A double dose of deadly delay

A tough, sad day with hard lessons to learn

Today was filled with a double dose of deadly delay. There are some statistics in medicine which you believe, even memorize, but never anticipate that you'll actually experience them. One of them concerns the large salivary glands in your cheeks called parotids. Tumors found in these glands are benign 80% of the time, but we remove all those benign tumors for one main reason: if left long term they can transform into a cancer that will kill you. So, we remove these benign tumors despite the fact that the surgery poses a risk to the facial nerve. Additionally, there are some specific surgical do's and don'ts that are critically important. So far in my career, I've removed these tumors, followed the patients closely afterwards, and have never seen the cancer that I learned the statistic about - until today. 

Seno's first parotidectomy showing facial nerve branches nicely preserved after tumor removal

Each year when I come to Tenwek, they assign a surgical resident to me to allow me time to train them in head and neck surgery. This year, a very talented and extremely bright fellow named Seno is by my side. Yesterday, I took him through his first parotidectomy. The facial nerve was carefully dissected, the tumor removed and she was smiling without weakness this morning. Praise God! Good job, Seno! But, today's news would not be so good. We began the same operation on another lady, but this time it was a revision. She'd had the tumor removed 13 years ago and recently noted a recurrence. A FNA biopsy pre-operatively suggested it was a benign recurrence. As hour after hour ticked away in the OR, it was becoming apparent that today would not be a surgical success. The branches of the facial nerve could not be separated from the tumor - not by Seno, then not by me. We took some biopsies to confirm our suspicion and closed up her incision leaving massive tumor behind. Within the hour, our biopsies confirmed the worst - the tumor was a cancer, one that can't be surgically treated. Perhaps radiation therapy will give her a small chance to live- provided she can raise the funds, make the 4 hour journey to Nairobi, and complete treatment. There's no Medicare or Medicaid here, so if she runs out of money, they simply will stop her treatments. Perhaps if she'd had adequate surgery the first time, perhaps if she'd had routine follow up surveillance, perhaps if she'd been warned about recurrent tumor, perhaps if she'd seen me five years ago on my first trip to Tenwek instead of delaying until my sixth.

Parotid tumor recurrence that would prove unresectable.

In the afternoon I saw a fellow who presented to the ophthalmologist 3 months ago and was told to follow up in surgery clinic with a CT scan. He went home to raise the money - about $70 US equivalent -and didn't return until today. The small tumor noted in May was now massive. The pictures are too gruesome for public display - his left eye gone and in its place bulging lobes of cancer protruding from his face. His mouth will barely open because the tumor was invading his chewing muscles. Nothing can be done, not here, not anywhere. His delay removed any chance we had for surgery. He will die soon, maybe a month or two. He wears a baseball cap with a scarf draped over that half of his face. His one remaining eye and the half of his smile that still works tells me that this is a likable fellow. My job today was to tell him that he won't be cured. It's not easy to say, not easy to remove all hope - but one thing prevents this from being a tragedy. He believes in Jesus Christ which allowed me to assure him that his healing will come. Not today, but soon; not here, but in heaven - where a God who sacrificed his Son for him will greet him with loving arms - and he will smile back with a perfectly healed face.