209. Pelvic Pain

I am rarely comfortable with my diagnoses of pelvic pain.  Any age, any body type, any psych profile.  Pelvic pain can be constant, intermittent, sharply defined, or a vague ache. Ovaries, fallopian tubes, bowels, bladder, may share common nerve pathways, and to a lesser extent, muscles, ligaments and tendons. So a patient may be convinced that her ovary is the problem when it may be the bowels.  Sometimes an ultrasound or CT X-ray will point to the source: a tubal pregnancy, say, or a large, twisted ovarian cyst.  But sometimes, no test helps. So I may suggest a tentative diagnosis, but doubt often remains.

Consider Rachael, a 29 year old who presented with severe pelvic cramping, lasting for 45 minutes after awakening, usually from a sexual dram.  During past year, frequency has increased to once every few weeks.  She states that they do not feel like orgasms, which are not painful.  The symptoms are relieved within 10 minutes of having a bowel movement, though she does not feel the urge to relieve her bowels.  Otherwise, no problems with her gastrointestinal system.  Her only significant history are migraine headaches. 

I suggest to the family practice doctor who consulted me, to manage her as a patient with irritable bowel, and if this proved unhelpful to refer her to gynecology.  I've not heard back

208. A Migraine with Aura

The risk of ischemic stroke for women from 15 to 45 is about 5 per 100,000 women per year. Ischemic strikes are caused by an obstruction in a blood vessel in the brain that deprives adjacent neurons of oxygen (so they die and don't grow back, though with time other parts of the brain may take over the lost function).

Add birth control pills (OCPs for oral contraceptive pills) and that number doubles to 9, presumably due to the estrogen component of OCPs.  Add migraines with aura, and now we're talking 50 to 60 strokes per 100,000 women per year. Add cigarette smoking and age over 35 and the number skyrockets.


Migraines are severe, disabling, usually but not always one-side headaches, usually associated with other neurologic symptoms. An aura is the presence of these symptoms (usually visual disturbances) just before the onset of the headache.

35 year old Bonnie has migraines, often (but not always) with aura.  Her headaches increase just before and during menses, but decrease when she takes OCPs every day (not pausing for a week as most OCPs are taken in order to trigger a reassuring ("my period started--I'm not pregnant") menstrual flow. I provided a very low estrogen dose OCP to minimize stroke risk.  But she developed acne.  She asked for a pill which may reduce not increase acne.  Such a pill exists but appears to increase strokes more than other OCPs.

So, fewer migraines on continuous OCPs, but great risk of stroke because of her aura migraines. But some experts say never ever OCPs for women with migraines with aura, but shouldn't the patient be the one making that decision, assuming she has been presented with and understands the risk data presented above?

207. Wear Red Friday

Friday was Wear Red Friday.  A couple of days before I met a patient whose story tells us why there is a Wear Red Friday.  She is a PE teacher, and for many years has participated in several runs a year, from 5 to 20K. Ten years ago she dropped out of a half marathon because of a nose bleed. The nose bleed turned out inconsequential, but in the course of an interview with the race's volunteer doc, she explained how she had become slower in the past few years, even to the point of dropping out of one race because of fatigue. 

She attributed this to age (47 at the time) but remembers him telling her that she should be getting faster with more races, or at least be holding her own. So re recommended follow-up with her primary care doctor.  She did and was scheduled for a treadmill test (in which one undergoes continuous monitoring of the heart's electrical activity while running).  A heart not receiving enough oxygen during exertion will show abnormal electrical activity. She "failed" the treadmill test and a week later underwent double coronary artery bypass.

Her weight is normal, she has never smoked, is not diabetic, and has no family history of cardiac disease.  Were it not for a doctor's perceptive questioning, she might have had a fatal heart attack during one of her runs.

The theme for Wear Red Friday:  Coronary Artery Disease is the #1 cause of death among women.

206. Socially-Acceptable Addiction

If I could buy stock in caffeine, I'd do it; caffeine's PR on such a rise lately:

1. increased athletic performance with increased adrenaline and access to body fat (= energy)

2. increased memory and general cognitive function

3. decreased risk of neurodegenerative diseases such as Alzheimer's and Parkinson's

4. decreased risk of some types of cancer, diabetes, some liver disease, kidney stones, strokes

These findings are based on association studies, as in let's study people with higher intake of caffeine (read coffee drinkers) and look at their health and athletic/academic performance.  But is it the caffeine, or the coffee, or some other yet to be identified factor?

All I know is that when I am driving long distance or need to be alert for a long afternoon clinic or night call, I pop a 200mg caffeine pill.  One of my partners apparently favors the 188mg caffeine Java Monster, about the same as coffee, which can range from 100 to 300 for a 12 oz cup, compared with 25-50 for tea or 40 for a Diet Pepper or Diet Coke (from caffeineinformer.com).

Spoiler alert: those who find that caffeine has lingering effects (say more than 4-6 hours), may be "slow metabolizers," due to a variant of the CYP1A2 gene, which increases risk of heart attack and/or hpertension with more than two cups of coffee daily. 

205. At A Shower?

I met Melinda for an IUD removal, which appeared to have migrated and penetrated the uterine wall, causing pain.  Though usually simple--just a gentle tug, this malpositioned IUD could be a problem. It seemed to come out easy enough but she experienced moderate discomfort. But it was out.

Then the retrospectively questionable decision to insert a new one at the same visit--she did need contraception, after all.  This insertion was painful and a week of persistent pain led to the IUD removal.

Unexpectedly the pain continued.  Blood tests did not show any infection, nor did an ultrasound reveal any abnormality. The patient requested increasing amounts of narcotics, as many as 70 tablets in one month.  With no explanation for the pain and with a history of opioid addiction, we decided to limit narcotics, first to 40 per month, then 30, and so on.

That's when she came and said her purse, with all the pills in it, had been stolen while at a friend's baby shower.  We've heard stories of pills being lost when a patient stood over a toilet while shaking a few out of the vial, and of pills stolen from a locked car or from a high alcohol density weekend party. But at a shower?

Whatever, during these tapering down or in some cases steady state prescriptions, we make it very clear that no early refills will be made no matter what.  We call that a pain contract.

204. Holoprosencephaly

One mouth, stomach, liver, spleen, pancreas, bladder, bowels.  One heart.
Two eyes, ears, lungs, hands, kidneys, ovaries

And one brain, or more specifically, one hind ("primitive") brain, one midbrain, and one initial forebrain, which is destined to develop into functionally separate but still communicating half-brains.

With holoprosencephaly, the forebrain never divides.  There are associated severe facial deformities. Most never make it to term, and if they survive labor, rarely live more than a few hours, though there are scattered reports of some with almost normal mental and intellectual capacity.

Easy to recognize on ultrasound, Elizabeth knew early on that her first baby had a single forebrain.  She declined to end the pregnancy and made it to term, with neonatal death at four hours.  Today she sees me to remove an IUD that was placed about a month after delivery a year ago. She is ready to try again--not an easy decision even though she knows that holoprosencephaly is not genetic--no increased risk of it happening again.

She is in tears as she describes her decision to again conceive.  One factor is the horrible lack of sensitivity demonstrated by her all male co-workers at her engineering firm, manifest by comments made during and after pregnancy.  She did not offer, nor did I ask for examples, but I can image her being asked why she didn't abort early on, or that wasn't it better that he died so soon after birth. Or who knows what.

She like her job; "I made good money."  But she just can't continue to work with these men, and her job is so specialized she couldn't find similar work in the same geographic area. so better leave her career behind her and become a stay at home mom. She never mentioned her husband, so I don't know whether he's part of the problem, part of the solution, or somewhere in between.

203. More Polyps

Same story: postmenopausal bleeding with ultrasound suggesting polyps.

The polyp is the tubular structure on the right, about half-inch in diameter.  Hard to see, but its stalk originates towards the back of the uterine cavity

At the top, the one-third inch suction morcelator, just finishing up the last remnant

of the polyp

The white patch at 6:00 is where

the polyp started, with a sense of slight excavation from the polyp.

Otherwise, the red and white patches are not significant.

The dark circular areas at about 2:30 and 8:30 are the entrances to the fallopian tubes.

 

202. Polyp

An endometrial polyp.  The endometrial (uterine) lining has the potential for rapid growth, part of the reproductive cycle, a potential that can persist into the menopause.  When one part of the uterine lining grows faster than the rest, it bunches up and forms a finger-like polyp. Polyp is a generic term for this uneven growth anywhere there are mucous membranes: vocal cords, intestinal tract, nose.  

In the uterus they can be the cause of abnormal (e.g. postmenopausal) bleeding and rarely can display malignant changes.  During a hysteroscopy a camera is inserted through the cervical canal into the uterus.  Here the camera has just entered the cervix and already the polyp is visible.  A device with a rotating cutting head and suction removes the polyp in a matter of seconds.

201. Resource Conservation

Resource conservation, another way of saying, save money.  Case in point.  Tillie comes in for a Pap smear and the provider can't see the IUD strings, which extend from the IUD's stem inside the uterine cavity, about three-quarters or an inch beyond the cervical opening. So an ultrasound is ordered: perhaps the IUD was expelled-gone. Or maybe it perforated the uterine wall, migrated beyond the uterus into the abdominal cavity. Or the most likely explanation: the strings may have curled up inside the uterus.

Long and skinny "alligator" forceps can reach inside the uterus grasp the strings to retrieve and IUD (after which a new IUD can be inserted, leaving longer strings).

So why wasn't this attempted, saving the cost of the ultrasound? Probably because ultrasound are seen as relatively cheap (compared to a CT xray, for example) and very safe, and some less experienced providers may be uncomfortable blindly inserting the forceps into the uterine cavity.  All true enough, but that's one reason why medical care is so expensive.

200. Svey Rieng Summary

All told, over five days in Cambodia I saw 27 patients with 11 going to major surgery and 3 having small epidural inclusion cysts removed (superficial cysts arising from blocked skin ducts, leading to accumulation of the secreted material--skin oils) as marble-size cysts. Nothing dangerous--these are not infections or malignancies), but can be annoying and unsightly, so I'm fine removing them.

Many difficulties with poorly trained or simply insufficient staff (often no scrub techs or experienced assistants, so I managed my instruments myself and did the best I could do with inadequate assisting.  And problems with instruments.  And as I mentioned no fellow abdominal surgeons.

All puts a downer on future trips, but I'll let a few more months pass then re-decide.

199. Svay Rieng Day Six

First patient today a 29 year old with an easily palpable mobile, non-tender cyst.  Mobile means not held in place by scar tissue which is more likely to develop with cancer or infection or endometrioma.  An ultrasound showed a 10 by 13cm solid mass.  I'm surprised that it is not painful.  Surgery showed a solid left ovarian tumor, not dermoid, probably not cancer.

This is the last surgical day, generally no complicated cases because we leave tomorrow which doesn't leave much time for follow-up, but yesterday I saw several more women needing surgery and I did not want to turn them away, so I kept adding on more patients.

Thien Mok, 45 years old, requested a hysterectomy because she had been told she has cancer; sounded like...

Finally, a 6* year old relative of local doctor with a mass on the upper right abdomen.  It was easily palpable, mobile, non-tender and by her history present for only a few months (which I doubted).  It seemed too far up for an ovarian cyst, but I couldn't come up with a plausible alternative so I agreed to operate under the assumption that this was a benign ovarian cyst.

It was not ovarian, and was easily dissected away from a base of fibrous tissue--no clear attachment to adjacent organs.  The cyst's contents were a solid but soft white tissue, that I would best describe as cooked cauliflower. The procedure appeared to go well, but the next morning her abdomen was distended.  

Internal bleeding can cause distension, but her vital signs were stable.  Accumulation of bowel gas is common after abdominal surgery but this seemed like a lot overnight.

Unfortunately the team was leaving and I had to leave her with local surgeons.  This is a hospital that performs cesarean deliveries, appendectomies, and treats abdominal surgery, so I was not uncomfortable leaving, but for future missions, I will not operate without a general surgeon on the team, and I will not do major surgery on the day before I leave.

198. Svay Rieng Day Five

Just two patients again today. I had been sharing an operating room with a general surgeon doing mainly hernias, but he left yesterday after just three days of surgery.  A lot of travel for just a few days, but he said that running a metropolitan trauma service left him burned out, and he thought that overseas work would be a win-win. There were also hints that a bitter divorce influenced his decision.

A vaginal hysterectomy for prolapse in a 48 year old, and bilateral removal of ovarian endometriomas in a 24 year old. In endometriosis, fragmented clusters of cells from the uterine lining migrate outside the uterus, ending up on surfaces anywhere in the abdominal cavity. On the ovary, these clusters can form cysts called endometriomas, or "chocolate cysts" because of the thick brown fluid contents of the cysts (encapsulated blood turns brown).

Endometriosis can cause painful periods and/or infertility and is difficult to treat, especially in Cambodia.

197. Svay Rieng Day Four

Today's OR schedule could have come straight from any of my home surgery days.  Two enlarged uteri--fibroids--too large for a vaginal approach, so both were abdominal hysterectomies.  

Both women had never given birth, perhaps infertility caused by the fibroids.  Or perhaps reflecting the loss of a generation of men during the Cambodian genocide. 


[Next week I will be operating on a woman who finally conceived after several years of trying and an operation that removed several fibroids but left the uterus intact (called a myomectomy, the medical term for fibroids being myomas).  She has again been trying to conceive for a few years but new fibroids have appeared, so another myomectomy and crossed fingers.]

Fertility was not at issue for the 54 year old and the 43 year old declined the option of a myomectomy.

Both women experienced minor complications--the first a small tear in the bladder, easily repaired, and the second post-op fever, treated with antibiotics that I brought with me.
A reminder that any hysterectomy anywhere has about a 5% risk of complications.

196. Svay Rieng Day Three

Primun No Nocerumm

Three major surgeries today. A lot of instrument problems. I brought many of my own, but some disappeared after I handed them over to be sterilized. I did keep hold of my “titanium” scissors and clamps but lost (temporarily as it turned out) some retractors. Some surgery became more difficult.

As in Ecuador and the Philippines, ultrasounds are abundant and can be misleading, missing an advanced cancer last year. So I was wary when an ultrasound suggested hyperplasia (precancer) or even cancer itself, and proceeded with a vaginal surgery under the assumption that the uterus was enlarged and the bleeding abnormal because of benign fibroids. Wrong assumptions: at the best hyperplasia, a precancerous condition cured by the surgery; at worst, endometrial cancer that might have been spread by the technique I used ("morcellating" the uterus into small pieces, allowing the vaginal approach). Abdominal hysterectomy usually removes the uterus (and its cancer) intact.

So, did I do her a disservice by removing the (possibly) malignant uterus through vaginal instead of abdominal surgery?

195. Svay Rieng Day Two

The hospital ob-gyn department (I think two, maybe three docs), had patients lined up, so within a few hours I had most of the week scheduled, planning just two major surgeries per day. The surgical team included one general surgeon, two orthopedic surgeons, and one oral-facial surgeon, but just one anesthetist (though we quickly arranged for local anesthetists to help). Moreover, we had no experienced OR nurses. That's because CHPAA formed it's own surgical team, rather than subcontracting out to exisiting surgical teams as they have done in past years and will do again next year.

So it seem reasonable to use just the two rooms offered to us (out of three, leaving one OR room for emergencies such as trauma or cesarean deliveries—though with a published CS rate of just 2% the latter is rare and we didn't see any). In Takeo we placed two OR tables in one of our two rooms so that three cases could be going on at the same time. But this time around two simultaneous surgeries maxed out our nursing support. So one room was devoted to the father-son orthopedic team and room to alternate general surgery and gyn.

First patient, a 40 year old GP with several months of pelvic pressure. A little young for uterine prolapse, but years of hard labor in the fields, and poor nutrition will do it. Similar story for the second patient, but she had something to eat while waiting her turn so was rescheduled for the next day.

194. Svay Rieng Day One

In December, I got a call from Dr. Song Tan, a Cambodian-born pediatrician now practicing in Long Beach and the head of the Cambodian Health Professionals Association of America. For five years CHPAA has sponsored medical missions (dental,eye glasses, prosthetic hands, family practice, and surgical to rural Cambodia. Two years ago I worked with them in Takeo; this year their Ob-Gyn cancelled and Song asked if I could come instead.

Buddhist Monks are great at crowd control.

I had already signed on for two weeks in the Philippines, with the second week coinciding with the one week of CHPAA's mission. You guessed it, I decided to both; better to have one ob-gyn each in different missions than two in one and none in the other.

We flew from Manilla to Saigon to Phnom Penh, then hired a driver for the 4-5 hr ride to Sva Rieng. He came from a village and managed to work as a motorcycle taxi driver.  He saved money, borrowed more from relatives and bought a car.  He's engaged and saving for a wedding, which is very expensive because the groom is expected to put on a big show--as in feeding the entire village. We arrived late Sunday night. Monday morning large crowds were waiting.

193. Dagupan Final Day

Dr. B is sick today (not traveler's gastritis, but a cold with too much coughing to be in the OR). So I manage 3 major surgeries: two vaginal hysterectomies for prolapse and abnormal surgery for a benign (or so it appears, one never knows) ovarian cyst. We are told that there is a pathology department, so all tissue we remove will be looked at under the microscope and if determined to be malignant, the patient will be contacted for follow-up care. Except for my other Philippine mission, none of my other missions have offered pathology evaluation, another sign that the Philippine hospitals where we work are a notch higher. The reality of the follow-up? Don't know.

192. Dagupan Day 6.

Door Number One or Door Number Two?

A very difficult day. My partner promised 37 year old Myra that she would try to remove a large fibroid, leaving the uterus as intact as possible, since Myra still wants to conceive, now 13 years married and never pregnant. Given infertility since her mid 20's, there may infertility factors other than the fibroid which was probably too small to cause infertility problems 10 years ago.

Cervix at the bottom; Fallopian tubes on either side

We start surgery and when the uterus is exposed, we can't tell whether there is a single or multiple fibroids (the latter would make it harder to leave a uterus capable of supporting a pregnancy). So Dr. B. decides to proceed with a full hysterectomy, which she had warned the patient was the most likely outcome, and which went well.

one large fibroid or a few fused fibroids

Afterwards I opened the uterus and found just one, large fibroid (or perhaps a few fused fibroids, though either way, surgical excison not difficult). In retrospect, then, it probably would have been possible to conserve the uterus. But who knows, after another 5-10 years of infertility, more fibroid(s) could grow, causing more problems, requiring surgery again, which may or may not be available.

191. Dagupan Day 5

Today I am the primary surgeon for vaginal hysterectomies, again assisted by the residents. About this time my German-born, Canadian-trained Go-Med partner (her first mission) asks, why are we here? She sees the many skilled residents, a well-equipped operative suite, and the common histories of patients who so far seem to have been experiencing their problems for just a few months. It's not like we are seeing patients who have been on waiting lists for years. The impression being that in out absence, the residents would be providing surgical management.

preop clinic: plastic table and chairs in a hallway

But who knows? Perhaps it's just been in the past few months that clinics have been picking up patients for us; similar patients who presented at clinics six months ago may have just been told to save up money for private surgeons, with only emergencies making it into the system.

The Philippines has an impressive medical system (witness the thousands of the Philippine nurses trained in the Philippines and now working in U.S. Hospitals). But the director of ob-gyn resident training informs me that Philippine health officials figure that the nation is a million doctors short of what is needed, and I assume like everywhere, shortages are greater in rural areas.

The operative suite bears out this suggestion of physician shortage. There are just four operating rooms in the largest (and only?) public hospital in the province. My U.S. hospital, one of the two largest hospitals in the county, has 17 operating rooms. All told, I would guess the county has at least 50 operating rooms.

190. Dagupan Day 4

Two fibroids, each about 1.5-2 inches led to such heavy bleeding that Lenora had to received 4 units of blood in December. One was at the top of the uterus, the other growing inside the uterus (a potential space, like a collapsed balloon, not an empty cavity), then pushing itself out through the cervix and into the vagina—a prolapsed fibroid. So first we carve out the fibroid, then the uterus, both through the vagina. A tricky procedure since the dilated cervix brings the operative site perilously close to vulnerable ureters (the tubes that connect the kidneys to the bladder—not structures to mess with).

The second case, also a fibroid causing abnormal bleeding, was not as difficult nor will her post-op life be not as dramatically improved, but she will still be very happy with her increased strength as her body recovers from almost constant bleeding.  Her husband showed his appreciation the next day with a box of mangos, apparently from a tree near his house, with a letter explaining that he didn't have much to show his gratitude, but what he did have, he wanted to share. One of our Philippine nurses translated for the several staff members who were around when the box arrived.

189. Dagupan Day 3

A light day, as the team learns to work with each other, and with local staff and equipment. I do just one vaginal hysterectomy for a fibroid associated with heavy bleeding. She was pre-screened as an abdominal hystectomy, but I changed that to a vaginal hyst, which went well. She went home in two days (would have been one day in the states, but here both patients and the local staff prefer longer stays.

In Baguio, the residents were eager to assist with vaginal hysterectomies, since they are not allowed to to vaginal hysterectomies for fibroids (only for uterine prolapse). But here interest is minimal; I don't know why the difference.perhaps because they are busier. Later in the week I asked one resident what her call was like the night before (she was assisting me on surgery the day after a 24-hr call): two ectopics, two CS, and 9 vaginal births, including two breech extractions. Whew). As with Baguio, all ob-gyn residents are women.

188. Dagupan Day 2

Sunday, more unpacking, meeting patients who were scheduled for the next day.  Like last year, local residents had screened patients. There are three waiting for us.  I'm working with a recently retired German-born, Canadian-trained ob-gyn.  I will do one case, she the other two, but we cancel one who probably has metastatic cancer and we'd like to talk with a local oncologist before accepting her has a patient.  A local oncologic surgeon, a luxury most of these trips don't have.

When I first heard that another ob-gyn had signed on, I felt some regret, knowing that would cut my productivity by half--I know, sounds like I'm trying to build up points for the platinum trophy. But really, I'm just trying to make best use of my time.  Having two of us in Cambodia worked well, one of us operating, the other screening, but here screening is already done

My new partner expects we will be working together.  In her home practice, she assisted her partners and vice versa.  I explain that we have residents to assist here and she appears to be okay with that.  In the end I'm happy she's here.  We consult with each other and can be around for difficult cases.

187. Dagupan Day 1

Most of the team left Vancouver around midnight, arriving in Manila Saturday morning around 0730, then for Dagupan by chartered bus.  With a different starting point, I couldn't get there that early, so came the day before, planning to just take a taxi to the the airport to meet the team at the bus departure point.

Hospital Main Entrance

But I got my days mixed up (multiple time zones, international date line, what can I say); they had actually arrived on Friday, so when I showed up Saturday, no one was there.  A quick look at the departure screen confirmed my fears since there was no arrival from Vancouver.  Two choices: taxi to bus terminal, assuming I could find a public bus to Dagupan. With no phone or internet access, this carried some risk (the 100lb of medical supplies was another factor).  Or, take a taxi, which with some bargaining could be done for about $115.

I chose the latter; which turned out okay, even though busses would have been an option, because just as the taxi arrived at the hospital, some team members, having spent the day unpacking, were about to leave for our lodgings about 30 minutes away.  Had I missed them (likely if Ihad used the public bus option), it would have been difficult to catch up with them.

All's well that ends well; I did get to spend a worthwhile day in Manila, and I didn't miss anything by arriving in Dagupan a day late.

186. Dagupan Prep

Last year I joined Vancouver-based GO-MED for a two week surgical mission to the Philippine mountain city Baguio; this year's trip was planned for the provincial hospital in Dagupan, a 4-5 hr drive up the coast from Manila.

About a week before leaving I received a call from the mission coodinator asking if I could obtain some more sterile gowns. My hospital uses standard sterile packs (containing instruments, a gown, and drapes) for vaginal deliveries that are opened as delivery nears. If a cesarean happens instead, the disposable drapes and gowns can't be reused, the hospital figuring that it is cheaper to buy new than re-sterilize. But my own clinic will take discarded but otherwise clean and unused supplies and re-sterilize them for me. I come up with ten more gowns.

When I finish packing, I have two 50 pound bags with these supplies, plus surgical instruments, medications, scrubs, and non-sterile supplies.

185. OPS

78 year old Mildred presented with an abnormal vaginal discharge. Premenopausal vaginal glands are active,yielding a white mucoid discharge, but after the menopause these glands become less active, so the normal would be a scant discharge or none at all. The malodor bothered Mildred the most.  The exam was normal as were the lab evaluation of obtained samples.

When I advised her of these results by email, she replied:

"Thank you for the follow up. I guess I will continue to be a water waster and enjoy lots of showers and baths. I wish there was something else to do. I've been comfortable with my body most of my life. This whole adventure has been miserable, embarrassing and depressing."

Although science appears to support an "old people smell," this is unlikely to be what's happening here.  After all, OPS exists in the nose of the beholder, not the beholden.

184. Ivan the Terrible

I meet 40 year old Mariya for the first time just a week before her scheduled repeat cesarean (she's has three prior cesarean deliveries, a number that puts her at risk for significant intraoperative complications).  

I note that there have been previous discussions regarding a tubal ligation, but as I try to confirm that, it is clear that Mariya wants a tubal ligation but her husband Anatoly does not. We've doing okay up to now he says, a generous use of "we." I suggest that a final decision can be made the day of surgery.

Delivery date arrives, no tubal ligation he says.  She's silent.  Surgery went well but post-op there's another difference of opinion.  He wants to name the newborn Peter, but Mariya and her 17 year old daughter prefer Luke.   

When I see her the next morning, Anatoly tells me, I think we'll end up with Peter.

183. What Would Cicero Do?

Understandably, my exam room explanations have undergone countless iterations and though perhaps smooth, may sound a little too polished, too rote.

For example, today 66 year old Sandra expresses concern about painful intercourse, and I explain that this is common due to menopausal changes: decreased estrogen leaves the vaginal surface dry, irritable, and less flexible.  I start to encourage her to consider a vaginal estrogen preparation, when she starts to interrupt me, but I won't let her, my prepared speech is too near it's conclusion to allow distractions, and concludes with the observation that the estrogen has no systemic side effects because it doesn't enter the circulation 

When I finish she resumes her objection.  It seems that a few years ago she tried a vaginal estrogen and within a few hours experienced breast tenderness, a clear indication of systemic absorption.  Furthermore her mother died of breast cancer, increasing her wariness about any form of estrogen.

I quickly backtrack, learning again that my primary role is not to provide fluent, persuasive explanations, but to listen, to guide the discussion with questions such as, is there a family history of beast or cancer, or have you used any hormone preparations in the past?

182. Pardon me for asking

Randy has scheduled a vasectomy 3 days before his wife's scheduled cesarean delivery.  When a prior provider suggested that the time may be not be optimal, Randy, a trial lawyer, said he had a six week trial starting in January and just couldn't take time off.

But I'll have to give him credit: in the same setting, most dudes would tell their wives, you're having surgery anyway, you do it.  Which attitude aside, does have it's point, a cesarean tubal ligation has fewer complications than a vasectomy, and does not make the cesarean recovery any more difficult.

181. Proactive

52 year old Lisa, on the other hand, has decided to learn from history, so as not to repeat it, as they say. During a recent exam, I thought I felt an abdominal mass, until I realized I was just feeling her abs.  I noted my observations and she said, yeah, I do core exercises all the time.  My mother had ovarian cancer, and she broke her hips just getting out of her chair. She just sat in the chair all the time. Go Lisa.

180. Fate

Theresa is 38 years old, never pregnant and not sexually active.  She is overweight, hypertensive, and pre-diabetic, without much evidence from the clinical records of much progress in managing these issues, but she did come in for cervical cancer screening ("Pap smear"), which was abnormal, prompting an office procedure called colposcopy--that's where I come in.

Pap smears screen; colposcopies confirm. 

The colposcopy begins with application of acetic acid (aka vinegar), which causes proteins to denature/precipitate, forming small particles that reflect light straight back to its source instead of scattering the light.  The examiner thus sees white, which is biopsied (a small--about 1/16th inch--sample is removed for microscopic evaluation). This contains more cells than the brushings of a Pap smear.  More cells = more information = more accurate diagnosis.

Theresa's biopsy showed cancer, early enough for successful treatment--she will do well. I was struck by her attitude with the news; as if she totally expected cancer; just one more health problem that fate has decreed for her.

179. Please, Mommy?

When I came on call Friday I looked at my schedule and saw a D&C (dilation and curettage) added to my schedule for 1:30, a miscarriage.  I looked up the chart and saw that Emilia also underwent D&Cs for miscarriages in 2013 and 2011.  

All told she has experienced 6 miscarriages and one life birth. The most recent miscarriages may be related to her age, 42, but there may be some other factors to explain so many.

She tells me that she didn't really want to try another pregnancy, but her daughter keeps pleading for a brother or sister. But this is it, she tells me, not again. I want to believe her.

178. Dead Poets Society

28 year old Samantha is about two thirds the way through her first pregnancy.  I always ask about work issues that may impact antepartum care; she told me she loves her job as a high school language arts/creative writing teacher, a career she attributes to an inspirational high school teacher.  

We also talk about two other issues noted on her problem list. She has had problems with "substance abuse" in the past, but is not shy to tell me that she will be two years sober in October.

And there is a history of depression, a subject which when raised brings tears and a choked admission that, "I'm having a real hard time with Robin William's death."  She's not alone.

177. Mission Accomplished

I like to know something about patients, more than just the "what can I do for you today." I asked Yolanda, age 39, about her family. She said she had two teenagers and a 20 year old.  Is the 20 yr old still at home?  No, he’s serving a mission for our church in Florida.  Well, I replied, that’s what I did many years ago in Brazil.  

She had come to the office after experiencing some abnormal bleeding for about 9 months; I assumed hormonal imbalance, but to exclude the much less likely uterine cancer recommended a routine endometrial (uterine) biopsy.  But the exam expectedly suggested cervical cancer. She’s not had a Pap smear in 10 years--no insurance. Regular Pap smears would have picked up an earlier and easily treatable “pre-cancer.”

Two days later I have the results: cervical cancer confirmed. I don’t normally have patients return for just a discussion of results ($20+ copay and a half day missing work just to be told, “everything is normal”).  So I call her with the news; silence then some crying as I explain and try to reassure.

So whenever an anti-Obamacare guy starts complaining about the surfer who expects free health care for his chronic ear infection, I’d like to direct the conversation back to Yolanda and her missed Pap smears.

176. Decision-Maker

Several years ago Myra delivered a healthy 7 pound girl; a couple of days ago she presented at one week after her due date with spontaneous rupture of membranes.  Labor progressed slowly, augmented by the contraction-stimulating hormone oxytocin (Pitocin).  Fetal heart monitoring was abnormal with several episodes of bradycardia (heart rate less than 110 for more than three minutes). Bradycardia prevents inhibits normal delivery of oxygen to vital organs.

Each episode resolved spontaneously, but the concern remained that the next bradycardia might persist, causing permanent damage.  Severe bradycardia (less than 60) cannot be tolerated for long; even a fetal heart of 100 or so can result in fetal harm if continues more than 30 minutes. So we faced the decision whether to interrupt labor by performing a cesarean delivery.

We hesitated because between the bradycardia episodes the heart monitoring was reassuring (no subtle signs of fetal distress) and because labor was progressing. We became hopeful when she made it to complete dilation but the first push triggered another bradycardia. At about 8 minutes into this episode, we recommended and Myra accepted cesarean delivery.  The baby was vigorous at birth, with no explanation for the bradycardia. 

Based on the exam (the baby’s heady was well descended into the birth canal), and her prior delivery (proving an adequate birth canal), I estimated that a vaginal delivery was only 10-20 minutes away. If she had requested a continued trial of labor, I would not have objected.  But she didn’t. It’s a joint decision--in the current parlance, “shared decision-making," and that 10-20 minutes could be devastating.

175. No Doc Call

Amy’s new partner not only donated sperm but also herpes virus, which became manifest when she entered labor, requiring a cesarean delivery (by a covering doctor she’d never met) to protect the newborn--neonatal herpetic encephalitis can be devastating if not deadly.  Too bad after 6 prior vaginal births.  But that was just the start of her problems.

First, postpartum hemorrhage, requiring a return to OR to control bleeding. Six units of blood transfused.  Then a blood clot in her ovarian vein, extending into the inferior vena cava. Hospitalized 10 days for anti-coagulation (blood thinners).  Sent home still bleeding.  Returned in two days when bleeding increased.

This is where I come in.  The same doctor who delivered her is again covering for her doctor, but she refuses to see him, so the ER calls me as the doc assigned to see patients without local doctors (aka community call, aka “no doc” call).  

She receives another two units of blood and responds to “uterotonics” (drugs that make the uterus contract; her overused uterus just can’t do the job on its own), meaning we don’t have to take her off the blood thinners, which would be a risky venture. Nor does she have to return to the OR for a hysterectomy, another risky option.

And yes, she did get a tubal ligation at the cesarean delivery. 

174. Primum Non Nocere, Part Two

Well, we made it to Singapore.  By arrival, his blood pressure had decreased slightly, to about 219/118, and his oxygen saturation level remained at 100%.

A medical team was waiting for us, but initially couldn't even make it up the aisle because the minute the plane stopped, passengers filled the aisle, pulling down suitcases, ignoring the flight attendant's timid request to remain seated.  So I stood up and very loudly (but not to the yelling state) said, "Everyone please sit down to make room for the medical team. This is a medical emergency."  That did the trick.

The medical team had three people, with a stretcher and a medical bag. A young man in an impressively neat, tailored white shirt and tie, presumably the equivalent of a paramedic, was clearly in charge.  I told him what I knew, and he proceeded with an initial assessment of heart and lungs then quickly inserted an IV (just like in the movies). 

Then he opened up the defibrillator kit (which can provide an electric shock to convert arrhythmic heart patterns to normal rhythms, arrhythmia a common consequence and/or cause of cardiac arrest).  But wait: he has a normal pulse, is breathing regularly, and is fully oxygenated (so clearly the heart and lungs are doing their jobs).  So why the defib? The defib routine begins with electrodes that are placed on the chest to provide an analysis of the heart's rhythm. Though skeptical of the need for this (why delay the transport?), I grant that uncommonly an arrhythmia might be present but undetected by a stethoscope exam (not that he asked for my opinion).

If the defib machine were to pick up an arrhythmia, it would verbally prompt the medical attendant to push a button to administer a shock.  In this case, with a normal heart rhythm demonstrated, the verbal prompt instead said, "begin chest compressions." Having just confirmed a normal heart beat, why would the machine's algorithm do that? Anyway, the paramedic knew more than the machine--that the patient's oxygen levels were normal. But he followed the machine's instructions and started chest compressions. Chest compressions are not harmless since ribs can be broken, and of course the continued delay.

Fortunately, he soon gave up on this and the patient was put on a stretcher and taken to a hospital, where he probably received a head MRI--when I later talked to an ER doc in my clinic, asking what he would have done, he just said, a head MRI, as soon as possible.

I headed for the terminal, wondering, as is my nature, if I could have done anything different.

173. Primum Non Nocere, Part One

First work, then play, right? Maybe not. 

We thought play as we left Bagio for Bali, flying over the South China Sea, with anticipation of tropical waterfalls and coral reef snorkeling, when the an overhead announcement asked if there were any medical personnel on board. Though not eager to volunteer--unless of course a baby has decided that time's up--I did catch the eye of an attendant.  A Filipino nurse also raised her hand. No one else.

An elderly Filipino man had become unconscious.  I noted normal respirations and a strong, steady pulse in the 80's.  Family members thought he took medicine for high blood pressure, but did not think he was diabetic.  He was already being given oxygen through nasal tubes.  The plane's medical kit produced a pulse oximeter which attaches to a finger and measures oxygen levels (anything over 90% is okay).  His level was 100%. 

We also found a wrist blood pressure cuff: 220/119, suggesting an hypertensive crisis which could cause a rupture of cerebral blood vessels, aka hemorrhagic stroke, leading to unconsciousness. Concerned about the accuracy of the blood pressure, I measured my own: 140/90, more than my usual, but considering the stress of the moment, it seemed to confirm the accuracy of the device.  I remeasured his BP: 228/122.  A normal variation or an accelerating, possibly deadly hypertensive crisis?


Other common causes of unconsciousness: drug overdose, seizure, cardiac arrest, and either hyper- or hypoglycemia.  Hyperglycemia from uncontrolled diabetes, hypoglycemia from accidental insulin overdose.  The history, setting, and elevated BP all point to stroke. 

The nurse knew how to use the glucometer also found in the medical kit; it showed a normal blood sugar level. I didn't really think he had blood sugar issues, either extreme value would not likely be associated with increased BP.

The kit also contained a number of medications, including some that could be used for hypertension; many with unfamiliar (non-American) names, but I did recognized one: nifedipine, occasionally used for gestational hypertension.  He can't swallow and I didn't have the resources to monitor intravenous medications, but nifedipine can be given sublingually

We were 90 minutes from the nearest airport: Singapore, which was the destination of the flight. Attempts were being made to contact an ER in Singapore, but no immediate response.

Should I give him an hypertensive agent, possibly preventing further stroke damage, but risking a sudden drop in BP which could lead to cardiac and cerebral ischemia as the body becomes unable to deliver oxygen to vital organs?  

First do no harm.

172. Final Baguio Post

Most fibroids grow within the wall of the uterus.
This "pedunculated" fibroid grew from the top,
 attached to the uterus by a narrow stalk

The dense, gnarled nature of a fibroid
appreciated when it is bisected.

That's the cervix underneath the bulky uterus fundus,
which had to be removed first to gain access to the cervix

Inside, it looks like multiple, not a single, fibroids

Again, multiple fibroids, this time apparent from the outside

That's just $13.50 per day for hospital room, but a hospital and doctor costs for a hysterectomy would add up to P60,000, or over $1300, we were told.  That's over $30,000 of gynecologic surgical care.
Assume an equal amount or more for the general surgeons and $2500 expenses for each of the 25 volunteers.
The result: an investment of $60,000+ for $60,000+ medical care plus some teaching along the way.
All in all, a pretty good return on that investment