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Bangladesh Medical

Double trouble

The telephone call woke me up. The Emergency Department doctor on duty wanted to discuss the management of a baby boy who could not pass urine properly because there was a stone blocking the flow. I looked at my watch, it was 5am.

“How do you know there’s a stone?” I asked.

“Because I can see it,” said the duty doctor.

“Have you tried to get it out?”

“My forceps can’t get a grip on it,” he said.

“Give him some pain relief and I will see him as soon as I arrive at the clinic,” I responded.

The stone was well and truly stuck. It was completely blocking the urethra. To deal with this, I made a  fine hook, using a hypodermic needle with the point broken off and bent over. I am sometimes able to ease the needle past and behind the stone, turn it 90 degrees to hook it and pull it out. Not this time. I telephoned the surgeon and explained the problem. He agreed to see the child.

About ten days later, I visited Dr Martin, the surgeon, and asked about the child. “He’s in traction to align his broken thigh bone,” said Martin. “Wrong patient,” I said. “Right patient,” said Martin, who went on to explain what had happened.

In order to find out where the stone was in the urinary tract, Martin had taken some x-rays. These showed a fractured femur, so he put the boy in traction. The stone was a minor problem. Martin asked the mother how the child broke his thigh, “Had there been any trauma?”

P1320325
This was the first X-ray, clearly showing the fractured right femur

 

She said that she had been carrying the child as she was running away from soldiers who were trying to kill Rohingyas. She tripped and fell onto the child. This had happened a day before she crossed the border from Myanmar into Bangladesh. It was probably how the bone was broken.

We went to see the child, who was lying on his back, with his legs vertically upright, hanging from a pole above the bed.

 

P1320320
The boy’s face is hidden to preserve confidentiality. The bags of intravenous fluid are used to provide traction to align the fractured ends of the thigh bone

 

 

A week later, the child was having trouble passing urine again. This time Martin could see the stone in his penis. Using the correct instruments, he was able to remove it. The child left hospital with a plaster cast keeping the bone ends aligned. Both problems solved.

P1320324
The lateral X-ray shows the fractured femur AND the stone in the tip of the penis

 

P1320323
Martin kept the stone in a glass tube

Hernias in the groin are common in childhood. They don’t usually cause serious problems unless the bowel becomes trapped or twisted. The little boy was crying. I could tell there was something wrong because the swelling in the groin was very tender. I diagnosed a strangulated hernia. He needed an operation so I referred urgently.

Two weeks later, the boy returned for review following the operation. I was disappointed to see that there was still a lump in the inguinal canal going down into his scrotum. I happened to have an internet connection via a dongle so I sent an email to the surgeon. He told me that the operation had been difficult and there had been a lot of bleeding. This had formed a clot which extended into the scrotum, a haematoma. He expected that this would reduce in size over the coming month.

“Why was the operation difficult?” I asked.

“Because the hernia was so large it contained the first part of the large intestine, the caecum. And on the end of his caecum there was an inflamed appendix,” said Brett.

“So he had appendicitis AND a hernia? I have never heard of that before,” I said.

“Yes, he got two operations – a hernia repair and an appendicectomy – for the price of one!”

 

By Dr Alfred Prunesquallor

Maverick doctor with 40 years experience, I reduced my NHS commitment in 2013. I am now enjoying being free lance, working where I am needed overseas. Now I am working in the UK helping with the current coronavirus pandemic.

3 replies on “Double trouble”

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