Today was a good day. First! Breakfast with no hog. Second! Actual feelings of accomplishment and usefulness, with maybe even a hint of job satisfaction. Rare last week, but definitely buoying me up as I walked home today.
Somewhat unexpectedly, this comes after two days of working with Mulago's gynecology cancer patients. As an ObGyn resident, our Gyn Oncology blocks tend to be a bit of bummer. Unlike our young healthy pregnant patients, who bounce right back to 100% even after the worst possible birth experience, our cancer patients are....well, sick. Their illness tends to put them at risk for all kinds of other medical complications, and all too often, they never get better. Caring for patients who are facing an unbeatable diagnosis is emotionally draining in a way that few of our other residency rotations are. I have great respect for Oncologists and Palliative Care folks who do this year-round; six weeks at a time in SF is enough to wear me out.
But I happen to be here with a UCSF Gyn Oncologist, Dr. Ueda, who's been coming here 3-4 times a year for the last three years or so. When she's here, she gathers the Mulago faculty with a particular interest in Gyn Onc and tries to do as much teaching, rounding, and operating as she can cram into a two-week period. And so this week, now that some of the house officers (Mulago hospital residents) are back on the floor and rounds are happening regularly again, I've decided to attach myself to her.
This turns out to be incredibly satisfying. The Gyn Oncology ward at Mulago is literally overflowing these days; as the old hospital undergoes very slow renovations, the department and its patients have been forced into an old Pediatrics outbuilding with far too few beds (and cartoon characters painted on the walls - feels a little incongruous). So patients line the sidewalk, waiting for someone to make a plan for them. And the patients who end up herded into the Gyn Onc ward may or may not actually HAVE cancer; more often than not, some other health care provider saw something he or she deemed suspicious (a pelvic mass, unusual vaginal bleeding, etc), decided it was probably cancer, and sent her over to wait.
One of the most noticeable differences in the Ugandan cancer patients versus American cancer patients is the dramatically different incidence of cervical cancer. It's more than five times as common among women here compared to American women, and it's also significantly more likely to kill patients here. Why? Pap smears! Hurray for Pap smears! One of the great medical inventions of the 20th century, I'm gonna say. Cervical cancer is a super-slow growing cancer, with many years passing between when a routine Pap might pick up something abnormal and when a patient might actually develop cancer; there's lots of time in a wealthy country to get a complete cure. But Pap smears are thin on the ground in Uganda. So patients here often present for care for the first time with cervical cancer that's already pretty advanced by US standards.
But the satisfying thing is that even when our patients have established cancer, we have tools that can help. Quite a bit, actually. Especially for patients who haven't tried any treatment at all so far - which is virtually all of them. Depending on how advanced their cancer is, there's only really two basic treatments: radiation or surgery. And it turns out you can get patients going towards one of those treatments in just a single visit. All patients need is a single good physical exam, a few basic labs, and maybe a chest X-ray for good measure - all of which is entirely feasible at Mulago under the auspices of Sister Eunice, Gyn Onc Charge Nurse.
So we the Onc team spent the day yesterday systematically making our way through seeing these women, bringing patients into our basic (read: a bit grim) exam room, checking their labs, deciding on a treatment plan under the guidance of Dr. Ueda, and making some moves. If you were a patient who needed radiation, you got a referral that very moment and could go start treatment in a week. If you were a patient who needed surgery - shoot, we could do it tomorrow if they were down.
And we did, today! From clinic to surgery in 24 hours! Fantastic turn around time. And one of our OR patients today was particularly satisfying for me. We'd found her in the chaotic Gyn ward last week, a 46 year old woman who appeared to be 9 months pregnant but was skeletally thin and malnourished - the hard mass filling her pelvis and abdomen had made it impossible to eat. We managed to get her out to our Gyn Onc ward and to find her later among the crowds of patients waiting on the sidewalk (luckily she always wears the same Boston shirt). And today, by golly, we took that mass out. I think it probably made up about a fourth of her total body weight. Crazy. And while we won't know if that mass is cancer or not for a week or two, I feel extremely pleased about the prospect of her eating an actual meal again without feeling too sick.
And I think that's Mulago Gyn Onc in a nutshell. You're seeing so many new patients, patients that no one has offered treatment to before, so you can give them the very best the field has to offer. And even in a poorer country, the field offers some decent stuff. If you're a lucky patient, you may get a complete cure. If you're an unlucky patient, you still may get a lot of good, pain-free years that you wouldn't have gotten otherwise. No small thing.
It won't make an Oncologist of me, but I can see the appeal. Looking forward to more this week.
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