I was slow to wake on the morning of our second day. This was partially by design, as I was starting to think our departure times of 730 were wishful thinking. My predilections were verified when I was the first to show up at breakfast. As the bodies slowly filtered in, we were greeted by breakfast potatoes, bananas, and bread with jam. I even treated myself to some coffee, which despite its richness and soothing properties, proved to be a suboptimal move for my bowels, but more on that later (you knew this was coming).

Arriving back at Health Centre IV, Alex went to the surgical tent and I checked in with the midwives. Walking into the obstetrics ward, pregnant women spilled out in volume impeding my entry. Inside, I found an office, with doors on either side and a big wooden table in the middle. One door, the one I came in from, opened to the front hallway while the other led through the office into a clinical space with several empty exam beds for pelvic exams and treatments. I found two staff members sorting papers, writing notes, and seemingly un-enthused about my presence.

‘Hi, we have just arrived to the surgical tent,’ I said. ‘Still okay for 9am to do the ultrasound training?’

‘9 o’clock?’ they said.

‘Yes. Is that too early? Tell me whatever works. We are here to help, not make more hassle.’

They exchanged a few words and one walked out into the clinical space before drifting back in.

‘We will be ready for 9 o’clock.’

‘Great,’ I said.

Back in the pre-op tent, Julie, our French junior surgeon with a predilection for knitting, was managing a cue of patients waiting for evaluation. Patients would arrive with a small, lined paper booklet, this was their ‘chart’. All of their history, previous visits, exams, and other info was handwritten. These patients referred here for evaluation, so it was always (or nearly always) clear why they were coming as written in their booklet. Many patients hardly needed booklets to make their problems obvious however, like the lady Julie brought to us with a goomba on her brow the size of a lime.

‘Can you guys scan this lady for me?’ Julie said. ‘As you can see she has this mass above her eye on the right side. It feels relatively firm, not fungating or draining fluid, and has been there for some time. It’s squishing her eye a fair bit though… We think it’s a lipoma, but I can’t really tell on exam if it’s invading the orbit or not.’

‘Let’s have a look,’ Alex said.

Using the probe and generous amount of gel, we fanned across the bridge of her nose to around her eyeball. I could see the mass’s tissue, it was non-cystic, without notable fluid pockets or septations. I saw a globe-like structure appear on the screen.

‘That’s her eye there,’ Alex said.

Carefully, he slid the probe and angled it to better see the edges, which appeared to be defined by a line of tissue separating it from the other structures.’

‘So you can see here it’s distinct,’ he said. ‘I think she can’t open the eye because the mass is pressing down on everything, but it’s clearly separate. I can’t say what the mass is for what it’s worth though.’

‘That’s fine,’ Julie said. ‘Answers my question.’

By this time I could hear behind me that Pradeep, one of the other surgeons, had entered the tent. He poked his head around the curtain and signaled for us.

‘Can you guys take a look at this thyroid please?’

The patient was a woman, likely in her forties or fifties. She had a mass the size of two softballs at the base of her neck. Immediately, I could tell it was an enlarged thyroid. The thyroid is a gland that sits at the base of the neck and secretes hormones involved in metabolic activity. It can enlarge due to tumours or immune conditions that cause it to become hyperactive, we call these goiters. In the low-income world, the most common cause of goitres by far is a deficiency in iodine, a crucial dietary element that forms the building blocks for thyroid hormone. We don’t see this in middle and high income countries because of better diets and fortified foods (mainly salt). Even with correction of the nutritional element, sometimes these masses are too big, and have to be reduced in size for patient comfort. I had only seen pictures in medical school of thyromegaly like this before, this was new territory for me. I nodded to Pradeep.

‘Are you able to see how far down the mass goes?’ he asked.

‘I can try,’ I said.

Getting Alex to help me, we mapped out the structures. I could see the tissue was heterogenous, but not cystic or disorganized. We identified the ithmus in the middle, which confirmed the mass itself was truly just a massive thyroid and not something else overlying it. Scanning towards the bottom of it, my ultrasound probe met collarbone.

‘It goes all the way down, deep to the clavicles’ I said. ‘Presumably that’s the concern right? It becomes a harder surgery if you have to dig down there?’

‘Yes exactly,’ he said in his soft Indian accent. ‘When it goes that inferiorly it projects into the mediastinum, we have to call cardiothoracic surgery to get involved. There are vessels and other structures down there that we don’t want to touch. We cannot do this case here.’

‘Got it,’ I said.

In short order, the other surgeon, Susana, came into the tent as well. She was UK trained but came from Spain. She and I got on well. She had finished seeing all of the post-op patients from the day previous and was checking in. She also had a patient with her she wanted us to scan.

He was a young man with a big round painful mass on his leg under the skin of his shin. She wasn’t sure whether the mass originated from bone, like an osteoma or bone cancer, or if it was a soft tissue density. The mass was firm, not fleshy, which raised her concern that if she attempted resection she might get more than she bargained for. I was happy to help, but this was starting to enter unfamiliar territory for me.

My experience with the ultrasound, while robust, was primarily for clinical decision making in medical patients with unclear pathology. Scanning hearts for pump function, lungs for fluid or infection, and the major organs of the abdomen for bleeds or acute disturbances: that was my jam. Thyroids, eyeballs, and soft tissue masses however? Outside of my scope of usual practice.

This opens up a conversation that comes up sometimes about the ethical role of physicians performing duties that aren’t part of their training in low resource settings. If you are not qualified to do it in your home country, you shouldn’t be doing it here some would argue, as this can exploitative and unethical. I think this is a fair point, although I would also say that I am a physician who swore an oath to help those in need to the best of my ability. If I can do that while respecting my vow to do no harm, should I be turning patients away because of a standard held a thousand miles away? I don’t do C-sections in the US, and I wouldn’t perform a C-section unsupervised out here, absolutely not, but would I consider doing it if I was the most qualified individual on site, had a patient that was certainly going to die without it, discussed the case with an expert, consented the patient to risks, and considering every single possible alternative before taking action? Maybe I would. Is that unethical? Ask a European first and then a Congolese refugee to see if they’d give you the same answer.

So despite not having done it before, I learned on the fly. I scanned the leg, identifying the features of the mass while verbalizing them to Susana. The tissue looked regular. It seemed to be originating from muscle sheaths and was distinct to bone by a few centimetres or more. What was it? Beats me. As Susana would go on to dub them, we were looking at a Kyangwalinoma.