Surgical challenge

Last weekend was a lazy one and this next weekend promises much the same.  I had intended visiting the forested hilly area of Mondulkiri in the east over a 3 days national holiday straddling the weekend but 2 days travelling each way on the bus with only one full day in the location was daunting.  Discovering that the elephant sanctuary would be closed at the weekend settled the matter.

It’s been another busy week at work.  There’s a back log of patients waiting for surgery and the doctors have settled into a kind of slow-motion triage system, sorting patients into operations for the local staff, operations for the barang and then operations for the barang to decline to do if he doesn’t want to.  I always seem to get the difficult cases but I do have the option to turn down those that are beyond my ability or unsuitable for a hospital of this standard to tackle.  There are also those which are misdiagnosed.

Take the carcinoma of cervix for example.  She came in with vaginal bleeding and offensive discharge; the doctor who assessed her diagnosed stage 3 cancer of cervix – that’s beyond operative surgery as a rule and would require radiotherapy and perhaps additional treatments.  At first I thought it was pointless that I should repeat the examination as I would not choose to operate on her; she would need to go to Phnom Penh for radiotherapy or radical surgery.  Second thoughts; perhaps an ultrasound is worthwhile to examine the bladder and kidneys, as bladder involvement is common and obstruction of the ureters is a serious complication of advanced cervical cancer.

Small uterus, big fibroid - not cancer of the cervix

The scan showed her cervix to be enlarged but it looked like a fibroid with regular internal echoes and a very smooth margin.  I had a good idea what we were dealing with because I’ve seen this before – I made the same mistake when I was a medical student and students I’ve taught since have done so too.  When the internal examination reveals a large hard lump filling the vagina and there’s smelly blood stained discharge on the examining glove, cancer is the first thing that comes to mind.  Yet, as I thought, the examination revealed a large fibroid extruding from the cervix with a clear healthy margin all around; obviously curable by abdominal  hysterectomy.  I was delighted to inform her she had a treatable condition, was pleased to have the opportunity to teach the staff something new, and I relished the idea of an operation which is more challenging and interesting than the usual hysterectomy, yet likely to have a satisfactory outcome.  Unfortunately she decided to go home when she received the good news!  Whether she will reappear after the national holiday remains to be seen.  I shouldn’t be disappointed, there’s plenty else to do!

Large ovarian cyst - correct diagnosis this time!

The ultrasound scan doesn’t always lead to the correct diagnosis.  The surgical challenge of this week was a lady who seemed to have a hugely enlarged liver and spleen extending down to her pelvis on the left side.  We had been doing tests for a week to rule out malaria, parasitic infections, blood diseases, etc and to check that her blood clotting factors and functions would allow safe surgery.  Beneath the lower edge of the liver she had a 10cm cyst of the ovary with internal echoes demanding some operative intervention.  Opening the lower abdomen was enough to convince me we should not proceed.  Firstly the massive lump was not liver and spleen, it was an extra-peritoneal tumour totally obscuring the bladder, uterus, ovaries and everything pelvic and displacing the colon and small intestine upwards to a small area alongside the stomach in the upper abdomen.  Secondly it was likely from its appearance to be benign – it had been there for three years and experience suggests that when such a condition comes to the attention of the individual or family (whoever notices the swelling first) it is likely to have been growing for a considerable time before then.  Finally, this would be a very lengthy difficult procedure with a significant risk of haemorrhage that could get out of hand.  A second opinion confirmed my impression but not before the general surgeon had extended the incision the full length of the abdomen.  Surgeons seem to like big openings!  Keyhole surgery has not made it to this part of Cambodia.  A long conversation with the family followed.  I don’t see any of our doctors spending time talking to relatives unfortunately, nor do the patients get much in the way of explanation.  They do get instruction which is a different thing, delivered in a different manner, and very cursory.  I explained the reason for our decision in terms of a possible good news-bad news scenario: “Good news!  We managed to remove all of the growth.”  “Bad news, the patient died on the table.”  They understood and accepted, and I hope the patient herself will too.

Hospital children play rock, paper, scissors

So here I am … back in Swae Sisophon instead of watching elephants in Mondulkiri.  This is my local town and the political centre of Banteay Meanchey Province, just 9km away from where I live and work.  It’s a bit of a faceless, frontier town, though it’s actually 50km or so from the border, yet it’s one of those places that grows on you and you can settle into feeling at home here.  And it has the restaurant which does excellent sweet and sour.  Sweet and sour chicken, beef, pork or simply veggies.  I look at the menu whenever I go and sweet and sour always talks to me, except for last night when I ventured onto another page and tried the hot chicken.  No, not the hot chicks, the hot chicken.  That’s exactly what the menu said and that’s exactly what I got.  Hot, in Khmai – hel, with just one ‘l’ and spicy.  And I got the whole chicken.  Not ‘a whole chicken’ but every part of the chicken chopped up, plenty of bone and splinters, liver and other innards – it’s how they like their chicken here.  So I’m off there again for lunch and for dinner today and it’s definitely back to the sweet and sour.

I was supposed to be here for dinner Wednesday night but didn’t finish operating until dark, then I couldn’t get a moto after dark to bring me here so I settled for a mango and bag of crisps.  It’s a good thing I didn’t come to Sisophon that evening – I hadn’t eaten more than a few sweet potato crisps when the phone rang and called me urgently back to the hospital, my patient was bleeding through the pelvic drain.  There was 75ml fresh looking blood in the drain when I arrived which is very little until you remember that she had a blood count 40% of normal a week ago and she was transfused with two pints of blood she bought from the hospital blood bank.  She had to buy it because her relatives had refused to donate blood for her and now we were totally out of blood compatible with her group, B+.  She’s a little lady probably little more than 40kg, so doesn’t have a huge blood volume.  I could not afford to wait and see whether the blood in the drain was just what had been left in the abdomen, or whether she had internal bleeding.  If bleeding, then we had to stop it immediately.  So we prepared the theatre and scrubbed up, carefully avoiding and stepping around the dozen or so people who were sitting on the scrub room floor eating rice, takeaways and drinking beer.  We set up a collecting system to salvage and re-transfuse blood from the abdominal cavity and we re-operated.  There was fortunately very little bleeding to be found, just a few small areas of oozing to oversew – she would have been OK to observe overnight but in this context the risk of waiting to see was too great.  She’s doing fine now.

always a queue for the Equity Fund ...

So here I am … eating sweet and sour with boiled rice and I’ll maybe eat the same again tonight.  Such simple pleasures!  And I complain about my hot chicken or my empty stomach while the ordinary people here are glad with their staple food, eating the same thing day after day, with little chance of anything else.  Poverty is so close for the majority here.  The balance is tipped by the slightest thing.  That’s why they don’t come for health care until the problem is really advanced and that’s why they come to our hospital; the charges are so reasonable compared with the private clinics, and there’s a fund for the extremely poor which covers the cost entirely.  There’s always a queue when the Health Equity Fund Office opens …



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2 responses to “Surgical challenge

  1. Teddy

    Great stuff Adrian. I’m so glad I’d eaten before reading this one! 🙂 I’m so grateful to God that he had placed you there at just the right time and given you the wisdom and knowledge to double check the lady with suspected cancer. How can we ever cease to praise Him? I was over in the north today where we (people from our church) had a booth at a New Age fair. We were able to minister God’s love to so many broken people. Broken bodies, broken hearts – how He loves us.

  2. Dorothi

    Hi there, good to catch up again. Thank you for the pc. Adrian reading your blog takes me down paths of medical care that I knew very little about! I like the way you then take us to everyday life in Cambodia and the people you meet like the young man who gave you a present of a coke. I was 60
    when I tasted coke for the first time! much to the amusement of my children whom I’d been unhappy with for drinking it. I’m certain that your experiences when you tell us all about them will take so long that you will have to stay put for quite a while! God bless you friend I’m sure that leaving will be difficult, but I’m also sure that the patients and friends you have met will remember meeting you for a long time. Rock Solid tonight, so I better get the ironing finished. Love as always Dorothi and the rest of the Evans’

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