One final reflection

My time in PNG has come to a close. I’m currently sitting in the Brisbane airport partway through my 3½ day trip home. As I think back through my time, there are a number of memories that come to the surface. To be honest, many of them are sad and difficult. I think about diagnosing a woman with twins and polyhydramnios (too much fluid) at 19 weeks and then a week later delivering the twins, too small to have any chance even if they had been born in a different setting. I remember the tiny three month old, suffering from malnutrition and likely some undiagnosed congenital syndrome who came in with respiratory distress and miraculously survived through the weekend only to die on Christmas Eve. I think about the mother with uncontrolled diabetes that we took back for a C-section due to failure to progress because her baby was 5kg. After the C-section, I went in to check on baby and he was cyanotic and had significant difficulty breathing due to his massive chest and the amount of fluid and meconium still present in his lungs. I knew in my heart that he wouldn’t survive till morning. And yet there are a lot of other memories that are more positive, although not as etched into my memory; the man slowly recovering and gaining strength following TB meningitis, the molar pregnancy I diagnosed in clinic after 20 weeks that could have been life-threatening if allowed to go much longer, the little boy with acute bacterial meningitis who slowly improved over time, the cord prolapse baby that survived, somewhat miraculously, to be born early Christmas morning, and the countless people in clinic who left with a diagnosis that could explain much of their pain and suffering.

Despite all the difficult moments, discouragement is not the predominant impression I have in leaving. To be sure, it is difficult to swallow that so many people, particularly children, are still dying of illnesses that we have had the ability to treat or prevent for over 50 years. There were a number of nights I left the hospital with a heavy heart. The more I reflect on it, though, the predominant impression I have in leaving is not the individual clinical memories, but rather the conviction of God’s calling me to medical missions work and to caring for the poor and most needy. It was reassurance that I have not wasted the last 9.5 years of my life and that my motivation, though deeply buried, was not fully destroyed by the medical training process. It was also a reassurance that there are multiple paths after I finish and a number of ways to obtain the skills that I will need to serve in such a location. Overall, I’m leaving with a kind of hope for what the future might bring and the changes that might be possible.

Thoughts on transitioning back home

My time is swiftly coming to a close here in PNG. Already I am starting to prepare for my departure and it is predominately with sadness. Here are a few thoughts I’ve had as I wrap up my time.

As I reflect particularly upon the transition back to my work in the States it is with mixed feelings. Here in PNG the main difficulties I have had have been the want of equipment and medications and access to procedures; from desiring the proper medication for patients in the clinic (BPH meds to Lasix, which we ran out of shortly after I arrived) to the ability to obtain a CT or MRI for a patient to clarify a diagnosis to the more heart breaking need for proper respiratory and ventilator support for critically ill neonates and children. Knowing that outcomes for a patient, particularly a child, would have been different if the necessary materials were available is difficult and it is nice to be heading back to where supplies are plentiful. However, it is also with reservations that I head back. Here in PNG documentation consists of the essentials to communicate important diagnostic information and treatment plans, but does not suffer the burden of satisfying medical billers or future litigators as in the US. The main purpose is patient care with an emphasis on efficiency. I was reminded of the stark difference reading through emails from home with numerous attached documents of the particular documentation requirements of a specific population with government insurance. I do not doubt that EMRs and the current documentation requirements have helped to provide more comprehensive care, however, I believe they also contribute significantly to burnout and decreased time in direct patient care.

I have had numerous discussions with the missionary physicians here about the differences in practice here and in the States. In the US, we frequently discuss whether or not a test will inform our treatment decisions in an effort to minimize unnecessary testing. Here it is taken to a whole new level. I had thought I was thinking carefully through tests before, but here there have been numerous times I have suggested ordering something only to be challenged on whether or not that will meaningfully change my plan of care. Over the course of my time, I have learned to rely more on clinical exam, nursing reports and typical disease course than on laboratory values or imaging. Although there is theoretically universal health care here, the only way for hospitals to make ends meet is to charge patients or receive donations or both. Tests here cost money for the patients (often between $1-5), which, for many of our patients, is a significant investment. Minimizing unnecessary tests has very practical implications for our patient’s lives and makes it that much more critical. It is frustrating that this has to be true as I wonder if care were truly free if we would see patients come in earlier and thus be more likely to respond favorably to treatment. Of course it’s impossible to know for sure.

Over the course of the month, I have been thinking about a quote I stumbled upon a few weeks before departing for PNG: “Tact, sympathy, and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs, and disturbed emotions. He is human, fearful, and hopeful, seeking relief, help, and reassurance. To the physician, as to the anthropologist, nothing human is strange or repulsive. The misanthrope may become a smart diagnostician of organic disease, but he can scarcely hope to succeed as a physician. The true physician has a Shakespearean breadth of interest in the wise and the foolish, the proud and the humble, the stoic hero and the whining rogue. He cares for people.” The last paragraph from Harrison’s Introduction, First Edition, Harrison’s Principles of Internal Medicine, 1950. In some ways, by removing the bureaucratic work and computers, PNG has helped me to come back to being able to see more clearly the humanity of my patients. In others, it has offered new obstacles of language and culture. I took one morning last week to do rounds with the chaplain through the Medicine Ward, which I had been working on for almost a week. By getting the chance to sit down with, listen to and pray for some of the patients, I learned a lot more about some of my patients than I had discovered on morning rounds. One of the women who had been admitted for a suicide attempt with gramoxone ingestion (a type of herbicide used frequently here as a means of suicide) informed us that she was pregnant, something that she had hitherto not shared. Another woman with undiagnosed abdominal pain told us about her unfaithful husband, her family’s refusal to let her divorce and her fear of contracting AIDs. I hope in the future, whether here or in the US or somewhere else, that I will not let the numerous obstacles that will always be present interfere with my ability to truly see, listen to and care for my patients.  

A Lighter Note

I wanted to write a lighter post as so much of my experience here has been truly wonderful and I haven’t fully expressed that here yet. First, I’ve neglected to give a little context. I did not know much about PNG before coming and am still woefully ignorant, but here are a few of the things I have learned. PNG occupies the eastern half of the island of New Guinea, just north of Australia. Two Indonesian provinces occupy the western half of the island. The island is incredibly culturally and linguistically diverse and slightly more than 80% of its population lives in rural areas. Over 800 languages are spoken in PNG and it is one of the least explored countries in the world. English is one of the official languages although it is not commonly spoken. Most commonly spoken, at least in the highlands where I am, is Tok Pisin (or Papua New Guinea Pidgin). There are numerous areas of the country with little to no connection with the rest of the world. That being said, there is also clear western influence in more populated areas of the country from music to advertising to knowledge of English. PNG has a fast growing economy secondary to mining and natural resources, but the vast majority of the population is unemployed or subsistence farmers. It has been at various times under German, British and Australian control, but officially gained its independence in 1975. It is still as a commonwealth realm with Queen Elizabeth II as its monarch and head of state. The island has an extremely diverse ecosystem ranging from coast to wetlands to rainforest to mountain (Mt Wilhelm, the highest peak, is 14,721 feet high!).  The most popular sport is rugby. The country is predominately Christian, although this is mixed with traditional, more animistic beliefs that tend to incorporate veneration of the dead and belief in evil spirits. The education and health care system is provided both by the government and church/NGO groups. It is incredibly beautiful in both its people and landscapes.

One of the first things I noticed about the people of PNG is how welcoming they are. As you walk down the road almost everyone will greet with you a wave or “Morning,” “Good day,” “Afternoon,” or “Evening” as appropriate. Smiles are common and quickly reciprocated. At church, there is often a good chunk of time at the beginning of the service to welcome all of the different groups who might be present.

Another characteristic I have noticed is how patient the people are. Many start lining up early in the morning for the clinic and often wait hours to be seen. Some of them have traveled for a couple of days in order to be seen at the hospital because the transportation system, outside of a few maintained roads and airplanes, is poor. Despite long waits and inconveniences, many of the people are very patient and thankful.

On a final note, one of the physicians here who worked here for 34 years is preparing to retire in about a month. His name is Dr. Bill. My initial meeting with Dr Bill was helping him to place a long arm cast. He kept making funny noises as he shaped or applied the plaster, either for his own or the patient’s amusement, I’m not sure which. To be honest, I thought he was a little odd at first, but as I got to spend more time with him I was amazed at his character. Through years of experience, Dr Bill has gained an incredible wealth of knowledge of both the people of PNG as well as the medical ailments that come through Kudjip hospital. He is the go to guy when an interesting case or difficulty diagnosis comes along. And yet, he is incredibly gentle, humble and overflowing with love. His quiet greeting carries a weight of affection behind it that is rare. One day in clinic I asked him to come help me with a patient that I was concerned had liver cancer based on my exam and ultrasound. Dr Bill confirmed the diagnosis and you could hear his heartbreak as he broke the news to the patient. Even after years of seeing cases like this over and over again, he was still present to this man’s suffering. Before we left, he wrapped him in a hug, something I had seen him do multiple times before, an expression that to me conveyed a longing to protect the patient from what was coming, to bring him closer to his heart. I don’t think Dr. Bill will get a lot of accolades or honors for his devoted work in this small corner of the world, but I can tell that here he is a giant and will be greatly missed. I hope that as a doctor I can emulate some of what Dr. Bill has accomplished here and, when I look back on my career, see the patients I’ve helped rather than the attention I’ve received.

Mortality and Calling

I had my first child die yesterday. A child born in a developing country is thirteen times more likely to die before they reach their fifth birthday than those born in industrialized countries (WHO Secretary General, 2008). “In 2006, more than 9 million children under five died of preventable causes. Of these deaths, 53% involved some level of under-nutrition” (When Healthcare Hurts, p. 234).

The child had pigbel, a disease I had never heard of before coming to PNG. The condition is an overwhelming infection of the intestine by clostridium, usually following a high protein meal such as pork in someone whose diet is predominately starch (potatoes).  The major complication is necrosis of the bowel requiring surgical resection. This child, a 5yo boy was so sick on arrival that surgery was postponed to try to stabilize him first, as it was not felt that he would survive surgery. He declined significantly overnight and was close to death by the time of rounds. After examining him, I touched his mother’s shoulder and she knew what was imminent. She began sobbing loudly, the sound echoing through the ward. Not knowing what else to do I stood there with her until local staff came to be with her.

It’s been a difficult transition here. This has not been the first child to die since I have been here, although he was the first one whose care I was directly involved with. There seem to be a number of potential responses to the immense suffering here. One that I see predominately in the local staff and missions doctors who have been here for some time is an acceptance. At it’s extreme is fatalism; this is how things are and how they will always be. It is something I have seen in other impoverished communities, a way of coping with the brutal reality of life in desperate poverty. It is not unusual to lose a child, even, perhaps, more common than not having lost a child. I do not think the response is a lack of love or compassion, but a survival mechanism to continue to care for what remains and continue to live life. On the opposite end of the spectrum, one of the physicians told me the story of a volunteer who got upset and yelled at local staff after a child had passed away in the E.D., something she thought might have been preventable if everyone had acted appropriately in performing resuscitation and bringing supplies for intubation, IO access, etc. As an outsider it can be easy to compare healthcare here to America and note all the shortcomings and flaws. However, it is often difficult to see how certain practices are the best way to compensate for a shortage of equipment, medications, personnel, etc.

On a more personal note, it has been a difficult experience seeing how quickly my heart can go to a fatalistic perspective. Multiple times in residency I have struggled with burnout, which often leads to difficulty empathizing with patients, particularly after a long shift. Too frequently I can see a patient as burden or nuisance instead of fellow child of God. In PNG there have been different challenges. Not speaking the language or knowing the culture, it can often be difficult for me to place myself in the patient’s shoes.

However, I have been incredibly encouraged to see the doctors here care for their patients. They often take time to pray with them after a difficult diagnosis or before a procedure. They stretch themselves to create a quality healthcare delivery system in this small community, and I can see the gratitude in the people they treat. I am starting to remember the reasons I started medicine in the first place. And standing with that mom beside her dying son I could feel God’s grief and reaffirmation of that calling to care for the suffering.

On a lighter note, here is a snapshot of what my day looked like on Saturday when I was on call to give a better idea of what life has been like for me here in PNG…

Rounds start at 8am. I start on Medicine ward and start seeing patient’s while my proctor starts on the other end. We work with the nursing staff and nursing students to go through vitals, orders and come up with a plan for the day. After rounds we do a quick I+D on a lady with cellulitis and an abscess in her foot that had been admitted for IV antibiotics. Then we head to our Obstetric Ward to see antenatal and postpartum patients. We do a couple ultrasounds on patients with suspected PROM (the diagnosis in PNG is based solely on pooling or leaking onto a pad which can often lead to ambiguity). There is a patient with CPD who we plan to take back for Cesarean delivery. While that is being prepared we swing by the E.D. to see a couple patients who came in early. After the C-section I go back to the Medicine ward to splint a man who was admitted after a fall who has a broken left ankle. I get a brief break for lunch and then get called back to the E.D. to see a couple of patients. One is a G1P0 at 18weeks whose ruptured 3 weeks previously. We ultrasound her and miraculously her baby is still alive, although her AFI is 0. After we finish in the E.D. we swing by the OB ward and find that one of babies getting delivered (normal deliveries are done by nursing students in PNG) is having bradycardia. We get ready for a vacuum but she is able to push baby out with the next contraction and my preceptor and I start resuscitation. The baby had thick meconium on suction and required PPV for 10-15 minutes but stabilized to go to the nursery. I’m able to go back to my residence for a short period of time and am just starting to heat up dinner when I get called back to the E.D. for a knee and a child. The knee is a classic ACL tear during a rugby game, which is unfortunate as surgical repair is extremely unlikely here. The child I am told has had a cough and fever for one week. When I see him he is lethargic and ill appearing with his neck arched back. I call my preceptor immediately and we perform an LP that shows cloudy liquid-acute bacterial meningitis. We start antibiotics immediately and admit him to our Pediatric ward. As I’m getting ready to leave, an old man from a remote region, about 2 days away comes in with abdominal swelling for 3 months and gradually increasing dyspnea. He has been treated as an asthmatic for a number of years but recently developed severe swelling.  He has severe ascites, lower extremity edema and fine crackles in his lung fields with an abnormal heart rate. A quick look on US shows a severely enlarged heart with diffuse wall motion abnormality. His blood pressure is borderline at 90/60 so we admit him for a gentle diuresis. I finally head home for a late dinner and some sleep before rounds the next day. I’m amazed at the breadth of knowledge of the physicians here and what they are called on to treat on a regular basis.

Welcome to Papua New Guinea (PNG)

My first several days of my trip has felt like a collage of events/moments juxtaposed together, both beautiful and sad.

With feelings of nervousness and excitement my plane took off from Denver to start me on my journey to PNG. The feelings were soon replaced with awe, getting to see this incredible state I live in from a different perspective, the Rocky Mountains stretching to the horizon covered in early snow, and slowly giving way to the desert. I woke up to see the Grand Canyon pass beneath the plane, incredible even from 10,000 feet.  18 hours later found me staring out as lightning lit up the clouds and Pacific Ocean below. Another incredible display of the size of God’s creation and reminder of how small I actually am.

As my plane started it’s descent into Mt. Hagen, the mountains rose up on either side, so close that I could count the trees, until, seemingly at the final moment, the ground dropped away into the valley where Mt. Hagen lies. I met Don, one of the career missionaries here at the airport. Flying down the road towards the hospital, we fly past one stunning view after another of green foliage, looming mountains and numerous inhabitants at markets, walking along the road or swimming in the rivers. The sun set behind the mountains was dazzling and I couldn’t help feel how lucky I am to be here.

A couple hours later that evening, as we were walking through the E.D. for my tour of the hospital, we stopped to see a patient who was victim to a “chop-chop” injury, the PNG term for the unfortunately frequent machete-induced lacerations. The man had received two deep cuts, one on his right shoulder through his deltoid and down to his humerus and the other along the left side of his neck, through the lower part of his ear and down to his mastoid process. We clamped off a bleeder (small artery) in the neck and stabilized the bleeding till the surgeon could take him back for more definitive management in the O.T. (operating theater). As we were evaluating him, my preceptor leaned over and said, “Welcome to Papua New Guinea.”

The next day was my first true day in the hospital. Mornings start with rounds in the Wards, which for me this week is the Pediatric Ward. My first patient is a 6yo boy who was admitted for several days of fever, fatigue and abdominal pain. He was positive for Plasmodium falciparum and vivax and had a hemoglobin of 4 due to hemolysis from the malaria. My next two patients are kids with diarrheal illness admitted for rehydration, a common disease here in PNG. The next child is a 2 month old that had been admitted for a groin abscess. Infections of the soft tissue, tropical pyomyositis, are very common here in PNG and often present far advanced. Fortunately for this child, he had improved with an I+D and broad spectrum antibiotics.

 
The next two cases are particularly heart breaking. Across from the 2 month old was a 14yo girl with advance heart failure secondary to a cardiomyopathy of unknown origin, likely rheumatic fever vs a congenital abnormality. She was admitted for worsening shortness of breath and abdominal pain secondary to fluid accumulation. Without access to advanced pediatric care, her prognosis is poor. Even at a well run hospital like Kudjip there are critical drug access shortages, far more significant than our perpetual shortage of IV Zofran and LR in the States. The government helps supplies medications, but even so important drugs are frequently missing off the shelves. While we have IV Lasix for her now, we currently don’t have any PO Lasix to send her home with, a necessary treatment to prevent her from needing to come straight back to the hospital. Next to her is a 5yo M who suffered a severe TBI from a tree falling on top of him and who is currently in a coma with little hope of recovery. What is most difficult in these two situations is seeing the concern of the parents who are sacrificing so much to try to take care of their children in relatively hopeless circumstances. Even in the U.S. these would be difficult things to work through and treat, but here it is impossible. The boy’s family had to travel two days to get him to the hospital after his accident and likely that time factored into his current state. As in America, geography very much dictates health in PNG. The farther you are from the hospital, the more likely you are to experience the negative outcomes of infection, obstructed labor, trauma, and innumerable other health conditions.

After Wards we go to Outpatient clinic and start working through the the line of patients. We see babies, pregnant mother, chronic disease, acute illnesses and everything in between. All of the patient's in PNG carry around their health records from hospital to clinic to health outpost. This allows you to see what care they have received at other locations, something that would otherwise be impossible. In clinic it is common to see broken bones, large abscesses, complicated pregnancies, fever of unknown origin, dehydration, septic joints and more all within the space of a couple hours. The team of doctors and nurses are incredible and work together to keep everything moving.

I have felt very welcomed and brought right into the thick of things. This is already too long, thank you for reading this far if you made it :) I'm on call for the first time this weekend and will try to blog again after that experience. Keep me in your prayers as a lot of this is very new!