She was twenty-five, and by all accounts a beautiful girl. I had just returned back from taking a presumed ectopic pregnancy "emergently" to the hospital in Arcahaie where she was admitted into the care of a group of Cuban physicians - As a follow up her family came by the clinic with some prescriptions for antibiotics and pain medicine. We just gave them some money. The surgery went well and she's at home recovering - #Crazy. But I digress. A twenty-five year old female is lying on the exam table when I get back. I can tell by the look on Angie's face that things aren't going great. I get a brief story:
She's been really weak recently. She was dripping blood as she was being helped into our office. And then comes the kicker. She whips out her camera and shows me an image that looks like an aerial view of a volcano when it has erupted. A charred looking mound with pockets of pink, red, and green. It was her breast.
I'm not about to pop off and say that I've seen x number of breasts because that would be totally misconstrued by those who may forget that I had to do rotations in Surgery and Ob/Gyn. But this was one of the worst presentations I've ever seen. I've seen pictures of breast abscesses and the peau d'orange skin changes. I've even seen mild cases of each in real life. But those pictures don't even begin to capture what this woman had been tolerating for quite some time.
More story: She's pregnant. She thinks she's 5, maybe 6 months along. And that might be why she has avoided seeing a doctor for this ailment with her breast for as long as it's been developing. Oh, by the way, she first felt a "lump" in her armpit area about 6 months ago. She thought it was an abscess, and it eventually went away. But then it moved anteriorly into her breast. And now she says she has bumps on the other side. Damn.
An exam is futile at this point. She's been bleeding from this ulcerated breast. You can't even call it a lesion because the tissue changes actually involve a greater circumference than her breast. Not only that, but she's hypotensive, her pulse is thready, and she's symptomatic. I don't think her breast cancer is her most immediate concern.
Angie has already hung an IV, and for what it's worth put her first line in since medical school. The patient was recovering from the blood loss. Her wound was dressed. Now we had to figure out how to get her to a hospital for treatment. She needed palliative care. There aren't a whole lot of those services in Haiti. A palliative mastectomy would likely benefit her as well as that might stop her blood loss. So that's what we're convinced we should try and champion for. And it's decided. Wesley and I are going to head back out and take her to a hospital.
More story: She's already been to a "local" hospital and was denied care... Okay. So we probably can't take her to Arcahaie if they weren't comfortable. Our other option is St. Marc's about an hour and 15 minutes away. Tap tap is on the way. #Bon.
When it arrives we load the patient up and Wesley and I hop in the back. We're off once again. It was a coastal drive much of the way and the water looked absolutely gorgeous. I'm talking major motion picture hottie gorgeous. Fortunately I'm able to train my attention to check our patient in the front seat with the IV bag hanging from the rear-view mirror. It's not like the drivers in Haiti use those mirrors anyway.
We make it to the hospital after stopping briefly for directions. Wesley and I help the patient get into the emergency room where we are greeted by a nurse. I calmly explain that she came to us, vitals in the trash, bleeding, and that we think she needs a surgery for her breast disease which is neoplasm vs infectious. Oh, #btw's, she says she's 5-6 months pregnant. The nurse takes down the dressing. "It's cancer. We don't have an oncologist. She should probably go to Port-au-Prince." Wow. That's not the response I was expecting.
I stand back and collect my thoughts. I call Angie for a peptalk. I give her the low-down. "They think she needs to go to Port-au-Prince." PAP is the opposite direction if you don't have a map of Haiti open right now. We'd actually go through our home of Arcahaie on the way. What to do, what to do? I decide just to try and refocus their energies. This woman would garner no benefit from an oncologist. Her prognosis is set, assuming it is cancer. But her problem is blood loss. I hang up the phone. I grab Wesley and try and talk about prognosis with the patient's sister. "Would she want to have a major surgery if it only extended her life by weeks?" I'm not sure it was well communicated, but we were told to pursue whatever avenue we could. Maybe it was so we could save the baby.
I go back into the "ER" and flag the same nurse down. I ask her if a doctor would come see the patient. "I know she has cancer, but that's not her primary problem. Her problem is that she's bleeding." I turn into a smartass... "Bleeding will kill her a lot faster than the cancer will." Fortunately I think the translation doesn't carry quite the sass. I've probably benefited from that more often than I should. But it works. She asks for the doctor as she asks for the Doppler to check the status of the baby.
The patient lays there as the physician directs a syringe into the middle of her breast. Luckily we gave her a percocet at the clinic and lucky for her that she was narcotic naive because that had to have hurt. At the same time the nurse runs the doppler over the patient's uterus. Swoosh, swoosh, swoosh. Clipping around at 120. I lightly grab the patient's wrist. Her pulse matches up with the doppler perfectly. That's not her baby. I shake my head at the nurse to let her know. She re-positions. Same pulse. That's not a good sign. Slowly I begin to realize that she's probably not pregnant. She likely never was. For her to have breast cancer at this young of an age and for it to be this aggressive, she has to have a genetic predisposition. And if you are predisposed to breast cancer you are likely also predisposed to endometrial cancer or ovarian cancer. Damn.
The doctor aspirates the syringe. A speck of blood, but definitely not an abscess. There is no pus. There was no cavity of infection that he could find with his probe. It seemed to be a solid mass. "Do you think a palliative surgery would benefit her?" He didn't want to operate on her. He wasn't sure he would even be able to close the skin as there wasn't much not involved. I wasn't sure she would survive an operation.
This isn't a happy story. It's a reality story. Twenty-five is ridiculously young to have what I have to assume was two primary cancers. And ladies I'm not trying to be dismissive, but usually breast cancer victims do alright. But we screen. We over-screen as a matter of fact. Xrays, ultrasounds, biopsies, oh my. This patient didn't have that luxury. She was from the mountains of Arcahaie. There was no family practice doctor that she could turn to when she had this abnormal lump in her armpit that she thought was an infection. She wasn't receiving any prenatal care even though she thought she was 5-6 months along. And after speaking with her sister and the nurse even more we came to find out that she was told that she had breast cancer at another hospital. A hospital where they could've treated it. But she didn't get it done. Be it cost? Be it the fact that she thought she was pregnant and didn't want to lose the child? I don't know. But she certainly didn't have a champion or an informed guide helping her navigate the treacherous and confusing world of healthcare. She had nothing.
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