A Most Memorable Patient

الكاتب : مجنون اونلاين   المشاهدات : 493   الردود : 0    ‏2004-07-05
      مشاركة رقم : 1    ‏2004-07-05
  1. مجنون اونلاين

    مجنون اونلاين عضو فعّال

    التسجيل :
    ‏2003-11-29
    المشاركات:
    850
    الإعجاب :
    0
    2003The American Society of Colon and Rectal Surgeons
    Volume 46(5) May 2003 pp 686-687
    A Most Memorable Patient
    [SOUNDING BOARD]
    Isbister, William H. M.D., Ch.B.
    Moosbach, Germany


    The clouds of war were gathering over Kuwait. Saddam Hussein’s tanks had been in the streets for some months, and because Sana had sided with the Iraqi leader, Yemeni workers were no longer welcome in the Kingdom of Saudi Arabia.
    Sarah was a 19-year-old Yemeni girl who was referred to me with constipation. Two years previously she had an “intracapsular resection” of a giant cell tumor of the sacrum. During surgery the rectum was damaged, “five hundred ml of tumor were removed by finger dissection,” and the damaged “bowel was reconstructed.” Intraoperative blood loss necessitated blood transfusion. Five weeks after surgery she had radiotherapy (4,500 cGy.). Twelve months later the patient was readmitted with constipation. Barium enema revealed a “smooth” rectosigmoid stricture with a suggestion of extrinsic compression. The bowel was “cleared” (GoLYTELY®, Braintree Laboratories, Inc., Braintree, MA); the patient was prescribed stool softeners and then discharged home. There was anxiety that the tumor had recurred but that little further could be done.
    When I first saw Sarah, two years after her original surgery, and just two months before the Gulf War, she was still complaining of constipation, but managed to pass a movement with the help of an enema once every three days. Communication with the patient’s father, who was a Mecca fruit merchant, was through an interpreter. He was reluctant for me to talk directly with his daughter. I also discovered that she had never been allowed to go to school. Sarah’s colonic stricture had narrowed considerably, and I attempted to explain that it would be necessary to perform further surgery to determine clearly what was causing her problem. If there was no evidence of tumor recurrence, I promised that I would try to resect the narrowed bowel but stressed that because of the previous radiotherapy it would be necessary to protect any anastomosis with a temporary stoma. At this suggestion the father exclaimed, “No, she would be better dead,” but Sarah herself wished to have surgery and started crying. A prolonged discussion followed, and it was finally agreed that the father and his confused daughter would go home to discuss any further management with the rest of their family.
    When I next saw Sarah, she and her father seemed to be happier; the family had persuaded the old man to allow his daughter to have a temporary colostomy, and they were at the clinic to arrange admission. After consultation with an enterostomal nurse and further reassurances regarding the temporary nature of the stoma, a date for admission was fixed.
    Sarah was admitted, and her father accompanied and stayed with her. Sarah seemed happy to be having surgery, but her father was still reluctant despite many long conversations. We talked together at length during her admission, and I learned, not unexpectedly, that Sarah wished to go to school. Sarah’s stricture was resected without complication, and she returned to the ward with a stoma. She soon learned how to manage it and was discharged from hospital. Her father was still anxious about the stoma and in an attempt to placate him and help Sarah, I promised to close the stoma early, provided that there was no evidence of leak, if he was prepared to allow his daughter to go to school. He agreed to this and they returned to Mecca, Sarah looking forward to the promise of school and her father pleased that his daughter was not to have her stoma for very long.
    A barium study was duly performed, no leak was detected, and I used the outpatient appointment to remind everyone of the promise to allow Sarah go to school. The Allied Coalition had given Saddam Hussein an ultimatum regarding his evacuation of Kuwait and Sarah was admitted for her final surgery. This time, because of the impending hostilities and the Saudi attitude to Yemenis, Sarah’s father was home preparing to close shop before his family’s return to the Yemen. Sarah was by herself, and her surgery passed uneventfully. There was still another surprise in store for Sarah. One of her original blood donors had become HIV positive, and this information had to be conveyed to her. Sarah’s blood was tested—there was no evidence of infection. The Allied deadline was approaching, and Sarah was frightened that she might not get back to her family before they were forced to leave the Kingdom. She decided, five days after surgery, that she had to return to Mecca, and because air traffic at the time was disrupted because of the fast-approaching declaration of war, she was forced to take a taxi the 989 km to her family. We said “goodbye,” and I reminded her to tell her father that I expected him now to keep his side of our bargain.
    The war started three days later with a massive bombardment of Baghdad. That night, three Scud missiles landed on Riyadh, and during the next few weeks a further 11 Scud missiles fell on the city. To this day I have only questions about my patient. Is she well? Did she go to school? Was she happy in Yemen? Did she remain HIV negative? Is she married, and if so, how many children does she have? Can she read? I do not know the answers to these questions, and now I probably never will. She has not returned to the clinic, she has probably not returned to Mecca, and I do not know whether she can write.
    Sarah and her family posed six main problems: How to manage a patient with a postsurgical stricture who had had a full course of radiotherapy, how to manage a father who was very averse to a stoma, how to correct the local community’s misconceptions regarding abdominal stomata, how to help ensure that Sarah was allowed to go to school, what to tell her about HIV infection in the absence of any likely follow-up and HIV counseling, and how to do all of this in the light of the political decision to expel the patient and her family from the Kingdom. In the event, Sarah was allowed to have her surgery, her stricture was resected, her stoma was closed, and her father promised to allow her to go to school. She was a memorable patient and one who caused me, for one, many sleepless nights. Inshallah, the experience taught her father, at least, that she was not “better off dead.”
     

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