Tsingoropa and a much needed update

 Two days ago was Independence Day here in PNG. In 1775, PNG became independent from Australia and thus was celebrating its 46^th birthday. It was a fun day full of color, traditional dress, lots of basketball and volleyball and a show of pride in their wonderful country.

Updates since my last blogpost

-I turned 30 and was wonderfully surprised by all the love shown to me, both from friends here and back in the US

-I climbed the highest mountain in PNG! (Mt Wilhelm which stands at 14,700ft-impressive for an island)

-We (my neighbors the Myatts and I) planted our garden

-I went to a cultural show that featured traditional clothing and dances from different parts of PNG

-I taught hurdles for PE for the missionary kids

Not part of hurdles, but a fun race nonetheless :)

-Our hospital faced a serious budget shortfall and was in the beginning stages of closing when the government came through with emergency funding and we were able to continue to provide care to our patients

-And, lastly, I went on a trip to Tsingoropa in the Jimi valley for a week of work in a rural clinic. I want to share more about that trip.

The Jimi valley starts beyond the hills just north of Kudjip. It is one of the most remote and undeveloped areas in PNG. In the 8 months that I have been here, many of our sickest patients have come from the Jimi Valley.

I traveled with Dr Matt for a week of work at a rural clinic in Tsingoropa. We were able to work with an awesome team of Nursing Officers, Gabriella and Moses, and a Community Health Worker named Joshua who staff the clinic. Our welcome was overwhelming, seeing the emotion of a community that had not had a doctor visit in a long time. Through the week we saw hundreds of patients, did antenatal visits and ultrasounds for 25 pregnant patients, and spent some time training the team of local health care workers. It was a full week including showing the Jesus film, sharing a devotion at a Thursday night fellowship, playing soccer and swimming in the river (just 2500 feet down the mountain and back).

Top: Dr Matt and I with Moses, a nursing officer at Tsingoropa; 2. Praying with a patient in the clinic 3. Matt and I with one of the mamas who had come to be seen by a doctor. 4. Wara Jimi 5. Another patient encounter 6. Peter and his mother waiting outside of the clinic to be seen

One of my favorite moments was one evening when I went to sit on the porch and watch the kids play rugby. Suddenly I was surrounded by a group of kids looking at me expectantly. Eventually I learned they wanted me to share a story, so I proceeded to give a paraphrase of The Hobbit. The kids loved the interaction and proceeded to tell me some stories of their own.

I was touched by the warmth and hospitality of these people, the way they welcomed us into their community and the difficulty of their lives. I hope to be able to go back in the future.

 

Hard days

Some days are hard.

 

I stood watching the baby struggling for breath, still cyanotic hours after her birth. She had swallowed a large amount of meconium during the birth process. Despite suctioning and resuscitation, we were unable to help her breathe normally. Now she was on maximum oxygen therapy after CPAP had failed. My heart sank even further as I read the chart. She was her mom’s fourth child, but of the three before her, only one was still alive. The next morning her crib was empty.

 

The morning before, I learned that Dora had died. Dora had been living in the hospital for the last several months. She suffered from chronic lung disease from tuberculosis as well as heart failure. Every morning I would see her, and she somehow usually was able to give me a smile. Each day I felt a little more helpless as I saw her slowly deteriorate, the medications no longer helping. She made me a beautiful bilum (decorative bag) the week before she died. We often prayed together, although I know towards the end, she was losing hope and the will to live.

 

 

Later that night I took care of a woman who had been brought into the ER after being tortured in her village, being accused of sorcery. She had burns on her back, chest, arms and legs and a deep machete wound in one leg. She struggled to answer my simple questions, on the edge of shock.

 

In clinic, I pushed through, but unable to fully hide the sadness and weariness I felt. A dear friend offered me some really good advice post-call-“Take a nap and then pray for these patients.” Later, I released them to God with tears, anger and confusion giving way to shared grief.

 

 

 

Henri Nouwen talks of service as an encounter with God, “a joyful way of life in which our eyes are opened to the vision of the true God who chose to be revealed in servanthood. The poor are called blessed not because poverty is good, but because theirs is the kingdom of heaven; the mourners are called blessed not because mourning is good, but because they shall be comforted.”

 

Today I’ve had in my mind the image of Jesus calling out to Mary Magdalene from The Chosen. Christ chooses to see us amid our brokenness, pain, and suffering. He meets us there. He was working here before I came and will stay long after I leave. He is working through my incredible PNG colleagues. I don’t always understand it, but it will always be a privilege to join Him in His work.

 

 

Wisdom from Dr Jim

It’s been a while since I have written. Sorry for the long lapse. Sometimes business makes it hard to write, but other times I find myself uncertain what to write. Life here is so varied and quick it can go from celebration to mourning to thanksgiving to frustration in a short period of time. Also, now as some of the newness has worn away it is harder to reflect on what I am experiencing.

 

So, I’m going to use a little bit of a structure to help me reflect. The structure was provided through the wisdom and life lessons of Dr Jim.

 

Dr Jim is somewhat of a legend around here. He and his family lived here for over 20 years serving as a surgeon to the hospital, and now his son Ben is our general surgeon, carrying on the legacy. All the workers who have been here long enough have a Dr Jim story, and on long runs I will run into older men and women up in the hills around station who ask me about Dr Jim.

 

Dr Jim was able to come help at the hospital as a volunteer as part of a Covid relief team. During one of our doctor’s meetings, he was able to share these pearls he learned from his many years here. Using each pearl (and combining a few to keep this from getting too long), I want to share a snapshot of my life here, what I’m learning and where I’m growing.

 

Recent staff meeting including volunteers Dr Jim and Dr Pringle

 

1 and 2. Know your calling and trust your God.

Some of my residency colleagues helped me to realize that having a vision and goal was a strength of mine, something that I hadn’t realized before. Prior to coming here my vision had been focused on making it through medical training to be able to serve people in a rural, underserved area just like this. Honestly, one of the big transitions in coming here for me was moving from having this big vision to living it, and thus no longer having a vision or goal for the future. I’ve had to learn to form visions again.

 

One of my great joys here has been running outside of station, partially because it helps me to see the big picture and think about the future. There are several different ways that I can go to get up into the hills just south of station and look back into the Waghi valley. These times help me to feel God’s presence and feel His heart for this beautiful place.

 

The view from one of my favorite running spots

 

3. Learn to laugh and have something to look forward to

A few weeks ago, I was able to go on vacation to Madang, a town on the PNG coast. It was such a blessing to have a short break and time to get to know some of the other missionaries better. We were able to go snorkeling, explore the area and have time to relax without call shifts.

 

 

 

Something that frequently makes me smile and laugh are the kids here. Yesterday during my shift, I met Maggie who had one of the best smiles I’ve ever seen. I couldn’t help but smile back and feel joy at getting to do the work I do.

 

 

One thing I’m looking forward to is a chance to climb the highest peak in PNG, Mt Wilhelm (14,793ft). I’m hoping to go with a few friends one weekend in August.

 

4. Focus on prayer

Personally, I’ve always struggled with prayer. My mind tends to wander, especially when I am tired. The last couple months I have been using a book to have fixed time prayer or “saying the offices.” It has specific prayers in the morning, noon and evening that come from the Psalms and church tradition. It has helped me to focus my heart throughout the day.

 

5. Bond with brothers and sisters

One blessing over the past few months has been getting to know some of my PNG brothers and sisters better. I’ve really enjoyed having my neighbors and some of the PNG doctors over to my house for dinner and occasionally watching a movie. Hosting is not the most natural thing for me, but there has been plenty of grace for my cooking 

 

Dinner with my neighbors and coworkers

Fellow doctors and some good friends

 

6 and 7. Say I’m sorry/Keep saying yes

Occasionally the work as a physician here can be stressful. There are many things that are new to me, and, unfortunately, sometimes I let that stress show through frustration. I have had to apologize more than once when I haven’t been very gracious or have been too task focused instead of relational. One night when I was grumbling about being called in, God showed me how a lot of my frustration was rooted in my fear of being inadequate to deal with whatever the call was about. He then proceeded to help change my mindset to curiosity and adventure, knowing that He would help me through whatever challenge might come.

 

Last weekend I got to spend a night with Apa and his family again, which was special. Hugging and playing with his kids made me feel at home and to see deeper into what the lives of the people I see every day in the hospital are like. Moments like these help me to keep saying yes to my work, especially when the work is less rewarding.

Mumu and morning fire at Apa's

Rounding

I wanted to invite you in a little closer to what rounds look like for me every morning. These are some of my patients from the Pediatric Ward.

 

My first patient is James, a 6-month-old who was readmitted after becoming a lot sicker following an admission for pneumonia. He was admitted by our ER staff overnight and in the morning my LP showed that he had bacterial meningitis. Thankfully, the ER staff had started the right medication to treat this. He initially required two anti-seizure medications to control his seizures, but on this day, he has completed 10 days of treatment and looks like a new kid.

 

 

 

This is James a few days later in outpatient clinic showing off his fancy hat.

 

 

 

The next bed is a 5-year-old girl suffering from typhoid. Sometimes these children get very sick, and they are often very irritable and uncomfortable until the medication begins to help. Next to her is a 4-month-old with pneumonia who was very interested in me, despite needing oxygen to help him breathe.

 

 

Moving across the aisle I have a set of twins, although only one of them is admitted. This baby got very sick after being born at home and had to be admitted for antibiotics and to help the baby feed. A few beds down from them is a 12yo girl who was admitted with a septic knee joint with the infection spreading to her femur. I had to make an incision in her leg down to the femur to help evacuate the puss to allow her leg to heal. While she was initially pretty shy, we’re now good friends and I go by to say hi in the afternoons sometimes. She’s starting to walk again and should be able to go home soon.

 

 

 

The next bed is a chunky 9-month-old named Eskimo who was also admitted for bacterial meningitis. Thankfully he responded quickly to the antibiotics and is well on his way to being better. The last patient is Tom. He was admitted for malnutrition. Over a couple of weeks, he gained over 1.5kg (3.3lbs). While he was initially irritable, he quickly became a very smiley and vivacious little guy. While I’m thankful for his improvement so that they can go back home, I’m going to miss seeing them in the mornings. It's been such an honor and blessing to me to be able to help care for these precious kids.

 

Loving the RUTF (Ready-to-use Therapeutic Food--souped up Peanut Butter)

 

 

In a few other updates, this week I moved to Medical Ward to take care of our adult inpatients. I was able to get my Covid vaccine, the Astra-Zeneca vaccine, thanks to the COVAX program. Also, here are a few pictures of my new house. Yesterday there was a large party to thank all of the workers who helped build the new fourplex that my house is a part of.

 

View from my back porch

 

 

I also was able to go to a rural “bush” church with a few friends this last Sunday. It was a beautiful and refreshing experience to be able to worship and pray with this small community (even though it was an adventure getting there :)

 

 

 

 

 

 

Foundation and Calling

 Hi friends and family,

Sorry for the long gap in writing. Life here has been busy and every time I have tried to sit down and write I have lacked the inspiration and energy. Initially I had planned a much different blog post, but that changed.

 

Pictures from a recent hike up to Mt Tapi

 

 

Life here is settling into more of a pattern. I am now moved into my permanent house that the construction team had been hard at work on to prepare for me. It’s nice to have a space that I can make more my own knowing that I will be in it for the next two years.

 

And yet, it still feels hard to find consistency. Call shifts can range from easy shifts with only a couple of phone calls to my last Thursday call shift where I was at the hospital for most of the night taking care of machete wounds, a patient with liver failure, two vacuum deliveries, a C-section and a repair of a third-degree tear. We also have a large number of people leaving in the next couple of weeks-volunteers returning home, families going for home assignment and a long-term family leaving permanently-even as we welcome a few new and experienced faces. I definitely feel some sadness and a sense of transience with these transitions.

 

 

One of my Peds patients who came in with burns from cooking oil-improved a lot from admission

 

Part way through a recent busy call shift I found myself dreading being called for something for which I was unprepared (any number of things really-trauma, complicated OB cases, anything in the eye…). I longed to be completely competent, ready to answer any call, or, on the other hand, to always have quiet calls with conditions that I was more than capable of handling. I wanted to have arrived, to be able to coast down through the rest of my work, not being ruffled or showing my vulnerabilities. Being exposed by difficult cases made me feel unsettled.

 

It’s easy for me, particularly as a physician, to find a lot of my identity in my work. When things go well, I feel on top of the world, glowing with a sense of competence and agency. However, when things are difficult or don’t go well, I often blame myself, feeling inadequate and uncertain.

 

My initial plan was to write this blogpost as a case study about a patient I was caring for on the Pediatric Ward. He was an 8-month-old that presented with shortness of breath and sores over his body. I cared for him for 2 and a half weeks, discovering his diagnosis and starting him on appropriate therapies. He seemed to be slowly moving in the right direction, until the weekend when I heard that he has passed away. I was stunned. Initially he had been so sick I would not have been surprised if he had died, but he had seemed to start to respond to treatment and had been there every morning as I came to round. My heart sank as I remembered his eyes looking at me as I would listen to his heart and lungs every morning and the deep sadness that was always in the eyes of his mother. I also felt the weight and doubt of the physician who has lost a patient, especially a child. The next day on rounds the empty bed bored into me with its silence.

 

 

I’m currently slowly working through a book called Walking with the Poor by Bryant Myers. A wealth of ideas about what poverty actually is and the complexity of doing development work well, it has challenged me deeply about my work here. Last night I read a sentence that hit home in regard to what I had been feeling, “An agent of transformation who is not also being transformed is capable of doing more harm than good” (sorry no page number-Kindle edition). Coasting through is not our calling.

 

A good friend recently asked me how I had changed since being here and I didn’t have a good answer. But I think that as I have become more proficient in the language, seen more deeply the ebb and flow of life here, I have found slowly growing in me a more profound love for my patients, a greater willingness to listen to stories and to see. I’m also being forced to find my identity and stability in something beyond my abilities and the outcome of my work. As Easter reminded me, in Jesus and the cross we have the perfect model as well as the perfect foundation.

 

 

Karen, Bill and Rose

 

I wanted to share a few stories of patients I have taken care of while here. These are by no means representative of the people here, or even necessarily my work here, but rather stories that have touched my heart in one way or another.

 

My second day out of quarantine I did my first C-section here in PNG. The patient’s name was Karen, and she was 30 weeks pregnant with twins. She had been hospitalized over a week before due to severe preeclampsia (a condition in pregnancy where the blood pressure goes up, the kidneys spill protein into the urine). She had been treated with steroids to help her babies mature faster so that they would be ready for a premature exit and treated for her high blood pressures, but that day her blood pressures were not responding to treatment and the team was worried that she might develop seizures or other serious complications from preeclampsia.

 

The first twin was in a breech position where the legs and butt are down instead of the head, so the decision was made to proceed with a C-section. Not having done a C-Section for about 7 months since the end of residency I was nervous heading into the surgery. As we prayed for Karen before starting the case, I tried to take a few deep breaths to steady my hands, and my prayer took on a greater sincerity. Dr Ben, the general surgeon at the hospital, was my overqualified assistant and helped me orient to doing surgery here. Thankfully the surgery went well and both babies were delivered safely.

 

 

 

A few weeks later I returned to work on our OB Ward. To my delight, I was able to resume care for Karen and her two babies, a boy and a girl. Over the next several weeks I was able to watch them grow, learn how to breast feed, no longer require the NG tubes (tubes through the nose into the stomach used for feeding) or the oxygen. This last weekend they had both made it past 2kg and were growing well by just breastfeeding. I was able to send them home. It was a bittersweet departure, joyful at their progress and ability to go back home but also sadness that I would not be able to see these twins grow and see Karen’s shy smile every morning.

 

 

……

 

I was convinced that Bill would not survive when I saw his mother carrying him into the emergency room. She was trying to breathe into his mouth while carrying him in, a sign that he was not breathing. I rushed over with the nurse and helped her lay him on a patient bed. Amazingly he still had a pulse, but he was not taking any breaths on his own. We started using a bag-mask to help him breathe while the nurse took vital signs and attempted to get an IV. His mother stated that he had been having bad diarrhea for weeks. After 5 minutes he began to take breaths on his own and after 10 minutes he no longer needed our support to breathe, just some oxygen. We were unable to get an IV so I had to place an IO-a needle that goes into the marrow of the bone to allow us to give fluids.

 

That night I walked up to the hospital two more times to check on him, each time a little surprised but also thankful that he was still alive. That night I prayed, trying to trust Bill to God. In my work here and in Malawi I have seen many kids die. Sometimes they came in like Bill, malnourished and dehydrated on the verge of collapse, only to die within a few minutes of arriving despite our attempts. Others suffering from malaria or trauma or premature birth would last a little while longer only to succumb to the overwhelming pathology. But thankfully, by God’s grace, his attentive mother and the nursing staff, he not only made it through that night but also the next one and the next one.

 

I checked on Bill several times over the next few days, every time seeing him more alert and interactive. A week after he was brought in, I took this picture.

 

 

 

Seeing children die can be overwhelming, heartbreaking and discouraging. But thankfully we are able to make a difference for many. And for Bill that difference means the world.

 

….

 

Rose was brought into our hospital by a helicopter from the Jimi valley, a large valley north of our hospital, that despite not being a long distance away (40-60km), can present an often-insurmountable barrier to access for our patients that live there. With a reliable car, it is a 4-5 hour very bumpy ride out to our small health outpost in the Jimi Valley. For many of our patients it can be a trip of several days. Luckily for Rose, she was able to be brought in by a helicopter for obstructed labor.

 

Rose had been in labor for 2 days but had not been able to deliver her infant vaginally. Our hospital is the only health care facility for our province of 350-400,000 people that has surgical capabilities and can provide blood products. As such, we see a large number of complicated obstetrical cases.

 

We brought Rose back quickly for a C-Section. The baby was difficult to extract due to the length of her obstructed labor and the moulding of the head into the pelvis. There was thick meconium (baby poop) that had obviously been present for some time. Thankfully Dr Ben was available to help me with the delivery. I scrubbed out of the case to help resuscitate the baby while Dr Ben started to close the uterus. After about 10 minutes of resuscitation the baby was crying and breathing on its own.

 

Over the next few weeks, I have been able to care for Rose and her baby. Rose initially healed very well; however, she subsequently developed a wound infection and has required further care and antibiotics in the hospital. As she is not able to get wound care near her home in the Jimi Valley, we have kept her here to continue to help her heal in a safe environment. Her baby has done very well and seems to get bigger every day.

 

Every morning Rose greets me with a soft, shy smile. She has been so patient throughout her time here. I am so glad that she was able to arrive when she did. If she hadn’t and if this hospital weren’t here, both her and the baby likely would have died.

 

 

I hope these stories encourage you as much as they have encouraged me. Sometimes seeing the health disparities here can be discouraging, but there are bright lights like Karen, Bill and Rose too that give me strength to keep working to help the people here. I am so thankful for the staff here who have been giving of their lives to help this community for years and years.

 

I would really appreciate your continued prayers. We are in the midst of our first large outbreak of Covid in the province and there is a lot of fear and uncertainty. Many patients are not coming into the hospital due to this fear and we know that this is probably leading to a number of patients, especially pregnant women, not receiving critical care. I’d also appreciate prayers for finding community amidst a pandemic and perseverance as I continue to have so much to learn, language, culture, tropical medicine and especially learning to make diagnoses/decisions in the face of uncertainty.

 

I want to end with a Henri Nouwen quote from a devotion today, “Learn the discipline of being surprised not by suffering but by joy. As we grow old…there is suffering ahead of us, immense suffering, a suffering that will continue to tempt us to think that we have chosen the wrong road…But don’t be surprised by pain. Be surprised by joy, be surprised by the little flower that shows its beauty in the midst of a barren desert, and be surprised by the immense healing power that keeps bursting forth like springs of fresh water from the depth of our pain.”

 

You all are in my prayers. I love hearing from you!

I do actually work too

Thus far I haven't really shared about my work in the hospital so I wanted to reassure you that I am actually working too :) Kudjip Nazarene General Hospital has 4 different wards-Pediatric, Medical (adult), Surgical and Obstetric. I have and will continue to rotate through working in all of the wards except Surgical. Pediatric and Medical Ward have around 32 beds and Obstetric Ward has more than 45. In 2018 there were 55,000 outpatient visits, 7000 admissions, 2643 deliveries (376 C-sections) and 908 major surgeries. I work with a staff of over 230 from all parts of PNG as well as a team of doctors from PNG and the US (sometimes Australia and New Zealand as well).

 

A normal day for me involves rounding on one of the wards starting at 9am. Once this is over I go to the Outpatient Department (OPD) or to the Emergency Room to see patients for the rest of the day. I take call overnight every 3-5 days. I did my first call shift by myself on Monday.

 

 

For my doctor friends (and other interested friends), this is a quick picture into my call shift last Friday. I don’t know whether or not this is representative of a busy call (or even if my experienced colleagues would call it busy), but I found it challenging but also fulfilling.

 

The day started with rounds on our Medical ward. Conditions that I have seen on our Medical Ward range from CVAs (strokes) and MIs (heart attacks) to TB meningitis and malaria to endometritis and incomplete abortions. I then went from there to the ER.

 

My first patient was a 13yo F with one day of confusion and fever. She was agitated and did not tolerate an examination. Fearing meningitis, I gave her some ketamine and did an LP that showed a high opening pressure and mildly turbid CSF. I started her on ceftriaxone (antibiotics) and dexamethasone (steroids) and admitted her to the Pediatric ward. My next patient was a 5yo M with a large abscess of his left calf and significant swelling all the way to the ankle, indicating pyomyositis, a common condition here where an abscess extends deep into the muscle and can spread along the underlying bone. He also had to be put to sleep so I could do an I&D (incision and drainage) and was admitted to the Pediatric Ward. Dr Mark then helped me to reduce a radial head fracture in a 20yo M that we then splinted until he could come back for casting in a few days.

 

Later that morning I took a pregnant mother who had been admitted with mild preeclampsia (a condition in pregnancy where there is elevated blood pressure and protein in the urine that can progress to severe disease marked by maternal seizures) who had breech twins for Cesarean delivery. I was assisted by Maxwell, a PNG native who is doing his rural health surgical rotation at our hospital.

 

 

After the surgery, I had a short pause that allowed me to run home for a quick lunch. As I was finishing lunch I was called back to the Obstetric Ward for a mother who had been complete for 2.5 hours but unable to deliver the baby and now the baby’s heart rate was low. I ran back up to the hospital and was able to assist the mother in delivering the baby by using a vacuum. Both the mother and baby did well.

I returned to the ER where I had a couple more patients to see, including a pregnant mother with malaria and a hemoglobin of 5.2. She also had had a positive VDRL and rapid HIV at a rural health outpost before she had been transferred to our hospital.

 

I had a brief reprieve after this before I was called back to see a mother who had spiked a fever and whose baby’s heart rate was in the 180s remote from delivery. After failed resuscitation attempts and starting antibiotics, I made the decision to proceed with Cesarean section. While the team was getting things ready, the ER asked me to evaluate a patient with a large bush knife wound to the head. I had to ask Dr Mark (one of the experienced doctors here) for help again, as the skull had fractured and was depressed where the knife had cut. Thankfully the patient had a normal mental status and we were able to close the wound and put the patient on antibiotics and anti-seizure medications. We then proceeded to the OR for the second C-section of the day. Mother and baby did well.

 

As I was getting ready for bed I was called back to the ER for a patient with a hemoglobin of 8 who was having significant vaginal bleeding. A quick look with the ultrasound diagnosed an incomplete abortion. The patient was symptomatic from her blood loss and we had to act quickly to transfuse her and do a D&C (dilation and curettage) to help stop the bleeding. Thankfully her bleeding stopped following the procedure, her vitals returned to normal with the transfusion and fluid resuscitation and she was admitted to the ward.

 

I was then able to sleep until early in the morning when I was again called to the Obstetric Ward for fetal distress during labor. The baby’s heart rate had dropped into the 50s when I had arrived (normal is 120-160). With help from a vacuum, the mother was able to deliver a healthy baby within 2 pushes.

 

After morning rounds, I was able to go home and get some more sleep.

 

There are a lot of new things for me here and I am learning a lot from the very experienced staff and doctors. Every day there is a new challenge. But I hope and believe that we are making a difference for the patients here. When I was out with Pastor Apa I talked to a lot of people, but one was a man along the side of the road near the Waghi river. He yelled out hello to me and then became a little sheepish as he was holding a beer bottle that he had been drinking. I tried to put him at ease, and we began to talk. He mentioned how having a hospital like Kudjip in the region brought pride as well as helped everyone who lived there by bringing access to a higher level of care than would otherwise be available. I’m proud of our team and what they are able to do and thankful that I get to be a part of the work here.

 

 On a run with my mentor Dr Matt (and a few kids)