Global Doc: A troublesome tumor

Author: Dr. Vincent DeGennaro Jr. ’02

Vincent DeGennaro

Dominique came to the internal medicine clinic desperately searching for help. The tumor had burst through the skin on his left shoulder, leaving an open wound. The wound had started to leak and had a distinct smell that indicated an infection. His mother haphazardly placed gauze over the wound in an attempt to keep it clean, but had succeeded in doing little more than keeping the maggots away.

The surgeons took a biopsy of the wound and we sent him to the Project Medishare wound care clinic. Each day the expert nurses there would clean the wound and work towards curing the infection without any antibiotics, even without antibiotics.

Dominique’s clothes were soiled with dirt and sweat from the various manual labor jobs he picks up when they’re available. The tumor had sidelined him from work, preventing the 23-year-old from contributing to his family. His mother, a weathered woman with an angular face, accompanied him on each visit. While we waited three weeks for the biopsy results, she helped him dress and clean himself, and ensured that he made wound care appointments. Both Dominique and his mother wore the same clothes to the hospital every day. Kind and soft-spoken, Dominique had a huge smile of bright white teeth, sheepishly offered whenever he became the center of attention.

We have treated nearly 200 patients in the last year, and, statistically, the patients in the program are doing really well. Most of them complete the treatment and follow up every three months with no evidence of recurrent disease.

But the failures are the ones that remain in my mind. The faces of the young women who succumbed to breast cancer. Middle aged patients who were responding well to the chemotherapy and died suddenly of a blood clot in the lung. The woman with cervical cancer whose disease progressed too quickly while she awaited a passport to go to the Dominican Republic for radiation. Would Dominique join this group?

The biopsy results declared that Dominique had a type of bone cancer called a sarcoma. A CAT scan showed that the tumor was still confined to his shoulder region. The good news was that the tumor was curable. The bad news was that it required complex surgery or radiation, neither of which was available in Haiti at the moment. While waiting two months for a team of specialized orthopedists and plastic surgeons from Canada, Dominique received two sessions of chemotherapy and the tumor shrunk significantly. The surgeons then removed the remainder of the tumor and, since there was not enough skin left to close the wound, they placed a skin graft over the hole.

Then the bad news started flooding in. While no one event was individually significant, the chain foreboded the beginning of the end. The surgeon informed me that they were unable to fully resect the tumor because residual pieces clung to the nerves and arteries deep in the armpit. An incomplete surgical cure meant that he would require further treatment — this time with radiation. Then his thin frame dripped with sweat as an infection took hold only two days after the surgery. The donor site where the skin graft was taken from had become infected, and Dominique once again had to resume daily changes to the bandages that covered his upper back.

While he was healing from the surgery and the infection, we started the process to obtain a passport in order to make the journey to the Dominican Republic for radiation. However, Dominique was born at home and had no birth certificate to document his existence, further complicating the process. He and his mother had to make the six-hour journey home to appeal to the local magistrates to grant him a birth certificate now, at the tender age of 23.

The wound finally healed on his back, but before he was granted a passport, the skin on his shoulder burst open. The tumor from grown from deep down in the armpit and had surfaced again. Sarcomas can grow quite rapidly, doubling in size every week or two.

The enlarging tumor and the healing of the wound consumed his extra protein stores, and Dominique’s mother could not afford to purchase enough food for him in pricey Port-au-Prince. At home in the provinces, his mother would cook beans and rice, but in the city, she had to purchase food on the street at a significant mark up. The cancer program at Project Medishare gave the family cash while they stayed at a boarding house in Port-au-Prince because malnutrition is a significant detriment to clinical improvement. We also supplied protein-fortified rice that he could down as snacks or meal replacements. Nonetheless, Dominique continued to dwindle away waiting for his passport.

Images of the patients who had died whipped through my mind. Four months of treatment, and we were back where we started — an emaciated young man with a tumor popping through the skin of his shoulder.

Mercifully, two months later, Dominique had a passport and the wound on his back was fully healed, a necessity if he were to undergo the rigors of radiation. We had told Dominique a dozen times that his mother could not accompany him on the trip; we couldn’t afford the fees for passport, lodging and food for both of them. Despite being in his 20’s, he was reluctant to travel so far from home alone. Nearly every day for two weeks he showed up at the ward with a new set of questions or excuses about why he couldn’t travel. The nurses, finally convinced him to make the voyage. On the morning of his departure, he had no possessions but the clothes on his back. We gave him another change of clothes and new shoes from the donated stocks at the hospital. Vaya con Dios, amigo.

He arrived safely at the boarding house in the Dominican Republic by the next evening. Six weeks flew by with no word from him. I imagined the scared young man watching the buses fly by and the bustle of the people on the street.

Last week, I received an email from the owner of the boarding house in Dominican Republic that simply stated, with no salutation or sign-off, “I will send you Dominique tomorrow, if God wants.”

When I saw Dominique at the hospital, the huge grin on his face shone like a beacon from across the cancer ward. He had made it, gone through Hell and back, and come through healed. He was sporting a Denver Broncos jersey and new jeans and shoes; he even had a yellow hat representing one of the political candidates from across the border. He embraced me and could not stop smiling, and neither could I. He proudly displayed the scar on his shoulder, now fully healed and closed off, no signs of the cancer that had ravaged the area for six months. We spoke about his experiences in the Dominican Republic, and he denied having a Dominican girlfriend with a smile. At long last, Dominique was healed and ready to resume his life in the provinces, helping his family.

“Can I go home now?” he asked with excitement.

“Yes. See you in three months for a check up. Bon voyage, zanmi.

Vincent DeGennaro is an internal medicine doctor and a global public health specialist at the University of Florida’s Division of Infectious Diseases and Global Medicine and works half time in Haiti with the nonprofit Project Medishare. See his An American Doctor in Haiti blogs.