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| PRACTICE STORY/OPINION |
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| Year : 2017 | Volume
: 15
| Issue : 3 | Page : 249-251 |
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Massive abdominal tumor – more than a medical problem
Vijay Anand Ismavel1, Ann Miriam2
1 Department of Pediatric Surgery, Makunda Christian Leprosy and General Hospital, Karimganj, Assam, India
2 Department of Anaesthesia, Makunda Christian Leprosy and General Hospital, Karimganj, Assam, India
| Date of Web Publication | 7-Aug-2017 |
Correspondence Address:
Vijay Anand Ismavel
Makunda Christian Leprosy and General Hospital, Bazricherra, Karimganj, Assam
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_67_17
How to cite this article:
Ismavel VA, Miriam A. Massive abdominal tumor – more than a medical problem. Curr Med Issues 2017;15:249-51 |
As a pediatric surgeon and anesthesiologist couple working in Makunda Christian Hospital, a remote rural mission hospital in Assam, we have come across some very challenging cases. This is one such case, which highlights several issues. The problem presented is not just a medical issue, but also social, economic, and ultimately, a human issue.
A 35-year-old female presented to us with an enormously distended abdomen in 2001. The mass in her abdomen had grown slowly over several months until she reached a stage where she was unable to sit, stand, or lie down due to breathlessness [Figure 1]. She had to be constantly in a kneeling position to support her weight and to breathe – she was in the same position when she was fed and when she relieved herself – shifting her weight from one knee to the other.
She had to be in a kneeling position in order to support her weight and to breathe.
She was from Tripura and had come with her husband. When they noticed a mass in her abdomen, she was taken to a doctor who said that it could be removed but the procedure would cost a lot of money. The husband was a rickshaw puller, and the cost was beyond what they could afford. They decided to wait to see if it would go away. When it did not, but rather grew in size, they went back to the same doctor who said that it could still be operated but may not be curable. Her family then decided to let her die. The reasoning was that if they spent all their savings, she could possibly still die and both savings and wife would be lost. If she died, at least the savings were intact to support the rest of the family and start all over again!
Unfortunately, her abdomen just kept growing in size until it had become enormous (at presentation at the hospital in Makunda) and she started having severe constant pain. She was brought to the hospital as they could not tolerate her groans and she was not dying. Her weight was 70 kg. Ultrasound examination of the abdomen showed a solid mass with free fluid suggestive of a ruptured ovarian tumor.
We decided to operate to relieve her of her symptoms. Under local anesthesia in the lateral position, the fluid component was drained using a trocar, and after that, she was put in the supine position, intubated, and administered general anesthesia. At laparotomy, a large ovarian tumor was found which had ruptured at one point and there was mucinous material in the peritoneal cavity with thickened peritoneal surfaces. Near-total excision of the tumor and total abdominal hysterectomy were done. The inferior vena cava was blocked by compression, and there were large vessels all over the abdominal wall with some crossing the incision - each of these had to be controlled to get hemostasis.
Postoperatively, she developed “reexpansion pulmonary edema” - fluid accumulating in the lungs following sudden decompression.[1] Over the next few days, she recovered and finally was able to sit, stand, and walk - she went home walking. The lady now weighed 35 kg after the surgery (the weight of the tumour was 35 kg). This must be among the largest tumors to be removed in India. Ovarian tumors often grow to large sizes before they cause death.[2]
Her biopsy was reported as “Mucinous Cystadenocarcinoma of the Ovary.” She was referred to the government hospital in Agartala, 220 km away, where free cancer treatment was available. She was lost to follow-up after this. It is very unlikely that she went for further treatment; she probably died of recurrent tumor. She never came back.
The husband had sold some of their possessions and brought some money. She was treated with what they could pay, and the remaining bill was written off. The hospital has a policy of treating poor people free, and this enabled this family to be treated within their means without making them destitute.
This story illustrates the plight of the poor. These individuals often do not have cash at hand and face pressures to sell vital assets (house, land, etc.,) to pay for medical expenses. Otherwise, they are forced to borrow money from moneylenders at exorbitant interest rates to pay for their medical bills. This causes them to fear going to hospitals and leads to decisions to delay or deny treatment, often waiting till the situation is beyond what can be tolerated or cured. In some cases, as in this one, the family finds it economically feasible to simply let the person die rather than let the entire family suffer.
This patient had a gynecological problem (ovarian tumor), a medical problem (reexpansion pulmonary edema), and a social problem (poverty). During our medical training, we are taught to handle medical/surgical problems, but in real life, the problems that a patient comes with are multiple. Treating the medical problem without being aware of or ignoring underlying social and economic issues often does not solve the problem. In some cases, it may even do more harm, pushing families into deep debt and destitution from a single major medical event.[3] A more holistic approach is needed to treat the poor.
This lady had a gynecological problem (ovarian tumor), a medical problem (re-expansion pulmonary edema), and a social problem (poverty).
As individual doctors, being sensitive about the economic impact of treatment on the patient and offering services at affordable costs is a vital aspect in the practice of medicine and surgery, especially in mission hospitals and with the poor. Hospitals aimed at the poor should take these into account when they plan strategies to make their services accessible to their target populations.
In 1993, Makunda was restarted after 10 years of closure. After a few years of analyzing the situation, an objective strengths, weaknesses, opportunities, threats (SWOT) analysis was done and a 30-year strategic plan was made. One of the aims of the first (10 year) phase of this plan was to brand the hospital as “poor-centric.” Some of the strategies adopted were:
- Creating an “ownership” experience for the poor so that they felt that “this hospital is for people like us.” This includes policies such as not having private rooms or private consultations and having all patients stand in the same queues
- Proactive identification of the genuinely poor and offering subsidized treatment or charity so that they do not sell vital assets and become destitute
- Writing off bills if an unexpected complication arose, as most poor families have not budgeted for an increase in costs
- Helping recover vital assets like houses, land, livestock etc. which were sold or given as collateral for loans in order to pay for treatment. This is done at the hospital's expense
- Adopting “revised gold standard” treatment protocols that take into account the paying capacity of patients and the locally available resources so that poor patients get the best quality treatment without being referred to other (more expensive) hospitals
- Branding the hospital as a hospital for the poor to staffs so that the staffs understand that the institution exists primarily for the underprivileged and they joyfully accept inconveniences and multitask so that expenses are reduced. This ownership of the vision by the staff is important, as staff expenses are one of the largest components of hospital expenditure that contribute to high costs to the poor.
Unless the gap between those who can and cannot afford access to healthcare is closed, no real transformation will take place.
Since the poor are the majority in most remote rural areas, these strategies enable the hospital to be filled with patients, be self-sustaining without depending on external grants. At the same time, this ensures that the poor lose their fear of hospitals and are able to save lives, reduce morbidity, and avoid crippling costs to their families. Unless the gap between those who can and those who cannot afford access to healthcare is closed, no real transformation will take place.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Bamba K, Watanabe T, Kohno T. Anesthetic management of a patient with a giant ovarian tumor containing 83 l of fluid. Springerplus 2013;2:487.  |
| 2. | Brown J, Frumovitz M. Mucinous tumors of the ovary: Current thoughts on diagnosis and management. Curr Oncol Rep 2014;16:389. |
| 3. | Raban MZ, Dandona R, Dandona L. Variations in catastrophic health expenditure estimates from household surveys in India. Bull World Health Organ 2013;91:726-35. |
[Figure 1]
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