My last day at Tenwek

As I sit on this plane to Ecuador I realize that it is finally time to write the final chapter on my Africa blog.  If you’ve read my stories from Kenya you may note that they seem to end abruptly- no wrap up, no final thoughts, no happy ending. And therein lays the problem. My final day at Tenwek hospital was one of the toughest I’ve faced as a physician and surgeon.  There are so many things that are different in the United States and despite 5 weeks of experience I encountered new situations on my last day. The issues concern a young mother of two who presented to the clinic with one of the worst mouth cancers I have ever seen. She could not close her mouth because the tumor was growing between her teeth on the right side and filled most of her mouth. She could swallow her secretions and liquids but was not able to chew and thus could not eat solid food. She was suffering constant, agonizing pain. The familiar smell of a cancerous tumor was evident to me from my first encounter. She clearly needed surgery soon as this tumor would soon fill her entire mouth and suffocation would soon follow.  The full extent of the tumor could not be determined -without a CT scan – which brought up our first challenge. Her family was very poor and the $250 surgery to save her life was going to require every financial resource she had. The $70 CT scan was beyond their means but critical to my surgical planning.

Paul reviewing a case with a surgical resident

                I would love to claim I was the answer at this stage, but to my embarrassment I was not. A fellow general surgeon from the US showed me the limits of my thinking and the lack of generosity I still suffer from. He quickly stepped forward to tell the family that he would pay for the scan, stating “we really want to help you.” As I write this it seems like such a simple solution - $70 really isn’t much money to an American surgeon - I’ve tried so many times to come up with reasons for my thoughtlessness but none seem to hold up. In the end, I still have so far to go. I thank God for Paul, the surgeon, whose actions so clearly demonstrate the type of behavior and attitudes that I need to emulate.  (A quick side note: Paul is a remarkable man who spends half the year as a missionary surgeon in Africa and the other as a preacher in a Houston church. He’s a great role model and his humble nature would certainly object to me praising him in this manner so I won’t reveal his last name. He does happen to have a famous brother who is also a preacher in Houston J)

We scheduled her for surgery on Friday, my last operative day in Africa. We turned away another man with cancer because I simply didn’t have enough OR time remaining.  She got her CT the day before and was bringing the films with her on Friday for my review prior to surgery. I still had to make sure we were planning the right surgical approach and that I was prepared for the surgical challenges that lay ahead.  A problem with getting the film read delayed her hospital arrival nearly  all day. We managed to convince the hospital OR employees to stay late to give this woman a chance at this life saving operation. This surgery was her only chance. The next ENT scheduled to come to Tenwek wasn’t arriving until February –much too late, she would not live that long without treatment.  Finally, at 4:00 her films arrived and I got my first look at them.  The film was of poor quality compared to what I typically see in Louisville, Kentucky and they were reminiscent of scans from 20 year old scanners.  I was devastated to see that the tumor was worse than expected. I could not see a clear plane between the tumor and her spine. Was it just the poor quality of the film? Would I get halfway through the operation to discover it had invaded bone and could not be resected? Could I find that it encased her carotid artery and resection would leave her with a massive stroke during surgery? Would I encounter uncontrolled bleeding as I attempted to remove the posterior (back) deep aspect of the tumor? What was the likelihood of her dying on the table?  These questions were overwhelming and I had the OR director asking me to make a timely decision as the OR personnel were eager to go home if we weren’t operating.  Confusing the issue even more was that this was a rare tumor type, a chondrosarcoma. The most common tumor in this anatomic location was a squamous cell carcinoma, a type that carries a much better survival rate than what she had.  I called a quick conference with Greg, an anesthesiologist visiting from Bellingham, Washington and Jason, a full time missionary general surgeon.  I reviewed with them my impressions of the scan and the issues – but neither of them shared my area of expertise and a second opinion was not to be found.  I have great confidence in my CT reading skills but here I was, required to make an immediate call without backup – no radiologist to call, no other ENT’s to bounce impressions off of. I was truly alone with this woman’s life hanging in the balance.  I was able to discuss with Greg and Jason whether it was right to even attempt the surgery. The surgery costs the equivalent of 6 months living expenses for her family and the hospital stay for several weeks of recovery would impoverish the family.  So, even if I was able to get the tumor out, how much of a chance would I be giving her to live and for how long? We quickly looked up some survival numbers – she had about a 25% chance of survival with radiation therapy being used as extra treatment. But, radiation therapy was only available in Nairobi, five hours away and she could never afford it! So, how much would we extend her life and at what cost to her family and for how long? Practical questions must be asked –would she choose to perhaps take away money that would feed her children? Would she give up her life to make sure her family could continue to afford food?

The tumor is bulging out her right cheek. The left edge of the tumor is adjacent to her upper teeth.

In America, even the toughest decisions that I face I share with the patient and family. The patient and family help bear the burden because physicians advise and recommend, but we rarely have to completely make a decision.  I rarely feel that I’m alone- I share my thoughts and rationale with the patient and they bear much of the decision making load. If I have doubts, there are experts in so many accessible places. But here I was, unable to communicate in her language, and dealing with an uneducated patient and family who weren’t capable of understanding all the issues. Talk of tissue planes, pre-vertebral fascia, metastasis, radiation, chemo, etc. were of no use here.

I quickly reverted to my training. I trained with some of the best head and neck cancer surgeons in the world. What would Jack Gluckman, my chairman at Cincinnati and role model, say about this scan and this situation? I imagined his voice in my head counseling me and could feel his comforting hand on my shoulder telling me that I can’t save everyone. I could hear his South African accent telling me some situations are beyond our abilities. I hated hearing those words in training; surgeons are fighters and fixers. We fix things that are wrong! We act! We choose to be surgeons because we’re built for action. Saying ‘I can’t’ isn’t part of the character set that allowed me to succeed in medical school and residency! But, wisdom comes from experience and sometimes experience is a cruel teacher.

I decided that the tumor was unresectable based on my best reading of the scan. Greg and Jason were kind to accompany me to tell the patient. We had to find a translator, who ended up being a native nursing student. What a cruel position to put that poor student in. She had to translate some of the harshest words I’ve ever had to say. I told the family how sorry I was and that we could not operate on her. I then had to tell her there were no options; she was going to die soon and the best we could do was to get her on some morphine to control the pain that would be unrelenting until her death.  Her husband and sister were there as we gave her the news.  The patient sat stunned as tears began to flow quietly down her face. Her sister began a loud and painful wail that remains burned into my memory. She was inconsolable and for the first time in my career I had nothing to offer. No chemo, no radiation, no second opinion, no hope for a cure.  I told them that we have no way of predicting her time left with any certainty but it would probably be 2-6 months.  I didn’t have the heart to tell her the 2-3 month estimate that experience leads me to believe.

Later that night, I ate dinner alone, packed and got ready to leave the next morning. On my last night, I thought I’d be celebrating a job well done and thanking God for the many gifts he has so abundantly blessed me with. I thought I’d be recounting all the opportunities where I felt I made a difference. I thought I’d be blogging about how much I got out of it and trying to inspire other ENT’s to join in the cause. Instead, I lay awake with tears streaming, wondering why my time had to end like this. I’d promised her I’d pray for her but my prayers seemed so inadequate for her needs.  I believe that God can do all things. I wanted God to save her by my chance encounter with her at Tenwek. I wanted to be the healing hands of God, but instead I was the bearer of devastating news. I wanted to make the game saving shot as the buzzer sounded but instead I came up short and the game was over.

I want to perform miracles, but only God can do that. God chooses the time and the place and I’m reminded that witnessing his love and generosity, in the way that I do, is a privilege that few are afforded.  He has blessed me with the skills and ability to perform surgery and in some instances save lives. But, He is in control and I am His instrument when He allows me to be.  With that thrill comes heartache and this was one of the worst for me. I don’t understand His timing or His selection. It is not my place to even question it. But I will bear it and go on with faith that there will be joys in the future and that he will guide my path if I just trust and allow Him to do it.