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???

My Booboos (part 1)

JOJO

This is a page that I decided to set up for friends/sisters (some whose bdays I forgot). Obviously, I was eaten up by guilt or love or friendship, and decided to come up with the worst form of PDA possible to simply embarass u girls. The truth is that I consider you all as my sisters, and wanted to wish you a wonderful Merry Christmas and Happy New Year.


1) Jojo. Sassy. Jojess. U know I heart u. Your bday is in Jan so I haven't forgotten your bday...yet. Just kidding!!! I just felt like posting this picture of us, that's all (I don't walk around sniffing sheets).

2) Sistur sistur, I can so be myself around u, and thats why I can get away with mistake (maybe). Sorry I forgot about your bday... but u know I yove yu Neye.Looking fwd to your big day!!!

Supreme Trio!!! Sume, hello. Le Bof on dit koi? I haven't forgiven you girls for going to to Rio de Janeiro without me, but I'm sure we can work sthg out. We've been friends since secondary school, and if there's anyone I can run to it's you. Can't wait to see u girls in t minus 24h.  


KAKA Brizzle!!! You know I can't forget you nah. You're ma boooooooooooooooooooo!

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So there are about 5 other pictures I need to add but the truth is I'm exhausted so what I'll do is continue some other time. That doesn t mean that I love them any less.
Remember, God gave us little angels in the form of sisters, to watch over us. May God bless us all during this season!!!

OB...G Y N

From one woman to another, we are special!!! Anatomically speaking that is. But the truth is OB/GYN has never been my thing. I prayed for my rotation to end from the first day. And lets not talk about the first delivery I assisted. I had sworn to never have sex. Delivering babies...not for me! Yet I could not run away. The unfortunate (or fortunate depending on how you see it) thing about being a General Practitioner aka GP in da house, is that you get to do EVERYTHING. Even sticking your hand in strangers' vaginas!
How many times have I wanted to defer genital exams. I'd stare round the room looking for a valid excuse, but when you're dealing with vaginal complaints, not doing an exam is medical malpractice. I just needed to make myself a reason. So I focused on the anatomy. Truth is I had shun away from vaginal exams so much during my cores that I wasn't even sure what to feel for. I mean, it was easy like ABC; all you had to do was stick your finger in there (uurrgh), but really, what was I looking for? So I had to read up! Labia majora, vagina, cervix- long, short, effaced, closed, 4cm dilated, posterior. At first, all the same to me. But the more I examined the better I got.
But let's not get carried away. I can't forget that night when I was on call. The nurse came to fetch me to meet the woman in labour. Honestly, I'd known that the day would come when I would be alone in a situation like this. God had already warned me: I had delivered a placenta, not the baby. This time, it was the real deal: a huge belly and a handful of nurses looking up to me. Somehow I had to live up to their expectations so I started with what I was good at: the genital exam.
Cervix was posterior, 60o/o effaced and 4cm dilated, but because she was primiparous I wasn't expecting her to birth anytime soon. I guess God decided to have mercy on me (and on her of course) because I had hardly worn gloves when I was already maneuvering the baby out of the vagina. When the baby was out and I had clipped off her umbilical cord I got this amazing feeling that I've never had before. Man, my first delivery!!! I was in heaven like for real. Too bad, the feeling didn't last as I remembered that I wasn't done. As I sashayed my arm around the genital tract I realized that I barely knew the owner. Also that I'd been right all along: OB/GYN wasn't for me. But since I get to do little bit of everything as a GP, why not enjoy this opportunity until I start a residency? Till this day, I've done several other genital exams and deliveries.

Have your eyes wandered...

October 18th 2012. I got my text from Our Daily Bread (ODB)-and it read...What has God done for me lately? Hmmm indeed catchy!!! So I couldnt hold my curiosity. The passage was from Matthew 20:1-16 and it goes on about some guy who decided to help a few young men by giving them a job. He hired them for a day, but at different times of the day. Obviously, when the day ended it was time for some well-deserved cheddar. Those who were hired last were called in first and got their pay. Finally, the first guys got their turn, and because they had worked longer than everyone else expected their pay to better. I mean think about it, if you work your ass off isnt the expectation to get greater results?
To their greatest disappointment (and injustice, they might have added), their pay was 1 silver coin or denarius, like the others. Now thats just cold! Grumbling. Gruntling.
I am a firm defender of fairness, and in all sincerity, I might have done just the same. However, the guys response to one of his dissatisfied workers made me ponder:
“I am not being unfair to you, friend. Didn’t you agree to work for a denarius? Take your pay and go. I want to give the one who was hired last the same as I gave you.  Don’t I have the right to do what I want with my own money? Or are you envious because I am generous?’
Till today I wonder why Jesus taught with parables... because truth is sometimes, I dont get it. But then I realise why the case might be. Perhaps he wanted us to think. He could have just made his point, but instead he told a story you could relate to, and left you to your own conclusion...so you could think about it. Thats just awesome except that some of us still dont get it, and thats why reliable sources like ODB  are needed to break it down.
Anyway, what I learnt at the end was pretty basic: be content with what God gives you, and stop comparing with others. The silver coin (which probably represented a lot) became insignificant the minute these workers focused on what their mates were getting. What God gives He does freely and generously so we ought to be mostly grateful rather than grumble over what He gave others, and not us.