Global Doc: Chemotherapy

Author: Dr. Vincent DeGennaro Jr. ’02

Vincent DeGennaro

“Have you ever worked in cancer care before?” I inquired of the well-kept young woman sitting across from me. It’s the first time I’ve ever had to hire an employee, and I’m probably just as nervous as she is. I asked her what she had learned in her eight years of school and work in the Dominican Republic.

Patrice has all the abilities we need for the oncology nurse program coordinator — she’s social, multilingual and possesses computer skills. I decide to hire her right then, but in order to act coordinated and professional I simply tell her that we’ll be in touch when we finish the interview process. We hire another dedicated and compassionate nurse as well. Cecilia has years of experience in pediatrics, obstetrics and maternity. The nurses will largely drive the oncology program, and we’re blessed to have two nurses whose skills complement each other.

A month later, the chemotherapy arrives in Port-au-Prince from India and the program commences. A Haitian-American chemotherapy infusion nurse arrives to instruct the new nurses in chemotherapy, which they had never even seen until the first day of the program. They absorb the information with aplomb, a sign of their grace under the pressure.

The program morphs from day to day and week to week. Some days are painfully slow for the nurses — the days when no patients show up for chemotherapy and no new patients come in for evaluation. Part of building a new program from scratch involves moments of quiet, spaces when you have more help than you need. The quiet recedes quickly as we fill up our chemotherapy schedule with at least one patient per day. In six weeks, the program has grown to over 30 women. If we were making money off of the treatment, business would be booming. Women are in different stages of the program; if they’re not receiving intravenous therapy, they’re waiting for biopsy results, healing from breast surgery or simply ingesting a daily pill for hormone therapy.

Patrice and Cecilia have adopted any and all jobs that the program requires, often without being asked. They mix the chemotherapy in a plastic case that is normally used to incubate premature babies, but now serves as a chemical hood for their protection in the case of a spill. We had to learn to maintain our stock of basic supplies like gauze and IV tubing since we started the program in a new building that wasn’t yet being utilized for clinical services. I devised complicated systems for documenting and tracking materials, but Patrice and Cecilia stepped in and told me that they would handle the supply chain, and that that had been part of their jobs in other wards. When the soot rising up from the street through the windows soiled the floor of the ward, they bought a broom and started sweeping. Only later did they ask me if we could hire a custodian.

As word of the program seeps out into the community, people have started coming to see us for other types of cancer. Some treatments could simply be added to the chemotherapy program, but others require creative and expensive solutions. There is a 33-year-old man with a bone tumor who had his leg amputated a month ago, or the 25-year-old woman with a thymoma, a tumor of the thymus glad that resides just above the heart and lungs in the chest. Both require chemotherapy and radiation therapy. We need to find a way to send these two young people to the Dominican Republic where they can get the radiation that they need to be cured. Without it, the chemotherapy will prolong their life, but not cure their disease.

We start looking around for funding because the cancer program doesn’t currently have the financial ability to afford the radiation therapy. I don’t know that we’ll ever find the money for their care, but we plunge forward with the process for a passport and visa anyway, desperately hoping that things will fall into place over the next month. Patrice and Cecilia take it all in stride. In the midst of administering chemotherapy, they work with the patients to help them get passports and visas. They adapt our electronic medical record to include new cancers. When we received a large donation of chemotherapy from a US hospital, I offered the excess to our partners that treat cancer around the country. Patrice gladly took charge of distributing and tracking the chemotherapy.

One day, a patient presents to clinic with a biopsy report stating that she has ovarian cancer. She’s 55-years-old, senior to the majority of the patients in the breast cancer program, and she’s surrounded by family. The cancer from her ovaries blocked off her intestines, causing them to twist and swell, threatening to burst. The surgeons at another hospital performed surgery and closed her belly after taking a biopsy and removing enough tumor to allow the intestines to deflate, but the rest of her insides were studded with thousands of miniature tumors. She’s incurable, but chemotherapy will help her to live another few years of high-quality life. Instead of dying within months with a belly three times as large as during a pregnancy, she’ll continue to care for her grandchildren and provide the wisdom for the family that only comes from a matriarch.

I wasn’t sure that we were ready to grow the size and scope of the chemotherapy program. New cancers meant new types of chemotherapy, developing treatment protocols and required further training for the staff. Treating all types of cancers also meant that the flood gates might open — instead of treating one cancer efficiently, we’d evaluate and treat everyone who walked in the door, perhaps diluting our abilities. Maybe we had already lain too much on the staff at this point.

“So far we’ve only treated breast cancer and she has ovarian cancer. What do you want to do for her?” I asked the staff. The doctor looked at me quizzically, not understanding the question entirely. He shrugged and said, “She needs chemotherapy. What protocol should we start her on?” With that, the program transitioned from providing chemotherapy only for breast cancer to include other cancers. With more tasks piling on, and the staff consistently astounds me by surpassing all expectations, and in doing so, they push me to do better.

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.