The Sound Keeps Coming Out

 Untitled Haiku
by Basho
(Translated by Robert Bly)

The temple bell stops.
But the sound keeps coming
out of the flowers.

Advent is a time of longing, expectation, waiting. We remember the anticipation of those looking for hope and light to come into the world. And we wait for God to come again, for His justice to be established, for the end of war and suffering, the coming of His kingdom.

 

But it is also a time of acknowledging his presence, seeing it not just in Jesus’ presence in Bethlehem at one point in time, but His continued presence among us now. Even though His physical presence is gone, His Spirit is like the sound that continues to come from the flowers, filling our hearts.

 

 

I’ve seen God’s presence here. I’ve seen him bring healing in situations beyond my hope. But I’ve also felt Him present in the grieving of a young mother with her dead child. I don’t always understand it. Sometimes I am angry or sad beyond words, but even then, He is present.

 

“God is a God of the present. God is always in the moment, be that moment hard or easy, joyful or painful.” (Henri Nouwen, Life of the Beloved)

 

In this advent, may you know God’s presence even as we wait for Him to return to make all things right.

 

 

 

Some of you already know, but my time with Samaritan’s Purse is quickly coming to an end. I am returning to the US in February for 3 months before returning to PNG through the Nazarene Church. I believe that God has called me here for a longer season. While Samaritan’s Purse covered some of my costs, I now need to raise the full cost of my living and working here. If you would like to donate to my work here, please use the following link: https://give.nazarene.org/pledge/dyer.

 

 

Celebrating the Victories

 As I looked back over some recent blogposts, I realized that I have dwelt a lot on the heavy and sad cases that happen here. Unfortunately, these stories represent a too common experience here. Pain and suffering are common. However, I perhaps haven’t reflected the victories as much as I should. And I tend to pass over the routine care of diseases like hypertension, pneumonias, and many others that we see and treat every day.

 

But I wanted to share a few of the victories.

 

One such was a young man who was admitted for progressive confusion, weakness, and fevers. By the time of his arrival at our hospital, he was comatose except for brief periods of agitation. I worried that he might have come too late, or that if he survived, he would have severe cognitive impairment afterwards. For days it looked as if I was right as he didn’t change with our therapy. However, after a week of antibiotics he became less agitated. On day 10, he was sitting up in his bed. On day 12 I could see the difference in his eyes, the understanding and light was back. As I sat down on his bedside, I introduced myself. I relayed that I had been taking care of him for the last week and a half, but I felt that this was the first day I truly met him. After that day his improvement was rapid, and he was able to leave the hospital soon after.

 

 

Another night, during a busy call shift, a little boy was brought into the ER by his parents. His name was John. He had fallen a couple of meters and hit his head on a rock 10 hours before. Completely limp in his father’s arms, he didn’t move, even as they placed him on the ER bed and started an IV. An Xray revealed a depressed skull fracture, the bones of his skull pushed down into space normally occupied by his brain. We started a few interventions to try to decrease the pressure in his brain, but discouragement hung heavy on my shoulders, adding to my weariness. Without much hope, I gathered the family together to let them know my concern for his prognosis. They nodded their understanding as I spoke. When I offered to pray, they were thankful and full of faith, more than I felt capable of at that moment.

 

With a heavy heart I walked back home. I prayed for John again as I went to bed, leaving it in the hands of the great Physician. I didn’t see him the next day, but that evening I found my colleague to ask how he was, steeling myself for the worst. To my amazement, my colleague had walked onto the ward that morning to see John sitting up in his bed and eating. The next day he was walking, and two days after I had feared he would die, John left the hospital with his family. We truly serve an awesome God.

 

***

 

This last Friday I was woken up by a call at 4am. The delivery room had a pregnant mother whose baby was coming out the wrong way and the umbilical cord had come out first. This can be devastating because the baby requires blood from the umbilical cord to breathe, and when it comes out early it can be compressed and closed off. The nurses couldn’t feel a pulse through the cord any longer. I hurried to the hospital and when I arrived the baby was partly out, but the midwife was worried he was stuck. I quickly put on gloves and rotated the baby just enough to deliver one of the arms and then the other. The head quickly followed. The baby was purple and not breathing. I had very little hope since it had been some minutes since the nurses had not felt a pulse in the cord. But after a minute of providing breaths for the baby, he began to breathe on his own. He was small, 1.5kg (3.3 lbs.).

 

The next day I went by, wondering if he would still be alive in the nursery. He was still there. And the next day and the next. He had very elevated bilirubin levels (jaundice, when babies turn yellow), but has done much better than I could have expected.

 

 

One last story-this one is also from our labor and delivery ward. I was called to see a patient who had delivered a baby and developed a bad tear. I knew immediately that it was bad as I saw the tear had gone through her rectum. These tears can be very detrimental to patients as they can lead to fistulas, permanent connections between the two tracts. I have repaired many bad tears here, but none were even close to this one. I hoped that one of our surgeons would be available to do it, but two were out of town and the other was busy. So, I found myself sweating as I sat down to begin. It went slowly, but thankfully I had some advice from a more experienced colleague, and it came together well. The next day I was thankful to hear from the patient that she was doing well. A week later in clinic, she came back to see me. She was very thankful for the care we had given her and was healing better than we could have expected.

 

There are hard moments here, but there are also moments of thanksgiving and joy. I am blessed to be able to serve here and work with the people of PNG. Thank you for your support.

 

 

A couple updates from my life. Stella continues to grow. She enjoys eating kaukau, eating rice, eating ham, eating chicken; basically, anytime she gets to eat is her favorite. Recently, some neighborhood kids have come over to play with her and everyone has a good time. The kids have also helped me work in our garden.

 

 

In a recent basketball mishap, I suffered an avulsion fracture of my pinky (a small piece of bone where the tendon connects was broken off). I will need to be in a splint for 6 weeks, which makes a lot of things at my job more difficult, but thankfully it was not worse. Please pray for my recovery.

I enjoyed my time away from the hospital for a week in Dubai for a conference with Samaritan’s Purse. It was a blessing to have a break and time to reflect on my time here in PNG.

 

 

Our Hope Beyond

 

The old woman gave me smile, a sad smile through her tears, as she reached over to hug my shoulder. She had been looking for a diagnosis for months, a way to understand what was going on in her body. Even though my news was a new weight, it was also a relief from the burden of not knowing. As we sat and prayed together, I could feel her faith through the grip of her fingers and the moving of the Spirit. She knew where she was headed if God chose not to heal her. 

As a doctor, I frequently see people on some of the worst days of their lives: a new diagnosis of a chronic disease like heart failure, the discovery of metastatic cancer, a serious injury or case of meningitis in a child. With all the advances in medicine, a new diagnosis often leads to overwhelming information on different treatment options available and their potential success rates. Resource limitation here in PNG often force me to draw closer to the patient and see where they are at emotionally and spiritually as our ability to treat medically may be very limited or nonexistent. This can be discouraging, seeing the vast disparity between the care someone in the US would be able to access versus what is available to the people that live right next to me in the villages and mountains around the hospital. However, people are more than their physical bodies. In the resource wealth of the West, it easy to neglect our souls and spirits in search of a physical cure.

Lester* taught me a lot about this. He had been in and out of the hospital several times due to worsening liver cirrhosis with hepatic encephalopathy. When I saw him on this admission, I knew that it would likely be his last. His skin was jaundiced (yellow) and he was wasting away, even as his abdomen swelled larger and larger. And yet, his smile every morning was radiant. He always greeted me when I walked in and tried to keep up his spirits despite his worsening condition. The reason for his peace and joy was that Lester knew Jesus. Lester felt His presence despite the misery. And you could see the effect this had on his family. While they were concerned for him, they weren’t anxious.

 One day Lester didn’t greet me on rounds. He had slipped into unconsciousness. His kidneys had been gradually worsening over several days and were finally failing along with his liver. The next day his bed was empty. It was tragic to lose him, especially as he was so young and full of love, but I know that I will see him again one day.

Someone else I will see is Esther*. Like so many women here, she suffers the ill effects of a broken health care system. She was dying from advanced cervical cancer, and she was young. As I broke the news to her, her face was placid, but I could see the tumble of emotions and thoughts behind her eyes. I tried to be present with her as she processed what was next. And then I couldn’t help but share God’s love with her, His overwhelming passion for her. She hadn’t known God before, but she prayed with me in the dark ultrasound room.

I pray that my patients might know the peace and joy from knowing God. I also pray and strive for a better health care system here that will decrease preventable deaths. I yearn for the young women and men who attempt to end their lives to know their dignity, worth and the love of God, and I try to show this to them in the hospital. I also yearn for a decrease in domestic violence and an increased power and voice for women in PNG.

Please continue praying for me here that I might be able to help show God’s light and to work for positive change alongside my PNG colleagues.

*Names changed

****

Life updates

Stella continues to grow. Everyone comments on how big she is getting. She is a good companion who helps keep me grounded after long workdays. Unfortunately, my garden has been a little neglected since she arrived, although after work today I did pick some corn, lettuce, spinach, cherry tomatoes, strawberries, and butternut squash. I recently had a weekend trip up to a cave in the mountains complete with sleeping in a tent for the first time here. I enjoyed getting to explore again. I have been facilitating a men’s group, which has helped me to get to know some of my fellow missionaries better. It has been rewarding thus far. A couple weeks ago, I hosted Apa and his family (my initial host family for my cultural orientation) for lunch. His kids have grown so much, it was good to see all of them again.

 

 

Clinic has been getting busier and busier as unrest from elections has begun to go down. We recently said goodbye to our only Pediatrician, Dr Susan. We miss her, but it was also neat to see the community respond to her 21 years of service here as she prepared to leave. I am attempting to learn some Pediatric echocardiography to make up one of the many gaps left by her departure. 

In a couple weeks I will be flying to Dubai for a conference with Samaritan’s Purse along with my colleagues from Nepal and Africa. I am looking forward to learning from them and sharing encouragement. It will also be nice to have some time and space to reflect on the last 21 months here, to process the difficult things and to grow more into the person God desires me to be.

 

Disease vs Accident

 My mother frequently asks me whether I am seeing patients with injuries or illness/infections. Usually, I respond both. However, unless I pause to reflect, it’s easy to lose sight of the breadth of work that fills up a day. This blog recounts a day of work for those who want to know a little more of what my days look like (this day was a while ago but I wrote some notes on that day).

Every day at 8am I round somewhere in the hospital, usually on our Medical Ward (adult patients) or on our Pediatric Ward, but sometimes in the Nursery or on or OB Ward too. On this day I am rounding in our Medical Ward. My first patient is a young teenager suffering from tetanus. His friends had done a circumcision for him without proper sterilization or tools (termed a “bush circumcision”). We were trying to control his spasms with antibiotics, magnesium and diazepam, and he was slowly improving.

View out the window of a small church I recently visited

Our wards are large rooms with beds lined up next to each other on both sides of the room. Rounding involves moving down the room from one bed to the next. My next patient is a young man with significant burns on his back due to an explosion. Another patient has pancreatitis, likely due to a gall stones. A small frail lady with weights hanging from her leg is one of the patients who has been here the longest, due to a femur fracture that requires traction for 4-6 weeks. I next see a young lady with a new diagnosis of HIV who came in very sick and weak due to secondary infections. Next to her is another young lady with leptospirosis, a disease that comes from contaminated water and can significantly affect the kidneys and liver.

Moving to the other side of the ward where our oxygen cylinders normally stay, I have several patients with pneumonia, COPD and/or heart failure. Unfortunately, we see a lot of older adults with chronic lung disease that eventually leads to heart failure. The lung disease is sometimes from smoking, but more frequently it is from the cooking fires that burn every day in their haus kunai (the traditional cooking houses made out of bamboo with thatched roofs from a durable grass-kunai).

 

On this particular day, I am also rounding in the nursery. Our nursery is a small, hot room off the OB Ward. There are 4 warmers on one side and several other cribs on the other side. The warmers can, and frequently do, hold two babies. The room is usually full of mothers feeding or looking after their infants. Our resources are limited for caring for early preterm infants, but we do our best. Our nurses are some of the best at finding IVs, even in the smallest patients.

A video of a Ribbon-Tail Astrapia (Bird of Paradise)

After rounds in the nursery, I head to the ER. I am on call, so I will be covering the ER for the rest of the day. My first patient is a young man involved in a car accident with severe back pain. Xray shows that he has a stable transverse process fracture of his spine. Luckily, it is stable, without fractures to the other parts of the bone, and he will likely be ok with a back brace and pain control. My next patient is a young female from a long way away who has had pain in her chest and SOB for 6 months. Ultrasound shows me that she has a large pleural effusion (fluid in her chest puching on her lungs). By using a large needle, I drain a lot of her fluid and give her the diagnosis of pleural tuberculosis. Now with the right treatment, she will hopefully improve.

The rest of the day is busy. I see two wrist fractures that need to be straightened, a young lady with severe heart failure secondary to rheumatic heart disease, a pregnant patient with a high fever, a couple of COVID cases, someone with chest pain, a young baby with meningitis and a patient with typhoid. I also have a young man with severe back pain and weakness of the lower extremities. His blood work is consistent with an infection, and he has a fever. My most likely diagnosis is a paraspinal abscess, a very serious condition that can lead to paralysis of the lower extremities of the body. In this case we were able to start antibiotics early enough to save him much of his motor function. I also have two children that came in very sick. While it was initially not clear, we started a workup for infection, including doing spinal taps for possible meningitis. Eventually it came out that they had eaten some beans the night before. Here in PNG there is a type of bean, that if eaten in large amounts and not cooked properly can lead to cyanide poisoning. We do not have the most commonly used antidote in the US, however, we do have two medicines that work well in preventing toxicity from cyanide poisoning. Both children quickly improved with the treatment and were able to be discharged the next day. Finally, I had a young female with a confusing constellation of symptoms-fever, joint pain, and rash, who was also found to have kidney disease and a blood clot in her leg on further examination. We are unable to do the blood tests here that would make clear her diagnosis, however I highly suspect a type of vasculitis, perhaps Lupus. We are trying to obtain labs for her while continuing her on steroid treatment.

Call shifts vary a lot here. Some nights I am at the hospital most of the night between the labor ward and the ER. Some nights I get to sleep most of the night. This night is fortunately calm, with only a couple of ER patients. Early the next morning, though, I get called for a woman who has been in labor for a while and pushing for more than 2 hours. She is getting tired and the midwife is starting to worry about the baby. One good pull with a vacuum and the baby comes out, much to everyone’s relief. The mother is exhausted but incredibly grateful. I tell her she did the hard work, I just provided a little extra help. She asks me my name. Confused, I tell her. She tells me that she will name the baby Daniel as well. My heart is touched by her gratitude. It is moments like these that make all the hard work worth it. I’m so grateful to be here, serving and working in PNG. Thank you for your support in making this possible.

                                                                ********************

A couple of personal updates. I am currently on my way to Australia for a short vacation. I am very grateful for this as it has been a busy summer, and we have been short staffed. A couple of months ago, I got a puppy named Stella. I am taking care of her with my neighbors the Myatts. She is very sweet, and I have loved having her here with me. Finally, PNG recently completed its election season. There was a lot of tension and some violence, however, I am very thankful to God that things have not been worse. Thank you for your prayers for the people here and for my work here.

 

The Pain on This Side

 Warning: This blog post contains some graphic descriptions of violence and difficult situations. Please read with discretion.

 

I sometimes hesitate to talk about certain experiences in my blog posts. There are a number of reasons for this—not wanting to dwell on difficult experiences, difficulty in expressing certain emotions, etc. Another reason, though, is that I know that I am in some ways representing the people of Papua New Guinea to those who may never have the chance to visit and have their own experiences. But all reports must in some way be limited as it is impossible to relate everything. It will always be skewed by the limits of my observation.

 

Therefore, I don’t want this to be read as representative of all those who live here in PNG. These are some of the difficult stories from the last month that weigh on my heart. But they are also relieved by the small kindness and love I see every day, the patient who brings me a papaya in clinic, the young mom who smiles at me on rounds.

 

 

On a call shift several weeks ago, I felt like I should go check out the ER after eating lunch as we had had a very busy morning. As I approached, I noted the large crowd of people, some of them wailing and crying. Our two trauma beds in the ER were occupied by two young men. One had a large cut in his abdomen with his liver and intestines protruding out. The other had a large laceration through his jaw and neck. Blood soaked clothing lay on both beds as the nurses attempted to get IVs started. They were brothers. They had been injured at a bride price celebration for the oldest brother (with the large abdominal laceration), the ceremony preceding the wedding where the groom’s family presents the bride’s family with money and pigs. The younger brother of the groom had come asking for money. When he was denied, he became angry and got out his bush knife. His two brothers became victims.

 

Our surgeons were able to take the older brother to the OR to suture his liver, clean out his abdomen and close the skin back together. We tied some large arteries on the other brother to try to slow down the bleeding and provided several transfusions. We intubated and had to perform CPR multiple times, however it soon became apparent that we could not fix his underlying condition and he slowly passed away on the bloody ER bed.

 

 

 

I had taken care of her for about two and half weeks before she started to deteriorate. She was young, around 20, and had a new baby as well as a three-year-old boy, who always looked at me with wide eyes before breaking into a toothy grin when I came to her bed. She had been beaten by her husband and decided to drink gramoxone, a commonly used herbicide. In the US gramoxone is heavily regulated and comes mixed with other chemicals to try to prevent ingestion, but in many parts of the world these precautions are not taken. Here it is a common method of suicide. Over days to weeks the toxin generates damage in the liver, kidneys and lungs, eventually leading to kidney failure and respiratory collapse.

 

For Helen (name changed) I initially had some hope. Her kidneys improved after days of IV fluids and her respiratory status was stable. However, as can often happen, the poison led to increasing fibrosis in her lungs over a couple of weeks. As her prognosis became clear, I sat down and talked with her and her family. She was scared and tearful, but she also knew where she was going after death, she had faith in Jesus.

 

The last day I saw her my heart sank thinking about her young children who would grow up without their mother.

 

 

 

She was transported in by a helicopter from the Jimi valley, a remote area of our province with difficult accessibility on a dirt road that can become impassable during the rainy season. She had been in labor for 36 hours, but her baby was sleeping sideways instead of up and down. The arm had come out but the rest of the body was unable to deliver.

 

I met her in the delivery room. I tried to sense how she might feel in this new setting, surrounded by bright lights and nurses and in immense pain. As I used the ultrasound to examine the baby, I confirmed what she already knew, her baby had died during the ordeal. We prayed with her and then prepared her for surgery.

 

 

 

As a doctor, I am frequently brought into some of the most difficult moments in people’s lives. It can be easy to forget within the comfort of our own lives what many people experience throughout the world, until that pain and brokenness comes rushing into our own lives. Without hope in a coming time when the light will break through and justice will come, it can feel bleak. But until then we pray for the coming of Jesus and try to let as much light shine through our brokenness.

 

Light in the darkness

In the moments of darkness here, I’ve been looking for the hints of grace and light. I had originally planned to write a post about some of the harder cases and pain that I had seen and experienced over the last 6 weeks, but as I sat down to write it, I struggled to begin and to feel motivation to share those stories. I then paused and looked back through the pictures on my phone. I saw different moments of life and joy that broke through the darkness, and I want to share those instead. Maybe I will still share those hard moments in a different blog, but today I want to show the new life and hope God is bringing forth.

 

I got to work in the nursery for a few weeks last month. I enjoy working in the nursery, getting to see the small babies grow, celebrating the grams gained since the day before. During my time in the nursery, I took care of a set of triplets. Most of the babies born this small don’t survive here due to their need for advanced respiratory support. But miraculously God had sustained these three babies. It was a joy to watch them slowly grow.

 

On my counter for the last several months I had avocado pits suspended by toothpicks into water. I got to watch them finally break apart sending down roots into the water and stems up into the air. A month ago, I transplanted three of them outside into my yard. Looking out at them in the morning reminds me of God’s work to sustain life all around me.

A visiting surgeon and his wife, Tom and Tina, have become close friends. They frequently have me over to play games, eat dinner, or make an occasional bonfire. Tom and I have gone on several hikes together. It has been good to have more fellowship the last couple of months, especially as some of my closer friends here have been back in the US. A trip up to Mount Tapi a few weeks ago showed me again the beauty of this place that God has called me to.

 

Last week in clinic I had a sweet 5 year old boy who came in with a supracondylar fracture (a fracture of the arm near the elbow). His arm was severely angulated, but he stayed calm even though he was in a lot of pain. We put him to sleep so that we could try to straighten his humerus. After three unsuccessful attempts, we finally felt some movement with the 4^th pull, so we repeated the Xray. While not perfect, he should heal well and be able to use the arm normally in the future.

Finally, while in the midst of chaos from a large car accident in which 20-30 patients came into the ER all at the same time, a young man who had been shot in the head was carried in by his friends. He was able to sit up and talk and had a small entry wound on his forehead that was bleeding a little. Spencer (a PNG doctor) and I were astonished by the Xrays. The patient stayed in the hospital for a couple of days and was subsequently discharged home. Thank God for the small miracles.

  Thank you all for your support and prayers. I appreciate and love you all.

Snapshots

 Sorry for the long delay between my blog posts. Life has been busy here and my computer is currently broken, which makes it harder to write blog posts. I was thinking of how I was going to convey all that has happened since I last wrote, and it came to me as I was looking through pictures. So I’m going to share a number of pictures from the last month with captions. I’ll start with pictures from the hospital and then move to life outside.

This is the ultrasound of the kidney of a male patient who came to see me with several months of abdominal swelling and feeling a mass on his left side. I’m unsure if it is a tumor or just severe hydronephrosis (swelling of the kidney) from some type of obstruction but he will be scheduled for a nephrectomy (removal of the kidney) with our surgery team.

This X-ray was from a young man who was hit by a car. He had complete paralysis of his legs and partial paralysis of his arms. The X-ray shows a cervical spine fracture. He was placed in traction but likely faces a very difficult future.

This is an ultrasound of abdominal lymphoma with lesions in the liver of a young man who came in with cachexia and fever. We initially treated him for helminths (parasites), presuming the lesions to be infectious. When he didn’t improve, he was able to drive to a different hospital and get a CT scan (prohibitively expensive for most patients) and the diagnosis was made. We started him on chemotherapy, but again, the prognosis poor.

This is the follow up film of a young girl that had come in with a week old fracture of her forearm. It was a really difficult reduction, but we were surprised and happy at the improvement. We end up reducing and casting a number of fractures that would go for orthopedic surgery in the US due to the limitations of our surgical capacity. 

One of my favorite patients, this little boy came from the Jimi valley, a remote and poor area of Jiwaka, with a badly infected burn to his head. Unfortunately burns are common here as many people cook indoors and children have a lot of independence. While he didn’t like dressing changes, he usually was a very happy kid, full of giggles and baby chatter.

A couple of months ago a local school was burned down, presumably due to some disagreements over land. This led to local unrest and vandalism at the hospital. We were unfortunately closed for a few days to ensure the safety of staff. Thankfully this did not last long and we were able to reopen to help our patients, but there are still scars in the community over this act of violence.  

My parents were able to come visit for 9 days a month ago. Thankfully they didn’t have too much jet lag because we crammed in tours of the hospital, a hike into the surrounding mountains, a mumu (traditional way of cooking with hot rocks and banana leaves in a hole in the ground), snorkeling and a hike to a volcano. It was a huge blessing to be able to see them.  

I am frequently mistaken for one of my colleagues (Dr Matt) at the hospital by many of the patients. The above picture may explain why. It has been a huge blessing to me to be able to work with and learn from so many amazing physicians here.  

Finally, I was honored to be able to give the Easter sermon at Konduk church, a small church in the mountains south of station. There were beautiful flowers and stirring music. I shared on Jesus appearing to Mary and the disciples on the road to Emmaus, how they both needed Jesus to open their eyes, and how he did so in such intimate ways. I pray that God may open your eyes in new ways to His love and presence as well. Thank you for all your support!