I have been on call a few times now at Tenwek.. My first patient to see late last night was a man who had been in a motor cycle accident 6 days before. He had some chest pain and an open fracture of his ankle. He was in the O.R. but the ortho folks wanted him to be seen due to his chest x-ray and low PO2. He initially had an O2 in the 50s but had come up to the 70s. He looked pretty good in person, but his chest x-ray did not, and the dilemma of how to manage him began. I remember little sayings in medicine, and one is, always treat the patient, not the x-ray, or whatever else might be confusing you, such as a monitor or such. I treated him with an non rebreather and increased his oxygen, held off on the ARDS dx, and intubation, and we both made it through the night. This morning I did talk to an American radiologist, Shane from Birmingham, and he said the chest x-ray looked like non cardiac pulmonary edema. Anyway he made it through the night.

What's your diagnosis?

One of the many things we do in endoscopy is put in esophageal stents. Here is how a lot of them go: Joyce is a 73yo here for an EGD to rule out esophageal cancer and have a possible stent placement. She has come from far away and has severe dysphagia. We pray prior to her EGD and someone signs a consent. We pass the scope under no anesthesia, and she does have a tumor at 25 cm. A wire is placed beyond the tumor because the scope cannot be advanced, and the esophagus is serially dilated to 36 French. She is re-scoped and her tumor is measured from 25-30 cm. Biopsies are taken, The remainder of her stomach and duodenum are normal. Her EG junction is at 37 cm. Her UES is at 15 cm. A 12 cm Chinese nickel-titanium alloy stent is marked at 20 cm, in order to deploy 5 cm proximal to the lesion, and is placed without difficulty or complication. The scope is re-inserted to check the placement of the stent, the wire is removed, and she is given the ceremonial cup of water to drink. No perforation is noted and she is discharged home with a hospice consult and a chaplain consult. This is all done with a total cost of 30,000 shillings. The shilling is 85 to one dollar, so it's around 350.00. The stent helps with swallowing and the average life expectancy of a patient after stent placement is I believe nine months. I have seen one patient that had a stent placed 17 months ago and we re-stented her last week. Tenwek is now well known for their work and are conducting research studies searching for the reason why this is a world wide hot spot for esophageal ca.




An esophageal stent