Hi everyone! It has been a very long time since my last post. Thank you all for the support after my last post! I’m alive, well, and enjoying life still. We have a lot of medicine to catch up on: Amina (our hyena-bite laryngectomy) is being discharged, we completed our first laryngectomy, have done 3 endoscopic transsphenoidals, and have seen some new amazing pathology. But that’s all for another post.
Today, surrounded by the sights, smells, and sounds of Tanzania, I’d like to talk about something different; contradistinction.
Now, lets be honest. I came across this word in an attempt to describe the comparison of different experiences culminating in some unique point of view. Now, there may be a better word for this (especially because contradistinction peaked in its use in the 1800s), so please let me know and forgive my lexicon.
Beginning with the obvious, I’m afforded this trip to Tanzania because my wonderful parents and one of my brothers came all the way to Mekelle to visit me. My other brother has a 1 year-old at home, so a transatlantic trip is not in his near future. We had planned this trip from the beginning to coincide with the mid-way point of my Mekelle journey. A way to show my family my passions, but also as a method to escape and re-set. As you can see from a couple of these preview scenes, the reset button was pushed the moment I looked out my window.
As most of you know, my life prior to moving to Ethiopia was simple, predictable and flush with all the comforts provided by the United States. And, although Mekelle has been a challenge to adapt to, it still provides the basic comforts. Nevertheless, the cold showers, dust, power loss, persistent illnesses and the ever-present threat of being attacked wears on you over time. Then, when directly compared with the incredible luxury traveling with your parents can provide, you’re forced to contemplate whats really important to you in life. My brother and I went on a long walk out of the first camp to a local village, just to explore. But instead, it provided us with a great opportunity to explore life’s contemplations together. Since I didn’t grow up with him, these conversations have been few and far between, mostly focusing on the superficial in order to use our short time together in the most amicable way possible. But, both of us inspired by the contradistinction of home and Tanzania, we challenged ourselves to identify what gives us fulfillment in life.
I’m not going to get into it here, but despite the above-mentioned challenges, my life is better than its ever been. I could have never dreamt my current life, but somehow it feels I’m living my dream.
Fast forward a couple days and we embark on a mesmerizing ecosystem hidden within the famous Great Rift Valley. Initially gaining notoriety in my life during medical school. The rift is associated with a single-stranded RNA virus transmitted from infected animals to humans by direct contact or mosquitos as vectors. If you’re unlucky, it can cause hemorrhagic fever and encephalitis. But today, it introduced me to ridiculous splendor. Specifically, we descended into the Ngorongoro Crater situated in the center of the Rift in Tanzania created by a massive volcanic eruption 3 million years ago. To the world’s delight, it left behind a unique ecosystem isolated by the high rift ridges that not only served as a geographic barrier but also as reservoirs to catch and distribute rainwater, luging it down to the crater floor.
As a result, 260 square kilometers of the rift supports a completely self—sustainable ecosystem where animal behavior is as unique as the crater itself. With one of the densest known population of lions, predator and prey lay together in the lush grass, drink together at the lake and seemingly respect each other’s personal space. Here we witness a couple of buffalo ask a large pride of lions to kindly move away while they grazed. The lions obliged. As opposed to other safari I’ve been on (in Botswana), theres no race to spot an animal. Copious radio chatter between guides is replaced by a chorus of biodiversity. Predator and prey alike were fat and healthy. In my mind, I imagined a ritual of sacrifice offered by prey each week so they could all remain to live together in paradise.’
It was here where our guide said something that caught my attention. He explained that the baby of wildebeest not only can start running hours after birth, but that their legs are the same height as the adults at birth. Thus, when looking from ground level (as their predators do), it would be difficult to tell which were vulnerable young. To summate these statements and many like it, he positions “everything happens for a reason.”
Now, this is a theory all too familiar. One which normally elicits a cringe for me. Typically used by those that don’t have answers, this statement is often used to explain away things that cannot be explained. A simplification used to relieve the mind of worry. But, to see it applied to biology and evolution was refreshing…and accurate.
The bone-crushing power of a hyena’s jaw (or larynx devouring power; I promise that story is coming soon!) happened to help them survive as scavengers. Tiny Dik-Diks have a preorbital gland that produces a unique sticky substance that they use to mark their territory to minimize conflict. Being small is tough enough in the Serengeti.
The seemingly playful evolutionary relationship the Acacia tree has with Giraffe is another great example. These trees dominate the Serengeti and Giraffe are specially evolved to pick between the thorns of their high branches. Clearly not a problem for the specialized tongue of the Giraffe, you’ll notice the Giraffe only stay at a particular tree for a matter of minutes. To battle the tongue of the Giraffe, the Acacia tree (when disturbed) releases tannins from the trunk to the leaves, turning the leaves bitter. These are the same substances that give red wine that “hairy tongue” sensation I distaste so much. So, the Giraffe is forced to leave that tree and move upwind to the next. Once the Acacia tree grows tall enough to be out of the reach of the Giraffe, it sheds its thorns and focuses all photosynthesis on its own longevity. Soon becoming the favorite hiding place for lions and leopards alike (although one is significantly more graceful than the other).
Although these evolutionary events didn’t just “happen” and are the product of thousands of years of trial and error, these changes have a “reason.” To increase the chances of survival. Although I was happy to see the phrase used to describe something I can understand and know to be true, proven and what drives all life on earth, I couldn’t help but think about the phrase’s most common use.
As a way to explain away the unexplainable, “everything happens for a reason” is a construct of human nature. A way for people to ignore an event’s true meaning or origin. Since its clear that I don’t believe in the statement when it comes to human nature, some of my greatest struggles in medicine revolve around trying to understand the origins of some human behavior.
For example, I understand why someone would target me in Ethiopia, attack me and steal my valuables. Being white identifies me as having wealth and I placed myself onto a street at night without any lights, alone. Something I wouldn’t do even in the states. I was an easy target for someone who doesn’t believe in civility. I don’t blame them for being criminals. Our society’s failures have pushed them there. In fact, they would likely use the phrase, “everything happens for a reason” to help explain away the series of terrible things that have probably happened to them in their life. Trying to explore the origins of their wrong-doings perhaps would be destructive.
But what I can’t understand is the terrible fate of one of my patients had prescribed to her by her sons just last week. A lady in her 70s presented to our ER in respiratory distress. When I arrived, she had loud biphasic stridor and was saturating in the 90s with occasional oxygen assistance. She had a large goiter. The family tells me that its been progressing over the past 2 months. Of course, given my experience the last 5 months in Ethiopia, my mind immediately jumped to anaplastic thyroid carcinoma. A universally fatal diagnosis of very aggressive thyroid cancer. Once the malignant transformation occurs, it eats through anything it touches. Thus, given it’s proximity to the trachea, it is often the first victim. Invading through the anterior or side walls, the growing mass slowly strangulates the patient. Death is usually just months away at best. The lucky patients have carotid invasion and die from a catastrophic carotid blowout. There is no reliable cure so the best we can offer is a palliative tracheostomy. Not only does this buy the patient some time but may also spare them from the agonizing death while slowly suffocating.
So, I was shocked when I opened the chart to see a fine needle aspiration report from 2 months ago beautifully describing those lethal bright blue cells with the diagnosis in bold reading, “Anaplastic thyroid carcinoma.” The family and patient had given me the impression that no diagnosis was known.
I reacted poorly, turning to my 3 senior residents in the room with an unnecessarily accusatory tone, “what the hell is this?” I could feel my anger rising as they explained the back story to me. If I had this information 2 months ago, I could have sat down with the patient and family, explained the diagnosis, prognosis and what we could do to help. But now, in front of our eyes, she was dying. Characterized by her uncomfortable posture, wide scared eyes, loud labored breathing and her aged skin retracting tightly around her contracted sternoidcleidomastoids with each breath. When your body desperately needs oxygen, it uses every muscle it can to increase the intrathoracic negative pressure and stent open the upper airways. When the neck muscles join in this complex concert of contractions, it’s an easy sign that somethings very wrong.
At this point, there were only two options for her. An emergent awake tracheostomy or slow suffocating death over the next hours to days. The former would bypass the obstruction and provide relief. Thinking the procedure through in my head elicited twinges of anxiety and panic in me. Just two weeks prior, I was suffocated. Looking into her eyes I could see her silently screaming for help just as I had done laid out on that dark, cold cobblestone road. Perhaps for the first time in my medical career, I knew exactly what the patient was feeling.
Continuing eye contact with her, my senior resident leaned to me with a quiet tone and explained that her sons didn’t want her to know the diagnosis. Further explaining, “she wouldn’t be able to handle it.”
This 70 year-old women had an isolated problem. Her airway was narrowed by an aggressive, but localized cancer. It required a lot of muscular effort to force atmospheric air into her alveoli. As a result, her overall oxygen demand was higher, her blood more acidic from cellular metabolism. Carbon dioxide slowly elevating. The body’s best mechanism for achieving homeostasis after muscular exertion is increasing gas exchange in the lungs. Exhaling carbon dioxide is just as important as absorbing oxygen. With a physical obstruction in the trachea, a lot of the carbon dioxide was being trapped. Forced back down into the alveoli with each breath, competing with space for oxygen to diffuse into the bloodstream. If carbon dioxide levels accumulate in the bloodstream, they can begin to affect the brain stem and essential cortical functions. You can become so confused and lethargic that rational thought is impossible.
This wasn’t the case yet. She knew exactly what was happening to her. She didn’t need to hear “you are going to die from cancer” to know that she was dying from something. The fear in her eyes told me everything I needed to know. She wasn’t ready to die. I let my emotions take over.
My residents know me by now. They knew exactly what I was going to do. I could feel all 3 of them emotionally and physically gravitate to me, forming a united front to sweep in and help this poor dying woman. They interpreted as I spoke.
First addressing the two sons: “Your mother is dying and she deserves to know that. I’m going to tell her and give her the option for treatment.” In my mind, I was already formulating how to speak to the mother as my residents interpreted what I had just said to the family. I carefully watched their reaction in real time. Their posture changed. They stood up straight, shoulders positioned posteriorly and chins elevated. I had seen in a hundred times on safari. When your masculinity is challenged, make yourself look as large as possible. In nature, the reaction is fight or flight, but for civilized humans, I knew they had no choice but to let this happen.
I proceed to explain what was happening to the mother. As I did, the sons scurried around the room — one even left — unsure of how to oppose my challenge. I explained to her that there was no way to save her and that a tracheostomy (if she survived the procedure) would only prolong her life for a short period of time. Enough to arrange the end of her life. To get home and die at home. This was paramount to Ethiopians in Tigray. Our last anaplastic thyroid carcinoma patient decided to forgo tracheostomy and attempt to make the 12-hour drive home to die on her own soil. As this represents the only other viable option, that was this previous lady’s decision and I was happy with it. I often also prescribe morphine to ease the air-hunger anxiety. This might be the only way to die comfortably from this terrible disease.
Once the explanation was complete, I could immediately see her answer in her wide, bloodshot, sclera-dominate eyes. She points at her neck and tells the residents to put in the trach. She made the decision in seconds. She had a way out from the agonizing suffocation and she was willing to take the risk. The second I say, “OK, lets go upstairs to the OR,” the other son barges back in, physically pics the mother up and takes her out of the clinic. We explained that she wants treatment, but he didn’t care. His beliefs were paramount over that of his mother’s. He knew what was best for her. As she was dragged from the clinic chair, her face shifted from hope to defeated despair.
I didn’t know what to do, honestly. I knew there was no way to verbally convince them. Physical intervention would be legal in the states (by police or security guards). In Ethiopia, it turns out, there are no legally-backed medical ethics to protect a patient in these instances. Culturally and legally, its OK for someone else to decide the fate of their family member even when they are perfectly able to do so themselves.
As you can tell. I’m not OK with this. This woman had lived 70 years of her life making her own decisions. She was so good at it, in fact, that she lived to 70 years in Ethiopia! She knows what she wants and deserves to die how SHE wants to die. She earned at least that much.
I was emotionally a wreck at this point and had to leave the clinic. I looked around me to the walls surrounding Ayder hospital and just knew she was somewhere out there. Slowly suffocating to death. We could’ve helped but had been powerless to do so.
Someone may turn to me after this story and offer a solution to my worries; “everything happens for a reason, Josh.”
Here’s a video of cute lion cubs to make you feel better about life. It sure does for me.
Global Head and Neck Surgery 