Ovaries
It was diagnosed by ultrasound- an enormous mass filling her pelvis. Also on the report was the statement that the uterus could not be visualized. Patients here frequently have surgical scars for which they have no knowledge of the type of operation, so it was unclear whether she had already had a hysterectomy. We scheduled her for surgical removal of ovarian mass. At the operation, we noticed that both fallopian tubes were attached to the mass, and its origin (right or left) was a mystery. We carefully extracted it without spilling its contents as ovarian cancer can be spread during surgery. I was assisting one of the other staff doctors, and he informed me that there, indeed, was no uterus present. I found this a bit hard to believe, with both fallopian tubes connected to the mass. Just below the mass, I located a slightly more firm part and told the other surgeon that I suspected that it was the cervix.
After removing the mass completely and closing the abdomen, I took the mass over to further investigate. On close inspection, it was clear that the uterus, small as it was, was connected to the mass. I was able to show the curious medical students the origins of the fallopian tubes and the parts of the uterus. Then I opened the mass. It was almost all liquid, but to my great joy it also contained hair and some calcium deposits (that we like to call teeth) - it was a benign growth and the woman had a great prognosis. These discoveries are a joyous occasion and just an example of some of the bright moments working here in Vanga.
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| Just before opening the mass to find out what it was... usually a pathologist would do this. |
Victories
It was the morning before my first
scheduled lecture at the nursing school for the 1st year midwife students. I
was sitting in morning report by the students when I saw one of the interns who
is working on OB/GYN leave suddenly. He returned a short time later and talked
with another staff doctor working on OB as well. The staff doctor looked at me
and made a slashing motion with his hand, indicating that someone had come in
that needed a C section. I walked out of morning report to talk more with the
intern. The patient had come in after laboring for 2 days at the health center
close to her house. She was completely dilated, but had been pushing since the
evening before, had a small pelvis, and the baby wouldn't come out vaginally.
She definitely needed a C section, he said, and told me he had the nurses
getting her ready. I told the intern that I would not be able to do the C
section as I was scheduled to teach, but I'd go evaluate her myself and return
to morning report after seeing and verifying the necessity.
I walked into the labor room, and the
patient had an IV and urinary catheter already placed. Indeed, she was tiny and
appeared at high risk for obstructed labor due to a small pelvis. But as I
walked toward her, I noticed that I could see the baby’s head. Unless all of
that was edema (basically fluid under the skin), that baby’s bony head had
already passed the point it should have gotten stuck with a small pelvis. I
asked the nurses standing there, “So have you asked her to push?” They replied
negatively, because obviously she hadn’t been successful for over 13 hours of
pushing… I put on my gloves. Indeed her pelvis was tiny, and the baby’s head
was clearly pushing the limits, but I felt like the bony parts of the head were
past the bony parts of the pelvis. I told the somewhat incredulous nurses that
we needed her to try pushing. Maybe the long journey had adjusted the position,
maybe they didn’t have her in a good position before, and maybe she could do
it. Less than 5 minutes later, she delivered her baby’s head. At this point, my
mind started racing because I just knew the shoulders would get stuck and we’d
have a different emergency called shoulder dystocia. However, the shoulders
came, and she didn’t even need stitches!
I walked back into the morning report about 20 minutes later, and I made a motion with both of my hands to the other staff doctors signaling that she had just delivered vaginally. He got a surprised grin on his face, and morning report concluded without further interruptions. It was a great teaching moment for the nurses and the intern. It is important to always examine the patients yourself, and always give the mama a chance to deliver vaginally as long as the baby is doing okay. I was also able to show them a couple of simple maneuvers that came in handy in this case.
I finished the morning with a very
enthusiastic group of new midwife students. Despite some limitations with my
French, they seemed to understand and enjoy the teaching quite a bit,
especially as I am currently in my third trimester and they were able to see first-hand
some of the things I was teaching about signs of pregnancy. Some days here are
like that, with happy endings, teachable moments, and the feeling that I made a
difference in the healthcare system for the women in this country.
Efficiencies
Truly, you read that right. I am talking
about how very efficient I can work sometimes here in this context. One
Saturday after rounds were done around 11 pm, I had 2 patients waiting to see me
for a consultation. I decided that they both needed ultrasounds, and since the
ultrasound room was open until noon (after that it simply requires that I open
it with a key and don't have help), I walked with them over to the pediatrics
building where the ultrasound room is located. "Oh Dr. Janeen, we are so
glad you are here! We have a patient for you." This is more often than not
the phrase I hear when I enter the room with one of my patients.
So I proceeded to do not two, but three
ultrasound examinations. One of my original patients I gave a prescription to
and sent home, the second I decided I needed to do an exam in the operating
room to remove her IUD (intrauterine device for contraception) because though
the strings were not visible, I could see it in place on ultrasound. The
added-on ultrasound was a pediatrics patient with cyclic pain for 11 months but
no period yet. The opening to her vagina was blocked by a septum. This is a
rare condition, but I have seen it twice in 2 months here. Also, it's easy to
treat and has a good prognosis. But with significant pain and an easy fix in
the OR, I felt like it would be a waste of resources to give her pain medicine
when I could just make an opening to relieve the pressure in a short time.
I walked with the two patients needing
surgery to the operating room. It was not yet noon, so I knew the staff would
still be there, though not for long as they take their lunch breaks from noon
to 2 pm unless there is a surgery planned. I discussed with the chief nurse in
charge of the OR that I needed to do two quick procedures in the operating
room. At first, he said, "Can't it wait until Monday?" (a scheduled
surgery day). Knowing he is a softie, I said, "Go look at her face and
tell her we'll wait 2 days." He smiled, and walked to meet the patient.
Sure enough, after seeing her pained expression, he put his arms around her
shoulders, looked at me, and said, "Ok, let's go."
I changed scrubs while they prepared the
tables, which were in the same room together. I quickly located the IUD and
removed it without difficulty. Secondly, I walked the 15 feet to the second
table and made an incision in her septum which immediately relieved the
pressure built up for 11 months in her tiny body. I left a little after 1 pm to
eat lunch. I could NEVER do that in a US hospital for a clinic patient. I had
seen 2 patients, done 3 ultrasounds, and performed 2 unscheduled minor
procedures in the OR in a couple of hours. Some things here can be very
efficient!
