Tuesday, August 12, 2014

2 in one day

I was called to the ER to see a baby with a distended baby.  As I was heading down, my mind was racing thinking of what could possibly be wrong with the kid.  I thought an infection causing an obstruction of the bowels producing the distended abdomen was going to be the most likely diagnosis.  Instead as I got to the ER, I see a little 1 month old baby, who was feeding really well, having no fevers, or pain, just had a big belly.   Mom and dad said that he was passing stool, just a little bit.  As I felt the belly, I knew we had a problem.  The belly wasn't soft, but was tight, distended, the colon was full of air.  I put my finger into the rectum to try and see if there might be a mass, and instead I felt a lot of air and lots of soft yellow stool pooled out, I had my diagnosis.
My mind went back 11 yrs, to when I was a medical student in Ghana, West Africa.  I remembered seeing an 11 yo boy who looked like he was pregnant with triplets, his belly was that big.  He had trouble passing stool his whole life as a result of Hirschsprung's disease.  I was able to assist on that surgery with the surgeon there, and still have a visual in my mind of how big his colon was. 
Thankfully, this little baby was only one month old, and although that is late by western medicine standards of making the diagnosis, for PNG that is really good.  Hirschsprung's occurs when the rectum and part of the colon don't get innervated like they should.  Something happens in the development as they are growing inside of mom to cause part of their bowel to form without nerves.  The nerves are what help us to contract and evacuate the stool inside of us.  Without the nerves working, the stool backs up and the colon gets bigger and bigger to accommodate the volume of stool that is there.  Often times they pass stool, but it is just a little, like in this kid. 
I talked to the parents and explained how we were going to need to do surgery on this little guy.  The parents were happy we could help, and so was I.  Our surgeon, Jim Radcliffe, is still recovering from his heart surgery, so for the last month, we had been without a surgeon who could've done this surgery, but last week Mike Pyle arrived to help.  Mike is a former missionary to Swaziland, and has been here numerous times covering for Jim and bringing students from Olivet here on mission trips.  Few surgeons can actually fill Jim's shoes when he is gone, but Mike can and I am so thankful that he is here.
It was 9 at night when I admitted the kid, so I waited until the morning to tell Mike about the kid.  After seeing my measles kids and adults on medical ward, I made my way to surgical ward to talk to Mike about the Hirschsprung's kid.  He told me he hadn't done one of these since residency - which was over 25 years ago, but he was willing to give it a try.  The parents were thankful they could have the surgery here (well the first part of the surgery, to relieve the obstruction by bringing the colon out to the abdominal wall where the stool will come out, a colostomy), so I prayed with them and Mike set off to finish rounds and get started on the surgeries he had already had scheduled, before reading up about Hirschsprung's at lunch.
I set off to clinic to start seeing those in our outpatient line.  About a hour later, I called for the next person and a 2 yo was carried into my room who had a huge abdomen.  I was worried about cancer or liver disease just looking at them carry the child in, but then I asked what was wrong with the kid.  They started to tell me a familiar story - the kid wasn't passing stool and hadn't been for some time.  The kid actually had had surgery about 9 months prior at another hospital, but it hadn't worked and his abdomen was just as big or bigger than it was before. 
Hirschsprung's isn't a disease that you see too often.  I have seen a handful of them since I have been here, but to have 2 in one day is really unusual.  I left the clinic to go and talk to Mike to tell him we had another one.  He was in the middle of a difficult hysterectomy and when he could stop and ask how he could help, I told him we had another one and had them put up the Xray of this little kid.  He couldn't believe it - 2 in one day, and neither could I, but he was up for the challenge. 
Thankfully, both kids have done well.  The 2 yo was more nutritionally deficient as he has had this problem for some time, so we are trying to beef him up before we send him out.  The little baby is from a remote area of PNG, the Jimi Valley, so we are trying to coordinate when he might be able to get a second surgery by a specialist in another part of the country to actually fix his problem.  I am sure thankful, that we were able to help both these kiddos and thankful that Mike was here to give us some surgical expertise that we miss when Jim isn't here.