Two Curious Cases

For the first time in three weeks we finally remembered that there was no morning handover meeting on Thursday and we enjoyed a sleep in.

Actually, that’s not true. I’m woken up at 4:00am every morning by the call to worship, and then again around 6:00am by drums and other music coming from who knows where. But, I lay in bed for longer than usual at least.

We share our accommodation with an Irish girl, Siobhan, and we were especially happy to have her with us this morning because she had brought back bacon from Moshi (the area we are in has a very high muslim population and bacon is very hard to get hold of). Chapatis and bacon make for an excellent breakfast.

Yesterday we had palpated the abdomen of a women who looked around 30+ weeks pregnant. She had been referred by the nurse and had received no antenatal care prior to this point. The obstetrician commented on the unusual shape of her belly – it seemed to have two grooves rather than just the usual one for the fundus (the top of the uterus).

The woman was referred for an ultrasound, which is where we saw her again today. I loved the ultrasound room; I could have stayed there all day. It had air-conditioning.

I made an observation about the patient that I hadn’t noticed yesterday; she looked older than most other patients I had seen on the maternity ward. I enquired as to her age – I was told she was “Arobaini” (forty). She pulled her Kanga back (a kanga is a piece of fabric often worn in layers by African women) and her bulging abdomen was evident.

The sonographer looked up at us and said “There is no baby. The uterus is empty.” I asked if there was a tumour, a fibroid or maybe a cyst? All I was told was “pseudopregnancy.” I was skeptical, but she was told the news and sent home with no further follow up. She was clearly upset to find this out and was concerned how she would explain it to her husband. I later asked how far along she thought her pregnancy was. The answer I was given: 1 year and 1 month.

Our morning ward rounds finished early and I decided to join Amy who was scrubbing in for an exploratory laparotomy. The patient had a history of abdominal pain and distention but without the ability to perform a CT scan there was no way to know the cause. An exploratory laparotomy was chosen as her condition was worsening and affecting her breathing.

What followed next was probably the most intense moment I have ever witnessed in theatre.

To preempt this, I will admit that I once tried to intubate a model and found it incredibly hard. I think I intubated the oesophagus (food tube) three times before I finally got the trachea (wind tube) – and even then I probably would have broken the patient’s teeth if it were a real person.

The anaesthetists were attempting to intubate the patient. They unfortunately had placed the tube into the oesophagus, and not the trachea. They were then trying to ventilate the patient (directly into her stomach). The monitor clearly showed that there was no carbon dioxide trace – something you would see if the tube was in the right place. The patient’s oxygen saturation was quickly dropping; 90, 70, 50, 30, 0….

Her blood pressure and heart rate were sky-rocketing and with no intervention she would very soon go into cardiac arrest. She started vomiting.

Mark is a surgeon from the UK who is spending six months here training other doctors. He is also now my new hero.

He quickly interpreted what was going on and incredibly calmly informed the other doctors “she is going to die if you don’t do something.”

They tried in vain to ventilate her and intubate her, but clearly there was a training deficiency. Mark knew that the only way to start this surgery, which could potentially save the patient’s life, was to take over himself. For those who are not familiar with medical specialties, surgeons don’t intubate patients – this is a role that is largely done by anaesthetists, ICU or ED doctors. Despite this, Mark was successful on his first attempt and the patient’s vital signs returned to a near normal level.

The surgery itself did not yield the result we were hoping for (something treatable). Instead, there were numerous areas of necrotic and calcified tissue which we could not identify. It may have been cancer, or it may have been advanced tuberculosis. Regardless, the prognosis was poor.

I will however end this post with a positive note. The boy whose photo I shared earlier (with the bullous condition) has been making an excellent recovery. The end diagnosis was bullous impetigo and his treatment has been effective. He was discharged today.

We finished our day with a visit into town to collect the dresses we had made. They are beautiful and we were delighted with the finished product.