Ectopic pregnancy


By Dr Lucianna


A sad twist


My husband, Dr W, was wielding the knife, ready to cut her open. Yeah, yeah… I know… I see you contort your face and I even hear the question from those who know him… but he’s a paediatrician, you say to yourself, how then was he wielding the knife? Simple question, simple answer: The University of Nairobi Medical School churns out all-round doctors. By the time a doctor graduates he’s trained to handle most cases in every discipline; be it surgical, medical, paediatric, obstetrics and gynaecology…whatever… ENT, ophthalmology, dermatology; the only thing we are not trained to handle, from head to toe, are teeth. Dentistry is a whole discipline on its own totally removed from a general doctor’s scope. Any doctor who then wants to specialise goes back to University for another 3 years for his masters degree in his chosen field. So, yes, before my husband was a paediatrician, he was a general doctor.


Now that I’ve set the records straight, can we go back to the story? Did I hear a yes? Thank you! So my husband was wielding the knife, call it scalpel, ready to cut. The woman had walked in with severe lower abdominal pain and spotting just a little blood vaginally. Were it not for the pain she probably wouldn’t have come to hospital when she did. Listen to this: a pregnant woman should never, ever ignore any bleeding no matter how slight, not even one drop! I have encountered countless women who came to hospital too late because they thought just a little blood was harmless. They ended up with serious problems. Some got miscarriage, losing a baby that would probably have been saved; but that’s a story for another day. Today we are talking about ectopic pregnancy.


Dr W was on call when this woman came in. He quickly examined her and established that she had an ectopic pregnancy that was about to rapture. What’s an ectopic pregnancy? Let’s go into a bit of biology. The uterus is a gourd-shaped organ hiding snugly in the pelvis of a woman. Its normal position is “bottom-up” and “neck-down”. The neck opens into a muscular tube. The layman calls this tube birth canal but there’s no shame in me calling it by its biological name, vagina. To the rounded part of the gourd, are attached two tubes one on the right and one on the left. The tubes bring eggs from the ovaries. So far are we together? Can you picture it? An upside down gourd with tubes bringing eggs from the ovaries? Faithfully, every month, one of the ovaries releases an egg and the tube on that side brings it to the uterus. If there are no sperms in the system, the egg is flushed out by the frustrated bloody tears of a sad uterus… menstruation.


If the egg encounters sperms on its march to the uterus, it is fertilised. It starts multiplying in the tube. It then happily continues on its journey, only this time not just as a plain egg, but as the beginnings of a baby. Merrily, merrily, merrily, merrily, down the tube it goes! The journey takes about 8 days and upon arrival the baby attaches itself to the uterus and continues to grow. This time, and for the next nine months, no sad uterine tears are shed. The uterus expands to accomodate the baby. But sometimes, by an accident of nature or disease, the baby doesn’t go all the way to the uterus. It attaches itself to the tube. It starts growing inside the tube. The tube expands a little to accomodate the baby but by around 8 weeks it can expand no more. It then bursts! Raptures! The bleeding that results is terrible… It’s massive… It can kill… It has been known to kill!! Ectopic pregnancy means a pregnancy in the wrong place, usually in the tube. It could be anywhere.


Immediately Dr W diagnosed ectopic pregnancy he planned for surgery and had the woman rushed to theatre. An ectopic pregnancy is a dire emergency because the mother can bleed to death if immediate action is not taken. If you were ever next on the theatre waiting list and you were told, “sorry, we have an emergency”, it was probably an ectopic pregnancy. In my practicing life I have seen many patients get frustrated because they thought we had been bribed to bump them off the theatre list. Sometimes there isn’t enough time to explain and even when we do explain we are bound by ethical considerations. So we just tell them we have an emergency and can’t wait and must skip the queue.


Dr W made the cut, opened the abdomen and proceeded with his surgery. He identified the offending tube. It had actually raptured and was bleeding profusely. He tied it, then cut it and then arrested the bleeders. When a tube is tied and cut, it is no longer able to carry eggs. So the woman is left to function with only one tube. She is still able to get pregnant. Most women will not even feel the difference between one tube and two tubes. They get their normal monthly periods. As Doc was wiping away the blood and trying to clean up the woman, he realised that there was still a bleeder somewhere that had not been arrested.


He swabbed again and held it up to look more closely. That’s when he realised the bleeding was coming from somewhere else. He meticulously inspected the area and followed the blood flow to see where it was coming from. And oh my God!! It was coming from the other tube!! Another ectopic!! He tied… and cut… and arrested the bleeding… and repaired the abdomen. What are the chances that one can get a double tubal ectopic pregnancy?? Studies show 5 in a million! God! I feel this mother’s pain. She had conceived twins, one from each ovary, and each got stuck in the tubes! Both raptured! The tragedy was, her fate was sealed. She could not ever again have a natural conception. With advances in science, she can have in-vitro fertilization, test-tube baby, but it’s extremely expensive. Given that she was in a public hospital, what are her chances of affording it? I asked my husband if she had other kids but he couldn’t remember. It was a long, long time ago.


Such things make doctors feel so helpless, so inadequate. But most of all, they remind us that we are not gods. We are simply human, but with a special gift.

The vulnerable ones


By Dr Lucianna


How do we protect them?


“Shiiister!! Shiiister!!” she called with the lisp and drawl of a mentally ill patient on largactil. This medicine affects their speech and they speak with an exaggerated drawl. She was shuffling towards the nurse, otherwise known as sister, as fast as her uncoordinated legs could carry her, calling her with all the urgency a drowsy patient can muster. “Aya ni …***!!!” I don’t have the heart to fill in the gaps… translation… “these two are… ****!!!”. And sure enough two patients, a male and a female were vigorously going at it on the unkempt lawn! Jesus! In the hospital compound! In broad daylight! With all the patients basking in the sun, only this one seemed to realise that what was happening was not proper. Sister, the female nurse helplessly looked to the male nurse for action. Listen to what he said, “it’s impossible to separate them. Let them get through with it.” Psychiatric male nurses are usually big burly fellows, I guess he was embarassed. I also guess he imagined the spectacle of separation would be worse than what was going on. He shrugged.


This was a psychiatric ward in a government institution. The patient’s sleeping quarters were set out at different parts of the facility separated by the office block keeping the males from the females. But during the day they were allowed to mingle, I guess in an attempt to create an environment similar to the real world out there. But, hey, somebody was supposed to watch them, come on!! Hellooo!! They needed to be protected against negative interactions like fights and rape and fake consensual sexual activities. I say fake because one or both participating partners may not be in a mental position to give consent. And in any case, who in their right minds would give consent in an unkempt lawn and in the full glare of everybody in need of entertainment. Both participants above actually needed protection from each other. Who was watching over them?


In a different scenario, I was working in an institution for vulnerable children. There was this teenage girl, call her so and so, or So-so for convenience. She was mentally challenged. Physically she was ok, well built, right for her age, but her mental growth was arrested at a pretty early stage. She was therefore just a little child in a teenager’s body. I had earlier treated her on two or three occasions. One day, months after our last doctor-patient encounter she came to the consultation room. Any time these kids came I would do a thorough physical exam even for unrelated systems. On this particular day, as I examined her abdomen for… maybe areas of illness she may not have talked about, I was shocked to get some unusual findings. My examining hand told me So-so was 28 weeks pregnant!


How did this happen? Rhetorical, I know, but who did it? These kids never ventured outside the institution! Yet it was no virgin conception. It had to be somebody within the institution! “Did anybody ever touch you down here?” I asked her. “Yes,” she answered as a matter of fact with no trace of embarassment. I asked a few other, but very modified questions to establish the facts. It turned out some man, highly likely one of the groundsmen would ask her to go behind some hardly ever used building and wait for him. He would then follow, I guess after looking around to make sure nobody was watching. He would then molest her. She couldn’t even properly describe him. I don’t know how many times it happened but it was not just once. I don’t even know whether he realised then that she was pregnant or he did so much later. And even then, did he realize it was his baby or did he think there were others like him? I reported to the institution management. They didn’t believe me… imagine! They didn’t believe me!


“How can you know with such certainty, just by touching her that she’s 28 weeks pregnant, or even pregnant at all! Have you done any tests?” They were expatriates and completely ignorant of the abilities of Africans. Some of these fellows are brought to the third world to run institutions but are completely ignorant of most basic things. All they do is earn big salaries and have a good time under the sun. Oh, the days of old! Expats were real experts. Anyway, I quietly suggested they send her for an ultrasound scan. Hesitantly they did and whaaat?? I was right. They thought I was superman. Annoying! Honestly, such basics! Basics, for God’s sake. I left the institution shortly after. I later got to know that So-so delivered safely but never got to see her baby. Baby was given up for adoption, so I was told.


There was this other girl, call her So-so2, who was mentally sound but had no legs. She had been like so since birth. Deformed feet were attached to her torso where the hips should have been. She was in the same institution as So-so above. Around the same time I also realised she was pregnant. One can’t even imagine the gymnastics employed in the process! Methinks it takes an acrobat to achieve some feats. So-so2 refused to divulge any secrets. Who was abusing these girls? What decay existed in this institution? So-so2 appeared quite happy with her situation. I guess as a woman she felt fulfilled. I discharged my duty, I reported to the management. Like I said, I left the institution shortly afterwards and never got to know what happened to So-so2.


How many underprivileged girls were abused in that institution by the so called caregivers? How many mentally challenged people are abused in the very institutions that give them care. How do we protect our vulnerable ones if the very people entrusted with their care molest them. I wonder, is there any difference between public faciliies and private run facilities in terms of abuse? Has anybody ever done some form of research to find out how extensive this ill is?


It just saddens me that society cannot take care of its own.

Stolen dignity


By Dr Lucianna


The trauma of rape


I looked at her, she looked so young, barely out of her teens. Oh, how so young! Dressed her age; leggings, dress-top and a light sweater. Her clothes were covered in dry grass and weed and the same was woven into her hair. I could barely hold back my tears… balancing, is what my kids call it. I’m in this PM room… I’m wondering what killed her, what the immediate cause of death was. That’s why I’m doing this PM, to determine the cause of death.


My earliest memory of a rape related death was a story repeatedly told us in boarding school… it was a girls’ catholic school. I was only 10 years old and most girls couldn’t really grasp what sin the nuns were talking about. Most girls that age were fairly innocent back then. The story was of a little girl, only 11 years of age who refused to be violated. She refused to surrender her chastity, whatever that meant. She chose death over violation. She was repeatedly stabbed in the chest by her would-be-rapist, a total of 14 times. A stab for each time she said “no, it’s a sin”. She later died and he was left frustrated because he never got anywhere near where she cherished. Her name was Maria Goretti. Her attacker was a young man, her neighbour who was in his twenties. He died at the ripe old age of 88 after having served jail time for his crime. His name was Alessandro.


Years upon years down the line I’m in this PM room with the body of another rape victim, a young girl who had not only been violated, but also killed. Her attacker or attackers had dragged her into an untidy grassy-weedy patch and left her body there. Judging by how the weed had worked it’s way into her hair and embeded into her clothes she must have put on a brave fight. She lost what she was protecting so vehemently, her dignity, and she also lost her life. Poor girl… Sometimes you wonder, is the fight worth it? Really? Some people will argue from a purely religious point of view and say, yes, it is worth it. Others will say, no, it’s not worth it. Better live to heal. The healing is a really complex affair. It takes counselling. For those who opt to live, we have counsellors to walk you through the trauma, to help restore your dignity. It othewise haunts you for life.


The trauma comes in many forms. I remember testifying in a court of law in Lodwar. I had been summoned because rape survivors who present themselves to hospital are examined by the doctor. Should the case ever get to court the doctor testifies. This particular rape survivor had identified her attacker and he had been taken to court. I won’t say what the criminal asked the lady but I will say what he asked me:


Accused: did I hear you say that you examined the victim after the attack?


Doctor: yes I did


Accused: did I hear you say that you found semen inside her?


Doctor: yes I did


Accused: how sure were you that it was my semen and not semen from a dog?


At that point the magistrate came to my rescue.


Now you can only imagine the kind of haunting trauma this line of questioning has on the poor lady. It completely robs her of any dignity left. Counsellors, I don’t envy you.


Other than the psychological trauma, there’s also the physical trauma. The more a lady fights her assailant, the greater the chances of injury. Some ladies have had terrible injury to the delicate lady parts and they had to be stitched back together again. Others have had ribs broken from the brute force used on them. Some, like my girl in the PM room suffocate to death from the sheer weight of the attacker on their chest. Others have been strangled to death as they attempt to scream for help. We have not even started on infections, STIs and HIV. We have not even mentioned pregnancy from beasts and the dilemma most women and girls find themselves in; to keep or not to keep.


Some also suffer trauma from the community. A certain community in Kenya ostracises rape victims. Their husbands or brothers completely reject them and they are thrown out of the village, total rejects, through no fault of their own. They were probably out there collecting firewood when the enemy pounced… and just like that their community life comes to an end. These are the type that would rather fight to death. I saw a lot of families in refugee camps seek asylum on the basis of rape, that is, if the husband was willing to stand by his wife. Unfortunately this has been abused. Couples do their thing and then cry rape… who is to know… the evidence is there for the doctors to find. When I worked there, DNA testing was not available to us… maybe today… I don’t know.


I am a fervent supporter of women’s rights, but I also believe that a woman should take responsibility and not unduly expose herself to some of these dangers. I know I’m trending on sensitive ground here. The world is full of good people but then again there are a few bad apples out there. In Nairobi many years ago, there were signs put up in dangerous areas, warning women not to venture alone or after hours. Surely, no woman in her right mind will want to go shouting “my dress my choice” in such a place. And sometimes “my dress my choice” is not just about rape. Say a man is walking to church with his son, and a girl walks ahead of them, body parts bulging out of her tiny dress, wriggling what her mama gave her… Oh, you can imagine the awkwardness of the moment! Ok, you can argue that it’s their option to look away, father-son duo, or change direction or run ahead and walk infront of the girl… What I’m trying to say is that we should take care of each other. There’s a time and place for all modes of wear.


Sorry, this is not about blaming the victim. Most times the victim has absolutely no control. We have heard several cases of women bus passengers being raped in the kinare forest and other places. Evil men commandeer buses with the primary motive of robbing the passengers, then along the way decide to give themselves a bonus, they abuse the women. I also remember attending to one lady who went out to relieve herself at night. It’s one of those homes served by a pit latrine outside the main house. She was grabbed by two men and violated.


There are only four outcomes to this heinous crime:

  1. The Maria Goretti outcome – struggle, protect your dignity and die.
  2. PM girl outcome – struggle, attempt but fail to protect your dignity and die anyway
  3. Lodwar lady outcome – surrender to fate, endure the shame, and live to heal and rebuild your dignity.
  4. Miracle – struggle, protect your dignity and live… best outcome by the grace of GOD

Study your odds and with a sober mind, make a decision… as sober as the circumstances dictate.

Low blood salt


By Dr Lucianna


Hyponatraemia

No, no dad, the doctor didn’t say, “don’t eat salt”, he said, “don’t eat too much salt”!! That was a discussion, or was it argument between father and daughter. The daughter happened to be a doctor. But unfortunately the daughter was losing the argument. What with all the “village doctors” having adviced the dad. Do you know there are several “doctors” in several corners of every village or estate who “know more” than University trained doctors? Oh, and there is also Doctor google, the most misleading of “doctors”! Ask her why you have a headache and malaria will be nowhere on her list… and yes, I’m saying “her” because doctor google is a woman!! Only a woman can know everything, right? …Whether she’s right or wrong, right?


I digress. The daughter had received a call in the middle of the night because her dad had been taken to hospital in a confused state. He was agitated and restless and had to be tied to the bed, infact crucified on the bed. His hands were tied to the upper sides of the bed and the legs to the lower corners. That was the only way to keep him from falling off the bed or pulling out the drip from his arm. He was on a “salt” drip. No, no… I don’t mean they put table salt in a drip! Oh no! This is a preparation that is very concentrated in sodium. Its called hypertonic saline. It’s medicine for people diagnosed with low blood salt. Doctors call this condition hyponatraemia. It’s dangerous, it kills. It especially kills old people because they have other complicating factors. And yet misguided people refuse to eat salt! They say salt is bad! What ignorance! By the time dad and daughter were having their argument the dad had stabilised. His salt level had been brought up. Confusion had cleared and he was off “crucifixion”.


I still remember those weddings of yesteryears where no salt was added to the food in the mistaken notion that salt is bad. Yak! that food… Lemme clear matters here: hypertensive people, that is people with high blood pressure should reduce the salt in their food. Notice I didn’t say they should avoid salt, I said they should reduce salt, especially those people on drugs called diuretics. Normal people can handle normal amounts of salt in food. All those village “doctors” I mentioned above preach that salt is bad. I’m sure I have some of them reading this, lemme tell you village “doctors”, the body needs salt. Without salt you will die. Yes , you will die. When body cells are sorrounded by low salt fluids they swell and the organs can’t function properly. The daddy mentioned above was in and out of hospital with confusion and headaches and vomiting because of low blood salt.


Some of my friends have noticed that I’m not a fan of water… yes water. I don’t particulary like water. It gives me nausea and sometimes vomiting, especially plain water at room temperature. I only take occasional sips when I must. So my friends ask me, “how do you survive without water? You doctors tell us to take at least 8 glasses every day!” When did I ever tell anybody that? Anyway, to answer that question already forming in your mind, I take fluids… yes, fluids other than water. I take water only very occasionally.


Why did I introduce the topic of water? It’s because some people are fanatical about water. They will down glass after glass, bottle after bottle. My own mom takes 2 litres before her first glass of milk in the morning and more in the course of the day. Do you know that there is something like “too much water”? Do you know that taking too much water can be dangerous? Ask me how… and even if you don’t, this is how: Water washes away the salt in your body. When you drink too much, you have to pass it out in urine, and urine carries with it salt. Your body is left minus salt. That is why even athletes shouldn’t take too much plain water, especially during training because they lose a lot of salts in sweat. Athletes have special fluids that help restore body salts.


How do you know that you are taking too much water? When you pass out copious amounts of very clear urine, then you are taking too much water. Your urine needs to have some amber colour for it to be considered normal. If the water in your toilet does not change colour after you are through, you are taking too much water. When you take water not because you are thirsty but because there’s a ration you must take, then you are taking too much water. If you want to fight me on this, you are welcome, you won’t be the first. I’m a veteran at this kind of war… veteran hmmm… and yet I couldn’t convince my own mother that she was taking too much water… ha! the ironies of life… even after we had to rush her to hospital in a hypontraemic state! Jeez! aren’t those salt tablets expensive! A word of caution here: if you are passing a lot of urine and getting very thirsty and having to take a lot of water, get your blood sugar checked. You could be diabetic. Lots of urine… and lots of thirst… and lots of drinking is a dangerous combination. It’s pathognomonic of diabetes. And by the way, a diabetic’s urine is sweet! Normal urine is salty.


Back to the daddy who had a doctor for a daughter: like I said, low body salt is particulary nasty on old people. Their electrolytes get completely imbalanced. The daughter would sing the salt song to her daddy, but the village “doctors” , the no-salt crusaders, shouted more… salt is bad, salt is bad! The daddy would appear to listen and obey when the daughter was around but backslide immediately she went back where she lived, which was over 600 km away. The doctors won several battles but the daddy eventually lost the war… after 2 years in and out of hospital with hyponatraemia. He died just over 2 weeks ago, 17 days to be precise.


He was my daddy… my daddy. I buried him that Saturday, just over a week ago. Rest in peace dad… sleep tight… you served your Lord well. To God be the glory.

Sleep disorders

Disturbed Sleep

By Dr Lucianna

Snoring

Wanjohiarts


Scenario 1


“My goodness mom! do you know that you snore?” My friend called me last week in panic mode. She had visited her daughter and had a sleep over. Come morning and the daughter was besides herself with giggling. My friend was alarmed, so she called me. “I thought it’s only men who snore!” she exclaimed. “Am I sick?” she wanted to know. “Why would I snore? Sweet Jesus!”


Scenario 2


There was this young lady who anxiously told me about headaches upon waking up in the morning. She was a busy banker and she thought her work was taking a toll on her. Every morning she woke up with a headache. It always cleared in the course of the day but sometimes she had to take panadol (acetaminophen). The headaches were nagging. I checked her BP and did the relevant tests to rule out other causes of headache. She happened to be anaemic. We handled the cause of anaemia but her headaches persisted. Why? We had to find out why. I dug deeper into her history, especially her sleeping habits and patterns.


Scenario 3


A long, long time ago, I used to experience wierd things at night. In the evenings I would fall asleep and yet not actually fall asleep. I would be half awake half asleep. I could hear and sometimes see things happening around me and yet I couldn’t talk nor move any part of my body. The best I ever achieved was wiggle my toes! Believe you me, it was a herculean task! The worst experience was occasionary having these scary dreams that an ogre was chasing me and I was glued to the ground or that he was choking me. Do ogres have gender? Should I call it “it”? Much later I learnt that I was experiencing sleep paralysis.


Scenario 4


Have you ever taken a long distance night bus sitting next to a “music maker” with notes from hell? One minute low tones of parrr, parrr… alternating the next minute with high tones of pirrr, pirrr… then swallow, swallow… don’t ask me what, then grrrrunt, grrrrunt, then stops breathing for several seconds, then again parrrr!!! and a flapping of lips! You would be forgiven to think the lips were wings! And the music continues, all the while he is leaning against you? You elbow him in the ribs! He temporarily wakes up, wipes the drool from the side of his mouth and gets back to parrr, parrr…you would be forgiven to think that he is related to a big cat! It’s annoying, to say the least. You can imagine if you had to share your bed with such a fellow! Poor wifey! or is it poor hussie!


Scenario 5


I am attending this fellowship and there’s this mother holding a toddler on her laps. The toddler is asleep and is snoring away and the mother looks comfortable, relaxed even. She doesn’t even notice because she thinks it’s normal. Meanwhile the baby’s head is sitting on its neck at a funny angle, the chin on the chest. I have witnessed many such scenarios even with complete strangers in public places; restaurants and public transport. I always intervene. If they throw darts at me I say, “I’m a doctor”.


Scenario 6


There was this family, my very close friends, they had a little girl who hardly ever slept. Whenever she was awake her mouth always hung open. The minute she fell asleep, as expected, her mouth would close… then she would start snoring… then she would suddenly wake up crying. When awake she would breathe through her mouth. It went on like that 24/7. I witnessed this torture first hand and we had to do something.


Why do people snore? By the way both men and women snore. There is one common denominator to snoring; that is narrowing, or call it obstruction of the airways. In scenario 6, my friends’ little girl had swollen adenoids at the back of her nose almost completely blocking her airway. That’s why her mouth always hung open. She had to breathe, helloooo… An infection in the airways of this little girl was a nightmare that complicated the picture even further. I reffered them to an ENT surgeon. The adenoids were removed. The surgery gave her a new lease in life, a permanent solution. Oh! The dramatic change in that little girl was unbelievable!


In scenario 5, mothers are usually ignorant, forgive my saying so. I’m not biased, it’s the truth. Look carefully next time at the neck of a baby snoring on their mother’s lap. The baby’s chin is almost always touching the chest. This causes the airway to kink and form a temporary obstruction. Any time I see such, even in a hotel, even with total strangers, I always get off my table, go to the affected mother-baby duo, and gently tilt the baby’s head backwards. It’s always followed by the baby taking a deeeep breath. This is because of the air hunger suffered. It’s then followed by normal breathing. Bye bye snore!


What do you do if you share your bed with a “music maker”? Look at him/her, they are almost always sleeping on their back. When one falls asleep all the muscles relax including those of the mouth and tongue. If one is sleeping on their back, the tongue falls into the back of the mouth thus obstructing the airway. The effort to move the tongue and other tissues away inorder to get some air through causes the vibrations called snoring. Its worse in obese people. Just nudge them in the shoulder and make them sleep on their side. You will immediately hear them take a deeeep breath because of the air hunger suffered during the snoring. Bye bye snore… and all say… Amen!


It goes without saying that when one snores they don’t get enough oxygen in their system. The brain suffers the most. By morning their brains are deprived and they wake up with a headache and every muscle in their body tired! This was the case in scenario 2 where the young lady banker used to wake up daily with a headache. Always make a deliberate effort to avoid sleeping on your back. You may feel good and comfortable lying on your back as long as you are awake, but the minute you fall asleep your tongue slips into the throat and trouble starts.


Long before I knew all this, I discovered that my wierd dreams and chocking experience described in scenario 3 would visit only when I lay on my back! I started feeling vulnerable and exposed to monsters as long as I lay on my back. Initially I would pray begging God to keep the monsters away, then I realised that sleeping on my side protected my vulnerable self from the monsters. Little did I know that all along I had been actually choking on my own tongue!


To date I always make a conscious effort to avoid sleeping on my back. Occasionally the person who sleeps next to me nudges me off my back… did I hear you call me a “music maker”? Answer at your own risk…Lol…

Nil by mouth

By Dr Lucianna


Paralytic ileus


“Have you passed wind?” I asked her. She was young, a first time mom lying there on the hospital ward bed after c/section. Helplessly she looked at me, then looked at the nurse and with a mixture of shyness and embarassment she said, “No, it wasn’t me” Oh my God! I just realised why she wore this wierd-funny look! She thought I was accusing her of unleashing a lethal one!! It always is a difficult question to ask a patient. It doesn’t matter how you phrase it.. it’s always awkward. I have heard colleagues ask, “umenyamba?” This is the most direct way of asking, “have you released a f..t?” There is no polite way of asking a lady if she has released foul smelling hot air from the rear exit!! And yet it’s important for the doctor to know. Some call them toxic fumes…ha ha, not in the ward though…


Any time a patient comes out of theatre the doctor writes instructions for patient care. I’ve done a lot of ceasers in my life, and instruction number one doesn’t even require thinking; NIL BY MOUTH or NIL PER ORAL. Simply translated, the patient shouldn’t take anything by mouth, not even water! The body is replenished intra-venously… iv… by drip. Where I was born and brought up people take doctor’s instructions very seriously. They will obey the doctor religiously. They will not forget to take their medicine, no matter how awkward the dosage. They will not miss an appointment. They will follow instructions to the letter, indeed to the dot. If doctor says don’t drink, they won’t drink. Period!


When I was an intern there was this other lady on whom we did a ceaser , my MO and I. I was in the learning stages, still under instruction. I was assisting my senior by pulling this way and that, cutting stitches here and there… learning as I observed. Doctor under construction! I don’t remember who wrote the notes, my senior or I; but notes were written. After explaining about the procedure that was done, there followed instructions on recommended patient care. First on the list was… you guessed it… nil by mouth.


That night I was first-on-call. I was called to review a patient in maternity who “had changed condition”. When nurses say “changed condition” you had better run. They won’t tell you changed condition from what to what, don’t even bother asking, but it is never for the better. By the time I got to the ward I had no idea what had happened. The patient we had operated on earlier was in a critical state. Her tummy appeared distended. Her breathing was wierd. We started resuscitating her even as I called my second-on-call. The patient in the neighbouring bed told us that the lady had pulled out her drip from her arm and drank it… drank from the tube… by mouth! She was still on instruction number one, nil by mouth!


During any abdominal surgery the intestines can’t escape it. Even when they are not the part being operated on they somehow get affected. As a result they get paralysed. You see, intestines have smooth muscles that help propel gut content forward, that is, food and air and anything else therein… yaay, I said therein! I sound like a lawyer! They are automatic muscles, they are involuntary. We don’t control them. If you want to sound like a doctor, say, autonomic! Normally, we don’t have to do anything in the propelling process.. that is other than the final push… except for those fellows who drink funny brews. You know the kind I’m talking about, those that have to tie strings around their ankles when they go to certain bars. You see them with trousers ballooned out with “content”.

Back to my story… After a short while post-surgery, the intestines recover and start propelling gut content. Whatever air was in the gut is pushed out first. That’s why we ask patients whether they have passed wind. It’s a sure sign that all is well. We then confirm by listening to the abdomen with the stethoscope. If the gut has recovered we will hear bowel sounds and only then do we allow the patient to start sipping fluids, sipping not guzzling! If the gut is silent we enforce further the nil by mouth instruction. Taking anything on a “silent” abdomen is suicidal.


Our patient thought that the nil by mouth order was punitive and unrealistic. After all she was thirsty, wasn’t she? And who did the doctor think she was anyway? My stomach my choice! Or was it my throat my choice? The “my-whatever-it-is-my-choice” brigaders sometimes get it so wrong. While I agree some orders may be oppressive, it would be prudent to really weigh some of these things. It’s a fact of nature, choices have consequences. The choice our patient made was suicidal…

I’m sad to report that she didn’t make it. Cause of death… paralytic ileus…paralysed intestines…

Eclampsia


By Dr Lucianna


And the little angel flew away…


Last week, on March 8th, we celebrated the international women’s day. What is it we celebrate women over? Some of those challenges they go through are just the roles asigned them by mother nature, true or so true? And yet we celebrate them! For something natural! Come on! Why? We do so because they nonchalantly grab their enemy-bull by the horns and emerge with multiple bruises, and yet willingly walk into similar challenges over and over again. Women have resilience! It made me recall one day being at this social gathering when I saw this lady… wait a minute!!! I had only seen her the week before and she was ok, at least she appeared ok!

On this day she was all puffy… the face swollen, the legs swollen, every part of her body that I could see was swollen. When I saw her the week before, it’s only her belly that was swollen… but that’s because she was expecting a blessing. I told her to go get her blood pressure checked immediately. She said, nah… I only saw the doctor last week and it was ok. She knew I was a doctor, so I told her that I was talking to her as a doctor… please gooo… I tried to explain to her how blood pressure in a pregnant woman can be ok one minute and skyrocketting the next. She told me she would consider it… Jesus! Don’t consider, ACT! Anyway, she didn’t. I had done my part, but apparently not convincingly enough.


When I was a medical officer in the maternity unit (in different hospitals), a few emergencies would actually make us vibrate, kind of like you see on TV. Most emergencies allow a bit of time for planning, but some are dire! They make us shift gears!! If you’ve never driven a manual vehicle you’ve no idea what shifting gears is! We get adrenaline powered! Talk of being turbo charged!! Eclampsia is one such emergency. Others like cord prolapse would set us ablaze. You see, the minute the baby’s umbilical cord drops out the birth canal it’s immediately exposed to the cold environment outside. The blood vessels in the cord go into spasm and constrict. Remember the umbilical cord delivers nutrients and oxygen from the mother to the baby.

In cord prolapse, by the time the baby pushes through the birth canal it’s already deprived of oxygen for a considerable time, long enough for the baby to die. So we don’t wait. We can’t afford to wait! Immediately we see the cord, surgery must be done. If it’s a busy hospital and there’s another case pending, we weigh the priorities and usually the prolapsed cord goes into theatre first. It requires speed to get that baby out before he dies of oxygen deprivation. My fastest caeserean section was a cord prolapse. I hadn’t even realised how fast I did it until the anaesthetist Dr K incredulously exclaimed… 16 minutes!! Skin to skin!! Sorry, the topic today is not the prolapsed cord…


My lady friend didn’t take my advice and before she realised it, she got terrible headaches. That was either that night or the next day, I don’t remember very well. She also got severe epigastric pains. The epigastrium is that area of the abdomen where breasts would meet if they attempted to whisper to each other. Then she started seeing double. Before her husband could get a vehicle to take her to hospital, she was convulsing…seizures! This is now full blown eclampsia. What she had when I saw her at the social place was pre-eclampsia.

When pregnant women attend antenatal clinic, one of the mandatory things monitored is the blood pressure. It doesn’t matter if it was checked yesterday. During labour, it’s even more closely checked. This is because it can spike without notice. There was a story in the news several years ago when a lady drove herself to hospital only to die there a short while later. The relatives could not understand how and they sued the hospital for presumed negligence. Only to realise later, according to maternity notes that her blood pressure had spiked! But Kenyans being Kenyans, and these particular Kenyans had just lost a loved one, thought the notes had been “doctored”. But it was proved to be so at post-mortem, autopsy.


Something else checked at every antenatal visit is urine. Here we are looking for proteins. Now I know this is getting a bit confusing for some people. Proteins in urine? You ask… Lemme take it a bit slow. We all know kidneys, right? Those bean shaped organs whose function it is to filter blood, yes? They remove all waste products and toxic substances from the body, yes? They regulate body fluids and elements… so far so good? Now, high blood pressure damages kidneys. One of the signs that kidneys are damaged is because the filters are affected and they allow proteins to pass through. So when your urine is found to have high proteins… we have evidence that all is not well. So don’t tell your neighbour at the antenatal clinic to share her urine just because you have an empty bladder and you are running late! Haiya… it happens. You don’t know ladies!


Pre-eclampsia is when a pregnant woman’s blood pressure is high and she has proteins in her urine. If it is not immediately attended to, she gets headaches, epigastric pain, blurred vision, vomiting and convulsions. This is now eclampsia. It is a killer. It has been known to kill both mother and baby. The treatment is anti-hypertensives and immediate delivery by the fastest means possible, usually caesarean section. If delivery is imminent, then vaginal delivery is allowed, but only if it’s imminent. A few times, mothers get eclampsia post delivery.


My lady friend survived the ordeal of eclampsia and had the courage to walk into yet another pregnancy sometime later, we celebrate her. But I’m sad to report that the baby didn’t make it. The little angel just flew away…she just flew away into the clouds…

Wanjohiarts

(If you know somebody who can benefit from this article, feel free to share)

Erectile dysfunction


By Dr Lucianna


“Guchokia machembe thitoo”
(Taking back the hoes/jembes to the store)

Wanjohiarts


One lady pulled me aside, leant close and in a conspiratorially low voice in my mother tongue she asked me, “What am I supposed to do? My husband has taken back the jembes to the store?” (Muthee ni achokirie machembe thitoo). I was a facilitator at a church organised ladies’ seminar. She couldn’t have asked the question during the main session for obvious reasons. I found her language very amusing. I don’t remember if I giggled. I must have. Most people take this “task” very seriously. It’s so energy intensive that it’s likened to manual labour. It’s serious work. It’s like digging a shamba. So when the system fails for one reason or another, it appears like the man has shelved his digging implements; jembes!


Not so long ago I received a call from a man I used to treat some years ago. He relocated to another town. After the usual exchange of pleasantries, that went on for a while (until I thought that was the main agenda) he got down to serious business. “I don’t think madam is very pleased with me”, referring to his wife. “I’m still young and strong, but…” he was in his fifties. His system had failed him. Men will sometimes go around in circles when faced with problems of sexuality. Sometimes they’ll just drop a bombshell on you. I still remember working in an outpatient health facilty in Nairobi. Men would just say, “machine imechomeka!” (my machine is burnt). I learnt this was the then street lingo for “I have an STI, sexually transmitted infection” , usually gonorrhoea. I think they would just drop it on me because they really didn’t have a choice. You see, I was relatively young and you don’t want to go discussing your machine-related-problems with a young lady doctor! Unfortunately for them the doctors were sent to the unit in rotation and the burnt machine was in such severe pain that they couldn’t afford to ask when the next male doctor was due. The pain wouldn’t let them wait. Ah!!! A doctor is a doctor is a doctor regardless of gender… so here we go… machine imechomeka!


I digress. I was talking about erectile dysfunction. Call it impotence if you want. This man who called me was diabetic. That’s what I used to treat him for those many years ago. I asked him a few questions pertaining to his diabetes and it appeared he was well controlled. I enquired into his relationship with his wife and it appeared to be ok, other than “little johnnie” refusing to respond to her. After a bit of discussion I adviced him to go see a doctor for proper check up and management. It’s not easy solving such problems over the phone. Indeed the only reason I gave him an audience was the realisation that this was a sensitive issue and he thought the only person who would listen was me. In the course of our doctor-patient relationship we had formed a kind of rapport. He trusted me to solve his problems. I referred him to the relevant specialist.


What is erectile dysfunction? ED affects men across any and every divide. It does not respect age, though it’s more common in those a bit older. It does not respect social status. It does not respect religion. It does not respect skin colour. It has no political affiliation. It respects nobody and nothing. ED is a condition where a man cannot acquire or sustain a “salute” long enough to please his partner or even himself. There are blood vessels in little johnnie that fill up with blood for purposes of this very important salute. Any disease that interferes with blood vessels in the body can affect even these particular vessels. Diseases like diabetes and atherosclerosis are the commonest.

Other causes of ED are excessive alcohol consumption and smoking. We all remember when women in a certain county here in Kenya took to the streets in protest. Their men had become non-performers. They claimed their primary schools had run out of kids! Serious!!! ED can also be caused by use of certain medications, like anti-hypertensives and drugs like Marijuana. You see, little johnnie responds to signals sent to it by the nervous system. So medications and drugs that interfere with transmission of these nerve commands can result in ED. Yet for some men it may be purely stress and fatigue related. Sometimes they may be having a very difficult time probably at work that drains all their energy. By the time they get home they are caput! It’s like a soldier running from one General to another, the body just gives up. He can only manage a feeble salute or none at all. It’s worse when his wife nags him or belittles his efforts. I know a woman, who was seriously lacking in wisdom, who sarcastically asked her husband, “If men were told to stand up to be counted, would you stand?” That’s one of the most savage blows a woman can deal her man.


Treatment of ED depends on it’s cause. I will not try to go into it because it should be tailored to each individual. Sometimes it will involve a lifestyle change, sometimes medication, sometimes a break from work, sometimes just a second honeymoon! Hey! Did you hear that last one??

Mama, oh Mamaaaa…


By Dr Lucianna


The helplessness of a doctor


The other day my brother asked me, “If you were to do it all over again, would you allow mom to undergo radiotherapy? Was it really necessary?” I looked him straight in the eye and without hesitation answered in the affirmative. Then he asked me, “why, with all this suffering?” It’s a question I had asked myself several times the first one or two years so I had a ready answer. So I gave it to him, “because if we hadn’t done it, we would have buried her long ago…” that’s a direct translation from my mother tongue, “tungiamuthikire tene”. Then I asked him, “what would you rather have, mom under the soil or mom in this state?” His answer was as expected, “mom in this state”. Radiotherapy is one of the most destructive modes of treatment. After the original disease is conquered, patients are left suffering from the effects of treatment. As radiation kills cancer cells, it does not spare the normal ones. Fortunately, the body is able to slowly repair itself.


Nobody really knows what causes cancer. There are several factors associated with the different types of cancer but even people not exposed to these factors can and do get cancer. I know a man who never tasted alcohol in his life except perhaps Holy Communion wine, and yet he died from cancer of the liver. One characteristic of this nasty disease is that it has a way of hiding in the body and staying undetected until it’s too late. It’s also terrible in that it is painless in the early stages. You see, pain is good, it’s a warning sign. Most diseases give us pain as a warning sign. Cancer doesn’t, until it’s too late to do anything. What is cancer? It is an abnormal multiplication of cells in an organ, cells that are incapable of performing the functions of that organ. As the abnormal cells multiply they squash the normal cells of the particular organ. The organ gets distorted because these abnormal cells are not subject to the control mechanisms of the body. The organ eventually fails. For example, if it’s in the lungs, breathing gets compromised and the patient dies from respiratory failure. If it’s the stomach, woe unto you! You’ll just loose your appetite and realise too late that a monster has taken over your stomach. If it’s leukaemia…


One particualary annoying thing about cancer is that it doesn’t sit in one place, it spreads. It will spread to the adjacent organs and compromise them. It will flow in the blood stream and go to distant organs and wreak havoc. It will also follow the lymphatic system and get to distant organs. Remember biology? The body has what we call lymph nodes. Those things that swell in the groin when you injure your foot, or in the armpit when you hurt your hands, or in the throat when you get an infection. Most people know of tonsils. On a light note I remember treating a man in one of the hospitals in Nairobi. He told me his “tonsils” were swollen as he put his hand in the armpit to show me. In my mother tongue all lymph nodes are called “ngai” pronounced “guy”. A liquid called lymph flows in the vessels connecting the lymph nodes. Cancer cells use this to spread.

Cancer treatment depends on the type of cancer, the stage of development of the cancer and the organ affected. If caught early surgery is very helpful. Usually the doctors will not know whether some cells have already left the original site and have started to spread. If there’s the slightest chance of such a likelyhood medicines are given to kill whatever cells may have escaped. This is “chemotherapy”. If the particular cancer normally spreads locally, radiotherapy is done. It is done to the original site and the possible areas of direct spread, like the lymph nodes. Sometimes the different modes of treatment are combined. It all depends on the type, the site and the stage of the disease.


It is adviceable to go for routine screening of the commonest cancers; i.e. cancer of the cervix, cancer of the breast in both men and women and cancer of the prostate. Check ups and a high index of suspision have saved a lot of lives. My mom was saved by a high index of suspision. She felt this small, painless lesion in her mouth that refused to go away. The dentist tried different treatments two or three times but it didn’t help. Most people would have ignored it because it was small and painless, but not my mom! She kept going back. The dentist decided to do a biopsy. This is a minor surgical procedure where a specimen is cut out and sent to the lab for analysis. In this case she cut out the whole offending lesion because it was very small. At the appointed time she went to check on her results.

Mom didn’t want to receive the results herself. Like most moms would do, she told the dentist her daughter was a doctor and could she tell her the results?? I was only a phone call away, 600 km of air separating us. The dentist was a young lady and she forgot that I was a daughter first and then a doctor! She dumped the whole raw weight on me! Unceremoniously! No preliminaries! Your mother has a POORLY DIFFERENTIATED SQUAMOUS CELL CARCINOMA! BOMBSHELL! I felt a sudden pressure rise inside my head. I felt like it was going to burst. I didn’t know what to do. I was sitting in my office and how does one sit still in the office after receiving their mother’s death sentence? I just remember darting out. The next thing I knew I was screaming in my car as I drove like crazy to the one safe place…HOME! Mamaa… oh mamaa!! Why God, oh why? On that drive I begged for her life, I pleaded… Oh how I pleaded! I’ve never felt so helpless in my life. Here I was, a doctor and yet so helpless. I was reduced to a little girl. Sometimes it’s easier being just a layman because you believe that the doctors will perform some impossible miracle.


I brought her to live with me. 4½ years down the line, she is slowly, painfully slowly recovering from the effects of radiotherapy. Some damage though, is permanent…

Woi Mami witu… Mama mia… Mueter… Maman… Aiti… Mamaaaa!

Saved by pacemaker…


By Dr Lucianna


Threatened by corona


There’s a dirty, nasty little organism called corona virus. It’s a shame it has such a beautiful name! Corona means crown. It comes in fancy shapes and sizes and variants. The variants have beautiful names from the Greek alphabet; like delta and omicron; pronounced oh-my-cron. It doesn’t really need any introductions because the whole world knows it. It was brought to us by the Chinese from a lab in Wuhan city. It causes a disease called “covid19”, that’s an acronym for corona virus disease discovered in the year of our Lord 2019. CO-VI-D-19. Take a little pause…


Let’s talk about an elderly man closely related to me. He had an ailing heart. He required a surgical procedure to insert a pacemaker right into the heart. When I mention pacemaker the mind immediately switches to Eliud Kipchoge; the man who defied limitations. He told us that no man is limited. I don’t know exactly what he meant by that because we are so limited in so many areas by so many things, including but not limited to our inabilities. Anyway, Kipchoge set out to prove that what men thought impossible was achievable. He set out to run the marathon in under 2 hours. Mind you, he holds the world marathon title at a little over 2hrs. He is the best marathoner of all time. I remember I was glued to the screen, excited like a little kid! And my, oh my, as he approached the ribbon, and zoomed past his pacemakers out running them, I was on my feet, screaming and cheering him on. He must have heard me cos he looked me straight in the eye as he threw his arms up in elation. We did it! We did it! I felt like I was in high school all over again, cheering my team. I was really talented at that! Shall we say, when it comes to cheering, this girl is not limited. Ask the old girls of Bishop Gatimu Ngandu…


I was talking about pacemakers… those men who ran alongside Kipchoge in a ring of protection. Before they could wear out with fatigue, they got replaced by others in smooth, precision transitions. These pacemakers made sure Kipchoge kept to the calculated speed and rhythm. A lot of work had gone into the preparations to make sure that Kipchoge ran steadily, neither too fast nor too slow. If he ran too slow he wouldn’t make the under-2hrs margin. If he ran too fast he would tire out and not make it at all. As long as his pacemakers kept the set pace, Kipchoge was good to go. This is exactly what a heart pacemaker does. It makes sure the heart keeps to the set pace, call it speed or rate; and that it keeps to the expected rhythm. If the heart tends to slow a bit, the pacemaker sends electrical signals to make it beat faster. It the heart tends to go off-rhythm the pacemaker helps it overcome the irregularity.


Now back to my close elderly relative who required a pacemaker. His heart was weak and not behaving too well. That is life-threatening. It was in danger of stopping suddenly, without notice resulting in sudden death. It needed a pacemaker to run the race with it. Our health services in Kenya are a bit wanting. We have all the experts we need in every imaginable field but only those patients who can afford private hospitals can access care in good time. Others have to queue for months at the government health facilities. Now my elderly relative waited his turn for several months at the Kenyatta National Hospital. You can add “Teaching and Referral” to this hospital’s name if it makes a difference to you. Finally, thank God, the surgery was done and it was successful. He finally had a pacemaker. His heart had a helpmate to run along with it in this life’s journey maintaining its speed, call it rate, and controlling it’s rhythm.


After he got home from the hospital, the whole village was excited. He was well known and well loved so a lot of well wishers came to celebrate with him and thank God with him. This was last year, 2021. The cabinet secretary for health Mutahi Kagwe, had kind of given up on his chorus, “if you treat this virus normally, it will treat you abnormally”. He had repeatedly told us not to congregate in large numbers, but who are we? We seem incapable of following simple instructions! “Please cover your nose and mouth” but we insisted we were suffocating under the face masks and took them off or wore them like necklaces. “Don’t cook for mourners at funerals”, but we bribed the chiefs and did it anyway! Who are we Kenyans? We complain that our kids are disobedient and running out of control, but they have learnt from the best. Our motto seems to be, what are rules for if you can’t break them?


Sadly, my elderly relative contracted covid19 from the very people who showered him with so much love, and so did his wife! Now the people kept off. They realised this nasty little organism was for real! It existed. So now the old man was recovering from pacemaker surgery and the ravages of covid19. The wife who would have taken care of him was also ailing. The calamity that resulted from this is that his wife succumbed… she died. A previously perfectly healthy woman… She died. He didn’t even get the privilege of burying his wife. He was still on his sick-bed!

Create your website with WordPress.com
Get started