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 .