WHEN I FOLLOWED MY HUNCH AND SAVED A PATIENT

 Just before Christmas, a daughter to a patient I had treated in 2022 looked for me . She came carrying a huge banana(that my family enjoyed thoroughly over Xmas week) . She wondered if I could remember her mother's history because she needed some reports and pre-authorization forms for a follow-up MRI written. I had seen them back when I worked in a public facility in Imenti South so all their documents were at the facility . How can I forget Madam Zulekha's history(not her real name) ? It was fresh in my mind to the finer details. She was surprised and reminded me that their mother will forever be grateful to me for diagnosing her rare cancer in Stage 1A and for a timely focused referral and care . She was currently in remission and living her life fully.

Zulekha and her daughter Hawa came to my then busy Wednesday public clinic.  A Clinical Officer in our facility had told them that the facility had since acquired a passionate gynaecologist. They had come in all the way from Embu. She was then 69 years old , had an abnormal pap smear report with a high risk precancerous lesion and wanted to know the way forward - a simple hysterectomy(uterus removal ) had been rightfully recommended by another gyanecologist . I examined her ; the cervix looked quite flushed up into the uterus due to menopause and it had some mild inflammation changes .A simple uterus-saving procedure called LEEP wasn’t an option for her due to the nature of the cervix with age. Removal of the uterus was the way to go.  Before I booked them for surgery , I noticed that their latest ultrasound had commented on a small vascular area on her uterine lining on colour doppler ; the lesion was about 4mm in size. It was an otherwise normal ultrasound but this small microscopic lesion was noted in the body of the report . The images showed a tiny drop of a bright part of the uterus lining . A very vascular area means a small part with an abnormally high blood supply that brightens up on an ultrasound setting called doppler. The sonographer who did the ultrasound my friend Enid swears that she couldn't remember doing the colour study and doesn't know what prompted her to do it ; possibly a small irregularity or lack of smoothness on the lining . I decided that I wasn't going to ignore this .  A colleague told me that I was overthinking; the lesion was so tiny and she didn't have any endometrial cancer signs and symptoms . My made was made up ; I wasn't going to do her hysterectomy before confirming what that 4mm lesion was - imagine 4mm  -how small ? I didn't have access to a pipelle instrument that can be used to biopsy the uterus lining in the clinic . I booked them for a D&C for biopsy purposes . We did the procedure the following day and sent the samples for histopathology . Thankfully her daughter Hawa was very supportive and respected my decision to take the long route. I promised them that I would proactively follow-up the case . It’s notoriously common for tissue samples to be lost in most government facilities- patients wait for months for reports , others die before they can have a diagnosis . I killed this bureaucracy during my time at the public facility by creating public-private partnerships with two top pathology centers. The patients would pay up directly to these centres , they would pick the well preserved samples every Thursday and they would relay the results within 6 days before the following Wednesday clinic .Due to numbers , I also negotiated favorable prices matching GOK rates . I was stoned a bit for this but the system worked and we never lost any patient to follow-up. Imagine first contact with a client on a Wednesday and discussion  of confirmed diagnosis and treatment options by the next clinic? Oh , I miss that facility and the pathology systems I set up . I believe that a patient in public is not inferior to a top client in the private sector - we are all equal . 

6 days later I get the results on my email . Zulekha had a very rare form of uterine cancer - a squamous cell carcinoma  - of the uterus . A very rare incidence of that type of cancer being seen on the uterine lining- it’s mostly seen elsewhere like the cervix or the skin. Imagine a 4mm spot ending up to be a 1 in 100,000 diagnosis ; what were the chances ? By 1996, only 58 cases had been reported of the cancer world wide - probably one of less than 5 known cases in Kenya to date . I quickly called Hawa and asked her to bring the mum we talk . The type of surgery she needed was beyond my scope because it would involve deeper dissection of lymph-nodes. It’s a cancer that can be extremely aggressive if not managed properly from the beginning . This would require a skilled Gyane-Oncologist to perform the surgery. My mentors tell me that one of the attributes of a good surgeon it to know when NOT to operate. I ordered an MRI and Chest CT-Scan to stage her and gladly she was STAGE 1A disease ; right at the beginning of the illness . I made some calls to Kenyatta National Hospital(KNH) and the team was enthusiastic to have her ; this was a rare disease type . They kept asking me how I picked it . Who are you daktari? I was tempted to answer them how my namesake and owner of my name , my late great-grandmother used to answer; 'I AM KHADIJA MBENEKA; DAUGHTER AND QUEEN OF THE MOUNTAINS! 😀😀😀'. A doctor there encouraged me to apply and join their Fellowship in GyaneOncology training program; he was impressed by my keen eye and interest . 

Zulekha was attended to promptly, she didn’t have to wait for the notorious KNH queue m, her surgery and follow-up oncology care was successfully done and she was fully confirmed to be Stage 1A disease of the exact type of cancer we had diagnosed. She made a full recovery and was due for her 2 year review this time when I was seeing them in 2024.

Had I not followed my hunch , I would have done a simple hysterectomy on Zulekha for the cervix pre-cancerous lesion and in the process potentially upstage her endometrial cancer . I can't thank Enid enough for picking up the microscopic lesion on ultrasound though she can't remember it . I'm reminded to always follow my gut and re-confirm any science deviations above all things to give my patients best care . There is no need to rush and in the end cause more harm than good . The daughter remains a star in my eyes , she has walked the journey with her mother without complaining and following all steps as directed without delays . 

We wish Zulekha a long and fruitful life with zero recurrences. Amen 

OF MIRACLES IN MY PRACTICE IN 2024

 

OF MIRACLES IN MY PRACTICE IN 2024

Early December 2024, a patient walks to my clinic as a referral from a former colleague . Let’s call her Juliet . She is light skinned but I quickly I notice that she is quite pale and has a belly bump. I kick off my essential history taking ; she is clearly not pregnant . She tells me that she had been bleeding endlessly . A thorough Gynecological examination and I notice that her uterus is quite big corresponding to a 6 month pregnancy . Cervix looks smart ; I concurrently do a pap smear while I’m there, so now I review any prior imaging she may have had. A prior ultrasound by a senior radiologist reveals that she has a large complex suspicious endometrial mass pushing and thinning uterine muscle walls ( endometrium is where the baby sits) . All alarms ring in my head - this could be a malignancy. Her blood hemoglobin level is a mere 5g/dl(normal is above 12). I wonder if to biopsy her in the clinic using a Pipelle ( a small plastic vacuum tube that is able to get uterine tissue samples with no need to anaesthesia ) or do I just take her in to theatre for diagnostic curettage . What if she bleeds out in the office; nitajitetea nikiwa upande gani ? I alert theatre , send insurance pre-authorization but theatre team alerts me that they wouldn’t allow me in with such crazy anemia; I agree. So we postpone for a week as we struggle to get her transfused ; blood availability is a nightmare when schools are closed. I’m disturbed in the week and I keep wondering if I’m indeed dealing with a very aggressive cancer called leomyosarcoma .  

Biopsy day comes and goes . I thoroughly curettage(kwangura) that uterine lining to get as much tissue as possible . Luckily bleeding is manageable. So we sent the samples to the pathologist, I discharge the patient and we wait . I keep bugging the pathology team ; I need those results in less than a week . Results come back as——drums rolling —— NON-DIAGNOSTIC . Ala !!! I took so much sample literally filling a tin ; how can it be just blood and necrotic tissue that couldn’t show anything meaningful?  The last patient I treated who had such results ended up with a LEOMYOSARCOMA after the entire uterus was sent to analysis - infact my mentor tells me that any uterine tumor you sample well and comes back non-diagnostic is a sarcoma unless proven otherwise due to the very necrotic nature of the malignancy. So I call in the patient , give her the results and we plan the main surgery . This time I notice that  she is pale again - we were back to a  Hb of 6g/dl after she bled heavily in the week we were awaiting results . This further supports my theory that we were dealing with something very ugly . It’s back to transfusion again and hustling for blood . I plan her surgery for a free saturday - I needed all my focus on her . I wasn’t on call so this would be perfect . God had His other plans . As I ran a busy Friday clinic ,  the nursing manager came storming into the clinic . ‘Daktari , Juliet has been transfused adequately but she has started pouring out heavily again ; her bedsheets are soaked and so we have to go in now’ - we had only one extra unit of blood . Goodness!!! I alert the clinic patients that I had to leave and would be back in not less than 4 hours . I realize I'm going in for a very rough case and in emergency so I seek blessings of one of my mentors in gyane-oncology and he tells me my do’s and don’ts but of importance he tells me that he is confident that I could handle this and that there was really no need to refer further and frustrate the patient . I call a fellow young  millennial Gynaecologist friend - I’m like ‘Bro, unataka kufanya tizi? I have an ugly interesting case starting in 40 minutes.’ He is 45 kilometers away and he tells me that he was coming . I have learned to develop a strong team and network of clinical friends , to jump in when they call me and to involve them in interesting cases too . A non-envious symbiotic relationship - we don’t ask each other for money - we just jump in and help each other . When they call me too I drop everything and run. We consult each other widely too for our patients for second opinions. 

Surgery starts !! Weh !!! Weh again !!! Ugly surgery . Uterus is a bag of boggy tissue and huge . We rush the surgery as a team to avoid more bleeding. We finish removing the uterus and we are debating about removing the ovaries . Juliet is only 39 ; why do we want to send her to a premature ugly menopause ? But again what if the cancer is already spread microscopically to the ovaries . I’m the lead surgeon so it’s my call . I ask them to open the removed uterus we see the content in the endometrium - ugly tumor - but to me it’s a book classical for a leomyosarcoma. Removing  ovaries has no scientific role in managing a leomyosarcoma. We debate some more . I ask someone to call my mentors on loud speaker after sending them WhatsApp images of the tumor and they agree with me not to touch the ovaries because it looks like a leomyosarcoma; however they remind me to chomoka with the omentum (a bag of fat that covers intestines) . She is too young to battle cancer care plus battle surgical menopause . We keep the ovaries and finish up the surgery . Did I tell you that we injured the  bladder in the process due to the invasion of the mass to the nearby organs? The bladder is a very forgiving organ ; you identify the damage in time and repair it well and it heals very well with no issues but you must retain a urine catheter for 14 days . 

Surgery ends well in 4 hours . I return to clinic and find loyalists still waiting for me ; this time it’s 7pm. I run a quick one and go back to check my patient in recovery before I exit . She was awake, a bit drowsy but the first thing she tells me is ‘Daktari asante , I’m alive and I’ll never bleed again’. Day made !!

We carry on with our lives , she goes home happy with her urine catheter and we wait for final histology report . It’s Christmas now and we are alerted that results will delay by 2 weeks . She recovers smoothly, catheter is removed and she is happy. A small part of me still wonders if retaining the ovaries could worsen her disease prognosis but in the worst case scenario , I would involve a colleague and remove them laparoscopically if we had to get to that . 

Fast forward to 2nd week of January and I call in for her results - I want her to start chemotherapy without delays . Results are relayed to my email - no evidence of cancer . Ala !!  I call my Gynaecology colleague who assisted in theatre  and he also agrees that there must be a mistake . I look for the contact of the reporting pathologist in Nairobi and tell him that he must have mixed the samples . He re-confirms and tells me that he will analyze afresh at no extra cost . I even send him pictures we took in theatre so that he understands the gravity of things. I tell him to take his time . A week goes back and he calls me again -‘Doc I can assure that there is no evidence of any cancer - we have rechecked 3 of us , it’s your patient’s sample- it’s was a very rare type of vascular , necrotic Leiomyoma(fibroid) with bizarre features .’ I jump in excitement for the patient . I call her and relay the good news on phone ; I just couldn’t wait for a clinic visit . She cries on phone and gives praise . She is happy ; very happy . I tell her that I felt like this was a miracle ; I was 95% sure that it was cancerous but Mungu ni nani . What a way to start my year 🙏; and yoh I was glad that I didn’t remove her ovaries! 

P. s I am a very passionate young doctor and I make sure I follow each and every case to the very end -an emotionally draining trait but oh so fulfilling and a win to the patients . 

THE DAY I REMOVED MY BRA IN THEATRE

 THE DAY I REMOVED MY BRA IN THEATRE

So it was a lovely Monday in 2024. I had a major surgery in the afternoon ; surgery to remove Fibroids . This was a repeat surgery and the fibroids were huge . The patient in her early 40s had no child and the plan was to preserve the uterus by all means but I had to face the reality and deeply counsel the patient to consent for a hysterectomy(removal of uterus) if things went south . When I'm met with the decision to preserve the uterus or the life of the patient , I would choose the life at all times - what’s the use of a uterus on a dead body ? These are rare  life threatening scenarios but they do happen . She promptly understood and signed for a possible hysterectomy. We were well prepared, she had been  transfused and optimized and we had 4 extra units of blood ready at standby and our very strong theatre team . 

Remember I mentioned that it was a repeat surgery; she had had a similar surgery a few years ago but the fibroids recurred - we encountered horrible adhesions as we started . The small intestine was plastered on the uterus and tubes and I had to be very meticulous to avoid injuring the bowel . This took me close to an hour including very careful repair of the bruised gut serosa(outer covering of intestine) . Thankfully the bowel wall was intact . The bladder was  also on my way and I separated it very carefully. Uterus was huge and totally distorted by the very large fibroid balls ; a number were very low towards the cervix and believe it or not one was attached deep into the left cardinal ligament (lowest deep supports of a uterus )- I had to clue how I would remove it and suture the fibroid bed . My assistant warned me that ‘hapa kitaumana doc , let’s just remove the uterus’. Khadija ni nani , I decided that she was childness and we would do our best to remove the fibroids and ‘reconstruct’ the uterus . This time we had already bled out a pint yet we hadn’t even touched the fibroid balls . 

So we injected vasopressin into the uterus - a drug that reduces surgical bleed . We couldn’t tie the uterus below to temporarily occlude the major vessels because the lower level was a mess . Off we started removing the fibroids . It was a blood bath .  I really wanted to save the uterus ; my team thought I was mad. This time round , more than 2 pints were down on the floor , the suction machines ,our drapes and theatre gowns  . I was determined ; we had already started transfusing at this stage . I breached the uterine cavity (where the baby sits) and the inside looked like a sac full of potatoes ; innumerous balls - hapa nikasalimu amri and accepted that I needed to quickly start removing the uterus because she was bleeding out and I wasn’t going to achieve any meaningful fibroid removal if I was to continue. If I was continue i would literally strip her entire endometrial cavity leaving her with no chance of ever conceiving and endless heavy painful menses requiring transfusions every month . So off we changed our plan and I embarked on uterus removal which was done in an extra 2 hours. Bleeding was fully arrested  and we ended our surgery after more than 4 hours of struggling . I knew that the post-op counselling was going to be brutal for the patient but hey she was alive and healthy.

As I removed my macintosh , noticed that my entire chest was soaked in blood . As I struggled with the myomectomy , I was literally hugging the uterus with my life as I dug on some deep fibroids . Blood managed to seep through mackintosh margins and my shirt was soaked . I didn’t feel a thing because I was 200% focused on the surgery and oh the adrenaline of the operation and the speed to ligate vessels and control bleeding . 

I peeped under the scrubs shirt and my bra was soaked . As a breastfeeding mother I got traumatized and disturbed . I moved to a bright room to examine myself before cleaning in the theatre female changing rooms and the blood missed my nipple by a whisker . Part of my areolar was blood stained . With the usual bites by my daughter and the active breastfeeding, I knew that I wouldn’t miss an open pore/bite on my nipple. All manner of infections crossed my mind but luckily my blood stained  skin was intact . Will I breastfeed my child ? Have I put her at risk ? What about intimacy ? My goodness !!! I didn’t know whether to celebrate the successful surgery or the danger I almost myself into by throwing my body and soul into a case .  I washed off carefully to avoid spreading the blood and gave my assistants the bra to soak in bleach . Throwing the piece of inner wear wasn’t an option because it was a favourite memorable gift from my mum . Coincidentally this was a day that my husband somehow had both our cars so he was to pick me . He knew that surgery would end latest at 7.30pm not knowing that he would have to wait longer till 10.30pm at the parking lot. All that wait and then the wife walks in without  a bra coming from a theatre with an all-men team 😝. I had to call before going down to alert him that I had a small mishap in theatre and declare that  I was bra-less 🤓. I took a picture of the bra before it got soaked in bleach and sent him. If I had a temperamental non-understanding spouse I would have probably had it rough. For a whole week I was too traumatized to breastfeed my daughter on the affected breast .

Fast forward the patient recovered well but got very affected by the news that we removed her uterus to save her life . She was bitter initially and clinics were tense but I never once opened up that our bloods almost mixed ( for lack of a better phrase) . I’m sure she wondered why I kept on ordering tripple serology tests for her with every visit ; I just needed to be sure that we were safe . So as you look at your surgical wound and criticise your surgeon , know that sometimes we risk our lives in the commitment to give our all to our patients. I always say that for every surgery we do , we almost always carry a part of each patient’s DNA home to our families . Medicine is indeed a calling ! 

P.S -This was my first macintosh accident and I have since enhanced my infection prevention measures by making sure that I wear larger fitting macintoshes and that I put my safety first all round including wearing long gyanecological gloves . I’ll be a mother and a wife for decades to come but a doctor to individuals for a few days at maximum .