Medicine without frontiers 2 (ectopic utopia)

The ultrasound revealed a right pelvic mass. Ok. Ultrasounds reveal all sorts of things...but what really caught my attention was the nature of the mass. The lady was actually a good friend of mine. She had come to me earlier that week because of her "missed period" and needed clarification.

A positive test later, we knew it was on. I began looking forward to a 9 month journey of constant reassuring and waiting and weight gain and other amazing body changes. My hopes were threatened by a sudden announcement of vaginal bleeding. Oh my! What could this possibly be? Fortunately, her genital exam was reassuring, but since playing safe always paid off, I asked for a pelvic ultrasound anyway. And to our greatest surprise, we found an ectopic pregnancy!!!

I knew the deadly implications associated with the diagnosis so nonchalance was certainly no way to go about this. At first, I wasn't sure what to do. First case ever, and even though I still had vague recollections of my med school notes I wasn't about to gamble on someone's life (knowing the other's was already condemned). I did remember that nonsurgical treatment was possible if caught early enough. I called up an OB/GYN and we briefly discussed my patient. But at the end, the decision-making was still left up to me: to operate or give methotrexate. That's when I turned to Fernandez's score, a clinical predictive tool to aid management decision making of an ectopic pregnancy.

Predictive score for successful treatment of ectopic pregnancy

Predictive score for expectant management and several nonsurgical treatments (Fernandez 1991)

CRITERION                               1 POINT                    2 POINTS                  3 POINTS

β-hCG (mIU/mL)                             <1000                           1000–5000                    >5000

Progesterone (ng/mL)                  <5                                     5–10                               >10

Abdominal pain                            Absent                             Induced                      Spontaneous

Hematosalpinx (cm)                     <1                                      1–3                                 >3

Hemoperitoneum (mL)                  0                                    1–100                             >100

Score <12: 80% success with various nonsurgical treatments, including expectant management.

Predictive score for single dose methotrexate aka nonsurgical treatment (Elito 1999)*

A quick look at that table and I began dreading the worse. Her numbers weren't looking good and due to her financial situation, I truly wanted to help but surgery was probably the best option at this point. I was still considering a trial of methotrexate, the drug that would interrupt the pregnancy nonsurgically when my friend barged into my office. She was in pain!!! Unremitting and excruciating pain!!! It took two injections of tramadol for me to realize that I had to abandon all I was doing and find the surgeon. Butterfly effect; 30 minutes later, we were in full mode operation for ruptured ectopic pregnancy and a life-threatening generalised abdominal contamination (peritonitis) caused by the bleeding. Immediate clean up was required for patient survival. 

our tiny embryo :(

We tried removing the embryo alone, but the whole fallopian tube had to follow because it was way too damaged by the rupture, a radical but inevitable approach (salpingectomy). Fortunately, the other tube is still viable for future babies. 

The experience touched me profoundly. I had been involved in chopping off part of a human being's ability to procreate... in order to save her life. Then it dawned on me: I was beginning to make decisions that would affect people's lives for ever. And there was no going back.

Yet God works in wonderful ways. Knowing how dangerous these (ruptured) ectopic pregnancies are, wasn't my friend lucky to be in the right place at the right time? I think she was divinely favored. I thank God that the surgery went well and that her life is out of danger. She is post-op day # 1 today, chilling in the ICU. Last time I talked to her she was in pain, but awfully pleased to be alive.

Drifting Consciousness...

Slowly but surely, I felt my strength leaving me. I yawned again but this time, barely noticed it. I knew either I sat down right away or crumbled like in the next 2 seconds. I was fainting!!! 
That's when the surgeon heard me mutter words like "sit down" "not feeling well" 
With whatever force was left, I dropped myself on a nearby stool. And the next thing I remember is people taking me out of the theatre to the prepping room next door. I must have semi blacked out for say 5 seconds??? 
All I know is that the minute I torn off my sterile gown, it's like I started living again. The heat was gone, and that's when I realized that my skin was soaked with sweat. But I was no stranger to this scenario. I had already fainted before and in exactly the same circumstances. I'd gone into surgery with an empty stomach and the heat from the room and triple layers of clothing just OUTed me. But just like a miracle, 5 min later, it's like nothing ever happened. I was perfectly fine. And I was defining going to finish assisting the C-section. Back in the O.R. the surgeon, my boss, was struggling with the wound closure. He needed help, but here's a perfect example of when something isn't good for you, you don't force it: I'd barely gone to the cutting table when I was leaving. The symptoms were coming back. And this time I wasn't waiting around; I left before anyone noticed.
I crashed on the couch in my office after making sure the door was unlocked. I knew my boss would come check on me after surgery. Only to wake up 30min later. No one had come! I can't believe I almost died and my boss was nowhere to be found. I mean are surgeons just cold across the globe? And the nurses- sweet and caring indeed! I packed and left the dreadful place. My mom would pamper me at home like it was due.
I went straight to her kitchen; you know, where the action is. My brother was already sitting there, not looking so well. After a few complaints, I knew it was malaria. Instantly, they both turned to me; the doctor had to find a solution. At the end of the day, I never told my mom that I'd passed out. She wasn't going to believe me anyway. My brother got all my mom's attention plus mine, and I just went to bed. What a day!!!

Tricked by Hepatitis B!!!

 

"Your test is positive" But she already knew that because the envelop was unsealed. Now I was preparing myself for one of those long and delicate conversations. The context afterall, was delicate: pregnant lady with an acute Hepatitis B infection. Certainly, not a laughing matter.

I took a deep breath. But the lady spoke. First, she expressed her doubt about the results, which most people do anyways. The reason why she insisted on a lab error was because she had gotten tested twice for hepatitis B beforehand, and both tests had been negative. Since then, she had been sexually active with one man-her husband, who was himself uninfected. I asked her if she had ever received a blood transfussion or if she was a health care worker constantly exposed to blood products. She said no. And thats when I began truly listening. Either she was not entirely truthful with me or there was something missing.

Hepatitis B is an inflammative disease of the liver caused by the Hepatitis B virus, one of the five viruses (Hepatitis A, B, C, D and E) that can cause liver injury. Of these, the B and C viruses (HBV & HCV) are the most concerning because they can cause chronic liver changes, which eventually lead to cirrhosis then liver cancer. More importantly, all pregnant women are screened for Hepatitis B in the first trimester because of high rates of perinatal transmission from an infected mom to her baby. Moreover, the risk of developing chronic HBV infection is inversely proportional to the age at time of exposure. The risk is as high as 90 percent in those exposed at birth, while the risk is much lower (about 20 to 30 percent) in those exposed during childhood.

 hepatitis-B virus HBV "Dane particles", or virions (PHIL*)

Needless to say, I couldn't have this future mother roaming the streets without appropriate management, but at the same time, I had to put her preoccupation into consideration. What if the lab had indeed made a error, and she wasn't infected? The easy way out was to redo the test in another lab, Antigene HBs being the routine marker. And I added Antibody HBc just because with both, you can't go wrong. And guess what: both markers came back negative. She wasnt infected!!!

The first lab technician was obviously summoned, and after a so-called investigation, admitted to mistakenly swapping patient results. The details arent as important as the fact that I learnt a valuable lesson: always listen to the patient first.

*PHIL Public Health Image Library 

All on a silver plate (Part I)

So I was pretty much myself... on call at the clinic. It was one of those dreams where you can tell you're dreaming but everything feels so REAL!!!
This pregnant lady came in, and she was in labour. I did what I usually do (which was so weird because remember, this was a dream): took her to the maternity ward, examined her and etc. But what I specifically noted was the way I interacted with her. For no particular reason whatsoever, I was extremely nice to her (not that I'm usually mean to my patients), but whoever was controlling my dream wanted me to be aware of that.

So fast forward, my patient delivered her baby without any issues, and then was well on her way home. I walked her and the baby outside the hospital ,and that's when I realized there was a sweet ride waiting for her with a driver. Brand new. Leather seats. She was loaded!!! Well, I helped her in her car, and when they were ready to take off, she looked at her. Relief. I could tell she was glad it was over. And then she reached out and gave me a piece of paper. It was a check. A blank check!!! I definitely didn't understand. She said how grateful she was with the way I'd taken care of her, and that was just a small token of her appreciation. FYI, per medical ethics we can't accept gifts from our patients, but let's be real for a second. Dream or no dream, it was a freaking blank check!!! I'd first take the check then listen to what the lady had to say, won't you agree? That's when she said I could write any amount I wanted on the check then cash it. 

That's where my dilemma started. First, I chose a generous amount. Then thought about it. I didn't think I deserved that much for my services so I went down some. Still couldn't agree on an amount. I mean, all I'd done was take care of her, which was my job anyway so I shouldn't even be taking anything. But then again, she said any amount was mine to have. If someone makes that kind of statement they know what they're counting on. I continued battling it out until I rose from my long slumber. Need I say I was very perplexed? 

Now, tell me. What would you do???