Saturday, June 5, 2010

Vacation Over

Remember how in Peter Pan, every time a person says “I don’t believe in fairies,” a fairy dies? I have a similar power. Every time I say “I think I’ll go home early today,” someone in Tororo immediately starts hemorrhaging.

I go to Nairobi for a long weekend, and getting back to Tororo requires an epic journey. My flight is cancelled without my being notified and I am forced to stick around another night (not a terrible development, as I get to spend more time with friends). I use 6 different forms of transportation (taxi, plane, matatu, walking, bicycle bodaboda and motorcycle bodaboda). I have to politely reject a man trying to hit on me in a matatu, then use the same man to protect myself from a drunk bodaboda driver yelling “MZUNGU LET ME TAKE YOU TO THE BORDER!” I cramp my legs trying to fit in the oddly shaped matatu, feeling whiny and wimpy as none of the Kenyans and Ugandans on the same matatu seem at all uncomfortable or fidgety.

By the time I make it to Tororo, I am sticky and dusty and exhausted, and my hair resembles a bird’s nest. Still, it’s only 1pm, so I head straight to the hospital to get some work done. I'm exhausted, but I figure I can just round on a few patients, check my email and go home around 3 or 4.

Soon after arriving, I get a phone call from a nurse on the Female Surgical ward. She asks me to come and see patients. There were some patients I knew were waiting for me from last week, needing ultrasounds. I grab the scanner and head over.

The ones I know about are in Beds 2, 5 and 7. I had taken notes on them before, and I am ready to scan them. There is also someone I had scheduled for a hysterectomy in Bed 9, who is admitted in preparation for surgery. Then the nurse points out that she would also like me to see Bed 6, Bed 8 and Bed 12. A clinical officer asks me to see a patient he admitted in Bed 10. As I start to see people, the nurse says “You know, there are also 2 people here who I was going to send home. I think they have cysts or something. Let me send them away, you have too many to see.” I stop her and promise to see them too. They are in Bed 3 and Bed 4. So I need to see Beds 2-10 and Bed 12.

I start scanning. Bed 5 has some kind of huge abdominopelvic mass. It looks most likely ovarian, but I can’t tell exactly. It’s more than 15cm. I am thinking ovarian cancer, but it’s hard to be sure. She will need it removed. I tell the nurse we will schedule her for surgery. When she translates, the patient reaches out for me as I am about to walk away. She grabs my hand and gives me the triple handshake, smiling and thanking me in Japadhola. “She is very happy. She is tired of that mass paining her,” translates the nurse.

Bed 6 is easy – she had a miscarriage earlier today, her bleeding is better, and her uterus is empty on ultrasound. Done, sent home.

Bed 7 has been in menopause for 20 years, but has been bleeding for 1 year now. Highly suspicious for uterine cancer. Another doctor attempted a D&C but her cervix was too stenotic. I scan the uterus – it has a large mass in it that looks like a fibroid, but she shouldn’t have a bleeding fibroid at her age. I contemplate my options – should I give her misoprostol to soften her cervix and repeat her D&C, or just go ahead and do a hysterectomy? I would prefer to do the D&C to check for cancer, but will I find a pathologist to give me an answer? I am still waiting on another patient’s path from 2 months ago. And if they do read it, will I still be here to do her hysterectomy? I am leaving in a month. Lastly, will it change my management? I am not a Gynecologic Oncologist, at most I can remove her pelvic organs, bu I can’t do node dissections, nor would it be useful without a pathologist to examine the nodes (and chemo/radiation). I can’t decide – I will think about it later and get back to the patient with my plan.

Beds 8, 9, 10 and 12 are still waiting for me. Bed 12 needs a pregnancy test, but the hospital doesn’t have any test strips right now. Bed 9 is for surgery tomorrow, and looks ok. Bed 10 is a young girl with a right-sided pelvic mass – probably a dermoid cyst (although she has gotten loads and loads of unnecessary antibiotics already). But first, I turn my attention to Beds 3 and 4, who are looking more urgent.

We start with Bed 4. She is visibly in pain, she looks like she is having episodes of cramping pain. She complains of heavy vaginal bleeding. Her last period was 6 months ago. I scan her and find a lot in her uterus. Looks like liquid plus some solid. I think it is probably an old pregnancy that died a while ago, and is just now coming out. The liquid is probably blood. I can’t see an actual fetus shape, but maybe it has degenerated. I decide to do a vaginal exam to see if she is dilated – and that changes my diagnosis. When I feel her cervix, it is rock hard, bulky and immobile – especially inside the canal. My guess is cervical cancer. The stuff in her uterus is not a pregnancy, but probably liquid and clotted blood. Her cervix has closed off from the tumor, and blood is collecting inside. She will need an exam under anesthesia, biopsies and a D&C to confirm.

Then we reach Bed 3, who supposedly has ovarian cysts. She insists she is not pregnant, although she last took Depo Provera over 1 year ago. She looks pretty good, not in visible pain. That changes when I touch her abdomen – she cringes and recoils. Hmmm. I do an ultrasound. Immediately, I see a small live fetus inside her uterus, measuring 9 weeks and 5 days. It has a visible heartbeat. It’s inside her uterus, so this is not an ectopic pregnancy. I notice that the fetus is in the upper part of her uterus (fundus) and she seems to have a round structure, maybe a fibroid, in the lower part of the uterus. Maybe her pain is from a degenerating fibroid? The pain seems excessive for just a fibroid, though.

Then I look outside her uterus. Behind it, there is a lot of black, representing fluid. What is all that fluid doing in her abdomen? And there also appears to be something more solid floating in the fluid. Is it a clot? What is going on? Did she rupture an ovarian cyst that is now bleeding? I can’t even find her ovaries. She has an intrauterine pregnancy. Could she have a heterotopic pregnancy, where one twin is inside the uterus and the second is in the tube? That is exceedingly rare – I have already seen it once in my life and don’t expect to see it again. I ask if she has a history of twins, but she doesn’t. She has 6 children, all born singletons.

As I am trying to figure out what is going on, I realize that she is becoming increasingly uncomfortable as I press on her abdomen for the scan. I ask the nurse to get her some pain medicine. As soon as I do, the woman suddenly closes her eyes and seems to lose consciousness. The nurse immediately goes to get an IV to insert and hang fluid. The woman looks pale and sweaty. I take her pulse – it is normal. What is going on? I notice her move her arms toward her face with purposeful movements; she is not unconscious. Is she just being melodramatic about the pain, or is the pain just incredibly severe and she can’t help but close her eyes? She opens her eyes again and the nurse gives morphine. A second nurse puts in the IV.

I need to figure this out fast. I know that scanning is creating pain, but if that is really blood in her abdomen, then I need to take her to the OR immediately. I review the chart. As it turns out, the woman just had an ultrasound at the TDH department. It is not a great report, and the person seems as confused as I am. Eventually, the sonographer concludes, the patient should be admitted and “we should reevaluate with a clear mind.”

What? No idea what that means. Then I realize what I am looking at. I re-scan the pregnancy. It is not exactly in the uterus, but along the upper border. What if it is a cornual ectopic –located in the corner of the uterus, which is a thin wall, and bursting through the wall? It would explain why the pregnancy is bigger than a normal ectopic (in the tube they tend to rupture around 7 weeks, this is almost 10). Still, cornual ectopics are rare, and a tubal pregnancy is statistically much more likely in this case.

Regardless, she needs to go to the OR now. It’s almost 5pm. Will I be able to get an anesthetist and theatre nurse at this hour? This is life or death.

“And I was going to send them away!” marvels the nurse. One has a probably ruptured ectopic, and one has probable cervical cancer. Good thing she didn’t.

I call the anesthetist, and to my great relief, he agrees to come immediately. I write notes on the other patients while I wait for him to come. When he arrives, we move the patient quickly to the OR.

I open her abdomen urgently. As soon as I open the peritoneum, blood comes pouring out. Blood, blood, blood, more blood. Liquid, rapid, bright red blood. It is everywhere. I scoop it out with my hands (there is no suction). The anesthetist puts a big plastic garbage pail at the end of the table, and the blood runs down off the drape, between the patient’s legs, into the pail. It also pours all over our feet as we operate, soaks the drapes and the patient’s abdomen.

I can’t see anything because of all the blood, but it seems like the bleeding is still active. I stick my hand in to see if I can feel what is going on, and maybe pull the aberrant ruptured tube (or whatever) out of the incision. I pull out clots, and reach back in. I feel something different, mushy and textured. I pull out an intact placenta and fetus in a sac. Holy moly. Where the hell did that come from?

I scoop out more blood, and sop it up with mops (large squares of gauzy cloth). I pull up the right tube, and it is intact. I pull up the left, tube, and it is intact. Finally, I find the uterus. More mopping, and I realize that there is a 2cm hole, about 3cm deep, in the right corner of the uterus. It really is a ruptured cornual ectopic.

And it is still bleeding like stink. I need to close the defect. I have never actually operated on a cornual ectopic before. I heard about other people doing them in residency, listened intently to other residents’ accounts of them in case I ever encountered one, but I never saw one. They are relatively rare.

But here I am, and she is bleeding. I figure the best thing to do is pretend it’s a myomectomy. This defect is similar to the hole that is left after you remove a small fibroid. I close the defect in layers, with tight locking sutures to stop the bleeding. After 2 layers, it has improved, and after the 3rd layer, it is hemostatic. Phew. Meanwhile, more blood has collected and I need to mop it out. There is so much that I worry that something else is bleeding. My kingdom for a suction.

I finally get all the blood cleaned up, inspect the pelvis carefully, and discover that everything else is intact. There is no bleeding. I close the abdomen.

When I step away from the table, I realize it looks like the scene of a massacre. There is blood everywhere, and the pail has a scary amount of blood in it. I have no idea what her blood level is – the lab can’t do that test right now. She was extremely pale before the surgery, but most of the blood loss was already in her abdomen before we started. Still, she might need a transfusion.

At 7pm, as the dark is falling and the last bodaboda is available at the hospital gate, I finally head home. I look in the mirror, and something is crusted on my forehead – is it dirt from my long journey or blood from my crazy surgery? I take a shower, and when I wash my hair, the white conditioner turns brown from all the dirt in my hair. Finally clean, I lie down on my bed, exhausted. Tomorrow, I will go and see all the patients I didn’t see after I discovered the ruptured ectopic.


danengber said...

hi Veronica, what's the TDH Department? When are you coming back to NYC? You are missed!

Khady,M.D. said...

keep them coming..

Veronica said...

Hi Dan!
TDH = Tororo District Hospital. That sentence referred to their ultrasound department.

I'm coming home July 21, and will be in NYC in August. But come visit me in SF too!

Claudia said...

Dr. V,
I'm in awe! This is riveting should create a tv series around it!!