February 23, 2001

Dear Friends and Family:
This has been an interesting week from a medical standpoint. Mike Chupp often says that each day, he is faced with a procedure that he’s never done before. I don’t have as much variety, doing only obstetrics and gynecology, while he does general surgery on men and women, and often does neurosurgery, orthopedics, and other subspecialty work. After 30 years in my specialty, I’ve seen most everything, or so I’d thought.
The week began with the vesico-vaginal fistula repair that I reported earlier. The jury is still out on whether that was a successful venture. On alternate days post op, the patient has been sitting in a wet bed or a dry bed. We’re not sure if she is leaking around the catheter, which is to stay in for at least two weeks, or if the repair has broken down in some way. Continue to pray for Wilkister.
Monday afternoon in the Maternal Child Health Clinic [MCH], the nurses asked me to see a two-year-old who was losing stool out of her vagina. I had never seen this condition of a rectovaginal fistula in one so young, as most cases of this are in adults as the result of childbirth tearing or radiation therapy. In a pre-teen, the cause might be sexual abuse or accidental trauma. The history given by the parents was that the child had a large boil formed in the area which ruptured and broke down the dividing wall.
The healthy appearing, round-faced child began to cry as I approached her, so I guessed correctly that she had been examined before with some discomfort caused to her. Sure enough there was suture material present in the wound. The parents then explained that a doctor in Narok had attempted repair unsuccessfully the month before. That failure would make repair even more difficult. I asked Russ White for his opinion as to what would cause such an infection. He was also mystified, since the child was beyond the age of a birth defect being the cause. Unfortunately, the mystery was solved by his ordering of an HIV test which came back positive. That likely means that both healthy-appearing parents are HIV positive, as the transmission sequence is usually from prostitute to father to mother to infant at birth. That almost certainly will mean that the older five children will be orphans in the not too distant future. All who saw this beautiful child were heartbroken with the news. AIDS is an ugly, ugly disease without respect for age or social status. Many of its victims have committed no sin relative to acquiring it, but are innocently harmed by the sins of others.
Monday night I saw a woman who had induced an abortion of her third pregnancy at three months and had considerable bleeding and some infection after passing the baby. I ordered blood transfusions, antibiotics, and a visit from the chaplain. The ultrasound showed that everything had passed from the uterus by the next morning so a D & C was unnecessary. She was quiet and somewhat withdrawn the first morning after admission, but the second day she was all smiles. In the interval between she had prayed to receive Christ with Chaplain Helen Tangus and the difference in her countenance was remarkable. We have observed so many people to walk out of Tenwek Hospital with changed lives.
Tuesday, my day was spent in the operating theatre. I began by performing a cesarean section on our clinical officer, Irene Mutai. Her toxemia of pregnancy had worsened overnight and she had a severe headache and the baby had stopped moving for the past six hours. We started magnesium sulfate in the intravenous line to prevent seizures which often follow the headache and irritability of the nervous system. She had a healthy 4-lb. girl and both have done well this week.
Next was the scheduled hysterectomy for uterine fibroids [large, fibrous benign tumors]. This case was fairly routine, although we narrowly avoided entering the small intestines which were stuck to the abdominal wall from her previous surgeries. Alice is a strong Christian who offered the formal prayer before her own surgery. We always begin surgery with prayer, but it is usually the anesthetist or scrub tech that prays.
As we finished the fibroid case, I was paged to Casualty to see a single, 23-year-old woman with a strange story of one day of abdominal pain. She had no knowledge that she was pregnant. Furthermore, the 20-week baby was dead, there was lots of blood free in her abdominal cavity, her blood pressure was low, and the ultrasound technician felt there was a placenta previa. [placenta located low in the uterus blocking the cervix]. This combination of findings made absolutely no sense. The patient denied a criminal abortion. I took the patient to theatre and found tissue in the cervix which looked like decidua [the lining that forms on the uterus in response to a pregnancy and which develops quite distinctly when the pregnancy is outside the uterus]. I asked Marilyn to bring her ultrasound machine to the operating room and look again with the idea that the pregnancy wasn’t in the uterus. Sure enough, what she initially thought was a placenta previa was the entire uterus itself. The baby was outside the womb and in the abdominal cavity. We requested blood to be made available and prepared the patient for an exploratory laparotomy. An abdominal pregnancy is the rarest form of ectopic pregnancy and is often a disaster as the placenta attaches to anything it can to gain blood supply and often involves the bowel or pelvic wall as well as the outside of the uterus or even the liver. Attempts to remove the placenta are usually disastrous. It often must be left undisturbed to absorb, if possible.
As we entered the abdomen, we were met by the well formed, but dead 20-week baby, and 2500 cc of free blood [about 5 pints]. We carefully searched through the clots and blood for the placenta site. Finally, we found a different rare form of an ectopic pregnancy, which I had only seen once before at a very early stage. The uterus was malformed with one normal half-uterus on the left and a “blind horn” of a uterus on the right which did not communicate with the vagina, other than by a fistula tract. The pregnancy had no way out! As it grew, it exceeded the capacity of the stunted little pouch of a uterus and it blew open like a balloon popping, releasing the baby into the abdomen. The bleeding had stopped by itself as the blood pressure was so low, that the patient hardly bled as we made the incision. As the patient received more blood and fluid and her pressure returned to normal, her skin incision began to bleed and needed some attention. The good news medically for this patient was that we removed the blind horn and she should be able to have children in the future with the remaining left uterus. The Good News was also received with joy the next day, as the patient received Christ when she met with the chaplain.
I was tired at the end of the day. A 14 year old was in labor when I left and progressing well. During the night it became apparent that the baby was too big for her and she needed a cesarean. Afterwards, her blood pressure skyrocketed and she began having seizures. The response by the staff was swift, and with the magnesium treatment, she stabilized and has done well. Another patient who I evaluated during the night presented with abdominal pain at 32 weeks. I correctly diagnosed her preterm labor, although she delivered a stillborn baby for reasons that weren’t immediately clear. Later in the day, her pain was still severe, so the surgeons were called. They operated and removed most of her small intestines, as they had twisted upon themselves along with the large bowel which resulted in the cutting off of the blood supply. I had never seen this condition in pregnancy before. This patient’s condition is serious but not hopeless.
Wednesday was clinic day and I saw Peris, the woman who we operated on six weeks ago and were only partially able to remove her uterine tumor which has proven to be malignant. It will not likely respond to radiation or chemotherapy. We got several tests of lung and liver function to see if there was any sign of spread of the tumor. The liver tests were non-conclusive, and I will see her back in two weeks for a final decision. If we operate again, we will need more blood available [we ran out last time] and have her bowel prepared for a colostomy if necessary. Even if we’re successful in removing the entire visible tumor, the chances of long term cure are still slim because of the likelihood of microscopic spread.
Thursday began another surgical adventure day into unfamiliar waters.[literally] Rusi is a 40 something mother with fibroids in her uterus the size of a 5-month pregnancy. She, like many patients in this agricultural area, did not know her age. Since many births aren’t registered, there are no documents to show a person’s age. The best guess can be made by what year she began primary school. We estimated 41 so we hoped to conserve the ovaries. That hope was dashed when we entered the abdomen and discovered that before the fibroids developed, she had had a significant pelvic infection [PID] which made all the surfaces stick together. Combined with the distortion from the volley ball size fibroid, the anatomy told us we were in for a difficult day.
The first rule to keep in mind when faced with such distortion is “restore the normal anatomy”. This approach allows you to safeguard against injury to vital structures while removing the diseased tissues. Fibroids are normally “fun” to operate on, because they can be shelled out like the inside of a nut if necessary and they don’t invade other tissues, but rather displace the other structures to the side. This case stopped being fun really quick. The adhesions from the old PID made the tissue planes difficult and the bulk of the fibroid made it difficult to get around to the blood supply or to identify other structures. We carefully made our way around thinking we had the fibroid shelling out in the right plane when we suddenly identified what seemed to be the left ureter cut in two. The general surgeons playfully accuse the gynecologist of knowing how to do only two operations. [Cut the right ureter and cut the left ureter]. In my 30 years of operating, I had never cut the ureter in two before. [I did put a tie around one once which resolved when the suture dissolved]. With my pride injured almost as severely as the ureter, we proceeded carefully. I asked the visiting general surgeon, Billy Rucker, to come in and help with the repair. I’d read about repairing a ureter before, but had never needed to do it or even seen it done. As we explored the damage, we found that I’d cut the ureter in two different places! Fortunately it was all reparable damage, but the case ended up taking nearly six hours. I was too tired to do an elective case to attempt to restore fertility for another patient, so I postponed her surgery until the next day. I went down the hill soaked to the skin in blood [the gowns are often not much protection] and a little discouraged, but more knowledgeable in urologic surgery than before. I felt like the starting pitcher who failed to get a batter out in the first inning heading for the showers; except I was on call that night instead of getting a four day rest before the next start.
On call, I had a busy night. I saw two patients whose babies had died before labor began. The nurses asked me to come and confirm their findings with the ultrasound. One patient was the sister of our head nurse on maternity. She was having her 11th pregnancy and she has only one living child. She has had repetitive stillbirths and again it happened at 29 weeks into the pregnancy that the baby had died suddenly without warning and with no apparent cause. The other patient came in labor at term and the baby was dead, probably from umbilical cord entanglement. The sorrows that people here have to deal with on a regular basis are difficult to imagine for those who have such ready access to quality medical care. At 1 AM I did a D & C for a patient who was having a miscarriage. She had fainted from blood loss and had a head laceration as well, but she refused to have it sewn up. Then I helped the midwife with a delivery where the baby’s shoulders were stuck. Finally, I did a cesarean section for a mother who was bleeding heavily from a placenta previa [explained earlier]. I have noticed while climbing the hill at 5 AM that one can see the Big Dipper low in the sky to the northwest and the Southern Cross low near the southern horizon. Other than Orion, that’s about the extent of my astronomical observations.
Today, we completed the tuboplasty [fertility restorative operation] but I wasn’t very encouraged as the scar tissue from the old infection was so dense and the tubes pretty badly damaged. We see a lot of patients with sterility, usually from previous sexually transmitted disease. Sometimes the penalties of the mistakes of one’s youth continue to be paid throughout a lifetime.
Only a few exotic cases to report this week for the other services. The man whose face was smashed by a bolder at the rock quarry died as he developed pneumonia. Patients with a tracheostomy don’t fare well here because the suctioning equipment is reused again and again and pneumonia frequently results. Another patient with Guillan-Barre, a temporary paralysis of young people, died for the same reason. In the developed world a patient with this would usually survive, but they usually die here for lack of quality ventilator care and airway managment. A man with an arrow in his chest came in by matatu from an hour north of here. He shouldn’t have made it, but he did. Russ White has a collection of five arrowheads in a display entitled “One night on call in Casualty room”. Perhaps Russ could have saved General Custer.
Prayer Requests

I have this weekend off duty, and I think I’ll just rest up a bit. I have been reading a book that I can highly recommend entitled E.M. Bounds on Prayer by E.M. Bounds. Although it was written a hundred years ago, Bound’s timeless insights into the nature and necessity of prayer are a challenge to any Christian. Whitaker House publishes the book in paperback. A prayer request I would have is for my prayer life to be more effective. I personally struggle with a lack of fervency in prayer, as I have guarded my emotions for so long as a physician dealing with cases such as I have reported to you, that making the transition to earnest, emotional prayer is difficult.
We will possibly visit an orphanage tomorrow with Robyn Moore. She and Tammie King were regular visitors at this facility in the past. Pray that we will be an encouragement to the children and staff. And I have two invitations to preach in local churches in the near future. Details are pending, but we will seek the Lord’s leading for the arrangements and topics. Peace of mind for family at home is another request for us.
Our good friends, Dr. David and Amy Brown, are flying home tonight for a month’s visit with family. Pray for their safe travel and time at home. Fellow Tenwek missionary Faith Shingledecker is a working visitor at a hospital in Sudan for three weeks. Sudan is a war zone and we are praying for her safety. Rachel Powdrill is in the US for tests. Marge Campbell is in the hospital again for cancer treatments.
We so appreciate your prayers on our behalf. Your letters and notes of encouragement are also a great blessing. Your notes of appreciation of our letters have only encouraged us to write more often. Holler if you’ve had enough!

Paul for all the Jarretts in Kenya in Christ’s Service

Tags: