THIS CAN HAPPEN: VOLUME IX
Dr. Gangadhar Sahoo
This can happen Volume lX
It was mid summer in early 1990s in Burla. Burla is known for its extreme climate. After the routine OT, I completed the post operative round and came back to my residence in the doctors colony of VSS Medical College, Burla. I was completely exhausted as the OT was not air-conditioned. After taking the delicious watered curd rice with its matching dishes in the lunch at about 2.30 pm I was preparing to retire to bed , when the calling bell rang. I thought it might be a patient from a distant place who had come for consultation. In Burla there was no fixed time for consultation. Usually patients from far off places come in the afternoon because of their bus reaches Burla at that time. We can't refuse consultation to those needy patients on humanitarian ground.
When I opened the door, I was surprised to see two of my unit PG students Sudha and Mami . Their face was reflecting their hidden anxiety and distress which they wanted to ventilate . I asked them to come inside and be seated in the drawing room . Gave them two glasses of chilled lemon drinks which they finished in one breath. I offered them the second glass which they obliged.
During discussion I came to known that they had come to meet me direct from the OT . They had not gone to their hostel nor taken their lunch. Their body language and voice was telling as if something had gone wrong in the OT which they were wanting to tell me . Shadow of guilt covering their face was clearly visible.
When I enquired they said that the last case a case of Fibroid with degeneration collapsed in the observation room a few minutes after she was transferred from OT . The ANAESTHESIOLOGIST was there who tried for intubation but failed to do so . I was shocked to listen that mishap . Immediately I started my two wheeler and reached the observation room. What I saw, was not expected to see. I did not crack my head to know what might be the cause of this mishap. Postoperative massive pulmonary embolism is the commonest cause for such type of death .
It was an interesting case . A young mother 34 years of two babies, last one being one and half years and lactating presented with off and on bleeding per vaginum for one week without missed period.
On examination I found a suprapubic mass of 16 weeks firm to soft in consistency , mobile & non tender . My provisional diagnosis was Fibroid Uterus ( a benign tumor of uterine muscle) with degeneration. The sonographic findings corroborated my clinical diagnosis. Then I advised the patient for myomectomy( removal of tumor keeping the uterus intact) / hysterectomy. After that she was lost for follow up . Came for operation after one month. She was trying by local treatment for regression of the tumor. Repeat ultrasound was done. The report came as 28 week gravid uterus size mass with degeneration. Such an exponential growth is only possible in case of malignant degeneration.
Without much delay the case was put up for surgery on next OT day under spinal anesthesia with two units of blood being arranged .
On opening the abdomen the uterus was found to be hugely enlarged, soft and highly vascular with angry look . When I incised through the uterus for myomectomy , heavy bleeding from the site started pouring which was difficult to stop .
Then I changed my plan from myomectomy to hysterectomy.
Hysterectomy was done without any problem. After removing the uterus I bisected the specimen. It was a totally different picture. It was an invasive mole not a fibroid uterus. Pulmonary embolism is very common during operation of such cases if operation was not done during a prior course of chemotherapy. I had missed everything. I was misguided by the sonography report done twice. I missed the trick that she had two babies with last baby was one and half years old . Moreover exponential growth in size of uterus within a span of one month failed to arouse suspicion in mind to think of something other than fibroid. I always teach my students that if sonologists give a report of fibroid with degeneration, always exclude invasive mole. Sonographically both look exactly similar . An experienced sonologist can differentiate because what eyes can't see mind can not know. Had the diagnosis couldn't have been missed, the result could have been different. I felt guilty for my mistake of missing the diagnosis and as a result of which a life was lost death . It was 100 % avoidable. Till today it is haunting my mind.
TAKE HOME MESSAGE
From this anecdote I learned many things which I want to impress my students and readers.
- Never be biased by a laboratory or imaging report .
- Apply your clinical sense.
- If any doubt don't be miser in seeking a second opinion.
- If there is no emergency, don't jump to a major operation. Remember any radical step should be the last option.
- Learn from the mistake of others. If I commit a mistake I should learn from it and will let others to learn from it also. If a mistake is committed never try to find excuses to cover it , rather take steps so that the same mistake will not be repeated.
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