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You give me fever...

Fun Fact: Did you know while Honduras is home to 17% of the population of Central America that 60% of reported cases of HIV in this region occur in Honduras?  It affects men and women equally and, unsurprisingly, rates are highest in the 2 largest cities in the country.  AIDS is the leading cause of death among Honduran women of childbearing age and is the second-leading cause of hospitalization among both men and women.  Now, whether these numbers are skewed by poor reporting by other nations in the region is unclear, but either way it is a very real problem.  

It's been an interesting couple of days - alternately insane and sedate. Thursday I scrubbed in on a surgery that was supposed to be a fairly routine hysterectomy to remove a suspicious looking uterine mass. The patient is a 22 YO G5P5 (meaning she's had 5 pregnancies and 5 deliveries), her oldest being 8 and her youngest 1 yr old. She noticed the mass in Oct, or at least that's when she first sought evaluation. She had an ultrasound which revealed what was thought to be a uterine fibroid, a benign growth, that was approaching 10 cm in size. That's pretty big.  By January when she was seen here it was much larger and not so benign appearing. I met her as she was being prepped for surgery, the visiting anesthesiologist starting an epidural.  She looked about 5-6 months pregnant, but thin, and scared.

Once the procedure started, the ob/gyn surgeon I was assisting made a large midline incision and the mass became immediately evident. What wasn't so evident is where it was originating and what organs were involved.  It was a grotesque thing, very friable with chunks of it falling off and extruding this yellowish, bloody, crumbly gunk every time you touched it.  Its surface was uneven and pocked with cystic structures that would periodically burst and spew thin, brown/green liquid.  Trying to free it up enough to lift it away from the abdominal contents and identify the blood supply was a losing proposition. Turns out it originated in the left ovary and had so distorted the anatomy that it was not immediately identifiable. It was stuck to, and trying to invade, a small segment of the colon and had started to latch on to the other ovary. We had to call the general surgeon to assist and he ended up taking out about 5 inches of bowel and leaving a colostomy. We took out all her reproductive organs, pulled out all the visible tumor, and washed out her abdomen with saline. Thankfully, her liver was pink and smooth.  The mass itself ended up being almost the size of a basketball. 

During surgery the spinal anesthesia started to wear off.  She wasn't numb enough.  So the anesthesiologist had to put her under.  Then, even intubated and unconscious she was moving and pushing so she had to be paralyzed. (We use a derivative of curare called rocuronium - one of my favorite drug names. Yes, I am a nerd.)  This was tricky since the ventilator didn't work and the anesthesiologist had to manually breath for her.  She lost a lot of blood, and having been poorly hydrated to start with, she required 5 liters of IV fluids. Then we had to call the guy who manages the farm to donate a unit of blood to give her. They took it out of him and we put it right into her. Then we neatly stitched her back up and stapled the skin closed. Her belly was concave post-op, with her hipbones prominent. She's doing well today after a second unit of whole blood yesterday. The family will carry samples of tissue to the nearest city in order for the pathologist to tell us what type of cancer it is and therefore the prognosis. I just hope her youngest child will know her. 

Friday was a very quiet day. I ended up seeing only 1 patient in the morning and didn't even go back for the afternoon, it was that slow. Ended up napping and reading all afternoon since it was raining outside. Had dinner with the missionary family that manages the finca (farm). They roasted a lamb they'd slaughtered last week. Played games and laughed 'til late into the night. 

Today was a little busier. I was on call (still am, actually), and got called around 9:00 this morning for a 14 YO boy with fever and right-sided belly pain. We've got no lab on the weekend, no imaging. I'm thinking "What if it's appendicitis?" Thankfully, when I saw him he wasn't that sick and he most likely has the stomach bug that's going around. Tylenol for fever, phenergan for nausea, a little fluid to perk him up, and away he went. A few hours later, just as I was hoping to go to down to the beach, I get called to the hospital for some administrative stuff. While I'm there, 2 patients arrive at the same time - a 53 YO man with a fever of 104 and an 80 YO man with chest pain who had passed out. The chest pain turned out to be stomach pain, so we watered him and changed his meds around and sent him home. The high fever, aches, headache, nausea is likely malaria. He was sick. And allergic to the most common malaria meds. So, he came into the hospital to control the fever and keep him hydrated and get started on alternate therapy. 

Tonight, as I was sitting down to an inventive late supper of mole chicken pizza with the folks I'm sharing the house with (2 med students from Iowa and 2 non-medical, education types from Virginia), I got called for one sick kiddo. I got the report over the radio of a 14 month old breathing fast, febrile, tachycardic, with low oxygen levels.  I grabbed my shoes and booked it to the hospital. I was expecting maybe a respiratory infection, wheezing, etc.  What I didn't expect to see when I got there was a baby convulsionando, seizing. We called a code in order to get support staff there and started trying to get IV access.  Ended up giving Valium rectally which after about 5-10 minutes (seemed much longer) broke the seizure. He vomited and continued to breath fast, but slowly came around and improved.  We finally got an IV site and started treating for a presumed meningitis - antibiotics, tylenol for fever, IV fluids.  It was scary, man.  It's scary to treat these folks without basic stuff like labs, x-rays, the ubiquitous CT scans of US ER's. But at least everybody's stable at the moment. Makes me a little jumpy, though. 

The weather has been a bit like the rest.  Some days it rains off and on all day, staying overcast and blustery in between downpours. Other days it'll rain a bit, but the the sun comes out and leaves it hot and sticky, more than usual anyway, just to cycle again within the hour. Then there's days like today when the sun shines bright, the sky is blue, the clouds are few, and the ocean reflects the sky's color in a deeper hue.  So far I've only admired the view from the hill, hearing the faint sounds of the waves when it gets real quiet. The sea surrounds us on 3 sides - we're on what appears to be a small point, of which there seem to be many along the coast. Looking what I believe to be ESE you can see a mountain that seems to reach straight out of the sea and into the clouds.  I'll get down to the shore eventually. 


( 10 comments — Leave a comment )
Feb. 5th, 2012 06:09 am (UTC)
That mass sounds like something out of a horror movie. I hope the woman does okay, that all your patients do well.
Feb. 11th, 2012 05:38 pm (UTC)
It felt like a horror movie. Thanks so much for your good wishes.
Feb. 5th, 2012 10:21 am (UTC)
Wow. I could never in a billion years handle the stress.
Feb. 11th, 2012 05:38 pm (UTC)
Scary man! But so rewarding when you get on the other side of it.
(Deleted comment)
Feb. 11th, 2012 05:39 pm (UTC)
*hugs*. Thanks for the encouragement!
(Deleted comment)
Feb. 11th, 2012 05:40 pm (UTC)
*snuggles you right back* Adventure time for sure!
Feb. 6th, 2012 06:17 am (UTC)
From this distance, safe over the internet, I can wonder and speculate at the mass in the woman and how impressive it is to do all this without the equipment that so many American medical dramas tell us are absolutely necessary.
Reading your fist hand account, I seriously want to be in your meatspace to see if I could help in any way, or at least give you a hug.
Feb. 11th, 2012 05:41 pm (UTC)
I'll take a hug for sure! So glad you are sharing this adventure with me, at whatever distance.
Feb. 6th, 2012 05:06 pm (UTC)
It's weird but until you said I never realised there was an AIDS problem in Central/South America. Everyone/thing over here mentions Africa and words fail me on the extent of that crisis.

The mass...funny but I always imagine (and I have to question whether I ever do *imagine* a mass...) that masses are solid and not this kind of mess but apart from anything else I bet the stench was diabolical. (Many years ago in a another life I had to attend PM's and they themselves were v.interesting but the smell...in another category altogether, added to the already awful formaldehyde of the mortuary!)

Then I thought, OMG you were reading and I bet some of it was my fic! Wow...I have difficulty imaging (and I have a vivid imagination, believe me...) that people in far flung places read my stuff! Lol!

D x
Feb. 11th, 2012 05:45 pm (UTC)
The mass itself was pretty diabolical, stench and all. It's truly bizarre how simply wrong it looks - unnatural.
Thanks for keeping me company on my trip - with your comments and your fic!
( 10 comments — Leave a comment )