Two weeks in the UK and, at last, this morning, July 2nd, I woke up after 6am! Perhaps it was the four-hour walk yesterday afternoon up Moel Emoel that tired me out. It was one of those sunny days with a light breeze and I had to be outdoors with the dog. On the hill-top the skylarks were larking about singing their heads off, climbing the sky in lazy fluttering spirals before diving back to earth with a rapid trill of triumph. Are they singing for the sheer joy of it and do they feel like worshiping the Creator of all things as I do on days like this?
We were thoroughly tired when we reached home but not too tired to visit the local school fayre in aid of ShelterBox, and to visit the Co-op for cut price Häagen-Dazs, cookies and cream, mmm! Which reminds me, I haven’t even tried it yet! Just a minute…
Aaah, that’s better! Cookies and cream! How could I have put it in the freezer and forgotten all about it? Because something better happened! I got an email from Dr Phally in Mongkul Borei to tell me my patient is still alive. I mentioned her in my 9 o’clock in the morning blog. She had a straightforward abdominal hysterectomy on 26th May for vaginal discharge and the suspicion of an early carcinoma of cervix and not long after became dangerously ill. The thing is, if she had had access to western medicine she would not have needed hysterectomy in the first place.
One problem is that there are no facilities for bacteriology tests in Mongkul Borei. Tests on the discharge could have revealed any significant organisms in the cervix – she may have had chlamydia, gonorrhoea, bacteroides, anything almost and any one of these could be treated with appropriate antibiotic. All infections in the hospital are treated blind, including peritonitis, septicaemia and meningitis. Some sick patients are given four or five different antibiotics simultaneously.
Another problem is the lack of histopathology services. Colposcopy, directed biopsy, histology and ablative therapy would have dealt with any other cervical problem aside from cervicitis. None of this is available. The only thing that can be done is to stain the cervix with acetic acid (white vinegar) and iodine which gives a suggestion of which part of the cervix may be abnormal, if any. On the basis of her discharge and the result of the staining test she had a hysterectomy. Even that is flawed thinking because abnormal cells in the cervix do not cause vaginal discharge unless the condition has progressed to the stage of an obvious cancer.
Ultrasound examination hinted at disease in the cervical canal but there was no means to investigate further. No hysteroscope, no endocervical curettage for biopsy and histology. Since women here present themselves too late with advanced cervical cancers, the opportunity to remove the uterus on suspicion of early disease in a woman who had completed her family was too good to miss, and a hysterectomy was done.
By 2nd June it was clear she had infection and ultrasound revealed a large collection of fluid in her pelvis and left flank. Laparotomy was done to empty a large abscess, wash out the peritoneal cavity and insert an abdominal drain. She remained septic and a third operation on 8th June drained a left sub-phrenic abscess and removed her appendix. She was receiving a plethora of antibiotics throughout this time with little effect on her peritonitis. Six units of blood were given and as she was not clotting well, some of these were fresh blood.
By Monday 13th I learned that histology (sent to Phnom Penh because I felt we ought to know what we are treating) showed no cancer but bacteria were present in the cervix. I haven’t seen the original report so have no idea what the bacteria might be.
Dr Phally’s email on 1st July reports that she has had three further laparotomies since the operation on 8th June, each time three 500ml bottles of metronidazole (an antibiotic particularly effective against anaerobic bacteria) were poured into the peritoneal cavity. The abdomen was left open for a time but is now closed and she is eating, drinking and passing stool. She has lost a tremendous amount of weight because intravenous feeding is not possible in this hospital. He sent me a photograph of her looking thin and drawn sitting on the bed between her parents. It’s a metal frame bed with a rush mat on the springs. They all are. The parents are the carers and nurses. That’s how it works here. She is not out of the woods yet. Please do remember this lady in your prayers…
PS July 11th: I’ve been hoping for the photo of this woman to come to light so I can post it in the blog and you can see her for yourself but I have lost it in the computer somewhere. Meanwhile another email for Dr Phally today says, “I would like to tell you that patient that we operated now she is fine, she eats, she smiles, she could seat and walk by herself. I would like to send you her biopsy result but by my another email because this email have problem attachment and hope you will visit Cambodia soon.”
I am delighted she is recovering. You have no idea how much this means to me. That she smiles is wonderful after all she’s been through. I still don’t know her name. I’m still hoping for another copy of the photograph. I’d like very much to see her biopsy result, and yes, I would like to visit Cambodia again. Maybe soon.