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The mola

 

Cesarean section in Ivory Coast, 2012

At around 10 am the midwife came to the Operating theatre where we had just started todays list after completing the morning patient rounds: Mostly minor cases, incision of abscesses, dressing changes. Now, a 19-year old pregnant woman had presented with continuous heavy vaginal bleeding. According to the midwife there was no fetal heart activity. According to the woman, she was in week 33. We did not have access to ultrasound. She needed a Cesarean section. With no obstetrician employed, this is the job of the surgeon.

10 minutes later the woman was in the operating theatre and we prepared for the Cesarean section. Probably a placenta previa I thought.  I opened the uterus and I still remember the subsequent moments of  confusion and disbelief when I removed handful after handful of what looked like small white eggs. There was no child inside. Instead this was a molar pregnancy, which the woman had carried undetected into the 33rd week  due to the lack of access to pre-natal counseling in the remote are where she lived. I removed the mola and closed the uterus. She was 19. She would be able to have more children.

However, the postoperative course was complicated, she kept bleeding. Was this perhaps an invasive mola?  We will never know exactly. I had to perform an emergency hysterectomy, but the vaginal bleeding persisted, however by now it was slowly diminishing. Was there perhaps also an element of coagulopathy? Possibly, but without adequate testing modalities, no way to know for certain and in any case no treatment would be available. After a few more days on the ward she was ready for discharge.

How does the future look, in this relatively remote part of the country, for a 19-year old woman, just married and  not able to have kids?

Not necessarily bad, I was told. In many such cases a childless couple would raise the children of other family members, such as her sister, as their own.

Obviously with access to appropriate prenatal care, the condition would have been detected far earlier and probably could have been treated.

Douekoué, Ivory Coast, 2012.

the girl who stumbled while playing outside

Inside the operating room, Aden, Yemen

Aden, Yemen, 2012.

It was late afternoon and I was standing on the roof of the brand-new MSF (Doctors Without Borders)  hospital in the outskirts of Aden, the main city in the south of Yemen. It was the beginning of May and already around 30 degrees Celsius while the muezzin called to prayer in a nearby mosque. Due to the tense security situation we were not allowed to leave the hospital at any time and the entire team was installed in rooms on the 2nd floor. If you needed a breath of fresh air you had to go to the roof. Only brief roof visits were allowed though, due to the risk of shelling.

The medical team leader came up and told me he had received a call from another hospital 4-5 hours away, a smaller facility where surgery was not available: They had received an 11-year old girl who had fallen down from a 1 meter high rock while playing outside. She was not doing well, they said, on the outside there was nothing to remark, but she had severe stomach pain and could not move. Could we receive her? Yes of course.

5 hours later the girl arrived and upon examining her it was immediately apparent  that she had peritonitis . She presented with a classic peritoneal reaction upon palpation of the abdomen. Blood tests, apart from hemoglobin, were not available, no imaging possible, but none was really needed: She required immediate surgery. 15 minutes after she arrived, she was undressed and intubated and the surgery began. I had talked to her father via an interpreter and explained the situation, told him that I did not know what was wrong but she may need a stoma.
Immediately after opening the abdomen I noticed the 2*2 mm perforation on the surface of the small intestine approximately 40 cm from the ligament of Treitz. I remember telling the anesthetist that this was good news, the surgery  would be completed in less than 30 minutes. I hope so, she said. As said, I sutured the perforation and closed the abdomen. The anesthetist was specifically trained in pediatric anesthesia as well as pediatric intensive care management and took care of the prescriptions in the recovery room. When I woke up the next morning I went to the recovery room, where the girl was sleeping. She was lucky, it went well, I remember saying. The anesthetist looked at me with an odd expression on her face: She is dying. She has acute renal failure. And there is no access to advance therapeutics such as dialysis, the only possibility to save her life.

The almost 24 hours it took for her to gain access a hospital with surgical facilities turned out to be too long. She died later that afternoon.

Below a video of what a day may look like in this hospital:

The boy with the bladder stone

I was standing in the courtyard outside the surgical ward, when a man approached me with his 14-year old son. Are you the surgeon, he asked? Then he went on to tell me how his son had suffered from recurrent urinary tract infections the past 4 years, resistant to the available antibiotics. They finally saved enough money to have an ultrasound examination that showed a 3*3 cm stone in the bladder. They came from a city 6 hours away by bus, and they had visited 5 hospitals already asking for advice, and everywhere they were met with the same answer: “No, this we cannot do. We do not do specialized surgery here.”

Hospital Duekoue Ivory Coast
Sterilized surgical equipment, Ivory Coast

In fact, the operation itself: A small incision, open the bladder, remove the stone and close again is relatively simple and takes no more than 15 minutes, however bladder stones are not common in the Ivory Coast and none of the general practitioners (with surgical competences) or surgeons had done it before. As recurrent UVIs may well harm the kidney on the longterm, there is good indication to remove the stone. I did not have access to ultrasound but I trusted the father´s description and scheduled the boy for surgery the next day where I removed the bladder stone uneventfully and inserted a normal Foley catheter. The only adverse event came after 7 days where it was entirely impossible to remove the Foley catheter as we could not empty the balloon, thus I had to open the bladder and puncture the balloon, remove the catheter, replace it with another Foley, wait another 7 days, after which this catheter was finally removed and the boy discharged. The last thing I remember was his father hiring a photographer for the money he did not have to take a picture of me together with his son as he was convinced that ”God and I had saved his life”:

Bladder stone Ivory Coast

March 2012, Duekoue, MSF supported hospital, Ivory Coast.

All stories and photograph with permission of the involved patients.