Not What You Think

Who runs on postoperative day two after a laparotomy?  Not many people.  But this young lady was literally running across the room.  She looked so much better, yet she still looked like a skeleton.

My medical student tells me I should write a case report on her, but part of me feels guilty for having to do a laparotomy.  It did work, however.

Bilal is a 17-year-old girl who presented to us last week.  She was a month or so post miscarriage of “4 months” (sex of baby was known).  The family explained that at another hospital she had already had FOUR dilation and curettages (D and C’s) in the month of December.  In her medical booklet, there is nothing written.  Often times people will have surgeries elsewhere, but we can never find an operative note.  It’s like people are scared to write what they did or didn’t do.

Upon arrival she weighed in at 30kg.  She had previously been 54kg… SEVERELY malnourished!  Bilal had no appetite.  She looked like death, like someone with HIV who was about to die.  I put her on triple antibiotics for presumed endometritis and ordered an ultrasound.  She also got a bag of blood for her hemoglobin of 6.  Her HIV test was negative.

Ultrasound done.  Dang.  She had debris in her uterus still.  Really?  After 4 D and C’s?  But here, who really knows what happened previously.  I repeated her ultrasound that showed no clear endometrial line with evidence of debris.

I told her not to eat in the morning and scheduled her D and C for the next day (Friday).  I would start the day with her on Friday, which I would later discover would be bloody Friday since all 3 of my cases bled like stink that day (her, a postpartum hemorrhage, and a ruptured ectopic).

Friday morning I started with her after rounds.  Just obtaining a spinal seemed scary enough since she was so thin it looked like you would poke right through her.

After an excellent spinal, I started her case with dilating her cervix.  It seemed a little infected which wasn’t surprising.  I was able to dilate her and gently put a curette up to her fundus with ultrasound guidance by my husband.  She was a big set up for a perforation so I was extra careful to be slow and intentional.

I could feel debris up in the left side of her fundus.  Some of it was coming off.  Great!  This might be easier than I thought.  I had previously consented her for a hysterectomy just in case things went south.  She was so young, only had had 2 pregnancies, and I hoped it would not come to that, especially since she did not have any children.

I continued.  The rest of the debris was so stuck on!  Some of it came off, but a good part of it would NOT come off!  Then she started to bleed!  A lot.  I tried to curette faster, but it would NOT come off.

Okay, plan aborted.  We are moving towards a hysterectomy.

But while I prepped for this, she was shooting out blood like a water faucet.  And she was so anemic already!  Second line was already in.  Someone was starting blood in a 16 g vein.  We were opening the hysterectomy kit.

I put a foley in her uterus with ultrasound guidance and added 40cc of water to the balloon that compressed the bleeding.  The bleeding stopped.  However, there was still debris in her uterus.  Quite a lot of it.  And it was infected.  It had to come out.

I wondered if I should try to open her uterus and pull the debris out under direct visualization, like a c-section.  No, dumb idea.  Fleeting thought.  She is sick.  She has been sick too long.  Her debris was causing a big infection in her body.  She needs to be healed.  Her family said to do whatever it took to get her health back.  They were at peace with a hysterectomy.  She was a peace with a hysterectomy.

While prepping her, I observed that she was so, so skinny to even undergo such a big surgery.  Her pelvic bones were so prominent.  But she was too weak to bleed or be infected any longer either.  Such hard choices.  But such easy ones too.  Do whatever it takes to give her her health back.

Dad and I scrubbed and opened her belly.

Patricia (medical student) dared to speak out loud and asked if we could just take it out like a c-section.

That’s just what I was thinking, I told her, but it was taking a risk because she could bleed more. Although we did already have the bleeding controlled temporarily with the balloon.

Classical incision into the uterus.  Wow, that debris is really stuck on.  I tried wiping it off with a compress.  I grabbed ring forceps and pulled it out chunk by chunk.  This was much more controlled than from below when I could not get it removed with ring forceps or a curette.  Eventually, it looked like it all had come off.  Hopefully not too much endometrium with it!  It was still bleeding after that, but not extensively like before.  I took some of the water out of the foley so that I could close the uterus back in 4 layers.  Then blew the foley back up to make sure she didn’t hemorrhage.

She may have been in partial DIC, because everything seemed to bleed.  I used a small needle to get the little bleeders left on the uterus, bladder and muscles.

Well, that was weird, but it seemed to work.  Praise God, we didn’t have to do a hysterectomy…yet.

I wrote on the operative note hysterotomy (cutting into the uterus).  One of the nurses interpreted it as hysterectomy (removing the uterus) and told the patient that night that she could no longer have any kids.

When Patricia went to see the patient later that night to check on her bleeding, she told the patient that we saved her uterus.  They both had tears of joy in their eyes.

On post-op day 1, I removed her foley from her uterus.  Very minimal bleeding!

Today, on post-op day 2, our patient is a whole new person!  She wanted to know what she could eat!  She hasn’t wanted to eat in over a month! She had been so skinny, and I told her she was going to stay here for a long time to regain her strength.  I stood her up to walk.  She asked if it was okay to move around.  I said, yes, she could run if she wanted to.  She started fake running across the room!  She was so happy.  Praise God.

The nurses at the other hospital had told her she had HiV and that’s why she was so skinny.  (She was negative here).  Her family told her there was no point going to another hospital because she was just going to die.  She might as well just die of her sickness.

Her sickness was an infection from retained products of conception (debris from her placenta)!

It will be a while before she gains back all of her weight, but she’s off to a good start!  Please continue to pray for her!

Story and photo shared with permission from the patient.