In organised private health and diagnostic facilities, every individual knows his job description and where he belongs.
I am usually amused when I watch debates in public and media fora where various disciplines in the health sector argue about parity in professionalism and remuneration. The truth about this is that when you look at the persons involved in these debates, they have one thing in common: they work for or in government establishments where the paymaster is an omnibus cookie jar and where things take political and various colorations.
In organised private health and diagnostic facilities, every individual knows his job description and where he belongs. One undeniable fact is that right from the very first lecture a medical student receives in Anatomy to his last viva voce questions in his final exams, he/she is being groomed for one thing: making a diagnosis. This is the ability to tell what health challenges the patient has and the organ system involved. Every other thing thereafter falls in line towards making the patient better, which includes various tests that need to be carried out and medications to be administered.
It may interest you, if you are very observant, to know that doctors do not even TREAT their patients in about 90 per cent of cases. Treatments are carried out by other health workers, like nurses and therapists based on the doctors’ recommendation after diagnosis. No matter the number of times you would have administered a medication for a lesion you have come to associate it would make you a doctor. It is only the doctor that has the power of diagnosis.
Today’s discuss is not intended as an advocacy but to bring to the fore the importance of ‘taking a careful look at all clinical conditions no matter how obvious they may seem. It is not uncommon for an abdominal surgeon to be complacent in making clinical impressions only to experience a pleasant surprise when he opens up the patient.
She had come to visit her friend in a facility where the later just had a myomectomy, an operation done to remove fibroid tumor from the uterus. The story she heard and what she saw impressed her very much. Close to the end of her visit she dropped by the consulting room to inform the surgeon that she has a similar condition. Perchance she was waiting for the outcome of her friend’s adventure! In the animated spirit following the success of her friend’s surgery, the surgeon decided to forego all formalities and asked her to lie down on the examination couch so that he could have a look at her abdomen. The abdominal swelling was so obvious that he didn’t bother to at least assess the tumor with the ultrasound scan machine in his consulting room. He had already come to the conclusion of giant multiple uterine fibroid. The patient, going by the experience of her friend, was eager to have her own surgery performed and wanted to know the cost implication. Always the bottom line in situations like this.
Unlike most patients that would chicken out at this stage, she came back after one week with a deposit payment and even wanted the surgery to be done that same day! She had to be counselled that there was a need to have some tests done and get blood ready for the surgery, bearing in mind that myomectomy can be hazardous sometimes. The earliest possible time was the next day. Quite naturally, the surgeon asked her to lie down on the examination couch for a second look at the abdomen. Again, the size of the mass was such that he considered ultrasound evaluation an unnecessary waste of time. The procedure was scheduled for the next day. Operating to remove fibroid is NOT an emergency in clinical practice.
By the next day, it was the patient that gave the surgeon a wakeup call. This he considered an over anxiety by the patient. He was not to be rushed. Eventually the surgical team was assembled in the theatre and good to go. This was when the drama started. For almost two hours, they battled to set up an intravenous line without much success due to collapsed veins. At a point a cut down to the saphenous vein origin in the leg and even the external jugular vein in the neck were all considered. These are the last desperation options in emergency shock conditions. Just at the point of giving up, the surgeons got lucky and secured what they knew was a lifeline.
Going by the size of the tumor, no cosmetic consideration was made with respect to the type of incision to be used on the skin. An extended midline incision was used.
On entering the peritoneal cavity was the next shocker. A massive intra abdominal bleeding or Haemoperitoneum! This was not a feature of fibroid. The bleeding in uterine fibroid is usually from the Endometrial cavity or rather inside the womb and comes out through the vagina. The surgeon at this juncture had to move fast and identify the source of haemorrhage before proceeding. The first good feeling he had was that as he tried to mobilise tumor with the largest size he noticed that it was SMOOTH WALLED. And as he delivered it into the wound,
he saw the dent at the back of the mass. Then the relief: the bloody mass was a huge DERMOID CYST that was twisted and now ruptured leading to internal bleeding! On both sides of this cystic mass were two uterine fibroid, the size of each like an avocado pear.
The dermoid cyst was removed using the ruptured site as the cleavage plane. The two fibroid masses were subserous in location and were easy to enucleate. The main surgery proceeded so fast that the initial stress did not translate to any technical challenges. The surgeon had even the luxury of time to remove the patient’s appendix. You don’t carry such generous scar and still have your appendix in the abdomen. It is very unfair to the patient.
Two lessons learnt here are firstly, if the surgeon had bothered to use his scan machine it would have been obvious to him that the huge mass was actually cystic even if it is semi solid. The sonological feature of a cyst is very easily distinguishable from a fibroid, a solid mass. This is based on the difference of the speed of sound in solid, liquid and air. Sound wave is fastest in solids. Secondly, when the patient became apprehensive, that would have been a sign that there was something going on. Unfortunately, our patient was a poor alarmist. I like it sometimes when my patient say: “Dr. I no get myself.”