221. Sign of the Times

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

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

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

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

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

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

220: Child's Play

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

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

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

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

219. Pancakes

At 34 weeks Rosie was hospitalized with “intrauterine growth retardation” and poorly controlled diabetes. Are the two complications related? One causing the other? Both caused by an unknown factor? Coincidental?  

Anyway, I walk in for morning rounds and find her eating pancakes.  I go ballistic!  Who allowed that? Then I found out that pancakes are indeed on the hospital’s diabetic diet because the venerable American Diabetes Association wants to make sure that diabetic patients get enough carbs so that they don’t crash from hypoglycemia (low sugar).  That’s fine and good for type 1 diabetics whose blood glucose levels vary widely.

But for type 2 diabetes, carbs are the problem, not the solution.  Many type 2 diabetes will resolve with low carb diets.  So no white bread, no white rice, no potatoes, no pasta, NEVER; and rarely whole grain breads and pasta, brown rice.  As for pancakes?  Give me a break.

218. Heroin part two

A month later, with negative urine screens for any opioids--not even the narcotics (Percocet) that I thought she took regularly, Carolyn returns to preop.  With no unexpected confessions, and a more flexible anesthesiologist, her hysterectomy proceeds without complications. At the eyesight level, the uterus, fallopian tubes, and ovaries appear normal, including no evidence of endometriosis (I wouldn't expect to see adenomyosis).

The pathology report not only confirms the presence of adenomyosis but also notes the presence of small fibroids, which can also cause pain. 

Carolyn went home the morning after as planned.  She did not need more than the usual postop pain medications.  I provided a prescription for 40 Percocet instead of my usual 30 since her history suggests narcotic tolerance--more will be needed for the same pain control.  

It's now been almost a week--I expected a call requesting a refill (at 2 Percocet three times a day, she would have run out by now), but have heard anything.  No news is good news.

217. Heroin part one

Hardly a day goes by without a news headline about the nation's opioid epidemic.  So no surprise when a patient's history reveals a history of substance abuse, including heroin. 

47 year old Carolyn was referred to me by a partner who didn't have time on her schedule for a hysterectomy.  Carolyn experiences chronic pain, especially with menses, which some providers attribute to endometriosis, others to adenomyosis. 

Adenomyosis occurs when the active cells of the inner uterine lining expand into the more sedate muscle fibers that comprise the uterine wall (which they are not supposed to do), Hysterectomy is the only effective treatment.  Remove the uterus--remove the adenomyosis.

Hysterectomy for pain can create more problems than it solves, but I reviewed the chart and said okay. 

The morning of surgery, Carolyn tells the admitting nurse that she used heroin the day before (just a little bit she said; "I didn't really feel anything").  The anesthesiologist promptly cancelled the surgery, saying he wouldn't do it unless he could confirm that she had been off heroin for six months.

But taken at face value, she does have a reason for pain; she takes narcotics for pain; trying to take her off of all narcotics and similar drugs for six months, is not realistic.

So we're going to try again, monitor her urine for a couple of weeks and try again after labor day.

216. Natural Birth

Sounds patronizing but when I have a laboring patient who I think is trying too hard to have a "natural birth" I make the observation that a woman wanting a really natural birth would forego the hospital and even the comforts of a king size Sealy mattress and find some wilder place for the delivery (and then eat the placenta afterwards--though I usually don't add that). The point I'm trying to make, probably not very successfully with the image I have chosen, is that "natural" is an imprecise concept, not helpful for labor decisions

Pain can cause muscles to contract (tighten), which in turn increases blood pressure, which decreases blood flow to the uterus (when muscles encircling blood vessels contract, the vessels are smaller, meaning less blood flow to the uterus and other organs).  There may be evolutionary explanations for this sequence, but none are helpful in modern childbirth.

That was my approach with Nelli, having her first baby at age 24.  To which her mother-in-law promptly proclaimed that she had delivered three babies all natural.  Thanks, mom.

After about 10 hours of labor (4 hours of hard labor), she requested an epidural and went on to deliver vaginally about 6 hours after that.

215. Saturday Morning, 3 AM

me:  ob on call, up with a patient in active labor--she will deliver about an hour later

CNM:  recently graduated midwife, new in our practice, not afraid to ask questions.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

CNM: my patient has been on Pitocin [intravenous medicine which initiates or increases labor contractions] for 12 hours now, and she is unchanged at 3cm.  What should I do?

me: did she get Cytotec [misoprosto--another medicine to induce contractions]? Or the Cook catheter [a plastic balloon inflated inside cervical canal to promote cervical dilating]?

CNM:  three doses, each 25 mcg; I tried to place a Cook catheter, but couldn't do it; never failed before and I've done a lot

me: that's a small Cytotec dose, why not [the usual] 50?

CNM: That's what Kris did [the previous CNM]; I don't know--I'm new here.

me: Well, Kris is wimpy, if she didn't come in contracting, start with 50.  If she were to present with irregular contractions, you might want start with 25 and then increase to 50 with second dose. But here, I'd have given her 50 from the beginning.  Have you considered another attempt to place the Cook catheter?.

CNM: maybe stop everything, let her sleep and start all over in the morning?

me: what difference is a few hours going to make?  Why not just sent her home?

CNM: we're inducing her for gestational hypertension

me:  what's her blood pressure now and what was her blood pressure at her first clinic visit?

[pause while records are being searched]

CNM, 126/84 now, 124/82 at first visit

me: doesn't sound like gestational hypertension to me; that was just stuck in to justify an induction for a patient that you didn't want to send home.  I'd try the Cook catheter again, while continuing increasing the pitocin.

[Cook catheter not attempted; pitocin continued: vaginal delivery around noon]

214. Clueless

I can usually come up with a presumptive diagnosis, or at least some testing (imaging or blood work) that would work towards either a diagnosis or a tentative treatment plan.

But with Caroline, I am clueless:

This 29 year old describes severe pelvic cramps lasting for about 45 minutes upon awakening, usually from a "sexual dream." Happened rarely until last year when they started occurring every few weeks; not associated with mens. She states they do not feel like orgasms which anyway are not painful to her. The symptoms are relieved within 10 minutes of having a bowel movement although she does not necessary feel like she needs to have a BM. She denies any problems with her bowel--in general is very regular. Her only significant history is migraine HA.

213. Deadly Combination

At 24 Melissa found herself in a dangerous situation.  She has experienced a life-long near absence of platelets--those blood components that help blood clot, important since small vascular tears are common and without some self-clotting mechanism, we'd bleed to death from a simple bump, bruise or scratch.

The normal platelet count ranges in the low hundred-thousands; mine was measured in January: 218,000--just right.  Melissa platelets hover between 2 and 5 thousand.

Second, she has experienced deep vein thrombosis, where a clot somehow did form (who knows how that happened) then broke off and obstructed some pulmonary vessels (pulmonary embolism).  These traveling blood clots ("DVTs") can also cause heart attacks and strokes. 

And finally, her menses started and just wouldn't stop (the low platelet thing).  Many of the medicines used for heavy menses can't be used because they increase the risk of stroke (having had one DVT means a rest-of-your-life risk for having another). 

In the hospital, she received fluids, and both whole blood and platelet transfusions, and my group was consulted, resulting in recommendation for progesterone pills--a hormone that can stop bleeding without--in theory at least--increasing the risk of.  The initial dose wasn't helping, so when I was on call I recommended doubling the dose.  A few days later one of my partners doubled it again, which is what I would have done.  That seemed to help--the bleeding almost completely stopped

A few days after that, still in the hospital, she coded and could not be resuscitated, a presumed fatal pulmonary embolism.

212: Second Opinion

Think of the schoolyard tetherball--an object at the end of of a rope twisting as it moves. That's not exactly what happens with ovarian torsion, but you get the ideal.  The ovary is suspended by one "rope" (ligament) attached it to the uterus, and at the other end, a ligament headed in the direction of the abdominal sidewall.  Blood vessels and nerves course through these ligaments. An enlarged (i.e., heavy) ovary is more likely to twist. Twisting causes pain and kinks off blood vessels supplying the ovary; the ovary could be lost.

Note the twisted ligament below the ovary

An athletic, 32 yr old emergency room physician, Beth just didn't feel right, so went for a run. When that just worsened the pain, she went to her own ER. A CT (xray) scan, an ultrasound, some blood tests and several hours later, I was called because the only abnormal finding was the ultrasound's failure to confirm blood flow into the ovary--a sign of torsion. Well, not the only abnormal finding, the CT suggested a "large fecal mass," i.e., constipation even though she felt her recent bowel movements regular.

In my ER told me she was feeling better--not uncommon as twisting can come and go, but still encouraging. That plus the normal size of the ovary led me to recommend waiting a few hours and repeating the ultrasound instead of immediately proceeding with surgery. Sometimes surgery can untwist the ovary, sometimes the ovary just has to be removed.

She agreed with me (if she had agreed, I would have been okay with the laparoscopic look-first-then-decide approach).  The second ultrasound, done by different technician and interpreted by a different radiologist, showed normal blood flow to both ovaries.  So she went home with some advice about laxatives.

211. Second Guessing

A normal pregnancy develops in the uterus not in the quarter-inch diameter fallopian tube. But that appeared to be happening for 32 year old Maria, her sixth pregnancy. 

She first experienced a week of spotting, then cramping. In the ER, the pregnancy hormone HCG was low, so all evidence pointed towards miscarriage. But an ultrasound seemed to show blood accumulating in the abdominal cavity, so maybe a tubal pregnancy after all. A tubal pregnancy can rupture the tube causing life-threatening bleeding as well as severe pain.  Her initial blood level was normal and when measured six hours later remained unchanged.  Also, no pain with an abdominal exam.

Decision point: Proceed immediately with laparoscopy to remove a resumed ectopic pregnancy, or wait, repeating the blood test after several more hours, resorting to surgery only if the blood level drops.  We decided on the latter. The blood level did drop a little, not conclusive but enough to proceed.  She did in fact have an ectopic pregnancy, and the damaged-beyond-repair tube was easily removed.  But there was no active bleeding and not much old blood either, the body's own protective mechanisms having stopped the bleeding and in the process of reabsorbing the loss.  

So, was this a needless, costly, and perhaps dangerous surgical intervention, or a wise precautionary move to prevent equally dangerous internal bleeding?

210. Zika

First pregnant patient today with questions about the Zika virus (what took so long?). Seems that she's going to DisneyWorld in Orlando. 

There have been 87 reported cases of Zika infection in Florida, most from overseas travelers, but with one sexually-transmitted infection. So Anna should be safe, though at some point local mosquito populations may become part of the problem when they bite one of these travelers and then transmit the virus to the local population

States where Aedes aegypti (the mosquito species most likely to transmit Zika) have been found.
With climate change, the blue wave will progress northward

We talked about insect repellents generally and specifically those containing DEET, which are the most effect repellents.  An urban myth makes DEET sounds like a poison, but aside from a predictable risk of local irritation (maybe 6% of users), which can happen with skin care products, from Ivory soap to any scented product, DEET appears safe.

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.