So here is one of the clinical dilemmas we face all too often here:

So here is one of the clinical dilemmas we face all too often here:

We have a 50+ year old man with a mass in the R upper lobe of his lung that was found in August and presumed to be cancer (long-term smoker).  He returned last week and really was not looking as sick as we thought for 6 months further along.  So...does he really have TB or another process going on?  Unfortunately, he lives on an island some 4 hrs away.  Still, he was able to afford a chest x-ray in Ketapung, so he returned with that this week and the mass is much larger -- still suspicious for cancer, but he is just not very sick and has no nodes we can palpate.  About the only thing we could actually treat would be TB; however, there is no DOTS (direct observed therapy for TB) worker in his village.  Add that to the substantial risk that if we treat him for one month, he likely will be lost to follow-up and increase the risk of developing MDR Tb (multidrug resistant).  Also, in-order-for the government clinics to prescribe the TB drugs for free, they require more proof of tb than what we have for him.  What to do??  Nur will call the govn doctor in his village and try to convince him to give a trial of TB meds for a month and provide follow-up.  We simply cannot risk treating him incompletely for TB.

Always, the care we provide is balanced with the ability of patients or families to afford what we suggest (sometimes x-rays or surgery).  Many decisions are made to forego the treatment we suggest because it's not affordable.  We do an amazing amount of care with just good clinical judgement.

We have just four more clinic days before departure and will see what new or old problems will confront us.

Jim

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