I walk through the wards and notice a crowd lounging around outside. A quick exit, a loud "rounds are starting everyone who's with a patient come in, all other visitors leave" and with a few agressive gestures and much repeating and translating most everyone clears out leaving the hospital with a rare moment of relative tranquility (maybe it helps that I spent an hour last night chasing out squatters with a broom handle).
Not for long. The pediatric ward and emergency room have been vacated so the leaky roof and moth-eaten ceiling can be replaced leaving us with all the patients crammed into already over-burdened wards.
I start with Pediatrics. The nurse in charge, Deuhibe, gathers the charts and calls the nursing students. The charge nurse, Jacob, joins us along with Camila, the Danish medical student and we start seeing the kids.
As I come to the last of the peds patients, a skinny ten-year-old boy with bulging eyes staring at us blankly, the child suddenly repeats his performance of yesterday that made me call the chaplain to see if he was demon-possessed.
He somehow manages to combine three extraordinary moves into one well-polished fluid motion perfected by years of habit and accompanied by a blood-curdling cry like a banshee being bit by a thousand bees.
In one simultaneous gesture the boy flips from his back to a kneeling position thrusting his anus up into the air, reaches his hand around his back and sticks it into his butt, and realises a stream of urine that thrases around like a fire hose out of control and that would make a race-horse proud. All the time he writhes around like a cat in a bag and screams like someone is slowly skinning him alive.
I'm shocked and unnerved. I quickly grab his arms removing his hand from his butt, flip him over and pin him to the urine soaked mattress. I notice the urine is tinged with pus. I ask for his lab results as he moans and groans and struggles uselessly. His stool test is normal and his urine not surprisingly shows an abondance of white blood cells.
For some strange reason (years of being a resident and hearing surgeons drill it into my brain) I decide to do a rectal exam. I quickly call for a glove and feel inside the child's rectum. Where his prostate should be is a large, hard, smooth mass that is somewhat oblong moving towards his bladder.
An ultrasound confirms a calcified mass in his bladder.
An hour later I poise over the boy's lower abdomen with a scalpel as Abel prays. A few slices later and I'm in his bladder. Even though I kind of expect it chills still run up and down my spine and my arm hairs stand on end as I reach a gloved finger into the bladder and touch the large urinary calculus.
It's so large compared to the small kid's bladder that it is quite difficult to extract. I finally open the wound more and slip some forceps around it and squeeze it out like a diffucult childbirth. There on the table before me is an 3 inch by one inch long kidney bean shaped stone.
After closing the bladder and belly and leaving it to catheter drainage I realize that the boy is actually quite smart and creative after all.
The weight of the stone caused urinary obstruction through gravity pulling it down to block the urinary outlet. When his bladder got so full he couldn't stand the pressure of the retention he flipped over, anus in the air so gravity and a well-placed rectal finger would push the stone off the exit releasing a high pressure urinary stream bringing relief but causing excruciating pain at the same time.
Who know's how long he's suffered with that? The parents say for all his life despite going to many hospitals and staying months. What's the difference in ours?
God helping me make a difficult diagnosis and bringing all the elements together to be able to confirm the diagnosis (ultrasound) and perform the surgery (equipment, generator, trained staff, instruments, autoclave, suture, etc. etc.)
So next time you have difficulty peeing, might I suggest a certain routine...
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