Saturday, May 24, 2014

Interesting cases part one

For those of you a bit queasy, this post is not for you. This is for those either a)medical or b)interested in medical stories.

This is a photo depicting the leg of a young girl, I believe she is 11 years old. The probe is in her femoral vein, if I remember correctly. She presented with a swollen, painful right calf. Two weeks prior she had cut her foot on a piece of a tin can. The cut on her foot had healed, and did not look infected. We did an ultrasound to look for DVT, but unfortunately did not look high enough in her leg (only looked from about the calf down, since that is where the swelling was). The next day she was admitted to the ICU with tachycardia, hypoxia, and right heart strain. She also developed high fevers. We did a more thorough ultrasound and found a large thrombus in her femoral vein. With all her signs and symptoms, we suspected a septic thrombus. We put her on heparin, but without thrombolytics, there wasn't much else we could do except amputate the leg above the thrombus. We did an amputation of her right leg, and this photo shows the amputated portion. When we cut into the vein, there was pus that came out. She improved dramatically in the days following the amputation. Clearly the surgery saved her life. She did fairly well emotionally too. Her father has some form of deformity in his legs (I can't recall what), so the idea of a person walking with crutches for their whole life wasn't foreign to her or her family. I think this helped her to cope, and had it not been the case, I'm not sure her parents would have agreed to the surgery. Dr Lindsey is looking to see if it will be possible to obtain a prosthesis for her.

This next photo is the leg of a sweet little girl who fell at least a year prior, and sustained an open tibial fracture. Obviously it wasn't well reduced (often a result of traditional treatment), and resulted in part of the tibia sticking out of the leg. We gave her anesthesia and pulled out the dead bone you see here, then put her in a cast to stabilize the leg as the remaining healthy bone heals in. I suspect her fibula will tibialize to support her weight. 

This little boy presented with abdominal pain, fever, and a distended abdomen. While the first concern from the history was for peritonitis, further physical exam and ultrasound confirmed a large abscess between his abdominal muscles and skin, which extended down into his scrotum. It required a very large incision to drain. This photo is after several dressing changes, when it was starting to heal. Soon after, we were able to close the skin secondarily, and he was able to go home.

This young lady, in her mid 20's, sustained this ankle fracture in a motorcycle accident.  (Which is where most of our Ortho cases come from.) She presented several months after the accident. This was beyond our ability to treat, as ankle/foot fracture of this nature are a challenge even to orthopods and podiatrists. When we told her we wouldn't operate, she fell to the ground, crying and pleading that we would do something for her. Then we called in her mother to console her, and when we informed her the same news we told her daughter, she also fell to the floor and did the same. They weren't without hope, as there is a doctor in a nearby town who was willing to operate, but they were hoping they would have something done at Nyankunde.

I came in one morning to see two of the Congolese doctors attempting a D&C for a retained placenta. They were using ultrasound guidance, and found the placenta seemed to be oddly placed...very superior in the fundus, and no plane of separation. This is because she had placenta increta, where the placenta has grown into not just the endometrium, but the myometrium (uterine wall) as well. Thankfully it wasn't through the serosa (which would make it placenta percreta), as that is more difficult to treat. Kimiko and I are doing a hysterectomy in this photo.
This young 40 something year old presented with early satiety and an abdominal mass. She was also anemic and appeared mildly malnourished. The mass you see in her abdomen is her spleen. The following photo is her spleen after we removed it. I believe it weighed at least 5 lbs! It was heavy, at any rate! It's not often we do a splenectomy for splenomegaly, but in her case, it was definitely warranted.

This x-ray is from a young man who presented with shortness of breath. Diagnosis? 
He felt much better after we placed a chest tube. 

This 30-something year old man came in with a leg mass that he had for at least 2 years. It has progressively increased in size. We offered to do surgery to remove the mass (it appeared well-circumscribed, no boney involvement) but he never returned for surgery. I'm not sure if he was still looking for money to have the surgery done or he decided to go elsehwere.

Tuesday, May 13, 2014


Endure hardship as discipline; God is treating you as his children. For what children are not disciplined by their father? If you are not disciplined--and everyone undergoes discipline--then you are not legitimate, not true sons and daughters at all. Moreover, we have all had human fathers who disciplined us and we respected them for it. How much more should we submit to the Father of spirits and live! They disciplined us for a little while as they thought best; but God disciplines us for our good, in order that we may share in his holiness. No discipline seems pleasant at the time, but painful. Later on, however, it produces a harvest of righteousness and peace for those who have been trained by it. Therefore, strengthen your feeble arms and weak knees. "Make level paths for your feet," so that the lame may not be disabled, but rather healed.
Hebrews 12:7-13

     This 33rd year of my life has been a challenging one. It has been a year full of transitions, and there are more transitions yet to come. I've transitioned from living and working in a hot, humid environment in Impfondo, Congo to living in cooler, less humid Indiana. I've transitioned from working in a culture not my own, speaking daily in a second or third language, and struggling with finding the right words, to working in the US, in my own language, but in a job less fulfilling. I've transitioned back to another culture, similar to the one in Impfondo, but yet different, in Nyankunde. I could at least speak French and some Lingala, but now limited by lack of speaking Swahili, and struggling with another language barrier.
     During all these transitions, my faith has been challenged. I've been forced to re-evaluate many things.  I feel as though God has been breaking down certain barriers I have built up over the years so He could either create new doors, or rebuild the wall in a structurally sound manner, rather than my feeble human-erred attempts.  He's calling me to draw closer to him, to put aside any distractions I've had in the past, and step out in faith.
    The question remains-step out where? I am not yet sure. I have some ideas, but I am not yet ready to share them with the world, and they require much more prayer before things are clear. I was hoping that during my three months in Nyankunde, I would have a clear direction as to the next steps in my life. However, the only thing that is clear is that I must trust God and depend fully on him. Jennie Allen, author of the book Restless, writes "He likes his kids completely hanging on to him for dear life more than he cares about the perfect plan being executed. He is after us, and uncertainty is usually what keeps us glued to his side. He is in the trenches with us. In the fear. In the uncertainty. He is in the unknown-knowing and leading and working. What we don't know yet is meant to lead us to dependence."
     Every time I read that last sentence, my mind wants to read "What we don't know yet is meant to lead us to independence. Which is exactly the opposite of what she is saying. Learning to be dependent is very difficult for this independent woman (ask my mom, I've wanted to do things myself since I was a baby. I wouldn't even take solid food until I could feed it to myself). But through these last three years, God has been asking me and teaching me to be dependent on Him and others, rather than trying to do it all myself. I've found through many mistakes and cultural faux pas that being independent often hurts ourselves and others-it deprives us of community and the ability to truly bear one another's burdens, and it causes undue fatigue and stress on ourselves.
  There are no words to thoroughly express the thankfulness and joy I have for my friends and family who have been by my side during this time. There has been some laughter, and many, many tears in the last year. I'm so thankful to have them nearby to wrap their arms around me (literally or virtually) and love me without condition. It's been exactly what I've needed.    
  So I ask you to gather round, pray for me as I pray for you, that we may bear one another's burdens. Pray for guidance for my future, and that I rest comfortably in the Savior's love for me. I will be praying the same for you.

Therefore, since we are surrounded by such a great cloud of witnesses, let us throw off everything that hinders and the sin that so easily entangles. And let us run with perseverance the race marked out for us, fixing our eyes on Jesus, the pioneer and perfecter of faith. For the joy set before him he endured the cross, scorning its shame, and sat down at the right hand of the throne of God. Consider him who endured such opposition from sinners, so that you will not grow weary and lose heart. 
Hebrews 12:1-3