1 Feb 2013
Laraí, a soft-spoken elderly woman with silver hair, waited for us in the patient room as we stepped outside get gloves. Drew and I were seeing patients together that day, a rare treat for medical students in the clinic – where you get to bounce ideas off a partner without the stress that comes with working with a superior.
It was Laraí’s third time in our clinic in two months. She had poorly-controlled diabetes (her blood glucose that day was over 200) and well-controlled blood pressure. We thought all we’d do that day was increase her metformin. But then she began to tell us that she’d been feeling out of sorts.
“No tengo ganas de comer.” I don’t feel like eating. “I’m tired. Food makes me nauseated. I just feel unwell all the time.”
Looking back at records from her previous visits, Laraí had lost weight. Ten pounds over two months.
And then she said, “And the mark on my arm isn’t getting any better.”
She held up the back of her left forearm to show a large lesion, dark purple with whitish flecks around the edges.
My first thought was fungus, which is relatively common here. But this looked unlike any fungus I’d ever seen. Then another look at her chart showed that Laraí had already been treated for fungus.
“Le pica?” I asked. Does it itch?
“No, but it hurts. And sometimes it bleeds.”
That’s when Drew and I stepped out to get gloves, so we could take a closer look.
Shutting the door behind him, he said, “I think it might be melanoma.”
Melanoma is the deadliest form of skin cancer. If caught early it is usually curable by surgical excision. If not, it has a remarkable ability to metastasize.
Something clicked. Drew’s statement released the same thought from the back of my head. Oh dear, I said with my eyes.
We came back, ready with gloves, a ruler, and the ABCDE mnemonic for melanoma.
Borders, irregular – Yes, they were.
Colors, multiple – It carried at least three colors: purple, red, and white.
Diameter, greater than 6mm – 40mm easy.
Evolution, or change over time – The patient said that it had been growing for at least a year.
We examined Laraí’s heart and lungs, and especially her abdomen. With her lack of appetite and weight loss, we were worried about metastases to that area. Everything was normal. Her belly was not tender when we pushed on it, we couldn’t feel any masses, and her liver and spleen appeared normal.
Yet with the lesion’s growth over a year, which seemed fairly rapid, and Larai’s symptoms and weight loss, Drew and I remained almost certain that she had metastases.
We went outside to speak with the Guatemalan staff about what to do. As with many of our patients with problems beyond our capabilities, we were to instruct her to go to the public hospital. She would have to line up before 7am to get an appointment with an internal medicine doctor, who would then hopefully refer her to one of their dermatologists.
The level of education in the US on skin cancer is high. If I had told a US patient that she likely had melanoma, possibly advanced, she probably would have been freaking out. But Laraí sat there being her soft-spoken self. She nodded occasionally, but her blank look cast doubt as to whether she fully understood the gravity of what we were trying to tell her. I worried that she might not follow through with the public hospital.
I had never been more frustrated with not being tied in to the system. Therein lies a big problem with being an outside, non-profit health clinic in Guatemala. (Although it’s unlikely that the government Puestos de Salud could have done much better.) I wanted so badly to be able to set up an appointment with the dermatologist myself. So that Laraí wouldn’t have to wake up early, travel to only wait in line, then possibly get discouraged and leave.
But it might not have mattered anyway. Our clinic coordinator, who is much more familiar with the system than I, told me that the hospital doctors would probably “leave it”. Because private providers in Guatemala City (read: expensive and far away) are the only ones equipped to give the treatment that Laraí needs. And because she’s “of age”.