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.

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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!

Fullness of Redemption

 My heart sank and my head went suddenly quiet as I found her kidney with the ultrasound probe. Time seemed to pause in the little ultrasound room. It was all I could do to keep from crying. She had severe hydronephrosis on the left side, a consequence of the large cervical cancer that I had discovered just a few minutes prior. I had hoped that maybe it was still early enough that surgery might benefit her. It was almost a minute before I could begin to tell her what I had found.

 

Unfortunately, stage IV metastatic cancer is not uncommon here. Without routine screenings for cancers (colonoscopy for colon cancer, Pap smears for cervical cancer, mammograms for breast cancer), societal knowledge of cancers that might lead to seeking care earlier (testicular and breast cancer especially) or routine interventions (hepatitis B vaccination-now becoming more common), cancer is often only found after it has metastasized or become too large for intervention. And, unfortunately, some of these patients are young, as Susan was (name changed).

 

 

We sat there together in the semi-darkness after I had told her what I had found. She saw my grief and knew the seriousness of the diagnosis. After some time, I began to explore more about her life. She had at one time been a Christian, grown up in the home of a pastor. But she had had a difficult life and had left her faith in God. She was currently in her 4^th marriage despite being in her late 20s/early 30s. I shared the love and the hope I had found in Jesus, despite my mistakes, and how there was always a way back to God’s open arms. She began to cry too as we prayed, and she reopened that door in her life to know Jesus again.

 

Earlier that day I had felt the same sinking feeling as I palpated the mass overtaking Wendy’s neck and clavicle (name changed). The mass had started in her left breast but had obviously spread. As I looked at her chest x-ray, the small sliver of hope I had vanished with the metastases in her lungs. She had a one-year-old at home and was still breast feeding, part of why she hadn’t come in sooner for evaluation. I was able to connect her with Dr Matt, one of our physicians who has started a palliative care ministry, where he provides spiritual as well as physical care in the homes of patients dying from various diseases that we are unable to cure.

 

Days like this can feel heavy. Patients shouldn’t be dying from these diseases at such a young age. But there is still hope in these black circumstances. In the midst of the brokenness of cancer, Jesus met these two women with hope. In a book I have mentioned before, Promises in the Dark, Eric McLaughlin talks about a phrase from a hymn, the “fullness of redemption.” So often here we see only brokenness and small glimpses of redemption. But in time, Jesus is going to bring everything to complete redemption, our bodies, souls, relationships, world. And there will be a fullness to that work. I’m glad that Susan and Wendy will be able to see it.

 

 

Waffa Trip

Witness by Denise Levertov

Sometimes the mountain
is hidden from me in veils
of cloud, sometimes
I am hidden from the mountain
in veils of inattention, apathy, fatigue,
when I forget or refuse to go
down to the shore or a few yards
up the road, on a clear day,
to reconfirm
that witnessing presence.

The start of this poem has run through my mind many times over the last year. Perhaps it’s the mountains that rise beyond the hospital, frequently covered in clouds in the afternoon. It can be easy to lose track of why I am here and get caught in the business of seeing patients. It can be helpful to have moments that help me to remember God’s calling, to see the mountain again. Visiting Waffa, one of our rural clinics, was one of those moments for me. It was both humbling and a joy to be able to work alongside the incredible nursing officers working in this area and to meet the hospitable people of Markam District.

 

Traveling to Waffa is in itself an adventure. It requires a 7.5-hour drive, wading across the Markam river, another 1-2 hour drive and crossing another river (by innertube or wading). After crossing the Markam river, we crossed several smaller streams and rivers as we traveled deeper into the bush. Grasslands turned to rainforest with high canopies above. I glimpsed wild hornbills and cockatoos as our car pulled underneath the trees. Partway through the trip, Gabriel, our director of Rural Health Services, leaned over to me and said, “This car doesn’t have any breaks. He just puts it into reverse to slow it down on the hills.” I just had to smile to myself and think about what my mother would say.

 

Walking into Waffa we were greeted enthusiastically. Some of the older members of the village sang and danced in their traditional way and we were showered with flowers as our team entered through new gateways of palm leaves. Then the younger villagers sang an English song welcoming us again. This display was humbling, and I hoped that we could live up to some of their expectations.

 

Our team consisted of me, Dr Spencer-a local PNG doctor and close friend, Gabriel Mahisu-the director of Rural Health Services, Peter Bill-a local Markam leader and his son Joel. While we were there, the family of one of the local Nazarene pastors made us lunch and dinner every day. We enjoyed kumu (greens from different plants including various trees and, my favorite, pumpkin leaves/vines), potatoes, bananas, rice, corn, and coconuts. We slept in the newly constructed staff housing on thin mattresses with which we had waded across the rivers. A newly constructed pit toilet was next to the clinic, and we obtained our water from the stream a few hundred yards away.

 

The first morning we wondered if we would have very many patients to see because no one was there at 8am. However, by 10 several hundred people had gathered outside. Over the next two and a half days, with the help of three incredible nursing officers, Kenny, Felix and Siba, we saw most of those patients. We had a large variety of patients from antenatal checks to malaria to yaws to a broken arm. We also had a few mysteries, patients we needed to refer to the hospital for further tests or imaging. Part of our time included a Covid education talk with the community.

 

Each night we would go wash in the river. We were accompanied by some local boys who showed us the best spots to go. One of them, Guam, became a close friend. We played together in the river and juggled his soccer ball on the field near the clinic. On our last day he woke up very early to go catch some fish from his family fishpond so that Spencer and I could eat fish before we left. His mother told me that he got really upset because he was having a hard time catching the fish, but eventually he found a net and was able to catch two. They were delicious. He and his family came with us back to Markam to visit relatives. On the car ride out he fell asleep on my leg (impressive given the road).

 

Our final morning, we spent time doing some education with the nursing officers. A maternity ward is currently being built next to the clinic. Currently, most of the women deliver their babies at home. There are no nearby supportive services and complications are often deadly. We taught normal vaginal deliveries as well as common complications like postpartum hemorrhage (too much bleeding after delivery), breech delivery (when the bottom comes first) and shoulder dystocia (when the shoulder get stuck). Spencer also gave a short talk on Yaws, a bacterial infection of the skin and bone, a disease that seems to still be endemic in this area. Finally, we got to pray with and offer encouragement to this team. They provide such an incredible resource for this community and rarely get the recognition they deserve.

 

Coming out was as much of an adventure as going in. We crossed the first river to catch a vehicle going out at 1pm. By 6:45 we had still not seen this vehicle, but we managed to find another car that was able to take us out. We arrived at the Markam river and crossed in the dark. Thankfully it was not high. The next day we loaded up our car with mangoes and coconuts and started the long drive back to Kudjip.

 

I am so thankful for my time with the people of Waffa. My trip renewed my love for the people here in PNG, and it was a good reminder of the level of adversity my patients face every day. Guam touched my heart and I miss his trusting friendship. The people up Waffa helped me to glimpse the mountain again, as Denise Levertov says:

“to go
down to the shore or a few yards
up the road, on a clear day,
to reconfirm
that witnessing presence.”