Stone

Just when I thought I had seen the weirdest that Kenya had to offer....
.....just when I thought my cast list could NOT possibly get more interesting..
...just when I thought I could not get more heartbroken on behalf of a patient......

She came to see me in the office.

The history was very hard to get.  A C section two weeks ago for premature rupture of membranes at 30 weeks.  She waited in a district hospital for two days for a doctor who knew how to do a C section.  Complaints of weeks of pelvic pain and leaking fluid before that. 

I was completely unable to do an exam in the office because she was so uncomfortable.  I suspected she had a vesico-vaginal fistula because of the copious amount of urine that was leaking, so I admitted her to do an exam under anesthesia.

To add to the ambiguity of the situation, I learned that she had presented a few days earlier to the outpatient department when this xray was taken:

After brainstorming with OtherDoc and deciding this might be a bladder stone, I consulted a visiting urologist and asked him to be on stand-by for the exam under anesthesia.

I was putting on my gloves when I heard the surgery resident say, "Dr. Huber, the stone is sitting in the vagina."

Whoa.  Back the truck up.  She has a stone in the vagina?  True, she wouldn't let me touch her in the office yesterday, but...seriously?

I examined her bottom and there it was....a shining white globe the size of my fist.  Dumbfounded - the first thing I thought was - let me go get my forceps and I'll pull it out that way!  On closer examination, the round mass was actually attached by a thin septum to a mass inside the bladder.  A vesiculo-vaginal stone? 

So, I called for one of the long term surgeons and asked the question that everyone dreams of hearing their surgeon say: "Do you think it would be okay if I just pulled this out?"

In the end, I did break the connecting septum and pull out the two pieces of stone.  And this is where it gets strange.

By this time, word had gotten around that something "interesting" was happening in Room 3, so scrub techs, rsidents, visiting staff and the visiting urologist - at least 15 people - had migrated in to see what was going on.  Amidst the crowd, the long term surgeon and I worked to get the large pieces of stone out of the young girl's vagina.  Just as it was twisting to come out, we all saw something....a plastic blue something. 

"There's something in there!"

It was some type of foreign body encrusted inside the stone.  Now, I admit - I was a little freaked out at this point.  And also happy that the patient did not understand english.

After some maneuvering the mass came out in several pieces:

The vaginal "stone"

Vaginal "stone": The whiter area on top (in the middle) is where it was attached
to the bladder stone.

Stone chipped away to reveal the foreign body - bottle cap - within

Baby Bottle Cap: Contraception? Preservation of virginity?  To protect
a pregnancy?  Punishment?

While everyone else marvelled over these events, the urologist and I did another exam.  There were 3 vesico-vaginal fistulas, the most distal one being only 1 cm from the urethral opening.  There was a large fistula opening where the connecting "septum" had been, but overall the tissue looked quite healthy.

A blue baby bottle top....placed in the vagina...that eroded into the anterior vagina, causing mutliple vesico-vaginal fistulas and eventualy was encased into a bladder/vagina stone.

As astounded by the situation as I was, I was more so astounded by the cruelty of these circumstances.  After multiple conversations with the girl and her family, I am no closer to understanding how that bottle top came to be inside her than I was that day in the operating room.  I only know that her life and possibly - her livilihood- are forever altered. It will be weeks before she is able to undergo surgery to repair her fistulas and it will require multiple surgeries.  Money and the overall poor prognosis will be roadblocks to her receiving a "cure".  It is all very crazy and senseless.

And why was it put there?  This was a young, reportedly unmarried girl who had just delivered via C section two weeks prior.  Obviously this foreign body had been there some time - but how long?  And for what reason?  The girl did mention that she was told she was leaking urine and needed a C section - both because of some sort of obstruction.  At least that part of the history makes sense now. 

These are the patients that are my struggle.  Especially at this time of year, when I am torn - already with the melancholoy of missing family and friends.  I miss Thanksgiving, the glitter of Christmas decorations and I even miss Black Friday.  How guilty I feel - to know I am wishing for commericialism when I am caring for a girl who may soon be a social pariah because of her medical condition.  This world - a place of sickness and unexplained cruelty draws me in with the sweet addiction of seeing new things and helping the hopeless...but it also turns me away with the many frustrations of never knowing....why? 

This is a strange story and I'm sorry to end it on a sad note.  But sometimes I am sad and angry and frustrated for my patients.  Behind the sensational stories, I know the people who have lived these tales.  But by sharing their story - and mine-  I hope you will join me in praying for faith and the maintenance of hope.

And a certain woman, which had an issue of blood twelve years, And had suffered many things of many physicians, and had spent all that she had, and was nothing bettered, but rather grew worse.  When she had heard of Jesus, she came in the press behind, and touched his garment. For she said, If I may touch but his clothes, I shall be whole. And straightway the fountain of her blood was dried up; and she felt in her body that she was healed of that plague....... And he said unto her, Daughter, thy faith hath made thee whole; go in peace, and be whole of thy plague.   Mark 5:25-34

It's Complicated

Life is complicated no matter where you live.  Sometimes its one big complication, a series of mini-problems or a waiting room full of patients with all their complications - but irregardless - life is definitely complicated.

Some of you may remember my blog from October "Not Far," in which I included the story of visiting my gardner and his family.  On this trip - I got to meet the cow that supplies my milk.  Recently, I learned that the cow was stolen.  Well, not really stolen - rather repossessed by a relative.  Turns out, my gardner was borrowing the cow from his grandma - who has recently decided to sell it to another relative - who has now repo'ed it from my gardner and now he - nor I - have milk. 

In the meantime, I am also a little caught up in the social complexities of my patients' lives.

I have a patient who is s/p a hysterectomy after a placental percreta.  Her uterus was ruptured, there was placenta in the abdomen and she lost 3 liters of blood while I frantically did the fastest hysterectomy of my life. She is not married but has three children - ages 3 to 12.  She lives 4 hours away and her children are home alone - the eldest caring for the younger ones, while we care for their mum.  She has no phone and presumably has not spoken to the children in ~ 2 weeks!  When I questioned her about this situation, she assured me that if there was any problem, the neighbors could look in on the children. 

Another patient just had her second admission this pregnancy for self-poisoning.  She is only 20 weeks pregnant and I suspect she is trying to abort the pregnancy. 

A couple came to see me recently for reproductive couseling.  She is HIV positive and he is not.  They want to know how they can safely have children.

The list goes on and on.....

It makes me think of Matthew 9:36...."But when he saw the crowds, he was moved with compassion, because they fainted, and were scattered abroad, as sheep with no shepherd."

I humbly admit that there are days when I am not entirely "moved with compassion" though.  Some days there is a great deal of frustration and self-pity.

Seriously? Who borrows a cow?
How can a parent seem so nonchalant about leaving their kids home alone for weeks?
Suicide and abortion are against the law - just call the police.
If one more person ask me for anything - I. will. scream. 
The patients aren't prepared on time for the OR, my case got bumped, I'm hungry, my back hurts.....

It's probably a good thing I wasn't a disciple, because I probably would have told the crowd: "Sorry, you need to leave and come back on Monday because that's when the Saviour has clinic."

In all seriousness, being in Kenya has made me vastly aware of how easy it is to either
1) become so emotionally overwhelmed by someone's suffering that your own judgement is affected, or
2) to become to tired, frustrated or cynical that you become completely de-sensitized to the suffering of others. 

Please remember me in prayer as I seek this balance in work life and home life.  It would be my prayer that I remain somewhere in the middle - compassionate, objective and totally in love with the idea of helping others.

On a completely unrelated note.......even my cleaning has gotten "complicated"..... now I know why this bathroom cleaner was on sale....it makes my toilet overflow with bubbles with every flush!

Transport

Transport: (According to Merriam-Webster) 1. v. To carry away or convey from one place to another. 2. n. Goods (or people) in the process of being received.

When I was in residency, I knew this word as the noun.  "We are getting a transport."  Any day teetering on the edge of goodness would be quickly pushed into chaos by this sentence.  It made everyone cranky: nurses, residents, attendings.  Especially if there were three transports.  Or unstable transports.  Or transports that had complications.

When I was working locums in rural Ohio, I learned this word as a verb.  "We need to transport this patient."  Suddenly, I was on the other side of the equation - being the physician who realized that she did not have the facilities to care for whatever condition the patient had.  Crankiness turned to anxiety in these days - getting the patient transported quickly, knowing I was responsible until she reached the next hospital, did I move fast enough? should I have caught it sooner?  did the other hospital hate me?

In Kenya, I am again on the receiving end of transports.  The big difference here is that transports are mostly concerned with the medical aspect and not so much with the legal.  In fact, if you - as the receiving hospital - say - "Sorry, we don't have an open beds in our ICU," you are likely to be told - "Sorry, the transport has already left."  There is also a common belief that once that patient leaves the facility - out of sight, out of mind!  Hence, I have received more than one transport that ends up receiving chest compressions within 5 minutes of them being at Tenwek.

Other popular reasons for transport:
       - no gauze, no IVfluids, no magnesium in stock (preeclampsia), no blood in blood bank
       - patient having difficulty breathing, patient can't be extubated after surgery (needs ICU care)
       - no anesthetist, on call doctor can't be reached, surgeon busy with other cases
      - failed induction of labor, needs C section - have had two of these patients who were actually not pregnant, but just had fibroids

Many of these district hospitals lack the medical training to take care of ob/gyn patients.  In addition, the patients who come to hospitals can often go from alittle complicated to  "needs ICU" in a short time. 

Take this patient:  a 34 year old multiparous patient who underwent a C section 2 weeks ago for cord prolapse at a district hospital.  Then 1 week ago, se developed a wound infection.  She went back to the same district hospital and had an exploratory laporatomy with a wash out.  Then she was hospitalized for daily dressing changes.  This past weekend, the hospital called saying that the family was requesting that the patient be transported to Tenwek for ICU care and dressing changes.  Unfortunately, at the time, we had no beds, so I declined the transport - but in typical Kenyan fashion, the hospital sent her anyway.  But it was a good thing they did....

When the patient arrived, the doctor on call took her immediately for ex lap because there was copious amount of pus draining from the incision site.  He paged me when he found a necrotic uterus and pelvis abscess:

Yucky necrotic uterus: I am pointing at the round ligament.

I began the very difficult task of debriding the necrotic tissues and doing a hysterectomy.  Luckily, I was able to at least "feel" the ureters and stay well out of their way.  Unfortunately, I can not even describe how badly this case smelled.  Then, just after we had close the abdomen, cleaned her up and began to move her to a clean bed....I spotted this.....coming out of her...uh...posterior area....

AAAAGGGGHHHH!  I hate worms!!!

Me and the worm

A bottom (low fundal) view of the necrotic uterus.



In the end, she went to the ICU on broad spectrum antibiotics - and albendazole.  She is still septic and will need lots of prayer, support (and washouts!) to get her through this.  Please keep her and our Gyne team in your prayers as we try to care for her. 

And to all my fellow medical co-workers: I am hoping that tomorrow will be a transport- free (both noun and verb) day for all of us!

Pictures - Work & Play

Interns doing a C section together.

 

Our recovery room in the main theatre looking clean and nice for a visit from the Minister of Health.

 

Sharing stories at the Samaritan's Purse retreat in September...

 

Visiting the Geddi Ruins with a fellow post resident.

 

End of the Rotation Party at my casa...

The success of any party in Kenya is directly portional to the number of shoes

you have inside your door!

A little "friendly" competition!

Chocolate chip cookies are a hit in any country....

Pictures - Home & Garden

Column Cactus Tree, Nairobi

Cactus Palm, Nairobi

At the Flower Shop, Nairobi



My newest pet - Wilson, the wooden giraffe.

In my flower garder 

I am also a farmer!

The Gremlin In My Patient

Here's one for the medical folks: 

She was a G1P1 who presented complaining of an abdominal mass.  We are currently training new ultrasound techs at Tenwek so I was asked to scan the patient.  I saw this:

An odd looking mass, but it was located just lateral and superior to the uterus - where one might expect an ovary to be and there was no ovary to be seen, so an ovarian mass it was.  Whatever it was - it was big (10x8 cm), tender and it needed to be taken out. 

Now from time to time, we find things on pelvic ultrasound that are incorrectly blamed as being of gynecological origin.  This happens in the USA and it happens in Kenya.  In residency, nothing was more frustrating that the patient who complained of abdominal pain and had been found to have a 0.5 cm simple ovarian cyst.  Or the patient with no ultrasound findings who is generally labeled, "PID" or "Chronic pelvic pain."  However, here in Kenya, more often than not - if the problem is not gynecologic in origin - you can be sure it is at least interesting!

OtherDoc and our rotating Surgery Resident took this particular patient to theatre.  I was covering L&D but I stopped by to snoop and see what they found:

 It was NOT an ovarian mass, but it was an abdominal/pelvic mass - it seemed to be growing from the posterior abdominal wall and several small loose "cysts" were found extruding from mass and in the pelvis.

It was Echinococcosis or hydatid cyst - a parasitic disease caused by a tapeworm.  Typically the disease is passed from dogs/wild dogs or foxes to sheep/cattle and then may be passed to humans via soil or animals that are infected.  The incubation period can be months to years before symptoms are noted, depending on the location of the cyst in the body and how fast it is growing.  Generally, the cysts are found inside the liver or intestine.  Strangely though, this one was in its own little capsule that encompassed many, many eggs.  It was totally sci-fi.

It is important to not spill any cyst fluid inside the peritoneal cavity because it may cause seeding of the abdomen with hundreds of these little worm egg cysts or even anaphylaxis (from the cyst fluid).  We had to have epi and steroids close by - just in case.  I felt like I was on House!  After the mass was removed (we called the General Surgeon on-call), I got to cut it open!  Take a look:

The patient endured the surgery without any complications - including anaphylaxis - and will now require long term treatment with albendazole (anti-parasitic).

Very cool.  So gross.  I love it! 



Not Far

There are many vague descriptors for distance here in Kenya: Very Near, Near, Not Far, Far, Very Far. 

Last weekend I was invited to visit the home of my gardner, whose wife has just had a baby.  In Kenya, it is a bigger honor for you to visit someone than for them to visit you.  So, I happily accepted.  I prepared some gifts to take along: a loaf of banana bread, a baby outfit, some baby socks and baby toiletries.  I also threw in some hair bands for the new big sister.

My gardner, Langat, was supposed to come to my house at 9am so he could escort my housemate, Heather, and I to his house.  I asked him how far away his house was, to which he replied, "Not far."
He was a little late, arriving at 1030, and off we set, walking through the Kenyan countryside.

And we walked.

And walked - Up hills, down hills, over bridges, through cow poo, greeting people all along the way.

After 45 minutes, I started to wonder if I shoould have brought my passport.

After an hour, I considered just camping out and eating the bread, maybe walking back later.

After an hour and 20 minutes, I thought maybe I would just live wherever we were.

After 90 minutes, Langat signaled us that we had arrived.  His house was lovely - nestled between fiels of maize and banana trees, with lots of flowers.  His wife, mother and sister in law were there to greet us.  

Daughter Faith enjoyed her lunch!

In honor of our visit, we had a lunch of chapati (Kenyan flatbread), boiled chicken, rice and milk.  I felt very humbled because meat and chapati are typically reserved for very special occasions.  It was evident that Langat and his family had worked very hard to make this day special for us!  The nicest thing was just sitting and talking with Langat and his family and learning more about their lives. Langat has worked for me for 10 months, but I had no idea that he led the choir at his church or played many musical instruments or that his wife sang in the choir. 

Heather and the new baby

Because I buy my milk from Langat - I got to meet the cow that supplies it! 
Talk about knowing where your food comes from!

Langat, his wife (Janet) and their two daughters

After touring Langat's garden and having a cup of tea, we started our trek back to Tenwek.  On the way back, the walk did seem to go a bit faster - maybe the chai helped!  Despite the rough beginning, it was a great day.

Raging river as it goes over the dam by Tenwek