This is the personal blog of Dr. Keith Forwith MD following his practice of otolaryngology in Louisville, KY and his mission work at Tenwek Hospital in Kenya.
“Trust in the Lord with all your heart and lean not on your own understanding; in all your ways acknowledge him, and he will make your paths straight. ”
Picking the right surgeon is not an easy task. A friend's wife was recently diagnosed with cancer and ended up with a surgeon they couldn't communicate with. Thankfully, they moved on and things have turned around for them, but picking the right surgeon sure would have saved them some heartache and frustration - especially at such a difficult time as this.
Read MoreI was happy to welcome an uneventful Friday- full of surgery, but not full of death or despair. Funny, how the past few days made a huge thyroid (bigger than we see them in the States) seem like a routine case. After Saturday rounds I gathered some fellow visiting doctors and we headed across the river and up, up, up. Our goal was a rounded hilltop called Motigo that offers 360 degree views of Tenwek, Bomet, and the surrounding areas. The walk was a slow ramble, Kenyan style, where we stopped all along the way to interact with the locals. Lots of kids - some of whom were afraid, but most delighted in our attention to them. One little girl was so excited to see us she came running to the road's edge with no pants on! Several of the kids asked for "sweets" - an unfortunate side effect of prior white visitors passing out candy. Yes, it makes the kids happy but it also associates white visitors with handouts. Passing out sweets also makes life difficult for the full time missionaries at Tenwek. An evening walk with a spouse can turn into a mob scene as local kids beg incessantly for "sweets." So, we resisted the urge to play Santa Claus and simply offered friendly handshakes, hellos, and their favorite - "snaps!" The kids don't understand that we want them to smile, so they'll get real serious for a picture, then laugh in delight when we show them the result on the camera screen.
Along the way, we met a furniture builder whose shop floor was 2-3 feet deep in saw dust and shavings. Cypress was his main wood as he was working on a reading desk for one of the Tenwek doctors. Large tea trucks passed by on their way to tea collecting stations where locals sell fresh picked tea leaves in 40 pound bags to the trucks. Tea is the largest crop, grown in rectangular fields that make the countryside look like a patchwork quilt. The pictures just don't do justice to the beauty of this place. Tea turns into chai - a national obsession made of black tea, milk, and sugar. It's deliciously addicting and unique but not as spicy as the Starbucks version. In English fashion, work days are interrupted for chai breaks, social gatherings are centered around sharing chai - in fact, the girl without pants invited us in for some chai!
We relaxed for a while at the top and soon found out that behind us about 20 curious kids had gathered out of nowhere to stare at us. They were terribly camera shy, but eventually they loosened up and in the end, delighted at their own images. While the trip up was mainly a wide dirt road, we took some shortcuts through the tea fields on the way down. A chameleon made for a short break near the end of our 4 hour journey. At the bottom we passed a large group of women who stared with wide eyes at us. As we passed, we could hear the clicking of camera phones. When we turned to look, the whole group had stopped and turned to watch us - now I know how the bison in Yellowstone feel! Back at the guest house, our tired legs were welcomed by a chicken curry lunch, finished off with what else? Chai!
A tough, sad day with hard lessons to learn
Today was filled with a double dose of deadly delay. There are some statistics in medicine which you believe, even memorize, but never anticipate that you'll actually experience them. One of them concerns the large salivary glands in your cheeks called parotids. Tumors found in these glands are benign 80% of the time, but we remove all those benign tumors for one main reason: if left long term they can transform into a cancer that will kill you. So, we remove these benign tumors despite the fact that the surgery poses a risk to the facial nerve. Additionally, there are some specific surgical do's and don'ts that are critically important. So far in my career, I've removed these tumors, followed the patients closely afterwards, and have never seen the cancer that I learned the statistic about - until today.
Seno's first parotidectomy showing facial nerve branches nicely preserved after tumor removal
Each year when I come to Tenwek, they assign a surgical resident to me to allow me time to train them in head and neck surgery. This year, a very talented and extremely bright fellow named Seno is by my side. Yesterday, I took him through his first parotidectomy. The facial nerve was carefully dissected, the tumor removed and she was smiling without weakness this morning. Praise God! Good job, Seno! But, today's news would not be so good. We began the same operation on another lady, but this time it was a revision. She'd had the tumor removed 13 years ago and recently noted a recurrence. A FNA biopsy pre-operatively suggested it was a benign recurrence. As hour after hour ticked away in the OR, it was becoming apparent that today would not be a surgical success. The branches of the facial nerve could not be separated from the tumor - not by Seno, then not by me. We took some biopsies to confirm our suspicion and closed up her incision leaving massive tumor behind. Within the hour, our biopsies confirmed the worst - the tumor was a cancer, one that can't be surgically treated. Perhaps radiation therapy will give her a small chance to live- provided she can raise the funds, make the 4 hour journey to Nairobi, and complete treatment. There's no Medicare or Medicaid here, so if she runs out of money, they simply will stop her treatments. Perhaps if she'd had adequate surgery the first time, perhaps if she'd had routine follow up surveillance, perhaps if she'd been warned about recurrent tumor, perhaps if she'd seen me five years ago on my first trip to Tenwek instead of delaying until my sixth.
Parotid tumor recurrence that would prove unresectable.
In the afternoon I saw a fellow who presented to the ophthalmologist 3 months ago and was told to follow up in surgery clinic with a CT scan. He went home to raise the money - about $70 US equivalent -and didn't return until today. The small tumor noted in May was now massive. The pictures are too gruesome for public display - his left eye gone and in its place bulging lobes of cancer protruding from his face. His mouth will barely open because the tumor was invading his chewing muscles. Nothing can be done, not here, not anywhere. His delay removed any chance we had for surgery. He will die soon, maybe a month or two. He wears a baseball cap with a scarf draped over that half of his face. His one remaining eye and the half of his smile that still works tells me that this is a likable fellow. My job today was to tell him that he won't be cured. It's not easy to say, not easy to remove all hope - but one thing prevents this from being a tragedy. He believes in Jesus Christ which allowed me to assure him that his healing will come. Not today, but soon; not here, but in heaven - where a God who sacrificed his Son for him will greet him with loving arms - and he will smile back with a perfectly healed face.
39 hours is a long time to do anything continuously, especially sit. I don't recommend you try anything for 39 hours. My entire back side was screaming for a break, but at last we were in Kenya! Five hours of flat sleep and I'd be sitting for another 4 hours prior to my arrival at Tenwek. This is my sixth trip to Tenwek hospital where my mission is to teach head and neck surgery to training African physicians. This trip was a long one, but I have a daughter along to sweeten the ride. Allegra and I arrived Monday afternoon and the excitement began. They had been expecting me earlier and had OR cases ready but had to postpone when I was delayed. A quick set of rounds, an evening walk to the Tenwek falls, dinner and I was ready for some shuteye. The power then went out granting me a nice quiet long night's sleep - ok, it really doesn't work that way over here! Yes, the power was out but at 2:30 am the fire alarm started it's warning beep every minute that the power was out! That lasted long enough to fully wake me up and fight jet lag insomnia for an hour or so, only to have the beeping return around 5:30. But it was still better than most residency nights.
I spent today in clinic seeing an incredible variety of pathology. While thyroid surgery is my specialty, they were keeping them off my schedule because of the large number of highly unusual cases of a more demanding nature. They did put one enormous goiter on for later this week - but all the small stuff (which was bigger than anything back home) was postponed for later. Best of all, nearly everyone we saw had some hope of healing. There were two who face grave prospects, but for an entire day in clinic here, that's quite good. I'm here two weeks and we could have booked three weeks of surgery today - so lots of teaching opportunities await! I feel blessed to be back here, blessed that so many warm, familiar smiles were here to greet me, blessed that God would use me for his purposes. I hope to share more if the internet connections hold up. There should be lots of good stories to come!
When you saw me a couple months ago you brightened my day with a simple compliment. You looked past my braces to compliment me on my smile that was slightly hidden underneath that hardware. I'm happy to report that I'm now free of braces and loving it!
In my practice, I strive to treat patients like family, like I'd want to be treated. While my practice is far from perfect, I think we do pretty well. But sometimes I come across someone who really has it all together. My orthodontists, Paul Tran and Kristin George, are examples for me to emulate. My experience as an adult going through treatment couldn't have been better. Literally, I can't think of a single thing that they could have done better! And I'm a critic! I spend a lot of time thinking about the patient experience and how to deliver quality care with compassion and understanding. This is a practice who has it right. It's not just the doctors, it's the whole team who makes it work so well. So, Panera girl, I will be smiling a little more often now!
Sincerely,
(formerly crooked teeth) Keith
Just a little compliment, but there were so many things she didn't know...
Read More5 months without speaking and an oral cavity mass about to take his life, this 12 year old boy was brought to Tenwek hospital by two American missionaries.
Read MoreMy return to Tenwek hospital in Kenya to serve with the Pan African Academy of Christian surgeons. I tried a new flight schedule, and suffered the consequences of what turned out to be a poor decision. Seeing a bit of the Netherlands was the silver lining though!
Read MoreImagine you're invited to watch the big game. The ticket is free and you have no conflicting obligations to keep you away. 200,000 people will attend! But, there's one small caveat - at this game, it's been determined that there is a 100% probability that one person in attendance will die from bullet wound to the neck. Yes, there is an assassin who will shoot one person and one person only. The shot will not kill you right away, and you'll have a chance to fight for your life - but you will lose and die with 100% probability. Would you take this chance? Would you let your spouse or child take this chance? If it's my spouse or child I'm not letting them take that chance!
A recent series of articles on thyroid cancer has hit many media outlets. They describe a recent publication from Mayo clinic that recommends "low risk thyroid cancer" be treated with observation only (which actually, is not a treatment). Part of their logic is that only 1 in 200,000 die of this type of cancer - called micropapillary thyroid carcinoma. As a thyroid surgeon, I'm dedicated to the preservation and improvement of my patient's health. Notice, that I state that in the singular, not plural. My dedication is to the single patient whom I'm treating. I can't look at a single patient and tell whether they are part of the group of 199,999 who won't die or the one who will. If it's my spouse or child, I'm not letting them take that chance.
So, what was wrong with the old site? Nothing really, but times change and mobile devices are becoming more prevalent. So, I've moved to a platform that should work well with smartphones, ipads, and tablets. Adding content should be easier as well - which means I can get more stuff onto the site! Please let me know if you'd like to see more of a certain thing - more robust explanation, more videos, subjects to cover - any suggestion you might have. I hope you like the new site and stay tuned for more content!
