Monday, July 20, 2009

Something I had only read about

Warning - this blog contains discussion of a medical condition - read at your own discretion It was the end of the day and Maria, our HEO - Health Extension Officer (like Physician Assistant or Nurse Practitioner), came and said she thinks she has a case of appendicitis in the ER. Ok, I finish my patient and Rebekah, new med student from New Zealand, and I go to check her. A 13 yo girl complains of 5 days of abd pain, still eating, no nausea, no fever - doesn't sound like appendicitis. On exam, she has a fullness and tenderness of her lower abdomen. On ultrasound exam, I find a large 10x10 cm mass in her pelvis, but I couldn't identify what it was, or where it was coming from. I asked her when her last period is, and she said she had never had a period. Huh. She had other signs of maturing that would make you think she should have had periods at this point. I explain to her and her mom that I needed to do a female exam. They agreed. On exam, I find a bulge of the skin covering her vagina, but no opening. When I push on the abd mass, this bulge gets bigger. She has an imperforate hymen. The hymen is the skin that covers the vaginal opening in women. Typically there is an opening in the hymen, which gets bigger as a girl matures. However, in rare instances (between 1 in 1000 and 1 in 10,000), there isn't an opening, and the blood that should come out each month in a women's period, gets trapped inside. This is something I have read about many times, but have never seen. She seemed to have a classic presentation and exam for it, which made it all the better in a medical sense. I was excited about the medical aspect of it, and was sharing it with Susan who was also in the ER. We were relooking at the ultrasound, when Jim walked in the ER. I told him what I had and Stephanie overheard and came over. I was asking Jim what we need to do, thinking when can he do this surgery, and Steph said she had done one in fellowship. Jim, to my surprise, said that we can do it. Steph was going to take the see one, do one, teach one approach and teach me how to do it. Wow - this case is getting even better, lets go for it. We got everyone and everything we needed and set off for the Minor Procedure Room. Typically one person could do this procedure with minimal help. Not so in our case. Besides myself and Steph, we had 2 nursing students (one from the US and one from PNG), one nurse, one med student, one OT person, and one nurse anaesthetist, and in the room to see this rare medical condition. With Steph's guidance, I was able to make the necessary opening in the hymen and we got out of the way as the chocolate syrup like fluid poured out of her like a fountain. As I was reading more about this later, the medical literature talks about making sure you have the most experienced gynecologist with expertise in these procedures do the surgery. I am certainly no expert in hymenotomies, or in anything, I still have much to learn. I am a missionary doctor who tries to do the best I can with the resources available, who wants to learn what I don't know, and who is trying to serve the Lord and His people in Papua New Guinea. Thankfully, her parents didn't care that I had never done it, they were just very thankful that we were able to help their daughter. Numerous times as we were doing the procedure mom thanked us and prayed God would bless us for our work. I was blessed just knowing I was helping this young girl by doing a simple procedure. Missionary medicine is great.