Sunday, May 1, 2011

#42 One month out

It’s interesting and scary the things you see one month after a delivery here in Tchad.  

I had 2 such interesting cases 2 days apart.

Two days ago I had a patient who came in one month after her delivery.  She had delivered an 8 month old at home and the baby died.  The placenta never delivered.  She wasn’t hemorrhaging, but complained of leaking pus for 2 weeks.  You think???  

Her hemoglobin was 5.8.  She was also the rare O negative blood type, of which we had none of in our blood bank (I already have plans underway to start a blood drive here and give away free t-shirts that someone donated).  None of the family was a match either.  So I was out of luck for a reserve of blood.  

My ultrasound confirmed retained placenta, a bad thing.  Also bad were air bubbles visible on the ultrasound within the placenta.  I don’t know if anyone in first world countries ever finds retained placentas a month out, but I’m pretty sure air bubbles mean the infection is really, really bad.  

I brought her to the OR and did a sharp curettage (we don’t have suction curettage).  Pus and dead tissue were extruding from the cervix.  One has to be careful with putting instruments into a pregnant or postpartum uterus because they are easy to perforate, especially one that is infected.  I pulled all I could out with a ring forceps, then finished with multiple passes of the sharp curettage.  Everything was infected and adherent.  I don’t know if her uterus will ever be normal again with such a large infection.  

After the operation I looked in her carnet (health booklet).  Two years ago she hemorrhaged after a 4 month miscarriage and had to have 2 curettages.  Her hemoglobin was down to 2.7 at that time!

We need some serious community education:  Come to the hospital if your placenta doesn’t deliver and...bring your friend/family member with you who is the same blood type when you go to the hospital.    

She’s on triple antibiotics and 2 days out.  She’s still anemic.  

Today another patient came.  The story started with Olen understanding the patient was 1 week out from delivering at home.  Maybe the placenta didn’t deliver.  Who knows.  History is often irrelevant here.  He told me the baby was really skinny too and not eating from her breast.  

When I asked with the same nurse to help interpret, the story changed.  The patient delivered at a hospital 5 weeks ago!!!  Still sketchy, who knows what happened at this other hospital.  Apparently she received blood a week out or something.  Her abdomen has been hurting for a month!  

Her abdomen was quite rigid and you could tell she needed an operation.

I repeated the ultrasound.  Is that blood in her uterus or in the abdomen?  It’s hard to see the uterus.  I do an pelvic exam while Olen helps with the abdominal ultrasound.  The mass is not moving in her abdomen.  

To the OR again.  Normally not a problem.  Today is day 2 for me of beaucoup de diarrhea.  Two days ago I ate a mango after just rinsing it, not really washing it.   I suspected that was the source of my problems.  Yesterday was back and forth between bed and the toilet.  Everything I drank came straight out the other end.  Also vomited about 4 times yesterday with much force.  

I was better today, but only planned on coming in to do a quick curettage.  I had no strength.  It’s already 2pm!

Once in the OR I decided to start with an ultrasound guided curettage just in case it’s in the uterus.  I start.  I put a small dilator in and quite a bit of blood comes out.  Maybe all that blood is in the uterus and I just can’t see the wall around it?  I’m able to put an instrument in, but with the ultrasound am able to find the other end of the uterus.  The uterus is small, and has nothing stuck inside.  That means all that blood has to be extrauterine (outside the uterus in the abdomen)!!!  Where is it coming from?  It doesn’t make any sense.  

I ask someone to call for Samedi (who is on vacation).  He’s not anywhere close, 7 km away visiting some family.  

Okay fine.  I get a little grumpy.   

Olen and I scrub, and I open her abdomen.  

That’s not blood it’s pus!  We evacuate 3 liters of liquid pus from her abdomen!!!  That’s a lot.  

All of the pus must have been walled off after such a long time.  I can’t find any of her intestines.  I can see her uterus.  Everything is inflamed.  I discover that all of her intestines have a thick layer over them, making them walled off.  

Maybe this is a TB abscess that she had before she delivered.  I still need to find her appendix.  I guess I have to cut into that mass somehow.  It’s too thick to feel where each part of intestine is.  I grab the mass and make a cut with the scalpel.  

Wrong place.  

I cut into the small intestine.  Yes, INTO.  However, I entered the space where all the intestines were, which is where I needed to be.  Poop comes out.  After separating some of the intestines from the thick wall of the abscess, I repaired the small intestinal hole I made.  

I am NOT a general surgeon!  

If I can just find the appendix to know if it’s okay, I will close her.  The intestines look better than I thought they would look.  They are adherent to each other, but peel away from each other also.  Maybe this abscess was just incidental.  We do find lots of those here.  

After quite a while of searching for the appendix, I get more frustrated.  Where is it?  I know where it should be, but still can’t find it.  I don’t want to close her just to open her again after a few days.  Second operations never go well.  

This is not supposed to be happening.  I didn’t come here to be the only surgeon.  What am I even doing here?  I haven’t had enough experience in operating yet!  How am I supposed to find this appendix?  I get pretty negative in my head, which I’m sure shows on the outside too.  Let alone the electricity keep going on and off because there’s a problem with the generator.  The air conditioner in the OR is also not working well (won’t work without electricity), and it’s the hottest month of the year.    

Someone please call Samedi to see if he can come.

Samedi finally made it.  He opens my incision another 5 inches above the umbilicus.  We search and search for the appendix.  Finally against the sidewall in the right lower abdomen Samedi says he found the necrotic remains of the ruptured appendix.  He clamped off the base and tie it off.  The bowel remained adherent to the sidewall.  

Lots of irrigation, a drain that doesn’t work well in her abdomen, and we closed her.  

I am thankful Samedi was able to come and help.  After the operation we had several more patients to see in the office.  The electricity wasn’t working well, so the ultrasound machine wasn’t either.  We finally got it working and made it home by 6 pm.  

I found myself still grumpy from working so hard when I was sick.  Then I had to think.  Many of these patients who were waiting to see us had waited hours and hours.  I asked one patient how far away they lived.  7 Km.  They probably will be walking home or staying out under a tree here until the morning.  

Please pray for the baby of the woman with the ruptured appendix.  They are feeding it some formula, but I’m sure they don’t haven’t had enough money to feed it well.  It needs to breast feed.  She has milk in her breasts too.  It is one of the skinniest babies I have seen here.  Five weeks old and so malnourished.

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