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.  

65: OP#8/Malawi: day 14 continued

My final task was to leave my written recommendations for the molar pregnancy with Dr Te Haal.  He was home and accepted them without comment, then asked if I had a few minutes.  Rainier explained that Dr. M. who had diagnosed the molar pregnancy probably would not be staying long in Nkhoma because better opportunities existed elsewhere in the country (my impression is that newly graduated physicians were required to spend a few years in rural areas).  He further explained that Dr. M. had expressed an interest in Ob-Gyn and might be accepted in a South African residency whose director was a friend of Dr Te Haal.   Dr M then might be enticed to return to Nkhoma if there were funds to supplement his government salary of about $700 per month.  $700 is fine for food and housing, but for cars, gas, computers, etc., it doesn't go very far.

We all know where Rainier was headed.  Could I talk with colleagues who together might collect funds to make all this happen?  I appreciate how difficult it is to ask for money.  If I hadn't come over with my notes, this conversation wouldn't have happened. It's obviously something he had thought about, but the opportunity just hadn't arisen.  It may have been just taking the happenstance of my coming over and the impending departure, or perhaps my interest in follow-up may have suggested that I would be a good candidate for this request.  In an event, I said I would think it over.  And I have.

To do this right, I would have to link with an existing non-profit (to make sure any donations were tax deductable), or even form my own foundation.  A friend of my neighbor was traveling in Vietnam and started a conversation with a cab driver who was an unemployed teacher.  One thing led to another, and now this friend returns regularly to VN to drill wells for villages without close and safe water supplies, using the driver as his local connection.  He started a non-profit to support this work.  Am I up to anything like this?

64: OP#8/Malawi: day 14

Part One

This is the most difficult day to write about.  I had a 9:30 deadline for the airport bus, but before that I planned on some rounding and data collection and follow-up notes for the molar pregnancy.  I left early and saw a few patients then passed by L&D because I wanted to look at the delivery log.  The C.O. on call asked me about a woman in her first labor, pushing for about 30 minutes.  He asked about a C/S.  My exam showed more descent than one would expect after just 30 minutes--almost crowning (many unmedicated first labors push for 2 hours), so I said I thought she would be okay, but I would finish up some other business and return in half an hour.  I asked whether the baby was doing okay and was reassured that there were no problems, though I didn't personally listen to the fetal heart.  I finished rounding and returned to find that some progress had been made, but not much. After 15 minutes, there was sufficient descent to allow a vacuum delivery, which I felt justified because of uncertainty regarding the baby's status.  The delivery was quick and uncomplicted but the baby was limp at birth, in need of resuscitation.  Vigorous tactile stimulation did not help--no breathing and no movement or tone, so I took him to the warmer and prepared for bag oxygen (meaning that I'm squeezing a bag of oxygen into a face mask).  A nursing student listened for the heart beat and confirmed its presence.  After a few minutes of oxygen, first by me then more competently by a second C.O. who happened by, spontaneous respirations appeared.  But still no tone, no movement.

I had to leave, so left the baby under the care of the staff.  On the way back to my room I passed the American pediatrician and explained the situation.  She said she would call the C.O. and encourage him to proceed with the neonatal resuscitation protocol.  In this case, it would mean intravenous fluid and antibiotics and if blood tests showed anemia, then a blood transfusion, nothing complicated or new to the staff.  I don't know whether any of that happened, but a few days later the pediatrician e-mailed to say the baby had died.

[nb: all my other pictures are from Nkhoma, this one is from the net]

63: OP#8/Malawi: day 13

Word travels.  Sister Christina was so happy with her vaginal hysterectomy that Sister Elizabeth showed up wanting one too.  But her fibroids were too large for a vaginal hysterectomy, so she underwent an abdominal procedure.   A more difficult operation than anticipated, losing about 4 times as much blood as an average hysterectomy (as is common with large fibroids). Would have been a difficult vaginal hyst.  Also, Sister Christina has a post-op infection.  For all their advantages, vaginal hysterectomies have higher rates of infection.  I brought antibiotics with me that I gave her by injection (more effective than pills)..  

The second major operation today was another dermoid, this one straightforward.

Meanwhile, the vaginal hysterectomy from two days ago ran a high fever.  I thought bacterial infection; the nurses shook their heads and suggested a malaria screen.  Positive.  She did well with medications recommended by a C.O. (I'd have no idea how to treat her). She also received 2 units of blood for a hemoglobin level of 6.6 (very low, normal range 12-14).  It wasn't intraoperative blood loss--she started with a level of 7.3.  So this may have been a malarial relapse (prior malaria would explain her chronic anemia) or a new infection.  Hospital beds have nets, but I'm not sure how often they are actually used.

62: OP#8/Malawi: day 12

Postmenopausal bleeding can be a sign of uterine cancer or a precancer condition called hyperplasia.  At 71, the concern increases, so a hysterectomy was planned and accomplished.  In the U.S. a pathologist would perform a microscopic examination of the uterus and any lymph nodes that we might have removed (cancer cells found in the lymph nodes would prompt chemotherapy).  But pathology (and for that matter chemotherapy) is not available, so we'll just hope either that there was no cancer or that any cancer present had not extended beyond the uterus, making the hysterectomy definitive therapy.

A 31-year old in her first pregnancy underwent a cesarean delivery for severe preeclampsia, a pregnancy condition that probably has it roots in the very beginning of pregnancy when the placenta fails to adequately penetrate the uterine lining.  Found worldwide, the only cure is delivery.

And then a 30-yr old who had a cesarean delivery, with neonatal demise and then a serious wound infection.  For the next several days, I will removing the packing, clean the wound and repack.  She's on the open postpartum ward with healthy newborns all around her.

61: OP#8/Malawi: day 11

One of the young Malawan doctors came to me a few days ago with an ultrasound image that he had obtained a few minutes earlier from a woman 4 months pregnant. He asked me if I agreed that it looked like a molar pregnancy. Instead of a fetus within a fluid-filled gestational (amniotic) sac, the scan showed the classic “cluster of grapes” described in books that he had remembered from medical school.

A molar pregnancy is essentially a cancer of the placenta, usually managed with a “D&C” (dilatation and curettage), a gentle suctioning of the uterine lining.  This is followed by serial measurements of human chorionic gonadotropin (HCG, now of diet fad fame), which is only produced by a placenta.  If there is any of the “mole” left, HCG will show up on the blood tests, prompting effective and well-tolerated chemotherapy (methotrexate).  No HCG means the molar pregnancy was completely removed; no further treatment indicated

Worried that with this advanced gestational sac, the D&C might not entirely remove the molar pregnancy, I recommended hysterectomy.  This was an unplanned pregnancy; she's 42; an easy decision for both of us.

Surgery went well, but follow-up will be difficult.  The hospital has no HCG blood test and no readily available methotrexate.  I recommended weekly urine pregnancy tests, a less sensitive measure of HCG; if repeatedly negative, she's ok, if positive, someone needs to find MTX for her.

The surgical day continued with a repeat C/S and a vaginal hysterectomy for chronic heavy bleeding.

60: OP#8/Malawi: day 10

Sunday: early rounds, everyone is doing okay.

Looking over the surgical log June though September, with some notable absences:

No cholecystectomies (removal of gall bladder), which must reflect the low fat diet of sustenance farmers.

And just one hysterectomy, more difficult to understand.  Hysterectomy is one of the most common procedures in the U.S., and though granted that many may have marginal indications, the severe anemia and pain that can accompany uterine tumors (fibroids) should show up in the surgical log.  I don't think it's diet or genetic, plenty of fibroids in my other trips, and by the end of the trip I will have performed 4 surgeries for fibroids.  Don't know.

59: OP#8/Malawi: day 9

Up at 5 for a 4+ hr ride to bland, the "commercial" center of Malawi, for the annual medical conference sponsored by the country's only medical school. There was some concern that we would have problems with the nation's chronic gas shortage (due to low foreign reserves), but we were okay.  


Some of the topics:

1.  in a survey of Malawan doctors, 65% expressed "general satisfaction" with their work. A recent survey of American doctors found 80% agreeing with the statement, "I like being a physician," but the same survey showed that 30% would like to change jobs or professions.

2.  Current HIV treatment recommends triple drug therapy, Malawi can afford only one.

58: OP #8, Malawi, day 8

Another morning in the antepartum clinic.   Malawi has decided to discourage traditional birth attendants (lay midwives), even to the point of criminalizing their activities, because attempts to bring them into mainstream medical practice failed.  With 90% having only a primary level education and with increasing age, they apparently were unable to assimilate the public health information and practice changes promoted by the Ministry of Health.  At least that's the government line.

57: Overseas Project #8, Malawi, day 7

First, a vaginal hysterectomy today for a 33-yr old nun (self-pay and able to afford a room on the "private" ward--two beds to a room in contrast with the open wards elsewhere, and a higher nurse to pt ratio).

Then, a  myomectomy (removing 12 marble-size fibroid tumors, leaving the uterus in place).  She is 34, never been pregnant but wants to be.  She lives in South Africa but couldn't afford this procedure there, so she came home to Malawi for the procedure.

Finally, the excision of an ovarian dermoid cyst.  A dermoid cyst follows an ovary's attempt to clone itself. It gets as far as some hair, cartilage, sebacious goo, sometimes a tooth or nerve tissue but nothing organized or complicated.  

This young woman presented with an abdomen distended with ascitic fluid, usually associated with liver disease or cancer.  

When an ultrasound showed on ovarian cyst, we were concerned about cancer, but after surgical drainage of 12 liters of ascites we removed a benign ovarian cyst.  There was no consistent lab evidence of liver disease, and I later found no reports of dermoids associated with ascites, so this remained a puzzle.

56: Overseas Project #8, Malawi, day 6

No cases today, so spent some time looking over facilities and reviewing the surgical log.

There are two operating rooms; this is the larger, plenty of lights from tall windows and skylights, an air conditioner which we didn't really need.  Our nurse anesthetist didn't trust the anesthesia machine (for inhalation anesthesia) so she relied on spinal anesthesia: pt is awake but numb from the upper abdomen down.

Home for the afternoon, a long nap prompted by a combination of fatigue/jet lag and mild gastroenteritis. Just what I needed; I was okay the rest of the trip.

55: Overseas Project #8, Malawi, day 5

I spent the morning in the antepartum clinic for high risk pregnancies.

Two women both had hemoglobin levels of 4.9 (approx equivalent of hematocrit of 15), a severity of anemia simply not seen in the U.S. There is a biochemical adaptation to chronic anemia that allows these women to function, though neonatal mortality is high.  The following week one of these women presented with fetal demise.  Malaria, malnutrition, parasites, or more likely a combination of the three.

In the afternoon a 17 year old who delivered 20week twins at home was brought in for retained placenta.
A curettage removed the placenta from what appeared to be a bicornuate (heart-shaped) uterus.  Then another C/S for failure to progress, again working with one of the "clinical officers" (CO's or clinicians), the approximate equivalent of physician assistants who regularly perform C/Ss and other surgeries.  Their technique and knowledge of anatomy were good, and they were interested in seeing my technique, unlike their counterparts in Mozambique.  One newly graduated CO had not previously assisted on a C/S let alone perform one, so was excited to throw some stitches a tie a few knots.

And then the difficult re-repair of a third degree laceration (meaning the rectal sphincter muscles were torn) that occurred during a 17 year old's delivery at a satellite clinic.  An initial repair had broken down so the patient was brought to Nkhoma.

54: Overseas Project #8: Malawi, Day 4

After OpenOffice for Ubuntu crashed its presentation program for the third time, I decided to go low tech, using chalk and chalkboard for a talk at the Monday hospital staff meeting.  I promoted the use of aspirin for women with a history of preeclampsia, given recent findings suggesting that early abnormalities in placental vasculature that lead to preeclamapsismay may be prevented by aspirin. And I encouraged the use of misoprostol for postpartum hemorrhage, which is in their protocols but not in their pharmacy--at least it wasn't until I gave the pharmacist the 100 I had brought with me.

After the meeting, I was introduced to Labor and Delivery, where I was asked about a woman making poor progress in labor--the staff suggested a C/S.  The hospital has C/S rate of about 20-25%, comparable to the U.S.  Higher than I would have expected prior to the Mozambique trip where I appreciated that it is better to perform a few extra C/S's than to have vaginal deliveries of babies in need of non-existent resscitation.  As in Mozambique, the nursery here consists of a single warmer where newborns stack up waiting for their mothers' recoveries.

Although augmentation of labor with pitocin would an option for slowly progress, given the long labor so far(unexpected for someone with prior deliveries) and her request for a tubal ligation, I agreed with the C/S.  The baby was 3700 grams (over 8 lb), a probably cause for the stall.  Afterward, when one of our nurses asked the mom what name she planned, she said, "you name it."  The nurse suggested David, and David it was.

53: Overseas Project #8, Malawi, Day 3

The adjacent Presbyterian church (Dutch Presbyterians founded the hospital, church, nursing school and theological seminary) has an 8:00 English service and a 10:00 Chichewan service.  English is the nation's official language, well-spoken by the educated, but most of the hospital's patients speak only the local Chichewa.  My camera caught a visiting choir.  Many mornings we were awaken by distant sounds of practicing choirs, and when the electricity was down at night, we again heard choirs.

The hospital struggles to stay solvent. Monthly hospital income: $31,000 patient fees (I have no idea where they get hard currency), $50,000 from the government for salaries, and about $15,000 donations, for a total of $96,000.  Expenses: $16,500 medications and supplies, $75,000 staff salaries, $7,300 maintenance, and $10,000 administrative costs, for a total of $109,000.  The government owes $24,000 based on prior agreements for capitated ob and peds, but that would cover just two months of the projected $12,000 monthly deficit.

By contrast my local hospital, St Joseph, has about the same bed capacity, but a billion dollar annual budget--that's over 83 million dollars a month.

52: Overseas Project #8, Malawi, Days 1-2

Two red-eyes dissected by a 9-hr layover in Healthrow pretty much destroys my credibility as a travel agent, but about 45 hours after leaving Seattle we did arrive at Nkhoma, Malawi for overseas project #8.

With a bed capacity of 200, Nkhoma Hospital and its 10 satellite clinics serves an area of about 30,000  subsistence farmers. Patients are on their own for food, bed linen, even IV fluids. Our anesthetist expressed concerns about postoperative patients being underhydrated (adequate hydration is a critical postop issue) because patients can't afford IV fluids.  But nursing neglect provides a better answer--no one walks around adding up supply costs for subsequent hospital bills.

For fourteen years Rainier Te Haal, a South African by birth but Dutch by heritage, temperament, and marriage, has been the hospital medical director. He is an all-purpose general surgeon and also takes call for anesthesia, providing spinals for cesarean deliveries. He has developed a specialty in vesicle-vaginal fistula repair, teaching the technique to Malawian colleagues. Rainier and Wilika have six children; the oldest son is in a boarding school in Nairobi, followed by three daughters and then two younger sons, both local adoptions. Four years ago he spent a Sabbatical in rural British Columbia and was tempted to stay, but “they need me here.”

51: No Age Limit

Usual story: 

Doris says her husband is controlling.

He grabs her, hard enough to cause bruising

He has directly hit her, but not often.

She can't leave because of financial considerations.




What's unusual, at least in my clinic:
Doris is 70.

50. Sangre

More than a burning fever or the loss of gastric contents up or down, more even I think than a seizure or loss of consciousness, the extravasation of blood remains the scariest and dramatic life-threatening sequellae of trauma or illness. Yet also very common (especially for those of us with inherited deviated septi for whom nose bleeds occur almost with provocation).

So no surprise when blood loss triggers either an over-reaction--perhaps because denial can be fatal-- or a careful descriptions of blood loss. Still, though, I had never before heard a clot described as a "slug."

49. Three Stories

Juanita is 17, pregnant with a second child, struggling as a single mother, working and trying to finish high school. I see her for an ultrasound to precisely date the pregnancy, important if she terminates.

Jane is 34; an 18 ultrasound showed a "Chiari II" syndrome, which means injury to the primitive brain due to a malformation of the skull (20% of these babies die in the first year because of respiratory failure; it's the primitve brain the controls breathing. There is also an injury to the spinal cord in the lower back; this child will never walk. She is hopeful that surgery within a few days after birth will release pressure on the brain.

Jasmine is 22, a life-long diabetic who experienced an epidode of diabetic keto-acidosis when she was a few weeks pregnant. Diabetes means that blood glucose can't enter cells; instead it stays in the blood, hence the high sugar levels of diabetes. The brain needs glucose but is the one organ that can't store it, so fats are broken down with ketones as a by-product. High levels of ketones are life-threatening. The risk of birth defects is high when DKA occurs in the first trimester.

Three women with extraordinarily difficult decision. Why should some old white guy from Ohio make this decision for them?

48. DV

From a chart note:

"Case worker called me back to say that [Anita] was admitted to [St Elsewhere] after a severe beating from her boyfriend. She was only recently discharged and case worker says she still is black and blue. FOB is currently in jail but she still has contact with him. She declines to initiate restraining orders. She told case worker that she occ uses cocaine."

Soap operas and learned commentaries both lament the difficulty that abused women have separating themselves from their abusive partner. It's counterintuitive and you wonder if it's an exaggeration of reality, useful for a plot twist or to create interest in a written report.

No, it's not.

47. Belly Dancer

L. is 42, divorced without children. She presented with abdominal pain. There was no associated gastrointestinal symptoms, no urologic issues, but her current menses, tho light, had been ongoing for 3 weeks. At our first visit, the exam and her membership in a belly-dancing troupe suggested a "soft-tissue" injury, that is, a problem associated with trauma to muscles, tendons or ligaments.

Over the next three weeks, we proceeded through a number of blood and radiology testing, the final an abdominal CT scan; all normal. At our last visit, I decided to start over with a history and exam.

When asked about stress factors, she describe multiple sources:
1. Work difficulties: called to task for being slow when from her perspective, she is just doing her job ("courtesy bagger" at Safeway). She worries that she is being set up to be fired so that she can be replaced by a lower wage (less senior) new employee.
2. Estrangement from family; her father died last year and her sisters didn't even tell her about it.
3. Financial difficulties.
She finally acknowedged that her current pain may be associated with one day when she had push a large number of grocery carts from the parking lot to the front of the store, a sudden stop jamming the cart handles against her abdomen. She has not returned, and has not answered by follow-up calls.

46. Intelligent Design

This morning around 3:30 while I was watching 9lb 6oz Gary trying to figure out an exit strategy with the help of a determined mother and a patient midwife, I decided that anyone who believes in "intelligent design" must never have witnessed a human childbirth, or if she/he has, it's been totally erased from conscious memory. I can understand how the pressures of natural selection could lead to such a strange means of reproduction, but as a thought-out, planned-in-advance design by a superior being? Nope.

45: Resistance Is Futile

From an office email I received last week (I'm not the one being addressed, I just happen to be on the mailing list):

"... good to run into you last night. You discussed with me that you were experiencing some resistance to standard deployment of the tools of [new program X] into your department as well as some concerns from some of your colleagues that movement upstream to primary care may cause problems…

As we discussed our job is to understand that resistance and work with our teams to move through it adjusting our strategy and work as appropriate based on their good thinking."

When I find myself in a room with these people, I don't know what to say, it's like I'm listening to a foreign language I learned in college. Sure, I recognize a lot of words, but I have no idea what is being said.

44:OK, I Believe You

T. presents with pelvic pain. The abdominal exam with its initial gentle palpation that tries to localize the pain and estimate its strength, was, frankly, unimpressive. T. must have sensed this; without warning she grabs my hand, pulling it deep into her abdomen. After a long 30 seconds, she lets go and assumes a semi-fetal position, tears streaming from pain. She explained that she just wanted to demonstrate the pain.

43: Thanks

received an email today:

"Thanks so much Dr. H. Enjoy your Easter Weekend."

Illness can make it hard to see a caregiver as a person, especially when we don't have much to offer (which happens more often than I want to admit), so when someone breaks through and says thanks, well... what can I say but thanks in return.

42. The C Word

from an email received March 23th:

"I have an appt. for the 15th of April - but I have to say - I think it's crazy you have to wait so long for an appt. when its something potentially as serious as this is. I'm having a hard time concentrating on anything else. My father was recently diagnosed with cancer so this is making me crazy. I think three weeks can make a huge difference in whether or not someone beats a disease... or not!"

Two possible replies:

1. Explain that an abnormal Pap smear usually diagnoses "precancer," (dysplasia) not cancer, and that the progression from dysplasia to cancer takes years, so a three week delay really is acceptible. Three months would be okay. Three years not okay.

2. Offer an appointment tomorrow, my call day so it may mean some extra shuffling back and forth from the hospital to the clinic, but usually doable.

Number two of course. The time to talk about the difference between dysplasia and cancer or about the natural progression of the disease is BEFORE not after the results are known. But I'm not the one who obtained the Pap smear.

p.s., biopsy obtained during the appointment; she has moderate dysplasia (maybe 10% chance of become cancer over a few years). She accepted a procedure that will remove a button-size segment of the cervix, almost always including all of the dysplasia)

41. Diversity

Apparently bored by my discussion about antepartum risk screening (the result being reviewed estimated that the risk of Downs Syndrome was 1:35 so not a trivial discussion), a father-to-be said, "Doctor, can I ask you a question?"
"Sure," I answered.
"Are you a mulatto?"
"Must be; my hair's from Bathsheba, eyes from Thor and my deviated septum from Genghis Khan. It's my genetic diversity that promises a long, healthy life."

[the question was real, the answer sadly, was really something along the line of, "Must be, if you go back far enough..."]

40. Macrosomia

Macrosomia, literally "big body;" in my world, babies over 9 lb at birth (greater than 90th %ile). B. delivered a "macrosomic" baby two years ago, 9 lb 15 oz. Uncomplicated vaginal birth. Concerned that a second child might be larger, an ultrasound was obtained yesterday, two weeks before her due date. Estimated fetal weight: 5000 grams, or about 11 lb. For most babies, the head is larger than the shoulders so once the head delivers, the baby slides out. But macrosomic babies may have larger shoulders that get stuck, an obstetrician's nightmare: injured nerves, fractured clavicle, paralyzed arms, stillbirth; I've seen them all.

So one of my partners, who herself underwent two uncomplicated Cesarean births, gave her the option of skipping labor, going straight that same day to the operating room for a Cesarean delivery. She said yes. I was on call and delivered a 10lb 5oz baby boy. Would this baby have safely made it through the birth canal? Probably. Would I have counseled her differently? Probably. Would she still have chosen an elective Cesarean? ... Probably.

39. In My Country, part V

The ultrasound demonstrated not one but several "echodense" (i.e., sound waves don't pass through so white area on ultrasound) areas, consistent with collections of silicone. Not something one wants to surgically remove (the cure possible worse than the disease) unless symptoms increase. So, we like to call, "watchful waiting."

38. In My Country, Part IV

I asked S to return, to discuss results of antepartum screening. Four pregnancy "hormones" are measured and in a complex equation compared with the results of other women whose outcome is known. The results: for every 71 women the same age and weight as S, with the exact same results, 70 had normal babies and one had a baby with Downs syndrome. So her risk of having a baby with Downs Syndrome estimated at one out of 71. Using age alone as the predictor, one would estimate her risk for Downs at about one out of 200. I offer her an amniocentesis--withdrawing fluid from the amniotic sac, containing cells sloughed off from the fetus, which can be nurtured, after a couple of weeks yielding enough DNA to give a definitive answer. Problem is that the procedure has a 1/400 risk of miscarriage. It's always a tough call. S immediately declines the amniocentesis, a decision entirely consistent with her earlier request for an elective cesarean delivery. Baby comes first.

37. In My Country, Part III

After our discussion about the Prenatal Risk Screen, S asked me to evaluate the recent onset of leg pain. It seems that several years ago in Peru she received an injection of silicone into her buttocks for cosmetic reasons. S has a normal weight and body shape; I'm not sure and didn't ask the exact location and rationale behind the injection. Anyway, she reports past episodes of this leg pain which her doctors attributed to the spread of the silicone into her thigh, with relief obtained by injections of steroids and/or antibiotics.

Today she has a 4 by 6cm firm, mildly tender swelling on the lateral right thigh, with just a blush of erythema (redness). There are no breaks in the surrounding skin that would suggest an infectious process. I have no idea what this is, but will obtain an ultrasound. Either that or tell her to take a couple of tylenol and see me next week.

36: Pheromes, part II

While we're on the subject, a recent study from Florida recruited young men to opinionate on t-shirts worn by women while sleeping on three consecutive nights. There were three groups of t-shirts, one set from around the time of ovulation (when there would be an evolutionary advantage to attract sexual partners), a second set from a time distant from ovulation, and a control set.

The men rated the ovulation t-shirts as most appealing. Testosterone levels were higher when the ovulation t-shirts were being evaluated.

An earlier study showed that exotic dancers received more tips around the time of ovulation. Many factors here, visual, auditory as well as olfactory, the t-shirt study being just olfactory, but the conclusion is the same: we can't entirely escape our evolutionary destiny, too much of it is unconscious.

35. "In My Country"

"In my country women of my age [36] always have Cesarean deliveries. They say it's safer for the baby." I told S that in our experience, women over 35 can delivery vaginally without putting the baby at risk. Then she explained that she is very anxious about labor and "just couldn't handle it."

It is not uncommon to receive and accept requests for scheduled Cesarean deliveries based on physical health issues other than a previous Cesarean, even though I often wonder if an underlying fear of labor may be the unspoken but stronger motivation. It's all out in the open with S: she acknowledges that it is all about anxiety and fear.

So is fear a valid reason for an elective Cesarean? Most of the health risks of Cesarean deliveries are for those performed after a long labor. There is not much evidence that a vaginal birth is safer than a scheduled Cesarean delivery. Easier recovery, yes; less expensive, yes; safer? perhaps not.

34. Pheromones

Women who live together may find that their menstural cycles synchronize, presumably due to pheromones (olfactory signals). This menstrual synchrony is generally accepted as real, though with many factors influencing menstrual timing, it may not be apparent for all groups of women living in proximity.

Now consider Mrs. H. who experienced a year without menses, which is the definition of menopause and totally expected for this 56-yr old. Then her daughter and family moved in with Mrs. H. and her husband. After a few months, Mrs. H's menses resumed, the timing synchronous with that of her daughter's menses. The daughter recently found a house to rent and may be moving out in a month or so. I'll be curious to see then what happens to Mrs. H's menses.

33. Grouchy

"Menopause makes me grouchy," she said.

Half-tongue in cheek I countered, "What makes your husband grouchy?"

"He's a guy, it comes naturally."

Actually the hormonal shifts of menopause do not increase depression or the irritability that is often the harbinger of depression.
Health issues that arise in the 50's (the knees, the back), kids leaving (or not leaving) home, careers of husband and wife at a plateau, and the earthly departure of friends and relatives--these are the triggers of acute depression. Along with existential angst as one considers, "is this as good as it gets?"

32. Breech

Near the end of the day I met K. for the first time. She is 38, about a month before her due date. Three years ago she adopted a Nepalese infant who suffered some brain trauma at birth (not sure whether or not K knew this at the time of adoption, I think yes, but not the extent). K thinks it may have been a vaginal breech delivery, a not uncommon source of birth injuries.

So of course she is worried whether this baby might be breech. My impression from an abdominal exam was that the baby was head first and I confirmed that with an ultrasound.

She was visibly relieved: "You've made my day."

"I wish it were always this easy," I noted. And we both laughed.

31: Pay Now or Pay Later

Eight states require insurance plans to cover in-vitro fertilization (IVF). Costly decision? Well, maybe not. Couples who pay per cycle (about $10,000) demand implantation of multiple embryos with each cycle, in order to lower total costs. While this may lesson the number of cycles necessary for a successful pregnancy, it also means more twins, triplets, etc., And that means millions more spent in neonatal intensive care units. The average cost of triplets is $300,000. These eight states have significantly fewer IVF multiple births.

30. Have You Thought About...

...going to Haiti? Yes, but my assumption has been that the need is for providers who have experience dealing with acute trauma, and that there have been more volunteers than the infrastructure can handle. To wit, the following comes from an email sent by a rehabilitation psychologist:

"Hi everyone. Just back from Haiti and I wanted to put forth a few thoughts to those of you who would like to volunteer… It is absolutely key and essential that ONLY people who have had large-scale and severe disaster experience go over at this point. Many of you know that I have been to Sichuan--have had many experiences with large hurricanes, Katrina, etc., but I cannot tell you how horrendous and very different this situation is right now… We were doing surgeries almost 24 hours a day....mostly amputations. Unfortunately many of the people who have had amputations have already become infected within a day or two of the surgery (remember essentially no aftercare)... The docs I flew back with came to the consensus that if 30% of the people they operated on survive, they will be lucky... Even the tsunami was in a country where you could find some infrastructure...somewhere. Here--there is nothing. For the first time in my life I truly had to consider [my own] survival …"

Other sources estimate tens of thousands of amputees, which will burden Haiti's health care for decades.

29. Foreign Bodies

T., a 29-yr old exotic dancer, doesn't want to have any more kids. She has three and thinks that's enough.

She tried an IUD, a T-shaped piece of plastic about an inch long that is placed inside the uterus. But then had it removed after several months because "it bugged me having something foreign like that inside of me." I restrain from making the observation that her breast implants aren't exactly natural.


So we decided on a tubal ligation, a day surgery.

"How long," she asks, "do I have to stay off of pot before the surgery?"
"Don't really know," I say, "how does 48 hours sound?."
"Good, that's what my boss says too"

Smart lady, getting lots of opinions before making a decision

28: Pulmonary Embolism

After several years of menopausal quiescence, Mrs. J's 60 yr old uterus erupted a few days before Christmas. What was the stimulant--stress hormones? More likely estrogen produced by adipose cells, of which Mrs. J has in excess. Whatever the source, too much stimulus can cause cancer, necessitating a biopsy, obtained last week.

Tonight I called her to explain the results: hyperplasia with atypia, just one stop short of cancer. I needed to tell her about my referral to a local gyn oncologist who will certainly recommend major surgery. Her husband answered, and I asked for Mrs. J. He paused and then slowly and quietly explained that she had gone to the ER last night, short of breath. And then died there. In the ER.

27. Zero-Sum Game

Ironic that tonight, while a sizable segment of America is salivating at the thought of defeat of health care reform, I'm on call for the ER. Two patients without insurance. One will have a shorter life because of delayed diagnosis of cancer. She couldn't afford a doctor despite telltale symptoms for several months. The other bleeds half of every month, receiving periodic transfusions in the ER, just enough to get her on her feet and out the door. Why does America think that health care is a zero-sum game: every benefit given to one means less benefit for another?

26: Ah, Now I Understand

Yes, I was annoyed when Dr. A called me on Sunday, asking me to come in to see a patient Monday morning (with the unspoken understanding that I would assume care for her). T. delivered six weeks ago (by Dr M), with a rare complication that required two subsequent minor procedures, one by Dr. M, the other by Dr L. She was later re-admitted by Dr J, and followed by Drs W., M, and A in the hospital. So why call me? Well, it seems that the patient made that request, having met me during antepartum visits. Well, of course--my unimpeachable bedside manner. But doesn't Dr A (or any of the others) have the communication skills to establish a relationship with patients in whatever setting? To make plans and carry them out? Whatever.

So we go to surgery, this time more of a final approach, gratefully not as difficult as predicted, and her uterus remains intact. Meeting her mother in the waiting room afterwards, I noticed a book peeking out of her handbag. Glenn Beck. Dr. A is black. It's not my bedside manner, it's the color of my skin.