For much of the day, my mind has drifted back to a young
lady I saw this morning. It is most troubling. Between cases in the
outpatients, I have been desperately trying to somehow magic up a solution for
her. It is beyond frustration. If I saw her in the UK, her pathway would be
very different from what she faces here. I have all the knowledge and skills to
offer her a world class treatment pathway, but none of the tests, equipment nor
ancillary / support services I need to do so. In the UK, such a discovery would
be devastating, here it feels like a death sentence. And my efforts feel like those
of a child trying to build a trench to protect my sandcastle from the
inevitable destruction of the incoming tide. With my hands tied behind my back.
She is just 29. I had been asked to see her on Friday by one
of the other doctors. She has had altered bowels and has been bleeding with the
passage of stool. When I went to see her on Friday, there was no KY jelly
available anywhere in the hospital (imagine that in the UK) and I wasn’t going
to examine her without it. Unfortunately, todays examination could not have
been much worse. Of all the possible diagnoses, she has a fairly low rectal
cancer. Whilst certainty in such situations invariably comes with definitive
histology (tissue samples) sometimes there is no doubt.
I am a specialist colorectal cancer surgeon and as my examination
revealed the pathology, my subconscious mind was immediately gathering all the
information that I would need to properly counsel and treat her. It was
posteriorly sited, big, its lower border at about 6cm, but it was just too high
to fully assess whether it was fixed or not (if so that would be a bad prognostic
indicator). But as I thought through how we could treat her, all my ‘expertise’
seemed wasted. All that information I was subconsciously processing is inadequate
on its own. For beyond that information there are major gaps that need filling before
I can treat her effectively. As a surgeon, it is fantastic that ‘we carry’ many of the resources we need within us. Just a few simple instruments and we can
actually do quite a lot. However in cases such as this, knowing what I know, without
more information, I am pretty helpless.
I had a couple of UK medical students with me today and we
took some time after seeing her to discuss the implications of her diagnosis.
For me this proved to be an opportunity to vocalise the stark reality of the healthcare
‘injustice’ she faces. In the UK I would call in one of our specialist nurses
to help support her through the information that I would need to explain to
her. She would have time and support. We would perform a colonoscopy and
acquire the definitive tissue diagnosis I described. She would also have a
special CT scan and a very special MRI scan to help define the cancer and give
us as much information about it as possible. That would all happen within about
2 weeks and we would then meet again to plan either primary surgery (keyhole
surgery with the intention of maintaining her ‘normal’ plumbing [ie being able
to poo through her bottom]) or if the cancer was too advanced, explanation and referral
on to one of our specialist colleagues for consideration of chemoradiotherapy.
This can then sometimes be a stepping stone to conventional curative surgery but
if that has not done enough, we can then consider employing the skills of some very
specialist surgeons who are pushing the boundaries of what is possible (and a
lady of her age would be a very suitable potential candidate). Furthermore, if
the cancer has already spread, that is not necessarily an end game scenario in
a lady of her age, as we now have options to chop out other sites of cancer with
the help of other specialist colleagues and within the framework of our extensive
(and to me sitting here in Africa, frankly mind-blowing) extended MDT –
multidisciplinary team. Oh, and not to mention the fact that as she is young,
we would also certainly consider a genetic anomaly contributing to things,
which would lead to her assessment within a specialist genetics service too.
Here….. yes, here…… Today I can offer her none of this. We
can certainly try to refer her to the national hospital for a CT scan and
whilst MRI is available, I am not sure that it would be of the sort I would require.
If she is deemed suitable for surgery, the practice in Tanzania would be to perform
an AP resection for such a cancer (that would mean removing her bottom and leaving
her with a permanent stoma) and my understanding is that the mortality (risk of
death) and morbidity (risk of other problems) from such surgery is very high
here. And that of course assumes that she has the means and support to travel
for such things. The last lady I sent for a CT scan has not returned for follow
up and being known to one of the clinical officers here, I now know that she
has turned to traditional healers (or witchcraft to use the words spoke to me).
In the UK, whilst these sorts of cases don’t come around
very often, they always hit you hard as a clinician. They are like a bucket of cold
water thrown over you, waking you up to the reality of life. I am sure
different people will do different things with such experience. For me they help
to remind me to appreciate what I have. I always return home, that little bit
more humble. I hold my hugs with the children and wife that moment longer, and I
give thanks for our current deal of the cards. That is in the UK. Here…. Here….
I am a little lost to be honest. I don’t know what to feel. I am powerless and
feel woefully inadequate. Surely I can do something? Yet however ambitious I am
in my thinking about what I could possibly do…….
The reality is that I will almost certainly just have to
accept her fate. However painful and wrong that might feel. She is just 29, so
young. And a mother too. I will try my best, but I strongly suspect that she
won’t be alive in 12 months’ time.
So sad.
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