We have just arrived on the internal medicine ward at St Therese Hospital in Hinche, a regional district hospital in Haiti’s Central Plateau. Despite its position as a district level hospital, the ward has few resources for diagnosis or treatment, and the resources it does have may be available only intermittently. And yet into this environment come patients with severe illness, often at late stages of presentation.
On the ward currently, we have a young man in his 30s. He was admitted with significant ascites (fluid in his abdomen) and leg swelling. He also had yellowing of his eyes, suggestive of liver disease. At the doctor’s request, his family had carried a sample of his blood to a private laboratory to best tested for Hepatitis B; his test result came back positive. This was only a piece of the puzzle: how severe was his disease? Did he have cirrhosis? Liver cancer? We were happy to discover the hospital (currently) has a working ultrasound machine. We jumped at the opportunity to ultrasound his abdomen looking for more diagnostic information.
Later in the day, the patient stopped us. He asked in Creole if we would please repeat the ultrasound on a regular basis. After days without any remedy, he thought the scan had been a form of treatment for his disease. No, we replied, this is not part of your treatment, only a diagnostic test. His misunderstanding, however, raised uncomfortable questions for me.
On the one hand, I felt guilty. I had been excited to try out my ultrasound skills, a new tool I hope to use in this underserved setting where our other diagnostic options are so few. I was gratified when successfully identified abnormalities on his liver, suggestive of liver cancer, because it offered an explanation for his presentation. While he and his family may also appreciate knowing the diagnosis, what they really crave is treatment. An ultrasound helped confirm our clinical suspicion. It does not get us any closer to treating his disease or even his symptoms. There will be no chemotherapy, no surgery, no TACE procedure for him. He will likely die from his cancer relatively soon.
But perhaps in some small way, our patient was right. The ultrasound is symbolic of one of the only tools in our arsenal here- time spent caring for our patients and investing in their care. While this at times feel grossly inadequate, when we are struggling against great inequity, our role as physicians may be simply to bear witness. This can take the form of sitting on the edge of the bed, holding a hand, and asking about a patient’s family. Or perhaps it can take the form of ultrasounding a liver, in the hopes of finding something to provide answers and if we’re lucky, find a disease we can treat. If we cannot, we have to ensure that improved diagnostics serve as the first step in advocacy, giving us the data we need to push for better access to cancer care.
By Dr. Robin Tittle – UCSF Global Health Hospital Medicine Fellow