It’s Wednesday afternoon about 3PM in Paoua. Walking along the road from the hospital it still feels like it is well over 90 degrees under the African sun.
I love surgery. I am grateful to be a surgeon. But I have always thought of it as something that I do for work, not who I am. However in Paoua, I am nothing more than the surgeon. It is who I am, what I do. When the hospital radios the residential compound after hours, the call is for “le chirurgien”, not for me by name. MSF brought me here to be their surgeon. Their expectation was that I could practice broadly in my own field plus was willing and able to practice outside the realm of general surgery including performing c-sections. I am also asked to provide care for problems that back home would be handled by other specialists; orthopedic surgeons, ENT doctors, urologists and dentists to name a few.
In the US, I never practice outside the field of my expertise. Although my training covered a broad range of surgical specialties, I have pursued a sub-specialty practice over the years. Over the past decade, I have performed the majority of my operations laparoscopically. Over the past year, I have performed the majority of my major procedures using the Da Vinci surgical robot. In the US, if I see a patient with a problem that can be better addressed by another specialist with different training or experience, I refer the patient. In Paoua, I have no referral options. There are no other surgical specialists in Paoua and only a limited number in Bangui. Most people I see here have severely limited resources and are no more able to seek a consultation in the capital as to take a trip to the Mayo Clinic. If we can’t help them in Paoua, they don’t get help anywhere else.
Yesterday during hospital rounds, I was asked to see a five-month-old girl on the pediatric service with a possible imperforate hymen or imperforate vagina. Many people know that the hymen is a thin membrane, usually present at birth, stretching across the lower part of a girl’s vagina. Most people don’t know that occasionally this membrane will completely cover the vagina, a condition called an imperforate hymen. It usually doesn’t cause symptoms until a girl goes through puberty and has her first period. Her menses backs up causing discomfort, she sees a doctor, the problem is diagnosed and the hymen is easily opened up with a simple surgery. But if the problem isn’t simply a thin membrane blocking the outflow, problems such as vaginal stenosis or atresia can be much more difficult to treat. For non-medical reader, as the body develops inside our mothers’ wombs, our cells go through an amazingly intricate series of changes, movements and fusions, all directed by our DNA and other forces. This process of how we form our body, brain, limbs, internal organs and the multiple tubes and openings that make up our digestive, waste and reproductive systems is called embryology. When a tube or opening is too narrow, it’s called a “stenosis”. When a tube or opening fails to form at all, it’s called “atresia”.
We were halfway through the pediatric service when we arrived at the girl’s bed in the corner of the barracks style extension ward. The story was that the baby girl always seemed to cry when she peed. Her mother had noticed this for some time but thought it might be normal fussiness until recently when she took a close look at her daughter’s genitalia. She was otherwise a healthy baby and there was nothing that sounded as if she had had urinary tract infections. And despite the fact that she appeared to be uncomfortable when she peed, it seemed to the family to be a normal amount and frequency. I sat down on the edge of the bed to examine the baby. Between the awkward position, poor light and my eyes I suspected that I would need to examine her in the Bloc with better positioning and lighting but I didn’t want to appear disinterested in helping her by not even trying here. With her mother holding the baby’s squirming legs apart and a nurse holding a pen-light, I took a brief look and confirmed that I would need better light to know what I was looking at. I said that I would need to do some research on the subject today and tomorrow I would examine the baby girl in the OR with better light. Unlike most of our patients going to the OR, she would be free to continue eating as we would not be giving her an anesthetic. As she was less than a year old, our anesthetist felt the risk of anesthesia couldn’t be justified for a simple exam.
Later that morning between OR cases, I took a look in our reference book “Primary Surgery” to see if there was any discussion of imperforate hymen. The three volumes cover a wide variety of surgery and anesthesia and should be on the shelf of any survivalist’s home library. It is written specifically for people providing medical care outside their area of expertise in remote areas with limited resources. It tells you how to deliver a baby, set broken bones and treat a flail chest among other things but not unexpectedly, there was nothing about an imperforate hymen. Once again, I am thankful for the internet. A Google search led me to a number of informational sites about imperforate hymen, mainly basic information about the problem, stressing that it is easily treated and nothing to be embarrassed about. It confirmed that symptoms usually start at puberty but gave me no insight into why a five-month-old should be bothered by the problem. The next search was at the National Institutes of Health site, www.pubmed.org, where I found several case reports on symptomatic imperforate hymen and vaginal stenosis in infants. I read as much as I could on the subject, trying to remember my embryology from medical school on how the female urinary tract and vagina are formed.
There was one last search to do. Although I have been a doctor for longer than I care to say, as well as having changed my infant daughters’ diapers as much as any dad, it was helpful to pull up a few photos showing the appearance of infant crotches including imperforate hymens and a variety of conditions that I didn’t expect to see. One photo even showed a girl about the same age as our patient with an imperforate hymen causing symptoms from a build up of mucous behind the membrane, possibly what I would find in this case. I now had a plan. I would get a good look at her genitalia in the OR. Depending on what we saw, I would then pass a small catheter up her urethra, which is the opening to the bladder, looking for any sign of blockage. If we saw an imperforate hymen with fluid behind it that might be causing pressure on the bladder or urethra, we would open it.
Today in the OR, I was disappointed to find no real vaginal opening, not even a pinhole, with or without a membrane. The baby’s urethral opening was small and we couldn’t pass the smallest catheter across. My suspicion was that she had some type of vaginal stenosis or atresia, possibly with some related narrowing of the urethra causing discomfort when she peed. But rather than try to stretch the urethra out and run the risk of scarring or probe further for a small vaginal opening and run the risk of bleeding, I simply stopped. There is a saying in medicine, Primum non nocere, which is Latin for “first, do no harm”.
At noon time I had a conversation with the baby’s family and the pediatrician. They listened attentively, the mother wearing a bright red shawl and long blue skirt accompanied by her father, the baby’s grandfather, dressed in what I took to be a traditional Muslim outfit. I explained what we had found and recommended that they do nothing more for now as long as the girl continued to pee and not have problems with infections. If all remained the same, I asked them to return to the hospital for another exam when the girl is five years old with the explanation that her anatomy might evolve as she gets older and an exam at that time may be revealing; my real hope is that they will be fortunate enough to be seen at that time by someone with a greater fund knowledge of pediatric urology and gynecology than I have.
During the final stages of the interview process with MSF, I was asked how I thought I would deal with the pressure of seeing patients in developing countries that I couldn’t help. My answer was that I see patients all the time in the US that I can’t help and that it’s never easy but it has always been a part of my job. What I hadn’t anticipated was how difficult it would be to see patients that I know someone else could do a better job for, but still be the one responsible for making the decisions and doing the operations. In surgery we talk about errors of commission and omission, recognizing that sometimes you can hurt your patient by doing the wrong thing and sometimes by not doing the right thing. There is a middle ground between being a surgical “cowboy” (surgical cowboy: a surgeon who does operations that he/she has no business doing, a surgeon who does unreasonable operations for questionable indications) and simply passing all the difficult problems on to other colleagues or simply just passing on difficult problems. Because I have no referral options here in Paoua, that middle ground may be shifted to the left but I still need and want to stay in it. My hope is that all my errors, whether they are errors of commission or omission, are small and have little consequence for the patients.
It’s a bit ironic that on this trip to a faraway place, I am more than ever defined by my job. For me, travel has always taken me out of my day to day life where I often feel defined by my daily routine, my responsibilities, my job and my possessions, and allowed me to think about who I really am and what is truly important to me, the so-called meaning of life. But that’s enough for now. MSF didn’t bring me here to a philosopher or a blogger. They brought me here to be a surgeon.