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Monday Clinic/Emergency Surgery

March 24, 2011

Melanoma

One of the challenges of medicine is diagnosing diseases or cancer before it is too late. This is a problem in the US and an even bigger problem in African countries where access to health care can be minimal and health education can be poor. Monday was a perfect example of this. I finished up ward rounds early (really teaching rounds–more on this in another post) and went to clinic with my consultant surgeon Dr. Lugaria. I was supposed to see only post-op patients, but I think the 6th year medical students wanted to move things along, and they “clerked” or staffed two new patients with me. One was a young lady with a two month history of enlarging bilateral neck masses. Her exam was quite impressive, and the history was not indicative of a diagnosis. So we set her up for a biopsy of one of these neck masses. I wonder if it will be tuberculosis related. She will probably be fine when the biopsy comes back. The second patient will not be so fortunate. The patient is a man in his fifties with 10 children. The 6th year (final year of medical school in Kenya) student did a nice job of presenting what was mobile large left thigh mass that sounded like a benign tumor that could be resected. But when the student mentioned that the patient had reported a skin lesion on the side of his left foot, I became very concerned. My worst fear was confirmed when I had him remove his shoes and socks. He had a large area of discolored and ulcerated skin on his left foot while his right foot was totally normal. It was clear that he had melanoma (an aggressive skin cancer) on his left foot and the mass on his left thigh was likely a distant site where the melanoma had spread. This unfortunately will likely take his life sooner rather than later. Another reminder to always check your skin everywhere for abnormal changes. I wish my Swahili was enough to talk to the gentleman about the long-term implications of this problem. It would have been nice to have provided him some comfort and hope in his native language.

Neonatal incubator

Initially, I felt remorseful that I had not made it to the OR (Monday is pediatric surgery day), but as with many things in life you can’t do everything. I stopped by the OR thinking that everything was likely over. Imagine my surprise when I stopped by the OR at 2 pm to find out that all the elective pediatric surgery cases had been canceled for today because there was no oxygen in the OR. Ah, the things that you can’t predict that set you back in a government hospital. They staff had finally resolved the problem which was good since there was a small premature infant (around 1500 grams–3 lbs 4 oz) that was two weeks old with abdominal distension and a high white count (a chemical marker of infection) in the Neonatal ICU. I saw the child in the incubator, and it was clear that the child had necroticizing enterocolitis with a bowel perforation.

So I had the opportunity to operate on the child with Daktari Tenge our pediatric surgeon (I mentioned him in an earlier post.) We both knew the outcome was likely to be poor. A child of this size in the US would require a lot of ICU care, IV nutrition and likely ventilator support.

Operating with Daktari Tenge

The bill for these services would be beyond most Kenyans ability to pay even if they were available at MTRH. The child did have an isolated perforation that we resected. But we knew that the challenge would be how to give the child nutrition should he survive. Feeding the child’s gut would be out for at least 7 days in this system. The child ultimately died 4 hours after the operation in our ICU. Daktari Tenge didn’t even have a chance to reflect on it, because he already had patients waiting to be seen out in town at the clinic. It’s incredible how much these doctors have to work just to make ends met. I don’t think the government salary is the primary source of these hard-working doctors’ income. All I can do is pray for these patients and their families.

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