Working Without a Net

By: Bruce Campbell 

ELDORET, KENYA — February 2016 — We are in the middle of an all-day ENT Screening Clinic at Moi Teaching and Referral Hospital. The local ENT physicians have scheduled about 100 patients to return to see our American team to be evaluated for surgery during our visit. We have already seen several people with baseball-sized tumors in their parotids, thyroids, or necks. The surgical schedule for the next few days is getting full.

A thirteen-year-old boy sits in the exam chair. His father sits next to him. Henry, my Kenyan ENT colleague, hands me an x-ray with some blurry images.

“This boy’s neck mass has been growing steadily for the past two years. We were able to get a CT scan at another hospital in town since our scanner has been broken for the past year. The radiologist believes he has a glomus vagale tumor.” Henry looks at me. “Do you agree?”

I hold the scan up and the light streaming through the nearby window to illuminate the images. The mass is very large — filling much of the side of his neck — and it displaces the carotid artery (the main artery between the heart and the brain). The mass is bright white on the scan, confirming its very rich blood supply, and extends from the level of the lower jaw to the collarbone. The diagnosis is likely correct although I am not completely certain. At home, I would lean on my radiologist, trusting her to confirm the diagnosis. This probably is a glomus vagale tumor, I think to myself, but what if it isn’t? I need to be extra vigilant this far from home.

“How would you care for this in the United States?” Henry asks me.

“Well,” I say, “we would probably get some additional scans and order laboratory tests to make certain he doesn’t have a condition that runs in his family or one that might cause severe blood pressure problems in surgery. And we would send him to the specialized interventional radiologists and ask them to squirt some material into the mass before an operation to cut down on the bleeding. Bleeding during this kind of surgery can be very dangerous, even fatal.”

“Most of those things aren’t available here,” Henry tells me. “He would have to go to Nairobi. Four hours away. Oh, and I should mention that we might not have any blood transfusions available for surgery.” Henry smiles at me. “Can’t we just remove it?”

“It’s not a simple case,” I protest. I have goals for the surgical procedures we schedule during these trips: every operation should leave the patient better off, it should expand the skill set of the local surgeons, and it must reside reasonably close to my personal surgical “comfort zone.” This case, with its less-than-certain diagnosis and potential for bleeding and significant complications, makes me anxious.

“The mass is growing,” Henry reminds me after talking to the boy’s father in Swahili. The boy sits quietly in the chair, glancing back and forth between his father and Henry. His face is placid.

Henry explains the risks of surgery to the boy’s father. The goal of an operation would be to completely remove the tumor with as little blood loss as possible while saving the maze of anatomic structures plastered to its surface. Bluntly, we warn them that surgery might cause a stroke or paralysis of nerves that control the tongue, voice box, and shoulder. He could die. What happens if we don’t operate, the father asks? The mass will enlarge and become more entangled. There are risks both ways. I suspect they will decline the operation.

The boy looks peaceful. The father speaks quietly to Henry in Swahili who relays his words. “They want you go ahead. Shall we schedule for Monday?”

Hoo-boy.

Working in Kenya sometimes reminds me of earlier times in my training.

When I was a junior resident rotating through the VA Hospital and at the Milwaukee County Medical Complex in the early 1980s, there were days where I felt as though we were “working without a net.” Sometimes, we cared for patients with what I see now was completely inadequate supervision, using illegible records, difficult-to-read x-rays, and archaic techniques. It was all we knew at the time, but I shudder to think of the disasters we barely avoided. As we contemplate this boy’s operation, I have a flashback or two.

“Are you certain that they really understand the risks?”

Henry assures me that they do.

Over the next few days, I mentally rehearse the procedure. What tricks can we employ? What old pearls can I conjure? What would some of my mentors have done? Over the weekend, I mention to one of the other team members that the case is making me nervous. “Yeah,” she says, “I wondered why you put that one on the schedule.”

I debate canceling. I think about the boy and his father. I alternate between confidence that we will be able to safely remove the mass and anxiety about the decision to operate. This isn’t straightforward, I think to myself. If we don’t take it out now, it will be even a greater challenge next year or the year after that. Then I think, but is that reason enough?

On Monday, I stand across the operating table from Henry and Susan Cordes, one of the other American surgeons. My son, David, a fourth-year medical student, is holding retractors.

Just as we predicted, the procedure is difficult. We immediately face a tangle of blood vessels ranging from fragile, corkscrew-like veins to large pulsating arteries. There are diffuse, dense attachments to the surrounding tissues and direct involvement of the vagus nerve (which controls movement of the vocal cord among other functions). Every move requires planning and care as we dissect the mass away from the major blood vessels and critical structures.

The mass begins to ooze, a little at first and then disturbingly. I try to cauterize the bleeding points but it only makes things worse. I hold pressure on the mass. This helps, but every time I release the pressure, the blood begins flowing again. “Just keep going,” I say. As long as I keep pressure on the mass, things remain under control. We press on.

Time telescopes. My whole body is on high alert. Everything is in sharp focus.

After two hours, thanks to great colleagues, caution, and good fortune, the mass is removed. The bleeding stops. Normal time resumes and I realize that the temperature in the operating room is in the mid-80s and I am drenched in sweat. We close the wound and send the patient to the recovery room where he wakes up quickly. He seems fine.

We make Morning Rounds the next day. The young boy is sitting in bed, not quite smiling but on the mend. The mass is in the pathology laboratory; hopefully, we will get a final report in about a month. As I look at his neck wound, I realize that I am still reeling a bit from the case and am incredibly grateful that he is alive and recovering nicely. I feel alive, as well.

As soon as we finish Morning Rounds, we head back to the operating room for another day of surgery.

 

OnSurg thanks Dr. Campbell for permission to re-post his blog.

Featured Image (CC): Tom A La Rue

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