I lost a patient today. She was not my first, and unfortunately, she will not be my last. But today was different.

Tuesday

She arrived yesterday on a typical Rwandan stretcher (see picture). This required eight people, who worked in shifts, to carry her up the mountain to Shyira Hospital at 6,000 feet above sea level. She was clearly in respiratory distress, so we bypassed the clinic and admitted her directly to our 35-bed internal medicine ward. As she paused to catch her breath between words, she described one year of a progressive dry cough and pain in her right breast.

I began to examine her, and she looked at me with a mix of fear and hope in her eyes as she pointed to her right breast. After I lifted up her shirt, I understood her fear. Her breast was a large, rock-like, solid mass! As I continued to listen to her extremely coarse breath sounds, I felt my own heart sink.

How could she have waited a whole year with this?!? Why do people wait so long before coming to us for treatment? In the U.S., she would have been knocking at her doctor's door months before, but in rural Rwanda, traditional healers are often still first line. She probably went to a healer, who told her that she had been poisoned. He would then give her something that might make her vomit. If she vomited, she had clearly been poisoned. If she did not vomit, she might then consider going to the hospital. These healers have nothing like a Hippocratic Oath, so patients always have to wonder whether or not their healer has been paid by somebody to give them something dangerous. This may be one of many reasons that Western medicine is growing in the region.

Despite that growth, I was still standing and looking at this patient that I now knew was HIV positive and had an oxygen saturation of 81%. While I had been pondering questions about how my patient ended up in such a dire situation, new and more dreadful questions hit me... What does she have? How can I possibly find out? What can I do for her?

Diagnosis

She most likely had a breast cancer or breast tuberculosis, although other causes could not be ruled out. To diagnose cancer or tuberculosis would require the ability to analyze tissue, which is not yet available at Shyira. We ordered sputum smears for tuberculosis, but she had a dry cough, and we are not able to induce sputums in Shyira. We were also out of the reagent used in the testing of the sputum.

Maybe imaging would be helpful? To get a chest x-ray requires a one-hour drive down the rockiest road that I have ever seen. Most patients vomit in the car either on the way there or back. The patients are usually dropped off there in the morning and picked up at night. To get a CT scan or pathology analysis would require a 3-hour drive each way to Kigali, the capital city. As if this was not complicated enough, the entire country was out of x-ray film. And of course, any such transportation is not possible with a woman in respiratory distress and an oxygen saturation of 81%.

Treatment

She was hypoxic at 81% on room air and had very coarse breath sounds and wheezing. At the very least, she needed oxygen. While we had oxygen available, we did not have electricity to run the oxygen machine. She needed some relief from her respiratory distress, but we did not have any nebulizers or inhalers.

Her breast mass was most likely cancer or tuberculosis. If it was cancer, it was likely inoperable, and we could not definitively say without imaging. Either way, surgery and limited chemotherapy would not be available except three hours away in Kigali. Radiation therapy does not exist in Rwanda. If it was tuberculosis, we could treat her, but we doubted whether the treatment could work fast enough to reverse the course of her very progressive illness.

We gave her antibiotics, anti-tuberculosis medication, and steroids and then hoped for the best.

Friday

I did not see her yesterday. I was at a meeting with the mayor and other government officials as we tried to organize plans to provide more consistent hydroelectric power to the area. The Rwandan government, Belgian government, American donors/investors, and Rwandan investors have all combined efforts and funds to help provide life-saving electricity to the area.

But as I look at my patient today, I know that these plans will not save her. She is breathing at a rate of 36 breaths per minute. She cannot talk as she gasps for air. We are making arrangements to provide her with palliative oxygen as we transfer her to a private room. At the end of rounds, I ask the nurses if she has been transferred to a private room. They reply, "Oui, mais elle est morte." Yes, but she is dead.

I pray for her and her family and then head to lunch.

Michael Bestawros is a Senior Resident in the Department of Medicine. He is currently completing a three month global health rotation at Shyira Hospital in Ruhengeri, Rwanda. This fall he will pursue a master's in public health at UNC.