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Diagnosis Deconstructed

Diagnosis Deconstructed

The Mistaken Identity of BT

Morchi, Ravi MD

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doi: 10.1097/01.EEM.0000461016.12781.30
    His House of Hope in Yei, South Sudan.

    BT was in her 20s when I mistook her for someone I could fix.

    We were in a new country, recently declared so and replete with the requisite power struggles and tribal skirmishes. A respected bishop in town had his ear to the ground. A nod of his head would have us headed to the air strip if he felt our safety were in question.

    The hospital had 40 beds. Twenty designated for peripartum mothers. Maternal health is the cornerstone to a new community. We hope to demonstrate, in a fragile society susceptible to violent young men, the importance of women by dedicating medical services to them. That lesson incorporates into the mind of every 6-year-old boy who crosses our path. Their appreciation of women and girls shifts slightly, and hopefully that trajectory is maintained throughout their lives.

    The remaining beds were for children and non-pregnant woman. BT occupied one of these. She was distended and febrile. Her respirations were cut short because her diaphragm could not descend into her tense peritoneal cavity. Her legs were thin, and she had slight temporal wasting. Intrinsic hand and foot muscles had yet to atrophy. She was a functional but undernourished young woman.

    History. She hadn't had a bowel movement for some time. It was unclear exactly how long. Villagers who live by the season and the timing of crops, rather than the ticking of a clock, have a different sense of time. Their testimony was translated to visiting Ugandan and Kenyan nurses, ones who crossed the border to serve their newly nationalized African sisters, and then translated a second time into English, the history corrupted at each step.

    PMI hyperdynamic, lungs clear, extremities warm. Bowel obstructions are not uncommon here, but my issue with BT was what I saw on her skin: a long midline vertical scar. Why the prior laparotomy? She and her family did not know.

    SBO. Fever sets in, and I imagine distended loops of bowel whose transmural pressures have risen so high that capillary perfusion is impaired. The resultant ischemia means a breach in mucosal microcirculation and bacterial translocation into the portal venous system. She involuntarily guards to light percussion, clinical confirmation of compromised bowel. We start saline and antibiotics, and place an NG tube and urinary catheter.

    Ultrasound. I see multiple distended loops peristalsing. No ileus. She has a small amount of free fluid. I tap it expecting to find enteric contents or the pea soup characteristic of typhoid perforation. I need to know if an operation is truly justified. Instead I find a cloudy exudate not diagnostic of perforation.

    I wait, hoping that peristalsing bowel will squiggle its way out of an obstructing adhesion. Nothing has improved by late that evening. I tell my Congolese physician assistant that we will take her to the operating theater.

    I entered her abdomen well above the prior scar to avoid adhesions. Her peritoneal cavity and everything in it was scarred down. Loops of bowel were not distinguishable in a forest of fibrosis. Blunt dissection had no role, and sharp dissection proved only to cause enterotomies. Even localizing the transition point was not possible. I repaired whatever enterotomies I had created, knowing she would now be worse than before. We irrigate, and I place a drain to try to control the inevitable enterocutaneous fistula. Not having the luxury of leaving an abdomen open, we close her with retention sutures.

    Postoperatively she expels feces from her drain but lives. I wonder if antibiotics and NG drainage alone would have been better for her on day one when her peritoneal tap was not consistent with perforation. I regret ever opening her abdomen.

    We talk with her family, and I apologize. They are immediately accepting. They have full faith in whatever happens as being meant to be. She had no other option. They thank me and shake my hand. I feel worse. She and her father are comforting me?

    Back home. Months later I receive an email from my PA. He was able to rehabilitate BT, remove her NG, and discharge her with a peritoneal drain so she could go home to die peacefully. Another surgeon operated on her at a distant hospital in a last-ditch attempt to control the leak. She died sometime after that.

    Most people want to hear the amazing stories about practicing in austere settings, about our success against all odds. They want to know how great it is to do what we do. But it comes at a cost. We carry a burden for mistakes made and moments we cannot get back.

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