Changing the tires while riding the bike

This tourist from Thailand stopped me to ask for help with his DSLR camera.

The simplest things can turn into an impossible task.  One of the (many) issues with breast cancer here is that many patients are diagnosed at an advanced stage and would benefit from receiving chemotherapy before surgery.  To give the proper agent you need a good core biopsy that can be tested for tumor markers (estrogen receptor, HER-2, etc).  Currently, diagnosis is always make with fine needle aspirate (FNAC), scraping off just a few cells with a small needle, directed by palpation by the pathologist.  Unfortunately, this is generally not adequate for special stains and so the patient goes straight to mastectomy in virtually every case.  Core biopsies are used for diagnosis in over 98% of cases in our hospital in Salem, and in the case of a palpable mass I can accomplish this in aobut 10 minutes in my office and have the answer in 24-48 hours.

At about 10:30 this morning I saw a 27 year old woman with a 5 cm mass in her breast which had appeared over 8 months.  The FNAC was read as "favors malignancy."  I wouldn't want to do a mastectomy with a lack of definitive diagnosis, not even in this low-resource environment.  So, I recommended core biopsy.  Is there a core biopsy device in the hospital?  Where is it stored?  Where can I do the procedure and who will help?  The patient had an entourage of mother, brother, friend, concerned friend of brother, who all trailed down to pathology to wait.  The procedure room was full. Other patients kept arriving for FNAC of cervical nodes, thyroid, etc.  Finally, about 1:00 pm we had the room.  Patient gets on table; my short list of supplies has not arrived (lidocaine and a scalpel blade.)  Patient gets off table another gets on.  A runner is sent to a different building for the supplies (requested over 2 hours ago.)  I finally prep the patient, only to find the core device is a tiny, flimsy 20 guage needle meant for prostate.  It will not enter the rock hard mass.  By 2:00 pm the patient is back in clinic getting scheduled for an open biopsy in the operating room later this week.

And so it goes.  Can I convince the surgical oncolgist to order the appropriate device?  Will it be used when it arrives, or is it easier to just keep doing things the same way?  In the case of overwhelming workload and high acuity of illnes where is there time to step back and come up with a better plan?

Washing clothes and getting clean.

The one thing this experience really has going for it is the ready-made community of other Health Volunteers Overseas staff.  In fact, the hospital is full of a little United Nations of volunteers:  A pathologist and an ENT surgeon from Cuba, hematologist from Australia, pediatrician from Germany, and at least a dozen from the United States in various specialties.  Some, like me are staying only a month; others have brought their families and are here for one or two years.  They range in age from last year of residency to post-retirement.  Information flows readily:  where to change money and use internet; how to set up lectures for the residents; where to find bathrooms with sinks and TP in the hospital; where to eat out and buy fresh fruit.  All of us seem to share the same mixture of frustration and guarded optimism.

This weekend four of us took an overnight trip to Punakha, the next major town to the east, over 10,000 foot Dochu La pass on the National Highway, a ragged, potholed, sometimes paved marvel of engineering that twists and turns and switchbacks throught impossibly vertical terrain.  Imagine taking this ride (3 hours from the town closest to Thimphu) in the back of a lurching ambulance at 15 mph with broken bones or an acute abdomen!

Tea time at the Nolanda Monastery, where visitors provide the useful service of letting the older monks practice their English.  They have internet service, where they can update their Facebook pages and watch foreign movies.  These three aspire to a lifetime of studying Bhuddism, although they would like to travel to England or Australia.

 We visited monasteries and temples and the fantastic Dzong (fortress), and slept like logs in lovely soft beds.  We got a little better understanding of the importance of Bhuddism in everyday life here, and the quantity of resources that are devoted to it.  Many boys and girls start in the monastery or nunnery at the age of eight, and then at 18 chose to stay or join secular life.  Meanwhile, they are supported almost entirely  by donations and as part of the government structure.  The fantastically elaborate temples and religious buildings are continually updated and repaired.  Every monk has a cell phone though--provided by their family to stay in touch, or earned by money given for performing special rituals and blessings.

Who am I to decide the relative value of all of that versus a readily available 14 guage core biopsy needle?

Ghos and Kiras dry in the sunny fields of chilis.