Heartbreak High

This morning I woke up in the convent in Korogwe to the ringing of bells at 6am and the beautiful singing of the thirty or so nuns in the chapel opposite our dorm. It was a running day (I had even packed my kit) and so sneaked out of the room in the evolving light, leaving my eldest daughter sleeping (we had split into two rooms, one adult in each). I was greeted by a few of the nuns not in church (presumably catering for us) and they certainly had a smile of interested bemusement on their faces (I have long come to accept that my particularly white Mzungu legs attract such a reaction).

I set off in the relatively cool breeze (hot for the UK) and ran out into the country side then along the dust road into a village. This proved to be an excellent decision as I was clearly a delight to the local children all walking to school. Every day between about 06.15 and 06.45 there are droves of children all over the country walking to school on their own. Some are quite little (certainly smaller in stature than my nearly 6 year old). If they are lucky, they have an older sibling to walk with, but many do not. They are all beautifully dressed, looking very smart – white shirts, bright jumpers and usually dark skirts / shorts / trousers. Although on closer inspection you can see the holes and repairs in the uniforms or the very worn shoes that most of them wear. They often carry large containers of water or firewood or twig brushes for cleaning. Clearly education is highly valued, and the local environment considered safe. I cannot recall how many times I replied “marahaba” to their respectful greeting of “shikamoo” (accompanied by lots of giggles), but I certainly felt like a celebrity. For whatever reason, I have not attracted this much attention elsewhere when I have been out running. At one point I had collected a little flock of followers, all running behind me. In some ways, I wish I had had a camera. But equally you can never quite adequately capture such things on film. It is a delightful mental image to carry away with me. Another highlight of my time here.

I returned to the convent, a hot shower (ironic that for once I didn’t want it, cold was blissful), a delicious breakfast and then it was off back to Muheza.

Sometimes I feel that I am reliving the same emotionally draining experiences time and time again here. Today was another such episode.

Having seen all my pre and post-op patients for the week (all doing pleasingly well), I was asked to review another patient on the ward round. A man in his 70s, I was told he had ‘some itching around his bottom, then developed a wound’. Great I thought, this sounds like a colorectal theme (my area of specialist UK practice). I was however slightly bemused by the sparse account of the story, which to be honest shed very little light onto what we might find. It dramatically underplayed the situation. He laid on the bed to reveal an extensive perianal ulcer that could only be a squamous cell cancer. My mind was racing. This is an area of sub-specialist interest for me. In the UK centre that I worked before coming to Tanzania, we performed salvage surgery for such cases. These are big operations and we work closely with the plastic surgeons to reconstruct anatomy using clever flaps of tissue. However, I was getting ahead of myself, because even apparently extensive tumours like this can respond dramatically to targeted chemo-radiotherapy. In the UK the cure rate in such situations is surprisingly good.

But even as these thoughts were passing through my mind, accompanying them were the almost inevitable responses I knew I would hear. But I didn’t want to hear them.

The Specialist Surgeon Nun had returned with us to Muheza and she was also present on the rounds. This was particularly useful for me as she would be considered an expert in what was available for surgical diseases such as this in Tanzania. Unfortunately, she confirmed what I already suspected. Yes, the only centre that can offer chemo-radiotherapy would be Dar es Salaam. However, I established that it would be nothing like the service that I would take for granted in the UK. I tentatively asked if the patient could travel there. Everything was explained to him and his reply was quite clear.

No. That would not be an option for him.

I felt my heart sink once again. It is genuinely painful. I find myself again confronted with a situation where I have all the knowledge and skills to manage this difficult situation, but none of the support teams, drugs, nor equipment. I feel helpless. Whilst I can confidently diagnose and offer theoretical options for this poor man’s predicament, circumstance means that there is precious little I can do to actually help him. He might be cured in the UK. Here…..

We discussed a defuntioning colostomy (this means that the bowel is brought onto the skin and the effluent collected in a bag rather than passing through the anus). In situations such as this, it is a palliative procedure to try and improve his quality of life. Whilst currently he is just about managing to pass stool through his bottom, it is only a matter of time before such things become either unbearable or impossible. The local and visiting team both felt that this surgical procedure should happen. I was slightly reluctant given that currently his symptoms were manageable. But in no uncertain terms it was made quite clear to me that his best option would be for me to perform the procedure before I leave. But I have not much longer left now. The decision must always ultimately lie with the patient. I was certainly clear that I would not do it today. We are away next week, but should he want it, I could do it on my return in a fortnight.

He wants it.