A middle-aged man with flank pain

A moderately obese middle-aged man with a history of treatment for kidney stones presented to our Indonesian village clinic with a history of severe left-sided flank pain for several days. He was febrile, and writhing with what appeared to be classic renal colic. Though we didn't detect blood in his urine, given his history and presentation, we still suspected he had developed another stone. Given the fever, we also wondered if the kidney was infected (pyelonephritis). More worrisome still was the possibility that he had both an infected kidney and an obstructing stone. That's a surgical emergency and beyond our capacity to care for at the clinic.

We began aggressive fluids, antibiotics, and antiemetics, and gave him the pain meds we have--Tramadol, paracetamol (Tylenol), and ibuprofen. Then we took a look at his kidneys with the portable ultrasound, hoping it would help determine whether we needed to worry about obstruction or whether this was just pyelo. The news was grim. The left kidney showed clear evidence of blockage in the form of hydronephrosis, while the right kidney looked normal. It looked like he did have pyelo and an obstructing stone. We discussed transfer options with the family.

They happened to be relatively wealthy, and they decided to take him to the city where he'd been treated for stones before. The five-hour speedboat ride was arranged to take place the following morning. We were worried about the delay, but it appeared to be the soonest they could arrange for.

Just after midnight, my colleagues and I were called to his bedside. He had become tachycardic, hypotensive in the 70s, and delirious. He had developed snoring respirations as well, though his lungs didn't sound fluid-overloaded. In short, he had developed septic shock, and his life was in immediate danger.

We stepped up our supportive care, but were now faced with several hard decisions. Do we attempt to get this patient to the city sooner than his scheduled 7 AM departure? Does the family have the money to make this happen? Is he stable enough to ride in a bouncing speedboat for hours on end? What about a plane flight? The planes that leave the nearest airport (about two hours away by car) don't have a first-class section, and the aisles are only two seats wide--that's not enough to lie down across a row of seats. In any case, it was hard to imagine putting this man into a wheelchair, let alone manually lifting that chair up the steep flight of stairs from the tarmac into the airplane cabin. And once he finally arrives at the hospital, is there a urologist there and an ICU bed?

Worst of all, if his breathing deteriorated, should we place a breathing tube? This is no small matter even in the highest-resource setting, because once you place a breathing tube you are committed to "bagging" the patient by hand, giving breaths, until he is connected to a respirator. Giving breaths manually is far from ideal--it is much too easy to give them too fast, too slow, or at the wrong volume. There are no respirators here, nor anywhere nearby.

Faced with these problems, the family swiftly chartered a boat to leave at 4 AM. They expected to be treated there by the same urologist he'd seen in the past. As we discussed treatment options, they told us they were prepared for the worst, but asked us to give "the best care" in the meantime.

What is the best care in this instance? Does it include placing a breathing tube if he goes into respiratory failure? That would generally be the right choice in a high-resource setting in a previously relatively healthy man like this. But here? Is it the best care to intubate someone out in a village, with no X-ray to confirm correct placement, no continuous monitoring available, no respirator to regulate the depth and volume of breaths? What if someone overinflates a lung during the journey and it collapses? What about the lack of easily-titrated sedative and pain medications to keep the patient comfortable? And, given that we are trying to save both lives and livelihoods out here (a trip to the city can completely ruin a family's finances), are we sending these people on a futile errand? Sometimes our job here is to advise against escalating care.

In this case, the family had the means to travel. And we were spared the intubation decision, as the patient's blood pressure improved with increased fluids and his breathing didn't worsen. Soon he and his family had sped away in the clinic's small ambulance, headed for the docks, an Indonesian doctor at his side with a bag full of fluid bottles and extra medications. And a bag to provide temporary breaths, just in case. We wait to hear how he did.

Breast cancer in developing countries

Cancers don't make top-ten lists of causes of death in poor countries, but that is because even larger numbers of people are killed by infections like diarrhea and TB. Make no mistake, those countries' cancer rates are high, and climbing. (The reasons for rising cancer rates are still unclear. Some think that nocturnal light as a byproduct of development is partly to blame.)

One of the worst offenders is breast cancer, now being called a worldwide epidemic at over a million new cases a year. I spoke last summer with Dr. Fred Okuku, a Ugandan physician who was at Yale learning medical techniques which he later took back to his own country. He told me that 95% of Ugandan women with breast cancer already have Stage IV disease when diagnosed. They notice a lump, then wait an average of two years before seeking treatment. As a result, many patients in Uganda recapitulate the terrible natural history of cancers with a thoroughness most Western doctors haven't seen in many decades. Okuku returned home with a mammography van and an ultrasound machine to try to change the grim statistics. (His colleagues there are well aware of the challenge and have risen to meet it: read on.)

What do doctors have to offer breast cancer patients in low-resource settings? What guidelines are available to those doctors? Which organizations are thinking about this?

Breast Health Global Initiative: Their 2008 Guideline implementation for breast healthcare in low-income and middle-income countries looks to be practical and comprehensive. They certainly know the need for such a guideline: "In high-resource countries, evidence-based guidelines...are resource neutral, they fail to consider variable resource distributions where overall standards of living are high, and they fail to recognize ubiquitous deficits in infrastructure and resources in LMCs. Moreover, they do not consider implementation costs or provide guidance on how a suboptimal system can be improved incrementally toward an optimal system. Such guidelines defining optimal breast care and services...have limited use in resource-constrained countries, and there is a need for resource-based guidance related to strategies for reducing the burden of breast cancer for settings in which optimal care is not feasible." 

Breast Surgery International: a group of surgeons interested in breast cancer in developing countries. Their 2002 paper is a summary of the breast cancer situation in Malaysia, South Africa, and Nigeria. It stops short of offering firm clinical guidelines. 

The Uganda Cancer Working Group, a group of Ugandan physicians based at Makarere Medical School in Kampala (Fred Okuku's school) in 2008 published a second edition of a set of guidelines for managing breast cancer in that country. (The first edition, report the authors, was well-received and heavily cited.) Interestingly, these guidelines emphasize breast self-examination while acknowledging that such measures are no longer being pushed in developing countries. What works in one context does not necessarily work in another.

Non-free journal articles on this topic include a set of guidelines from Stanford physicians, a review of treatment trends in the Arab world from the American University of Beirut, and a discussion of breast-conservation strategies in the developing world from Banaras Hindu University. Those with access to Breast Journal can find a number of relevant articles, including an article analyzing testimonials from patients in limited-resource countries which found several themes: "1) the experiences and fears of breast cancer survivors, 2) beliefs and taboos about breast cancer that hinder awareness programs and treatment, 3) the need for public education and breast cancer awareness programs in countries with limited resources, 4) difficulty in translating the concept and ethos of advocacy into many languages, and 5) the experiences in establishing and maintaining advocacy groups to promote breast cancer awareness and to inform public policy."

Ultrasound in Rwanda

Ultrasound is something I've blogged about before--I'm excited about an inexpensive pocket-sized version. Something like that may be what replaces the stethoscope in the near future, and American medical students and residents are already being urged to make it part of their armamentarium--though takeup is still not as good as it could be. My father frequently laments the difficulty of getting his residents to look for pleural effusions at the bedside, and very few ER physicians routinely do an ultrasound of the heart to determine if an elderly patient with low blood pressure is suffering from a weak pump or a dry one.

But as helpful as ultrasound will eventually prove in wealthy settings, it could be revolutionary in low-resource clinics. Paul Farmer's NGO Partners in Health studied ultrasound in Rwanda, training local physicians in its use. They found that the scans were accurate and sustainable: the Rwandans' and the American trainers' image interpretations agreed 96% of the time, and the clinic continued to scan avidly after the Americans had left. It was found to be particularly beneficial in planning surgeries and in caring for pregnant women.

Every low-resource clinic should have at least one ultrasound machine. The trouble is that the damn things are expensive--but there are a lot of older-generation models lying around the US, and getting those to where there are none would be a good start. Thomas Jefferson University has an equipment donation program, as does the World Federation for Ultrasound in Medicine and Biology.