dark blue (Hawaii, Washington, Oregon, Utah, etc), have a "significantly higher" use of electronic medical records; as for Florida, Louisiana, Kentucky--well, what can I say?

141. Papal Influence, part 2

And....     the hospital pharmacy will now carry drugs and devices (birth control pills and IUDs) generally prescribed for contraception but having other uses as well (e.g., alleviate abnormal uterine bleeding).

Of course the assumption is that such prescriptions will cite these other uses.  But another loophole to be sure.

140. Fast Work, Frank

Pope Francis has been in office for only a few days, but already his influence has reached the shores of the Pacific.  The local Catholic hospital is easing up its rules on elective sterilizations, a Catholic no-no (perhaps not quite the "machination of the Father of Lies" as the new Pope has characterized gay marriage, but still verboten).

Routine (i.e., no advance approval required) tubal ligations have been allowed at this institution only if performed in conjunction with a cesarean delivery.  In my limited experience, this has been the case in other Catholic hospitals run by nuns; in those under the direction of priests, no tubal ligations under any circumstances. The principle is that if the woman were to have a tubal ligation as a separate procedure in the future, that additional procedure would carry more (albeit negligible) risk to her health than by doing it at the same time as a cesarean delivery.

Now any procedure can be included under the same generalized exception: "surgical sterilizations not needing prior approval... existing medical condition requiring surgery and/or treatment modality that increases health risk should the patient become pregnant the tubal ligation becomes medically necessary [sic]."

Two loopholes here (yes, you can drive a truck through them).  First, the phrase "increases health risk" as opposed to the "risk to life" that is the usual exception to Catholic health directives.  Second, before just cesareans, now, you name it, as in, "while we're removing your ingrown toenail, would you like your tubes tied?"

139. Takeo Eight: Wrap Up

So, about a hundred cases.  Four general surgeons did mostly hernia repairs, with some partial thyroidectomies, and one mastectomy (which may or may not be curative for a large tumor present for a year and with no options of chemotherapy).  

The two gynecologists saw mostly prolapsed uteri, a combination of poor nutrition (weak ligaments), heavy work in the fields (heavy lifting), and for some many births (though the average operative patient had just two or three births, again poor nutrition's effects on fertility or perhaps many war widows).  Also, a couple of uterine fibroids, ovarian cysts and an exploratory surgery for an ectopic pregnancy based on external ultrasound, which "strongly," but in the end mistakenly suggested ectopic pregnancy. 

I did 10 cases over 5 days, which is about what I had planned for (I brought ten pre-sterilized surgical packs with drapes, gowns and "lap tapes"--think small wash cloths).  We had more than enough supplies and medications and in fact left much behind for hospital use.

The only organizational disappointment was lack of pre-screening, which put us behind a day, but not more than that.  On other trips lack of pre-screening has had a much more negative impact. Within the surgical team, many working together for the first time, communication among the staff couldn't have been better; I'd work again with any of them, docs or nurses, anytime, anywhere.

Finally, we used almost no narcotics for postop pain.  Other missions have had limited amounts of narcotics.  We just provided ibuprofen and.... ice.  Families would go out and buy block of ice which would be wrapped and placed on the patient's abdomen. Just based on my visual observations, I don't think these patients experienced any more pain that what I see with patients who have immediate access to various narcotics.

138. Takeo Seven: Pride

Given that Americans have made such incredible blunders under the banner of pride, let's give some slack to our hosts.  Often unwilling hosts.  Sure, local political and ecclesiastical leaders may ask us to come (well, maybe better said responded favorably to our requests to come), and perhaps hospital administrators as well, but the front line staff seem less eager to see us. Some may view us as adding to their already busy, poorly paid days.  More rooms to clean, instruments to sterilize, crowds to handle.  

And medical staff: do they ask our opinions on difficult cases, request lectures, or ask to watch surgery, to learn new techniques?  By and large, nope. At the end of the week, we heard (warning: second hand info here) that in a new wing of the hospital, there were new and better equipped operating rooms. That's okay, why should they suspend their schedules to give us free rein? The staff doctors didn't even know we were coming, the hospital administrators curiously keeping that to themselves.  Or maybe they did know, but said they didn't to justify their wariness.

And then there's Halothane.  Since Queen Victoria used ether during childbirth, anesthetic gasses have come a long way. Introduced in the 1950s, Halothane is cheap and has a positive side effect as a bronchodilator (relaxes airway muscles), but because it's slower (slower to sleep, slower to wake up), and because of rare cardiac complications, it is not even available in U.S. Cambodia, on the other hand prohibits the use of any anesthetic agent other than Halothane. This could be a pride issue--rather than admit it can't afford the other agents, the latter are simply outlawed--or it could be a reasonable attempt at cost control. Maybe something we could learn from. Darn it, there's that pride thing again.

137. Takeo Six: For Me?

Left: student Botha; Right: team RN

As happened in Mozambique (there fortuitious, here planned well in advance), medical students served as translators. I think they learned a lot, their studies not having yet exposed them to patients. I was explaining preeclampsia to one and drew some diagrams. Finished, I handed him the drawings; he looked surprised and asked, "For me?"

Three medical schools, two private schools teaching in English and the French-speaking government school, serve Cambodia's 14.8 million population. Private school tuition $1000 per year, going up to $2500 next year, they tell us. Combined, the three schools graduate about 150 new doctors per year every year, so one per 99,000. Compare that with America's yearly class of over 17,000, or one new doctor per 18,000.

Medical economists don't think that's enough to replace physicians who are retiring earlier than predicted, or who have cut back their hours. 

That retiring issue--not so much a problem in Cambodia, since many (most?) of retiring age physicians did not survive the Khmer Rouge brutality.

136. Takeo Five: Local Support

We try to bring our own supplies, personnel and meds, but are still rely on local facilities for OR rooms postop beds, and night nurses (I haven't seen any teams bring their own nurses for care of postop patients at night).

This hospital had the best night nurses I have worked with: reliable, knowledgeable, and good at documenting their care. The ORs have relatively new anesthesia machines (which means ability to monitor heart rate, oxygenation, and flow of anesthesia gasses). Overall, better facilities and support than I have seen elsewhere.

Interesting bed, you're thinking, but where's the mattress?  See the straw mat--that's it. And note the stacked porcelin dishes under the bed--families bring food.  Finally, the red pail? A chamber pot.  Yes, a chamber pot; patients stand up and pee at the side of the beds, which are of course in open wards. There is a squat toilet down the hall, but for postop patients not yet able to walk that far, if they can just stand at the side of the bed, they use the pot. When you think about it, not that much different from the bed side commode we use in the States.  Sit or squat, behind a curtain, or not, it's all relative.

135. Takeo Four: In the Spotlight

Two scrub assists, each ready to go

Yesterday we had two tables set up in the same room (a common practice for overseas teams); it's a large room and although sometimes a bit noisy and hectic, works out.  Infection control freaks will object but for the low risk (infection-wise) procedures that we are doing, this is not a deal-breaker.

The room has just one overhead spotlight, but otherwise well lit, and I have my head spotlight--an item researched and bought for me by my son.  Similar spotlights are found from Costco to REI, for night bikers, hikers or campers, but adaptable to the OR, though my light has the advantage of being more focussed. So I didn't mind the overhead light being used by the other table. I was overoptimistic: the first case (see yesterday), didn't have the best lighting and I initially thought just wasn't up to the task at hand.

Then a "duh" moment.  My batteries! Almost dead. So I waited for the other table to finish (just a few minutes) and had the overhead light moved over.

Later I replaced the batteries and noted that the dead batteries were the original, now a couple of years old; with new batteries I had all the light I needed.

Lesson: start trips with new batteries or newly charged batteries in spotlights, cameras, whatever.

134. Takeo Three: Blood

Last year I posted on the difficulty I had in Guatemala because the anesthesiologists were reluctant to do hysterectomies without a blood bank immediately available. I've heard  this debate in conferences. For elective (non-life threatening) surgery, why take the risk of a dying because of blood loss?  But "elective" is a relative term; a day to day functional disability may not be life threatening but still makes a reasonable candidate for surgery.

Haun is a 51 year old who presented with uterine prolapse: the uterus has pushed down into the vagina, turning the latter inside out.  So part (or rarely all) of the uterus is hanging outside the vagina.  Uncomfortable as tendons stretch and the vaginal skin--not made for such exposure--is raw and susceptible to bleeding and superficial infection.  A vaginal hysterectomy for prolapse is not difficult and rarely presents with bleeding complications.  

But this hysterectomy was problematic from the beginning.  It was difficult to separate the uterus from adjacent tissues, I had inadequate lighting at the end of the case, when it's most important.
An hour postop I was called to see the patient in recovery for bleeding.  Light bleeding is okay after this type of surgery, but this exceeded normal expectations, so I placed some packing in side the vagina.  Apply pressure to stop bleeding, right?

Well, not in this case; bleeding continued and we returned to the OR, reopened the vaginal incision and immediately found a small artery bleeding.  Not much, but like a leaking faucet, builds up overtime.  A single suture easily stopped the bleeding, the vagina was reclosed.
We had checked her blood level before returning her to the OR; it was low so she received a unit of blood.  The next morning there was no further bleeding but a recheck of the blood level suggested another unit would help her recovery and so received a second unit of blood.

Lessons?
1.  Blood bank or not; always proceed with extra caution; the first time bleeding was noticed, she might have been returned to the OR
2.  Check blood level before surgery; she may have been low at the beginning and therefore not a good candidate for surgery
3.  No surgery without an immediately available blood bank?  Not so sure about this but certainly this case is an argument for this conclusion.  However, some remote areas will never have available blood.  Does that mean those areas can never receive gyn surgical teams? "First do no harm" says no surgery in these areas. Reality says, think about it.

133. Takeo Two: Baby David

Within a few days of conception the placenta invades the uterine wall.  Maternal and fetal blood vessels don't directly connect,  but as tiny capillaries from each system develop side to side, oxygen, water, nutrients and (from the fetus) waste products easily pass back and forth through thin vessel walls. 

It appears that early malfunction of this process may be the root cause of preeclampsia, the major cause of maternal mortality in the U.S. and second in the developing world (after hemorrhage). Symptoms usually don't appear until the increasing demands of late pregnancy stress the system.  The disease process can involve different organs: brain (seizures), liver (bleeding disorders), kidney (swelling, high blood pressure), and placenta (poor fetal growth).

So when 27 year old Kaun arrived at the Takeo hospital at 36 weeks with high blood pressure (173/117), massive swelling (lower legs looking like elephant trunks), Kaun's diagnosis was easy and the treatment straightforward: immediate cesarean delivery. 

Linda in grandma's arms; David is with his mother

She had been experiencing the swelling for a couple of weeks, but hadn't come in, we think because of she couldn't afford to.  Perhaps she heard that our free clinic was in town, so she came on the first day.  She did have some prenatal care, enough to know she had twins and hypertension, but did not have access (for whatever the reason) that either diagnosis would warrant. The surgery went well with the delivery of a 2.5 pound girl and a 4 pound boy.

During the first night Kaun experienced seizures with no apparent harm.  In the U.S. intravenous magnesium protects against seizures, given continuously from diagnosis until 24 hours postpartum; she received all that we had in a single dose, only finding out later that the hospital itself had magnesium, which the local night nurses knew and used, though only in response to seizures, not as a preventative measure.

After the first night, Kaun's blood pressure stabilized, her urine output increased (necessary to get rid of the extra fluid before it ends up in the lungs). Lower leg swelling continued, but with the placement of compression stockings and truly elevated feet (not just propped up in bed but higher than the level of the heart), swelling dramatically decreased.

Dad and Auntie with Twins

The main issue for the kids is not prematurity (36 weeks is about average for twins), but growth. At 2.5 pounds, baby Nancy had severe intrauterine growth retardation (IUGR) --the placenta just wasn't delivering. Once born and no longer dependent on placenta, IUGR kids should do okay. But feeding can be a problem. It takes a lot of energy to suckle, and 2.5 pound babies don't always have the energy reserves. They consume more calories nursing then they take in so need to be feed with tubes, eye droppers or gravity fed bottles. But miracles (a word I don't use easily) happen, and a few days later Mom, Dad and babies went home, all doing well. 

Kaun asked one of the nurses to name the babies, the result being David and Nancy, after the doctor and midwife who performed the surgery.  She also asked how much they owed us.  Nothing we said, and to carry this point further gave her some money so the babies could be seen in follow-up in a few days, otherwise they would not be able to do so. What else can you do?

132. Takeo One: Full Circle

This blog began three and a half years ago with a story of a Cambodian woman who gave birth while fleeing the destruction of the Cambodian-Vietnamese War.  Initiated by the Khmer Rouge, they were soon overpowered by the Vietnamese army, who installed a puppet government. Decades would pass before Cambodia knew peace.

Two to three million Cambodians died during the 4 years of Khmer Rouge rule, including this young boy whose picture taken in the S-21 prison, where 28,000 prisoners were interrogated before taken to the "killing fields" where they were executed and dumped in mass graves. No one survived this particular prison.

Today our medical team arrived at the rural hospital in Takeo, not far from the Vietnamese border. No one mentions it, but I wonder if some of us are looking for an atonement of sorts, since it was American bombs that helped destabilized Cambodia, opening the way for Pol Pot and the Khmer Rough.

First day, over 1200 showed up for the free dental, eye, medical and surgery clinics.  Most too poor to avoid private care; and public care rarely accessible. The Bhuddist monk is there for crowd control. Police may provoke fear, but the tremendous respect shown to monks allows them to easily handle the large number of waiting patients.

131. Stroke

Alma's Her husband had a stroke in December and returned home after a 3-day hospitalization. Irritable and argumentative, he has blamed her for his stroke, though she thinkss it was because he stopped taking his blood pressure medicine years ago.

Stroke, also known as CVA, for cerebral vascular accident, occurs when small blood vessels in the brain either rupture (20%), leading to the death of adjacent nerve cells now deprived of oxygen and glucose.

We think of strokes as causing paralysis, usually one-sided, or speech impediments (pronounciation, word-finding difficulties, etc.), but for many, the damaged area involves emotional centers, with consequences that Alma is experiencing first hand.

130. Mandatory?

28 weeks gestation, just entering the last third (trimester) of pregnancy: time for a final set of blood tests, screening for anemia, bladder infections, and diabetes.

Now 31 weeks, Rhonda feels a little guilty about having failed to have this done, writing in an email:

"I apologize I forgot abouty lab work that you ordered.  Are those labs mandatory? Being that im scared of needles if the labs aren't mandatory, can I not do them?"

I replied, also by email,  that nothing is mandatory (was I a little condescending when I said that?), but there are reasons for the blood tests, looking for treatable conditions that pose a risk to mom and baby.

129. FDA

56 year old Jean considers herself knowledgeable in pharmacologic matters, with 9 daily prescriptions meds and who knows how many supplements. But I had forgotten this when I saw her for her six month follow-up of uterine cancer (an early pick-up, common for this cancer, makes recurrence highly unlikely) so I was unprepared for her response when I noted that the FDA has recently approved a new approach for her overactive bladder.

“The FDA“ she sniffed, “Don’t get me started on the FDA.”  Though curious, I felt duly warned and chose not to pursue this subject, nor did she offer more, and we moved on to another topic: her request for my opinion about green coffee bean extract for weight loss, an item brought to her attention by Dr Oz.

So if any one asks what Dr Oz and I have in common: we both rank above the FDA... at least for Jean.  

128. Sympathize, Offer Info, But Don't Argue

27 year old Beth and I spent about half an hour discussion her plan to delivery vaginally after a previous cesarean deliver (VBAC).  Her first labor was long, she pushed for a couple of hours, but in the end it appeared that the 8.5 lb baby was just too big.  Second babies are usually larger, and she has gained over 40lb, so what are the chances that this one will fit?

Current recommendations would have her schedule a repeat cesarean.  Most complications from a cesarean delivery occur when there has been a long labor preceding the delivery.  And a long labor increases the risk of the previous scar breaking open.  This uterine rupture, not surprisingly, can be catastrophic for mom and baby.

If she had a previous breech that required a cesarean, and this baby was head-first and appeared average weight, then a VBAC would not be discouraged.

So we talk, and she continues to express desire for VBAC, but did agree to reconsider (at least I think she agreed to reconsider).

Then I noticed that she had refused both flu vaccine (safe in pregnant and important since pregnant women experience higher rate of complications from the flu) and the Tdap (whooping cough, diptheria and tetanus) vaccine, which can be deadly if the newborn (who can't be vaccinated for several months) picks it up from a family member.

Had I noticed this earlier, would I have changed my approach?

127. Tears

A nurse came to my office in tears the other day asking me to see a patient also in tears.  No, she repeatedly said, her tears had nothing to do with the patient, this was just a "very emotional day."

22 yr old Lacey presented because a much respected previous doctor told her she needed to be seen after an abnormal Pap smear and with concerns about not being pregnant after 4 months of unprotected intercourse.  My partner couldn't make sense of the patient's explanations and since records were not available, told the patient that she couldn't be helped that day. Regrettable words were said on both sides.  The perceived infertility never came up.

My goal was to provide a blanket apology and to see if I could piece together explanations and plans for both issues.  It's a tricky ground because my partner may have simply been ambushed by someone on edge, unhappy over having to abandon her other doctor, unwilling to consider that the latter might have been wrong, or unhappy that the Pap smear overrode the more important infertility issue. Overtreatment is common with abnormal Pap smears and I assume that my partner didn't want to pursue a previously recommended but inappropriate treatment.

Well, I failed on both counts, the patient unsatisfied with my words, leaving in tears and insisting that she would simply go back to the other doctor.  As for the nurse, her 20-something daughter had experienced a similar encounter with an urgent care doctor a few months ago, an open wound it appears.

Fact or factoid:  a healthy couple requires an average of 7 months of unprotected intercourse prior to conception?  Perhaps a factoid, but helpful in encouraging patience, especially for a 22 year old.

126. Anxiety Dreams

According to Forbes (my top source for workplace issues, yours too I'm sure) lists the top ten work-related anxiety dreams, which include various tech frustrations or being late/chased/naked at work.

Here's mine:  for unclear reasons, I leave the operating room in the middle of surgery. Then I can't find my way back.  I wander inside and out, through rooms and corridors, up and down stairs, and just can't find the OR.  I know it's not good for the patient to be under anesthesia for a prolonged period of time, especially with an open abdomen, so I keep on looking, my sense of unease and distress ever increasing until I wake up.

125. INS, Another Happy Ending

Remember Inez? She wanted her husband to be present for her delivery, which required INS approval since he is a citizen of Mexico.  At her request I wrote two letters, the first making the request, the second advising against air travel since the INS had suggested that she go there instead of him coming here.

I saw her last week for a postpartum check.  He didn't make it for the delivery, but is with her now, the INS demonstrating some unexpected compassion.

124. Happy Endng

Did I mention that Jeannette is hypertensive and diabetic?

Four days after finding out about her pregnancy, Jeannette developed severe preeclampsia, probably triggered by her hypertension, and requiring induction since severe preeclampsia can be life threatening (to mom and baby) and has no cure other than delivery.

She did well during a protracted induction and just one week after she found out she was pregnant, she held in her arms a healthy newborn 6 lb, 6 oz baby girl.

123. How Could She Not Know?

A couple of months ago Jeannette visited her family practice doctor.  She was constipated and having abdominal pain.  The doctor thought there might be a pelvic mass and ordered an ultrasound, requiring a month or so to be scheduled.

You've guessed by now: she's in her 8th month of pregnancy and will deliver this month or next.
So of course we wonder about her apparent cluelessness.

But think about it.  Many years of attempted conception; pretty much given up on it.  Too many months with periods a day or a week late and thinking, "maybe this is the month, maybe I'm really pregnant this time."  And then the tests return negative, the period begins.  Disappointment, tears, the self-promise to never allow expectations to rise again only to be inevitably broken.

So of course she's not going to allow herself to think that her weight gain, the abdominal expansion, the lack of periods, the intra-abdominal turmoil, could all be signs of pregnancy.

122. I'm Going to Bring Him Back

Marissa received two units of blood (about a quart) in the ER a few weeks ago; one year of heavy menstrual bleeding had left her severely anemic.  We discussed less invasive options, but decided to proceed with a hysterectomy.

Then she explained why she needs to be as strong as she can.  Her 19 yr old son tried to hang himself last year.  Found in a closet, revived, but paraplegic with severe brain damage.

"I'm going to bring him back," she says.  Irrational? Sure, and she would probably be first to admit it, but how else can she keep going every day, day after da?

121. Penny Saved, Penny Earned

So how can my group contribute to the trillion dollars that some of my favorite experts claim can be cut from American healthcare expenses without cutting quality?

Starting this month, the trash cans in the doctor's offices will not be emptied nightly; twice a week if we're lucky.

Don't worry, though, the exam room waste will stil be cleared daily.

120: INS

Round One
At 30 weeks Ines asked me to write a letter to the INS asking that her husband be given a visa so that he could travel from Mexico to be with her for the delivery.  I have no problem with that, so letter composed and sent. I don't know her immigration status, but since she is openly petitioning the INS, I would assume she is a citizen, or has a green card.

Round Two
A few weeks later she tells me that the INS denied her request, observing that she could simply return to Mexico. So she asks me to write a second letter recommending against air travel. I agree, though I'm on shaky grounds; there is no generalized recommendation against air travel for pregnant women at any gestational age. Some airlines require a doctors note if past 36 weeks, and of course there can always be case by case exceptions, for example, a pregnancy at risk for preterm labor.

Round Three: stay tuned.

119. Scratch-Itch Cycle

Joanna presents with severe itching and pain in the "groin"--the crease or junction between the thigh and the torso (or more specifically, the vulva).  The area is a bright red patch with superficial excoriations--she has scratched herself so much that there are tiny breaks in the skin, which causes further irritation and more scratching. The goal is not so much to determine the original cause of the irritation as it is to stop the scratch-itch cycle.

But she is fixated on that original cause, certain that it started in a "conversation" tub at a nudist resort in Florida. She wants me to know that she simply accepted the invitation of some friends, not knowing it was "that kind of place."

It looks and sounds fungal but fearing a secondary bacterial invasion I provide both anti-fungal and anti-bacterial meds.  A subsequent culture confirms a bacterial infection.  And most important, I give her the strongest topical steroid that I have, whose anti-inflammatory actions should stop the scratch-itch cycle.

A week later she is doing great, the skin healed and no longer red and tender.  I've already been back in the water, she says, apparently having learned little from the episode.

118. Obamacare

Tubal "ligation" really means "transection"

Last year, at 34, 10 years after the birth of her second child and tired of taking birth control pills, Janet decided it was time too do something permanent.  But when she inquired about an operative tubal ligation, she found it wasn't covered under her insurance; she'd have to pay $6000.

This year she asked again and was told that effective August 1st, the Affordable Care Act requires that eight health care prevention services for women be offered at no cost, including contraception. She's scheduled for Aug 31st.  And that's that.

117. Do Something

36 year old Ashley recently ran a marathon.  She is 5-5 and weighs 130.  Her first words to me are, "people say I look pregnant. I need you to do something about it" 


Internal scarring from her two cesarean deliveries cause a retraction of subcutaneous tissue at the site of the incision, with a subsequent small bulge above the incision.  I acknowledge that scar tissue has resulted in unwanted anatomic changes.


But I don't tell her that she looks pregnant.  And I can't how imagine friends or co-workers could come to that conclusion.  Are they feeding into a serious self-image problem?  Or is she making it all up to stir me to action, thinking, I guess, that I can perform or approve some type of corrective surgery?


My options:
1.  Reassure her: "No, you look fine; your friends are just jealous."
2.  Pass the buck: "We don't have cosmetic surgery here, you need a cosmetic surgeon."
3.  Tell it like it is: "You have a body-image distortion."
4.  Or, a Rogerian:  "I see what you mean; sounds like you are really frustrated to have worked so hard but still short of your goal."

116. Memory

Talk with 88 yr old Rose for five minutes, about the weather or the goings on at her retirement home or her current medical problems (bladder, it appears), and you think, that's how I want to be like when I'm 88. Her eyes sparkle and maintain contact with whoever is speaking.  Hair in place, rosy cheeks, a straight back.

Then you ask about some bleeding that she apparently experienced recently, and she just shrugs her shoulders and says, "You know I have early Alzheimer's, and my memory isn't worth anything."

Sometimes Alzheimer's wears the face of depression, confusion, a wordless inward withdrawal; or sometimes anger and frustration and stubbornness.  But there can also be an engaging and seemingly engaged senior who just can't seem to remember anything that happened yesterday or the day or the week before that.

Memories.

115. Independence Day

Seems only reasonable for a themed post.  We are all into patient independence these days. Forget "paternalism," where the doctor made all the decisions not only about the course of treatment but also whether or not the patient should even know the diagnosis.  Forget "informed consent," where the doctor still made the decisions but at least informed the patient who then gave consent.  Welcome "shared decision-making," where all the options, risks, benefits are laid on the table with a full discussion and then a consensus decision.  I suppose the next stage in this progression is, "you've googled it, tell me what you want me (the doctor) to do."

So, a 26 year old walks in and says she wants a hysterectomy because of painful menses.  She's already had a tubal ligation, so she's made it clear that she doesn't want/need her uterus for it's natural function.

Removing the uterus doesn't guarantee absence of pain.  "I know that."  And there are potentially life-threatening risks to major surgery.  "I know that too."  Can we keep the ovaries intact?  "No."

Okay, how does July 25th sound?

114. Three to Ten

Andrea came in for day surgery last week, a simple procedure to remove an asymptomatic ovarian cyst.  She had been adamant about its removal even though at 32 her risk for ovarian cancer is low. Most of us would recommend a follow-up ultrasound in 3-6 months, rather than surgery, but because it did not have the characteristics of a simple, benign cyst, it was, in the parlance of modern medicine, a "shared decision-making" decision.

Before surgery, I asked her for permission to have her father present for the routine immediate postop talk (though she might appear alert, her short-term memory will be impaired and her father could serve as a back-up memory).  She explained, however, that he probably wouldn't be in the waiting room, since he might be with her mother in the car.  Her mother, she further explained, had Alzheimer's and would be disruptive in public.

Several times a year I talk with patients who want to hold off on necessary but not urgent surgery because they are the primary caregiver for a spouse with Alzheimer's Disease.  Unspoken is the shared knowledge that such deferment may not be long.  The interval between diagnosis and death can be just 3-4 years for patients older than 80 at diagnosis, up to ten years for younger patients; I would assume that Andrea's mother fits in the latter category.

I wonder if there is any association between Andrea's insistence on surgery, and the burden that she and her father carry.

113. from the Latin

The computer screen that displays my schedule tries to stuff in a lot of information, including name, number, time, age, reason for the appointment, plus a few other details. Abbreviations are part of the deal.

So when I saw "cerv mass" on the schedule the other day, I should have thought about a growth on the lower part of the uterus, right?

But no, I thought, "why would someone wanting a neck massage make an appointment with me?"

112. Stop!

Vulvodynia:  the medical term for chronic pain involving the the outer (i.e. visible) female organs.  Acute (transient) vulvar pain can be caused by fungal or bacterial or viral (e.g. herpes) infections, or mild trauma (pants too tight).  Chronic vulvodynia is much more difficult to understand and manage.

Yesterday I met Tabitha, an 18 year old who ostensibly came in to talk about abnormal bleeding patterns, but her real issue was vulvar pain, centering around the introitus--the opening to the vagina.  There is no visible sign of infection or trauma, but even the light touch of a q-tip elicits pain.  She can't use a tampon let alone tolerate sex.  

Tabitha denies past or current sexual abuse, but one possibility is aggressive intercourse (not rape per se but an unknowing or insensitive partner who has watched too much porn and an inability--for whatever reason--on her part to say, "it hurts, let's stop.") that if repeated leads to a reflexive tightening of adjacent muscles, making entry even more painful, and so a vicious cycle and chronic pain.  

My recommendation is simple: stop.  No penetrative intercourse; instead, a slow and progressive self-touching starting at the inner thighs and working in, to unlearn that reflex.  Any contact that causes pain means a return to the level of touch that did not cause pain. And the warning that this may take months.  

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.