D.V.T - THE SILENT KILLER

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This week I assigned myself the task to make a presentation about Deep Venous Thrombosis (DVT) to my colleagues in Chaaria. Its a silent killer that kills in seconds. It reminds me of the death of a popular TV personality who was found dead on her bathroom floor sometime in September. Rumors went round about the possibility of poisoning or bathroom accident because she was as fit as a fiddle but autopsy made a conclusion that she had succumbed to embolism from a DVT.

DVT is the formation of a clot in the deep veins of the limbs especially in the legs. If the clot dislodges( what we call embolism) and goes to the lungs, it causes death in seconds. I have atleast two DVT patients in the wards every month. A few succumb to embolism because they present to the hospital with breathlessness when it is too late. I have had to force some of the patients to be admitted in the hospital despite resistance. I confront them and tell them point blank that I do not want to be responsible for their deaths. It's one condition of which I put my foot down and refuse discharge against medical advice.

So how does it present? How do you know that you could be suffering from DVT? It classically starts as swelling of one leg which could be painful especially at the calf. The leg might get warm and reddened with time. Superficial veins sometimes get visible and in the extreme cases, the limb might get gangrenous or start turning blue. What are the risk factors for DVT? These are generally categorized into factors that cause Stasis of blood in the limbs, increased clotting of blood in the body and injury to major blood vessels. These include being immobile for long hours or days(especially in bedridden patients or long distance travellers), cancers which predipose to hypercoagulation of blood, trauma or fractures of limbs, recent abdomino-pelvic surgeries (e.g hysterectomy, prostatectomy, caesarean sections etc), recent bone surgeries(orthopedic surgeries), use of estrogen containing contraceptive pills, cannulation of major blood vessels of the body especially in dialysis patients,patients with diseases like nephrotic syndrome, pregnancy e.t.c. The list is endless.

Diagnosis requires color duplex ultrasound of the affected limb. This can be combined with other more complex investigations. Treatment requires compulsory hospitalization for anticoagulation and strict follow up in the months that follow. ( I will not bore you with the specific treatment modalities). So if you develop swelling of one leg no matter how innocent it looks, run to the hospital before death runs to you. It's not proper to ignore. We should also avoid sitting or lying down for long hours. This targets everybody including those who sit in offices for long hours, long distance travellers or frequent air-travellers. Those who are in hospital and having undergone surgeries should learn to ambulate early and walk around. How many times have we heard of stable patients collapsing on discharge or collapsing in the toilet just before discharge? (Why is the toilet the most common place for death in DVT patients? Food for thought!!!!). Or how many healthy people have we heard found dead after a perfectly normal daily activity.

Let's be careful. Let's spread the information and learn to take any swelling of one limb seriously. Let us also get active. That simple standing from your chair and going to the dispenser in the office could save you from death. The frequent air travellers should learn to walk to and fro the aeroplane isles at-least 3 times in the flight (DVT is also called the 'pilots disease'). I hope that this week's post will help someone out there. Have a great start to February!!!! BEWARE!!!!! Let's be alert.

CANCER 2

Following the previous week's post on cancers, I did get many responses, comments, suggestions, cancer stories that made me cry  e.t.c. Of note was a message from 'Brian'(not his real name), one of my cancer patients aged 21. He messaged to ask why I had not included his story in the post. I had actually written about him but deleted the paragraph the last minute because I needed his consent first. I met Brian in April-May 2014. By that time I was working at Meru Hospital and would only come to Chaaria during my free time. He came for his histopathology report for stony hard masses that had developed in his abdomen. The report read  'Desmoplastic Small Round Cell Tumor'. What was that? I had never heard of such a name. There is a chance that it was somewhere underlined or highlighted in my pathology textbooks and notebooks during medical school but I couldn't remember what it was. Are these not things we read just to pass exams and quickly forget about them because they are rare? Was it malignant or benign? What was it's nature? I dashed to my boss's office where we have a mini-library. I couldn't get it in the first book I checked and almost immediately my boss and our most senior surgeon Dr. Pietro walked in and I informed them of my dilemma. They informed me that it's a rare type of soft tissue sarcoma that mostly affects males at the adolescent age or early 20s. It mostly presents as abdominal masses of no known origin. The sarcoma responds very well to chemotherapy. Armed with this information, I dashed back to my office and explained what I had just learned to him. He had not come with his parents so i counseled him the best I could like a younger brother. Brian was surprised but he had the motivation to seek specialist help without delay. I wrote his referral letter and took down his number because I wanted to follow up. He was very brave and I could see determination on his face  to conquer this illness. I naturally expected review in KNH after a few months but because of his drive and enthusiasm, Brian was able to get booked for chemotherapy without delay. We keep in touch at least once a week and he is well, almost done with Chemotherapy. He is responding very well to treatment but he tells me that sometimes he gets very weak after Chemo sessions. The journey he says, has not been easy. There are times he messages me that his white blood cells get down and he has to boost them with Neupogen, there are times his Chemo drugs run out of stock in KNH and he has to wait longer for his sessions, during the KNH doctor's strike he had problems getting doctors to administer his chemo,he has lost weight etc. Brian gives me the motivation to face life positively. He is doing very well and responding well to Chemo.  He tells me that he is the first person in his family to have cancer but he has taken it positively. He tells that the KNH oncology clinic is always flooded with patients and he only gets seen in the afternoon despite coming in very early due to the long queues.  Brian's is a success story,he says his life has not changed. He refused to let cancer change his life.  I'm praying hard he becomes cancer-free and becomes a motivation to other cancer patients.  I hope we all learn from him. I'm so glad our paths crossed and he is truly a source of inspiration.


   The next person who messaged me about her story validated something that a surgeon had asked me in theatre one day. We were doing a thyroid lumpectomy and the  surgeon asked me if we had done cytology or needle-biopsy of the thyroid lump. I had not thought about it because we were going to send the removed lump for histopathology anyway and thyroid cancer is extremely rare in our setting. I have never seen any case of thyroid cancer since i graduated. All our histopathology reports gladly come back negative for malignancy.  The incidence in Africa is  1 case out of 200,000 population per year. This friend messaged me that she was touched after reading my post. She had lost a close relation to Thyroid Cancer in the age-gap of early 30s last year. It was a thyroid lump that was never investigated properly and in the end the lady lost the battle to metastatic thyroid cancer. It's a mistake that all of us in the society and us doctors make by presuming that any thyroid swelling or Goitre is benign. The message made me think deeply and conclude that all thyroid swelling must be biopsied before surgery and still sent for histopathology after surgery . The cancer might be very rare in Africa but that one life lost is a lost generation, a lost parent, child, sibling, friend e.t.c.  We should not take chances with thyroid swellings no matter how rare the cancer is.


 This week, we had a class by Fr. Gaido about Esophageal cancers. He mentioned to us that it was so common among men from the North to the extent that any male patient from the North presenting with painful or difficulty in swallowing is almost always esophageal cancer . I have had arguments with some of them when I recommend OGD, they insist it's not necessary only for most of them to turn out to be cancer.  We discussed why it was a common disease in that area of the country and especially on men. Is it because of taking very hot burning tea? Does the resulting corrosive injury lead to cancer? Women only get to take the tea after the men have had their share so their tea is usually cold by then. Is this why the cancer hardly occurs among women of the same region? Think about it and tell me. 'Tafakari hayo.'  I'm considering doing a research on this.  Similarly, Liver Cancers are so common among Kambas especially those from drier parts of the region. Is it because of aflatoxins from poorly stored maize? Have a good week ahead. I pray that the blog-posts impact positively on each reader's life. 

THE CANCER MENACE IN THE 20s-30s AGE-GROUP

  It's Monday the 19th January 2015 at 5.30p.m and I'm lazing on my couch trying to review something. My mum calls me and tells me that she has not seen my blog-post for the week. I told her that I didn't feel like writing because my last two posts did not get much reads. She reminded me that that's the life of a writer, there are high and low seasons. I got motivated, dropped the book I was reading and started writing. I had so much to share, I could feel it boiling up in me. 

  Last week was a very tiring week for me. The magnitude of the diseases I saw was too heavy for me to bear. This is because it mostly involved my age-mates. Let me brand the week's experiences 'cancers affecting my agemates' We diagnosed two breast cancers in    girls old enough to be my age-mates if not younger . One of the girls allowed me to share her story. The little girl in her early 20s came in with complaints of a breast lump.  On the first half of the history, I automatically presumed it's the harmless Fibroadenoma mostly encountered in late teens and early twenties.  I thought so because of her age.  Examination of the breast and further analysis of her previous medical notes made me conclude the worst. It was breast cancer !!! Yes, at that young age. We went ahead and recommended a mastectomy which was done later in the week . I was almost in tears. Here was girl, younger than me and having to bear such sad news. Infact, she is the age of my younger sister. I couldn't imagine my sister going through that, she is too young; she is a baby. Despite being a medic and having the knowledge , I have always intentionally  presumed that breast-cancer is a disease of the 40s and above . But here was a girl, barely past her teenage-hood and diagnosed with it. I don't remember the last time I did a self breast examination, are we too ignorant and presumptive? We diagnosed her cancer at stage 3. Is there a chance that it would have been diagnosed much earlier? How often do women from age 13 examine themselves or report any minor anomaly? A Breast cancer relapse in a patient in her 30s who had fast become a friend topped up my sorrows for the week. We had successfully done her mastectomy two months back but she couldn't access chemotherapy/radiotherapy because of the inadequacy of such facilities to the poor patients in the country. Sometimes, you cannot avoid taking patient issues too personally. This reminds me of cases of three women, all at age 30 who came to the hospital at different times with  complaints of heavy persistent menstrual periods. We all thought it was Dysfunctional Uterine Bleeding(D.U.B), fibroids or the side effect of contraceptives. Ultrasounds confirmed the worst. They all had 'cauliflower' masses arising from the cervix. On vaginal examination, they had fungating,friable and bleeding cervical masses. (We should have done the examination before the ultra-sounds but African women are hesitant to have vaginal examinations during menstrual periods). They had Cancer of the Cervix. They were shell shocked. They had come for simple medication to stop the 'periods,' only for them to learn that it was not periods.  We did a biopsy and histopathology confirmed all the three cases. They had come to pick the results last week. I had to endure the heavy task of breaking the news and giving advise on what to do next. One of the lady stared at me in shock and asked me to slowly repeat what I had been saying because she had switched off completely in panic and fear. To her, it was like a death sentence. All three are exactly 2 years older than me, with dreams and ambitions, but cancer had come to interfere with their good life. I could feel their pain. None of them had the history of cancer in their families, they had started the history!  When did you last have a pap-smear done? It could happen to anyone. It knows no age group and it doesn't matter that you don't have a family history. 


 There was pancreatic cancer diagnosed on a 29 year old. We all presumed it was distal stomach cancer after a series of investigations and had him set for a partial gastrectomy (removal of half the stomach). In theatre we sadly learned that it was  pancreatic cancer. An inoperable cancer. It's what claimed Steve Jobs' life ; the founder of Apple Inc. It was very sad! Wasn't cancer a disease of the west?? I have learned to be careful. I have stopped taking things for granted. I have stopped presuming that cancer is a disease of the old timers. Each time I'm tempted to skip eating fruits and vegetables, I remember my two advanced colon cancer patients who died at age 35 and 38 respectively here in Chaaria. Each time any of my family member presents with acid regurgitation I treat them promptly to avoid barrett metaplasia and consequently cancer of the esophagus. Each time a patient comes in with a persistent lymph-node enlargement I quickly advise on a lymph-node biopsy because hey, I have already seen more than 5 lymphomas this year. Each time I hear anyone complain of bloody urine, I quickly dash to do an ultrasound; haven't we diagnosed bladder cancer on girls in their twenties? I associated almost everything with cancer last week. It got to my head so much, I could have easily misdiagnosed simple TB for Lung-cancer. I didn't want to presume anything. It's good for all of us to be on the look-out. A small ailment could end up being a horrific experience if not followed up early. Most cancers are also preventable by making simple lifestyle modifications.    

 There you have it. I hope that we will all be on the alert and stop taking things for granted.  I pray that all cancer patients receive the care they deserve and get on with their lives . I hope that a time is coming when cancers will be detected timely and completely cured. I mostly pray a time is coming when all cancers will be preventable.  P.S: Cottolengo Mission Hospital should be made a cancer diagnostic centre. We diagnose at least 15-20 cancer patients every week. The top on the list are the many esophageal and stomach cancers, the many liver cancers mostly from Tseikuru, prostate cancers , colon cancer once in a while, nasopharyngeal tumors, occasional brain tumors, the many lymphomas,cancers of the head of pancreas has become the first differential diagnosis in patients with obstructive jaundice. The list is endless.

AFRICAN TRADITIONAL MEDICINE

It's the 1st of January 2015 at around 8.00a.m and I'm lazing on my bed in Machakos. My mum walks in to wake me up and immediately after wishing her a happy new year I ask her if there are any PPI's (antacids) in the house. I was bloated, having serious GERD, hyperacidity and was convinced that I must have caught H-pylori. I happened to be sharing my room with my grandmother Mwaitu who had come to visit us. Immediately grandma heard me ask about antacids she told me that I was definitely having KAVASO and she would 'lift' it for me. KAVASO is  a Kamba word for epigastric pain and hyperacidity  believed to be caused by retraction of the sternum and subcostal region mostly associated with stress. It can be lifted with oily warm hands or using a cup heated up to create a vacuum. I don't really connect the pathophysiology behind KAVASO and hyperacidity so I naturally refused to have it 'lifted.' After coaxing and explanation, I agreed to have the 'procedure' done just to please grandma.  One has to be Nill Per Oral (N.P.O) ; i was all set because I had just woken up. She rubbed glycerine on her palms and the painful exercise started. She dug her fingers deep behind my subcostal region and sternum and literally lifted my rib cage. It was very painful (there was no anaethesia used) and I was screaming. She told me that I was a terrible patient and had to learn to endure pain. She went ahead and made 'intra-op finding' of my KAVASO being 'swollen' and that I would need 'post-op' care in form of bitter herbs to be taken once daily for 3 days. I decided to faithfully take the concotion out of curiosity.  I still couldn't make any connection between the rib-cage and hyperacidity. The procedure ended well and we went to have breakfast with the family. There was alot of feasting during the day and the days that followed,   spicy food, nyama choma, fizzy drinks and generally unhealthy eating. I did not get any hyperacidity or epigastric pain despite the sinful feeding. Did grandma's treatment work? What's the medical connection and pathophysiology of KAVASO as an illness ? I don't know!! I probably need to do a research on this, formulate a hypothesis and see if there's any explanation; who knows, it could be a new medical discovery.   

 The previous day, a heavily  pregnant neighbour came in and told us that she had breech presentation(legs first) at 30weeks discovered on examination and on ultrasound. I did Leopold's Monouver on her and confirmed the diagnosis. I reassured her that it would be well  but  advised her  that if the baby remained in such a position at 38 weeks then she should opt for an elective caesarean section.  My grandma jumped in and told us that the baby could be turned traditionally to cephalic presentation( head down). I needed to know more about it and she told me that she had done the procedure to several women successfully over the last 40 years . My own sister was a breech and was turned to cephalic presentation at 40weeks just 4 days before she was delivered normally and without any complications . This correlates perfectly with an obstetrics manouver called EXTERNAL CEPHALIC VERSION. After explaining the traditional procedure to me, I realized that it was exactly as explained in Obstetric text books.  It is known and accepted in modern medicine but not widely practised now due to the complications that may occur; some parts of Europe and America still practise it but under strict ultrasound monitoring. We got talking more and I realized that my own style of doing obstetrics examination was almost similar as my grandma's. She told me that she had even done INTERNAL CEPHALIC VERSIONS (through the vagina) successfully for transverse  and oblique presentations that had come in labour mostly during the colonial era . There were stories of successful 'incubations' for pre-term and low birth weight babies using banana leaves and warm ash under strict controlled temperatures those many years back. It was a very interesting talk and i agree that probably the only thing our wise old women didn't know was how to perform caesarean sections ( I should probably invite grandma to theatre one day). We concluded that indeed the external cephalic version is a manoouver that could be done but we expounded on the possible complications, how they present and what to do in the event that they occur.    


  When I had mumps in childhood at 9 years, I was successfully managed by my grandma. We had an adventurous way of managing it that was well known by the kids in the neighbourhood.   She took me to a river very early in the morning at around 6.00a.m . Calabash derived ornaments were hang on my ears and we sang and danced a known 'mumps song' in  Kikamba while facing a tree called KIVUTI. 'Kivuti mbunye ngumbu, na tata ndae ngumbu, na mwaitu ndae ngumbu' (Kivuti remove my mumps, father did not have mumps, mother did not have mumps). We then hang the calabash ornaments on the tree branches and I was told to run home straight without looking back or talking to anyone on the way . The mumps would apparently be 'transferred' to the tree. In just one day I was totally mumps-free and back to school. As a medical doctor now, I try to give a medical meaning to this traditional treatment and I realize that it's probably all in the mind. Mumps being a viral illness is self-limiting so it was going to heal without treatment anyway. I only give paracetamol and recommend oral rehydration to kids who present in my office with mumps and reassure them that it would heal on it's own. I however give special consideration to male children just incase they get orchitis (testicles inflammation). My own children will undergo both traditional and modern treatment of mumps to get a feel of their culture and customs.

 I can go on and on about experiences in my childhood. For instance Mwaitu was my 'dentist' as I grew up and my teeth are perfectly aligned (a beauty model would be jealous). She would fill my cavities with raw pawpaw pulp and the 'fillings' have remained intact for over two decades. A septic leg wound resistant to antiobiotics was successfully treated using fresh Aloe-Vera juice and it completely healed with no scar.    There you have it, should Traditional African Medicine be mixed with modern medical practices? You tell me and feel free to share your thoughts and experiences. My drive to study medicine was highly influenced by my two maternal grandmothers;  probably it's a gift that has been passed down but in form of modern medicine.