not the greatest picture, but i took it with my cell phone. massive thyroids seem to be the order of the day. this lady's supposed "asthma" got so bad they had to intubate her. on the ct note the retrosternal mass totally displacing the trachea and esophagus. note the aorta arch as well as the superior vena cava.i'm thinking sternotomy, but i'm open to suggestions.
9 comments:
I would try a cervical incision first. A lot of these substernal goiters can be hefted out that way. Maybe a pre-op angiogram to make sure no abnormal feeder vessel from the aorta directly. Good luck.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17285472&ordinalpos=9&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
mpumalanga is an interesting place. firstly the anaesthetist refused to dope because of fear of filling in death forms. (no anaesthetic risk because the patient is already tubed. only surgical risk and that is less than spending the rest of her life tubed). secondly, the admin of the state hospital where i was supposed to whip out the thyroid today officially forbade me from working there any more. for those who have followed my blog from the witbank days will understand. otherwise get an overview by reading the post, failure.
basically put, there is no one here now to operate the patient. i phoned pretoria to try to have her transferred, but they have no icu bed. so the patient is doomed because of the fact that admin wants to save face and the anaesthetist would rather she die outrite than take the chance of her dying on his table.
i realised today that the health sector in our province is a microcosm of zimbabwe. they are in fact mugabeing the system.
that's horrible. Going to just trach her then?
sometimes in surgery you need to be able to turn away, even when you know it will mean the death of someone, but when that someone can actually be saved and is only going to die because of an administrative f#%k up of others when i know i could make a difference really tears my soul out. i truly understand now when allan paton says 'cry the beloved country'.
she can't be trached. the thyroid is in the way. anyway, the stupid anaesthetist wouldn't dope her for that either. same anaesthetic risk (the greatest risk would be moving her across to the theater table). so the f#%ker won't come to the party. you've gotta wonder if to do nothing when you have the power to save someone isn't the same as actually actively killing them.
So sorry bongi for yours and your patient's predicament.
How absolutely horrible for the patient (and you)....is there nowhere she can go ?
For the record, even though it appears moot, I'd agree with Buck that I'd start with a cervical incision; I'd predict it would be removable that way; but I'd prep and drape and be ready for sternotomy. As to the rest, the politics: I remain amazed at the conditions in which you work, and your ability to rise above it. You have my unending respect.
sid, your comment is appreciated. in retrospect, if i'd just told the stupid anaesthetist that i was goin in cervically, the fool would hade let me go for it. once i let him know i need to open the chest it would be too late. i know the books say cervical will work, but let me assure you, the scan was amazing. i would anyway have opened the neck and only gone through the sternum under great duress, but having seen the scan from all angles, i'm pretty sure there would have been duress. my political mistake was that i should not have let that bloody anaesthetist know i even considered sternotomy until the neck was open.live and learn (for me i mean. too late for the patient. she is screwed.)
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