Saturday, February 14, 2009

Case #5: My Funny Valentine. (Case Reports from Kijabe Hospital)

Warning: This post is one of a series that describes a patient (case) that I have taken care of in Kijabe hospital, and it may contain graphic descriptions or photos of medical pathology written primarily for clinicians. For my non-clinical readers, use discretion before reading, and please excuse the medical jargon.

Afternoons in OR#5 are not pleasant. OR#5 is the smallest operating room in the theater with barely enough space to get the gurney in next to the operating table. It is does not have nitrous. The suction is particularly anemic. The radio does not work. The lights are arcane. But the worst part about OR#5 is that it get’s blazing hot in the afternoon. The windows are situated in such a way that the afternoon sun just dials the temperature up to broil from around 2pm until 5pm. Usually, we try not to do cases that require gowns in the afternoon in OR#5 (endoscopy, hemorhoids, etc), but sometimes you just have to suffer, and put on a gown (made of heavyweight cotton no less), and sweat half of your bodyweight off to get the work done.

OR#5 also happens to be where I have all of my block time. Even in Africa, there is seniority, and since I am the newest surgeon here, I have the privileged of spending most of my time in OR#5… I didn’t know any better when I got the assignment, but now I realize why Dr. Bird (the head of surgery) has all of his block time in the cavernous cool comfortable OR#2.
But even though I am banished to OR#5 and walk around with totally sweat-soaked scrubs most days, I try not to complain. I am the least busy surgeon and I don’t do nearly as many “big cases” as my colleagues. But every now and then, I operate on a patient that is sick enough that they remove the velvet rope, and let me into OR#2. TW was one of those patients...

***

TW is a 60 year old woman with minimal past medical history. She presented on a Wednesday afternoon to the outpatient department of our hospital with complaints of abdominal pain and generally feeling unwell. Dr. Mwaka who is an excellent family practice registrar was one of the first physicians to see the patient. On exam, he noticed that she had a pulsatile abdominal mass.

As an aside for my non-clinical readers: A pulsatile mass in the abdomen of a patient having pain or unstable blood pressure is a surgical emergency. The patient likely has a ruptured abdominal aortic aneurysm (AAA). When one ruptures the main artery that carries blood to your legs, you can quickly exsanguinate. In medical school we learn that half of people who rupture a AAA at home will die before getting to a hospital, and of the half, that make it to the hospital, half of those will die. The ones who survive usually have a very difficult course with many complications such as renal failure.

Dr. Mwaka quickly checked the patient’s vital signs again (which had been nearly normal when she registered at the front desk), to find that she was only mildly tachycardic but had dropped her systolic blood pressure about 20 points since her arrival. Dr. Mwaka ordered the patient to have an IV placed and get some fluids on board and a blood sample to the blood bank, and then quickly made his way to the operating theater to find a surgeon. Since it was a Wednesday and all three general surgeons have block time on Wednesday, he was certain to find someone willing and able to care for the patient…at least you would think.

Dr. Mwaka looked into OR #2, and there was a patient who had just been anesthetized with the surgical registrar starting the case in cool comfort with classical music playing softly in the background. Dr. Bird had not even arrived yet. He looked into OR#3, but Dr. Davis was knee deep in a common bile duct exploration. Then he looked into OR#5. And there was a sweat-soaked Dr. Wilson struggling to get a thyroid goiter out of the lower neck/chest. He decided to pitch the case to the dehydrated surgeon:
“I have a lady in OPD that I think has a leaking AAA. She presented with complaints of abdominal pain, and has a pulsatile mass, with a drop in her blood pressure since arrival.”
When he told me about the case, I was skeptical… “What do you mean leaking?” “Did you really feel a pulsatile mass?” “Was there really a change in the blood pressure?” “Does she really have abdominal pain radiating to her back?” Then I tried to deflect. “What’s Dr. Davis and Dr. Bird doing?” No luck. “Well I have at least 30 more minutes here so can you give her some fluids, and put an ultrasound probe on her belly to confirm the diagnosis”, thinking to myself, ‘these guys freak out every time they can feel the abdominal aorta…she’s not gonna have a AAA.’

Well 30 minutes or so went by, and I finished the thyroid and pealed off my gown, and began to do the pinch-the-front-of-your-scrubs-off-of-your-chest-and-shake it- so-it-can-air-dry-maneuver that I have perfected when I remembered, 'Oh yeah...there’s some bogus consult in the outpatient department I have to go see'. So I sauntered out of the theater and began to make my way down to the outpatient department, when down the hall I see Dr. Myrick (the family practice consultant who supervises Dr. Mwaka) pushing this lady on a gurney toward the theater quite briskly.
Uh-oh…
Dr. Myrick informed me that the ultrasound had showed an 8 cm pulsatile mass where the aorta was suppose to be, and she had dropped her BP another 20 points.
Okay, I’m a believer now…
So I U-turned back to the theater with the patient and took her into the recovery room which doubles as our resuscitation area for sick patients. I alerted the theater staff that I wanted to do an emergency AAA repair, and then went to OR#2 to ask Dr. Bird where I could find some vascular grafts. He was just finishing his mastectomy, so he alerted Dr. Newton, the anesthesiologist who was working in his room, and we had a brief discussion.

What I did not know is that Kijabe had a terrible record with ruptured AAAs. Even though they had a vascular surgeon there up to a few months before I arrived, they had not had a patient survive and go home in recent memory (about 5 patients), and they had seriously thought about not doing any more ruptured AAA, because it utilized too many resources in our resource limited setting to justify little chance of saving the patient. Additionally, now there was no one who was “comfortable” with AAA repairs, so weather or not to operate certainly was a worthwhile discussion.

So we quickly reviewed the information, but agreed it was worthwhile to try. The next 15 minutes went by in a blur of running around to find the right vascular grafts, getting a central line into the patient, and getting blood ready. Of note, Dr. Jeremiah (the M.O. intern on Dr. Bird’s service) ran down to the blood bank not only to make sure they were preparing the blood but to donate as well. By this time, OR#2 was empty and cleaned, and Dr. Bird had volunteered his operating room. Also, Dr. Davis (the other general surgeon) had finished, so all 3 of us discussed who had the most experience with AAA repair as the patient was wheeled into the room. We all agreed that we had watched a fair bit of aortic surgery in training, but had limited experience doing more than retracting and sucking. Fortunately, I had actually done one in residency (thank’s Dr. Balcom at Salem Hospital). Dr. Davis had several other cases to finish in his operating room, so Dr. Bird and I decided to give it a go together.

So there I was in with the patient prepped from chest to thighs. I said a brief prayer as the soothing music played over the speakers, and I took a deep breath of cool OR#2 air into my lungs as we finally made our incision. When we got into the abdomen, we fortunately encountered no intra-peritoneal blood, but the retroperitoneal hematoma look formidable. We decided to get a supra-celiac clamp on first before opening the hematoma and trying to get a clamp on the infra-renal aorta. (We had already decided that if the aneurysm went above the renals that we would back out and not waste any blood products, because without hemodialysis, we would almost certainly not get her out of the hospital if we had to clamp above the renals for any significant period of time.) After placing the supra celiac clamp, we opened the hematoma, and while initially it appeared as if we did not have aortic control, we quickly were able to get the operative field dry enough (with the powerful OR#2 suction) to see and place an infra-renal aortic clamp. We removed the supra-celiac clamp, and from there everything went rather smoothly. We opened the aneurysm sac widely, oversewed a few bleeding lumbars, controlled the iliacs with foleys since there was not too much back bleeding, and sewed in our graft…proximally then distally. (The graft was actually a very nice 20 cm by 20 mm tube graft from Gore. We have a charitable relationship with a rep from Gore, and really appreciated the donated materials, since we can’t actually afford any Gore products.) After the graft was in, we had good femoral and pedal pulses, so we then closed the aneurysm sac and the abdomen and then took her to our “ICU”. Then we practiced our specialty at Kijabe Hospital…we prayed.

The graft sewn in proximally and distally within the sac


Over night, things did not look so good. She was very confused, made little urine, and her creatinine bumped up to above 3. She got another couple of units of blood that next day bringing the total up to 8, but miraculously, and I mean miraculously, she began to turn the corner. Her urine output picked up. Her blood counts stabilized, and her confusion improved. Over the next 2 weeks, I rounded on her painstakingly (just ask my intern). The patient and I had an unusual daily interaction. She always frowned when I came around. I assumed it was because I would push on her belly or do something else noxious, but she always looked like she was unhappy to see me, even if all I did was smile and say hello. I would try to find out what was wrong, but the language barrier was quite substantial as she spoke no English and even her Swahili was limited, and there were few individuals around who could understand her mother tongue. She complained about abdominal pain and poor appetite, but nothing could explain her apparent displeasure at the sight of me. I guess I am sensitive, because I wanted her to like me…after all she was my favorite patient. She was a living, breathing, walking miracle. But I never got anything other than rolling eyes, sighs, and frowns. Well like or dislike, she survived, and went home a little more than 2 weeks after she was admitted.


The week of Valentines Day, she came back to the hospital for her post-op visit. I opened my mouth to speak, and there she went frowning again, but she was looking well, so I just moved on. Fortunately, her daughter was with her who was able to translate clearly. She said she was doing okay, except her appetite was still not back to being totally normal. Then after the interview and examination, I just couldn’t let it go…I asked the daughter why she seemed so unhappy and didn’t seem to like me. The daughter explained that she hates not understanding what people are saying, and that my speaking English was particular distressful to her, because she wanted to understand me. So I had the daughter translate. I told her almost jokingly “I’m sorry for speaking English around you, and that I wish you liked me. She spoke to the daughter in a very sincere tone, and the daughter said, she says “it’s okay and that she does like you”. I was a little taken aback, and then I told the daughter to tell her, “I think you are a miracle patient and I want to have my picture taken with you, because you are so special, and are the first person to survive this operation in our hospital in a long time”. The daughter translated, and for the first time ever, I saw a little smile curl up at the corner of her face. She spoke to the daughter, an then she translated, “she would love to take a picture with you, but only if you give her a copy. She thinks you are a very special doctor, and says thank-you for saving her life”.

Me and the ruptured AAA survivor Teresia in clinic

Well needless to say my heart melted at her kind words. Some people want to feel romantic love on Valentines Day, but this year I felt something much more powerful and enduring. I felt the sincere appreciation of a patient for doing my very best. So this year my Valentine is Teresia. She reminded me of why I love being a surgeon. She showed me that I could get through a difficult vascular operation despite my limited experience. She demonstrated that God can take my feeble attempts to treat, and work a healing miracle. And just when I was feeling unappreciated, she made me feel like the best doctor in the world. But most importantly…Teresia is my Valentine, because she got me into OR#2…if only for a few minutes.

Yours in feeling loved and appreciated,
chad

“Everyone wants to be appreciated, so if you appreciate someone, don’t keep it a secret”
~Mary K. Ash

8 Comments:

At Sun Feb 15, 07:53:00 PM, Anonymous Abeel Mangi said...

Chad, superb work under formidable conditions. Next time, if you are committed to a supraceliac clamp, you need to get the mesenteric patch perfused quickly; but you can put a Pruitt into the renal ostiae and inject 150mL of ice cold Ringers' into each artery. That will buy you at least 15 minutes of cold ischemic time per kidney...

 
At Mon Feb 16, 10:46:00 PM, Anonymous Wolfee said...

Chad I am SO proud of you. Perhaps not as proud as Mangi is (I think) but still so proud...

 
At Sat Mar 07, 11:25:00 AM, Anonymous Christina C. said...

Chad, this one made my heart melt too. Great work.

 
At Tue Mar 24, 05:24:00 PM, Blogger Kacy said...

yay! dr. papi is awesome. you have some great DNA my friend...

miss you lots and lots valentine's day or not...

oh yeah...my new address is

1641 Ellsmere Ave., LA, CA 90019

 
At Fri Mar 27, 03:51:00 PM, Blogger Betsy B. said...

Chad, great work! I am loving reading your posts. I only wish my Durant Fellowship had been as productive.

Sending lots of prayers from Bigelow 14.

Peace and love,

Betsy

 
At Sat Mar 26, 07:20:00 AM, Blogger Mies said...

I’ve been into blogging for quite some time and this is definitely a great post.Cheers!

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At Tue May 10, 12:12:00 AM, Blogger Robert Crawford MD said...

im looking for pictures of ruptured AAA on google and I bumped intothis. Best of luc in NY Chad...Maybe I can take you to Ecaudor on the these days...Robert Crawford, Baltimore, MD

 
At Thu Apr 24, 05:40:00 AM, Blogger John Dudley said...

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