tribal dispute, the market, and more on my first day off

Saturday, March 22nd 10:30pm
As implied by the title, today was my first [most of the] day off at the hospital. I was on call last night, where I saw something pretty cool. But I’ll save that for later. I’ll tell you about my day first.

I got up early today to round on my patients so we could hurry up and get to the market. I was able to discharge a few patients who had recovered well, which is always a good thing. Another adult patient I had been called on last night who was hanging on by a thread was still alive this morning. Also a good thing. I did have to sign the chart on the baby who died, but in looking over it again, it made me feel a little better to know I couldn’t really have changed anything. Maybe better isn’t the right word … maybe just a little less bad. Anyway, after that I came back to the house and we all got ready to go to the market in Mt Hagen, about an hour away. We were escorted there by Dr Andy Bennett’s wife Judy and their teenage son Sam. They are very nice people, and actually had us all over for dinner tonight. It is great how people are reaching out to us and making us feel at home.

First we went to Best Buy, not the electronics store, but a grocery that is pretty similar to what we have back home, just smaller and with things I didn’t always recognize. Then we went to the Market, which is a huge open air market with tons and tons of people at tables selling their produce. This picture isn't really representative of how busy it was. Most places were packed, but there was a little break and I thought it was a good photo op. Vegetables have never looked so good! Everything is so fresh and delicious looking. They have some fruits and vegetables pretty unique to here, whose names I can't remember for the life of me. There were also some chickens being sold, which captivated Caleb’s attention for a solid 10 minutes. I don’t know who was more entertained, Caleb watching the chickens, or all the natives that gathered around to watch Caleb. Evidently pale blond haired kids are pretty rare in these parts! Most of the day I was holding Caleb while Stephanie did the shopping, but when I did set him down for a bit, one lady selling bananas tried to make friends with him by giving him a couple. Apparently this happened pretty often when Caleb went on Monday with Stephanie and Sarah.

For lunch we went to a really nice, modern hotel in Hagen. The food there was pretty good as well. I had a BLAT, which is a BLT plus avocados. I have never been a real avocado kind of guy, but I tried it and definitely liked it. There is a pool there, and Caleb stripped down buck naked again (same as Monday) and played around in it a bit. When it was time to eat, I asked Stephanie, “You think we should put a diaper on him before we eat?” She replied, “Nah, it’ll be alright. He’ll want to get back in soon anyway.” All was well for the majority of the meal, until Caleb had finished and was getting a little restless. He stood up in his high chair, as is his custom, but instead of asking to get down, he was acting kind of fidgety. I wasn’t paying too much attention until I smelled a very distinct smell, looked over, and saw a pretty large turd sitting in the middle of his high chair. Yeah. At least everyone got a pretty good laugh out of it, and they didn’t deport us.

When we got back home, I played basketball for an hour (the elevation here really killed me) and took a shower. After I came back into the living room, we started hearing a big ruckus coming from the road in front of the station. Evidently, there was a huge tribal clash between the Kumas and Suare (sp?). There were basically in two large groups with a well-defined line between them, yelling and throwing rocks. In the past, this has escalated to real fights with bush knives and whatever else is handy, but that is apparently rare. We heard lots of gunshots, which we are told was the police trying to disperse the crowd. It evidently didn’t work, though, because there was just more yelling. It wasn’t until sunset that things quieted down, which is evidently the unwritten rule: quit fighting after dark unless you really mean business. Josh and I were thinking we’d have to go to the hospital and help sew some people up, but no dice. Things ended pretty quietly. We were also told that if there was a real fight, the hospital only sees one side. The other must travel down to Hagen to be seen. I hadn’t thought about it before, but it actually makes a lot of sense. You can’t have fights erupting in the hospital, after all. The way they decide which side to treat? Whoever gets here first.

Oh, about the cool patient from last night. It was a lady who had just given birth at home and had come to the hospital within a few hours. She was moaning a lot and acting like she was in some distress, but she was oxygenating well, heart and lungs sounded good, etc, so we were ready to just give her some meds to help her relax and call it a night. Then a nurse asked us to take a look at her neck, because she was complaining of some pain under her jaw. Dr Erin felt her neck, then asked me to examine it. I said in astonishment, "Is that crepitus??" and she affirmed. Crepitus is basically when there is air in the soft tissue under your skin. It feels a little bit like rice crispies. Some of you may remember my prisoner blowing up his face story - same type of deal, but to a much lesser extent and not intentional. I'll save you most of the medical reasoning and everything we did next, but the end result was actually what we intended to do in the first place. Since we did a chest xray and ruled out a large pneumothorax, we decided to just help her be comfortable and let everything heal and dissolve by itself over the next couple of days. Not something you see every day.

Hopefully the pictures are a good addition. Internet here is available, but quite a bit slower than I am accustomed to, so adding pics is a bit tedious. I’ll try to do a better job!

all about the Haus Sik

Well, I promised to let you know about the hospital, so here it is. It is now Friday evening the 21st, almost 9pm. I noticed that the last post was dated US time, so I'll try to let you know from now on when I'm writing PNG time.

First, a little disclaimer. Medicine here is much different than in the States, and I am still getting used to it. Much of the difference is solely the result of inadequate resources. Everyone here cares deeply for the patients and want the best for them. It just so happens that the best here is a bit different than the best in our US hospitals.

The very first thing you would notice about this hospital is the smell. People here don't really take showers, at least not that I can tell. There is the distinct odor of sweat and unwashed bodies that permeates. Compounding this, of course, is a lack of air conditioning. The second thing you would notice is the big smiles that just about everyone will give you if you make eye contact. The people here, though lacking in the hygiene department, are certainly not lacking in friendliness. The hospital is made up of two main buildings: outpatient, including the ER, clinics, xray, lab, and OR; and inpatient, consisting of four wings - pediatrics (A ward), maternity/birthing (B ward), adult medicine (C ward), and surgery (D ward). The ER and clinics are primarily staffed by experienced nurses (all nurses here are native PNG'ers), who either treat and send away or pass along to a doctor to see. Note: here I count as a doctor, even though I am probably not as proficient as many of the nurses when it comes to practical tropical medicine. Fortunately, I don't speak Pidgin, so for now I must be accompanied by said nurse or I tag along with a missionary doctor. In the ER and on wards, it is the former, in clinic, generally the latter (though that will change soon).

Note that I said xray, and not radiology. The only radiology here is xray, and the quality is not quite what I have become accustomed to in the States. Most of the time, though, it is good, and they are always willing to re-take xrays with special instructions if it is necessary. I never realized how much we rely on CT scans and MRI's back home. I mean, it is literally like taking a step back 50 or so years. You non-medical types might not understand this completely, but it's a little like the difference between a road map of a town and a full miniature model. You can tell some things from a road map, many important things in fact, but there is a lot you just don't know until you can see the buildings, the elevations and reliefs, etc. One nice thing, though, is the debate about whether to get some expensive test is gone. No more needless head CT's in the ER "just incase!"

The lab and pharmacy are also not quite what I am used to. The lab has the ability to run basic blood counts and some chemistries. That's about it. For you who are interested in such things, let me know, and I'll post more in depth about this subject. The biggest thing missing is any kind of micro lab. You can order a gram stain, which often doesn't show much, but that is the extent of it. No confirming what bacteria you are (or aren't) treating, no susceptibility testing, no cultures at all. This makes for a lot of shotgunning treatment, but it makes you much more aware of fever curves and white counts. The pharmacy has probably been the biggest struggle for me. For one, some of the medicines are known by different names. For example acetominophen, aka Tylenol, is paracetamol, which is its British name. Another dilema is that supply is limited, and medicines in stock are constantly changing. There is no such thing as a concrete formulary, though there are some medicines that are generally available. Of note, drugs here come from two sources: what is donated, and what is bought from the government supplier. The donated meds are much more hit or miss, but the supplier evidently is not great at sending meds and supplies on time or in the correct quantity. Add to this that I have never in my life treated malaria or typhoid, and you have me struggling to catch up. I'm doing much better, though, and by the end of next week I should have things down pretty well.

My typical day this week has started about at the hospital around 8am. In the morning, the doctors round on their inpatient ward, around 25 beds each, and then head over to clinic to see the hordes of patients waiting in line. Each ward is a long room, approx 50 ft long or so and maybe 20 ft wide. The cots are lined up on either side, much like you would see in a WWII movie. Their are two semi-private rooms near the entrance to each ward for patients with highly communicable diseases, the kind who whould be in negative pressure isolation back home. I have been on A ward (peds) with Dr Susan. Everyone here goes by their first names, making me Dr Ben. Here, the families don't really have a surname. They do it old school: first name is the given name, and surname is their father's given name. After that, they are identified by their tribe. For example, there could be a man named James Isaac, of the Jimi tribe. His son could be Peter James. You get the idea. At any rate, for the first two days, I rounded with Dr Susan on every patient in A ward. Then on Wed, I began seeing some myself with the help of a nurse. They are actually nursing students at the nursing college here on the station. They are all very nice and helpful, and have been working with me on my Pidgin. The patients sure get a kick out of it, and I am happy to supply some laughs. One nurse, Mark, tells me that my Pidgin is getting much better, but when he says this the patients all start to chuckle... I think I have some work to do!

After rounds, as I said, it is time for clinic. It operates much like it does in the States, except the setup is much more like an Urgent Care than a prive office. There are usually 4-5 docs seeing the next patient in line. Susan, though a pediatrician by trade, abides by this as well, which is pretty remarkable. She sees kids, adults, pregnant ladies, and the elderly, just like everyone else. Everyone breaks at noon or there abouts and takes an hour for lunch. After lunch, it is more of the same until everyone is seen. I'm not sure when they stop taking people in the line outside, but sometimes they just keep coming and coming! After this, we head home. I am really glad that Stephanie and Caleb joined me in coming here. I would be pretty lonely without them. I am definitely sapped for energy, though, when we finally put him to bed. I think I am still recovering a bit from the big trip. I was also on call with one of the docs on Tuesday, which meant a little less sleep than usual. Tonight I am on call by myself, with a doctor for backup.

Good medical stories so far.... well, there was a guy today who came in around 1pm with a chop-chop. This basically means he got hacked with a machete. His story was that he was at a family get together, he and everyone else was drunk, and he went out to get some more booze. When he was returning, he heard the voice of a man he knew and then saw "lightning", which was evidently the machete. Probably not the whole story, but the result was still a drunk guy with half his face hanging off. The cut went from about mid nose, under the eye, and down the cheek past the corner of the mouth on the right side. I unfortunately didn't have my camera handy, so there is no picture to show. It was not a strait on cut, but rather from the side and a little behind. Thus, the cut was relatively shallow, no bones were involved, but a relatively large flap of skin, including half his nose, was just hanging on.

There is also a little kiddo I admitted a couple days ago with meningitis that is doing better each day. He looked really terrible that first day, but now is starting to feed and really come around. I feel like I really made a difference for that little guy, and hopefully he will be really out of the woods after the weekend.

Not so good stories... I lost a patient today. It was a one week old baby I admitted this afternoon for neonatal sepsis. I saw tons of these kids at Children's Hospital in Columbus, OH, but never lost one. The difference is probably the amount of time between when a kid gets sick and when they go to the hospital. I started the little boy on the appropriate antibiotics, called in my backup to double check, and admitted him. This evening, during dinner, I was called to the hospital because he wasn't breathing well and had briefly stopped breathing. When I got there, he was looking worse, not responding well, cool, vitals looking very sluggish. At this time, I again called my backup, and we decided/hoped that the baby had had a seizure and was just post-ictal, so we started seizure meds and also added malaria meds in case this was causing seizures. We also made him a DNR, since it wouldn't change his outcome. I was called about an hour later and told the baby had arrested and they were trying CPR. I had to tell them to stop. Death is a very real part of medicine here, as I am just learning.

Let's get this party started

It is now day three here at Kudjip, PNG. I literally have not had time to sit down and write before now, and now it is only because I woke up early to get some things done. (I know, I know, you can wipe that suprised look of your collective faces now)



First, about the trip here. Suprisingly, it wasn't as bad as I had expected. Of course, I had expected it to be the worst 26 or so hours of my life. Caleb didn't sleep nearly as much as he needed to, only about 2 hours on our flight across the Pacific, and then another 6 on the flights from Tokyo to Mt Hagen, PNG. Yes, I did have to utilize the Benadryl, though the kid really did have a stuffy nose and cough, so it was easily justifyable. When we arrived, Dr Bennett was waiting for us at the airport, and lined along the fairly small fence were about a hundred PNGers tightly packed, watching the goofy foreigners arrive. All our bags arrived safely, which we were definitely excited about, tempered only by the tedious experience of having to pick up our bags at the baggage claim on both our stops along the way, exit through customs, re-enter through customs, and check in our bags again.



We then rode about an hour from Mt Hagan to Kudjip, where the Nazarene Hospital is located. Along the way, there were the kind of images you would expect: beautiful tree covered mountains, little thatched huts, and a few little "markets" where people had their produce lying on the ground to sell. The suprising things was just how many people seemed to be just wandering around aimlessly. I was talking to one of the doctors last night, and apparently it's because people just don't have to work all day to make a living. Here in the highlands, most people are subsistence farmers and the ground is incredibly fertile. Most people plant a garden, have a few coffee trees, and maybe a few pigs and chickens. After they plant the garden, the rest of the work is really not all that time consuming, so people have plenty of time to wander about, gamble, chew boi (more on that later), smoke PNG gold (aka marijuana), and chop each other with machetes.



When we got to the hospital complex, the first thing you notice is the large fence with barbed wire surrounding the whole thing and the guards at the gate. Tribal violence is still fairly big here, and law enforcement is apparently not great. I think they need a good dose of Deputy Kumorski! Anyway, they do a very good job of keeping that stuff out of the station. The set up here is very nice, sort of a camp-ground feel with gravel roads that stretch out in a couple directions from the main circle where the hospital is. We are actually staying in one of the temporarily vacated missionary houses with our friends, the Adams. It is so much nicer than anything I expected!! It is a three bedroom, one bath house that you would expect to see in any town in America, with a few add ons. The water we use is rainwater collected in a large corregated cistern next to the house. We do have hot water, supplied by a solar powered water heater on the roof. Electricity is not a problem here, because there is a small river that runs just down the mountain from us, and the station maintains a small hydro-electric generator. The power does go out frequently, but some mysterious super hero then goes down to the generator and fixes it somehow. We are forever in his debt! Supposedly the water from the cistern is drinkable (depending on who you ask), but there is a large micro-pore water filter on our kitchen counter we have been and will be utilizing. The water is, by most accounts, safe for other things, like brushing teeth and bathing, so that is nice. It almost feels like cheating being able to take a hot shower, but I'll take it!



Time is now running short for me this morning, so I'll save the description of the hospital for another time. I don't want to sign off, though, without giving some props to the missionaries here. They seem like some pretty incredible people. The Meyers (Susan is the pediatrician here) had us over for lunch about an hour after we arrived on Sunday. The meal was wonderful, and their kids were really cool and very good with Caleb. We ate with the Radcliffs last night (Monday) and had a similary great experience. Jim Radcliff is the surgeon here who has been here for over 20 years. We asked his 15 year old daughter if she has gotted back to the States much and she replied, "Yeah, we get back about every three years" Wow. They have 6 kids, four of which were born here at Kudjip. Pretty incredible people. Well, I'm off.

Time Change

Just FYI. You can think about the time change to PNG in two ways.

1. they are 9 hours behind us but a day ahead of us or...

2. they are 15 hours ahead

I have been thinking the former, since we are traveling west (time going back) but crossing the international date line in the process (day ahead)

The day has arrived!

Well, folks, it is about 4:30AM or so and I am finally (almost) done packing. Nothing like a little procrastination to get the juices flowing. I'm anticipating this to be one of the most exciting/awful days of my life. On the one hand, I can't wait to finally get going to PNG, where I hope to learn and do so much. But on the other hand, there is the whole 20 hours of flying with a two year old. I know what most of you are thinking, and no, I don't plan on spiking his sippy cup with GHB, alcohol, narcotics, or any other potentially harmful substance. A little Benadryl, however, never hurt anyone, especially when they are "fighting some allergies." Hey, whatever helps me sleep better at night.

In all seriousness though, it really will be a challenging day and a half. Then as soon as we arrive, we will deposit our belongings in our rooms, go to a missionary's house for Sunday lunch (they're a day ahead), and get a tour of the hospital. Jet-lag be darned, because evidently I'm starting in the hospital the next morning whether I feel like it or not!

Wish us luck and send up a prayer for the three of us if you think about it, because I we're sure going to need it! Hopefully there will be some adventures to report soon and some cool pictures to follow.

Suprises abound

If there is one thing I have learned the past few months, it's that not everything goes exactly how I plan it. Now, if I didn't have such a thick head, number one, I would probably wear a more normal hat size, and number two, I would have learned this lesson a long time ago. I mean, I didn't go to the medical school I thought I would, Caleb came along well before we expected him, and I didn't even choose the specialty I thought I would going into med school. That said, everything seems to work out for our good, just as the Lord promises in Romans 8:28. What a lot of people forget about in that verse is the qualifier, but that's another discussion for another day.

At any rate, preparation for this trip to PNG has been anything but smooth. First, our visas were late and we had to cancel our flights. We couldn't reschedule them because there was no way of knowing just how late our visas were going to be. Normally, it wouldn't be that big of an issue, but flights into Mt Hagen, PNG only occur once a week. On top of that, we are dealing with the airline of a "Least Developed Nation" that only deals with paper tickets, meaning there must be at least a week leeway between when we book our new flights and the date we actually fly. So, we went ahead and booked our flights for March 14, two weeks after our original departure date. That meant that we would be there for 7 weeks, one short of the normally required 8 weeks for a two month rotation. I was convinced my medical school would be understanding, however, so there was no problem.

Then, yesterday, our visas arrived! We were pretty pumped. On the half-empty side, that meant that we could have scheduled our flight for this Friday, the 7th, but it would have been a pretty big gamble. No biggie. Then, however, we were told by our travel agent that our return flight date had to change. Apparently, when you cancel a flight with PNG's airline (they have only one), you must cancel the whole deal. When we tried to re-book our return flight, there was no room. So, we have to leave either a week earlier or two weeks later. We were expecting/hoping to leave our return flights the same when rescheduling due to our hectic schedule of house hunting, graduation, moving, settling, then starting residency when we return to the States. But, a week earlier just isn't an option because that would cut our trip too short. Guess our hectic schedule just got a little more hectic!

Sorry to those of you who struggled through those last two paragraphs. Welcome to our confusing world! The end result is that our trip is back to a 9 week adventure, just shifted two weeks later. I guess that's just what happens when you work with a third world country. The upside: I get to do a whole bunch more and genuinely help a lot of people while I'm there. The downside: it is a whole lotta work and money to get there. To those of you planning to do this in the future, just be ready to be flexible!

In the mean time, Josh Adams, the best man in my wedding and fellow med student (attending a different med school), will be getting into town this week, so we are excited to spend time with him and his wife before we all leave. They will be joining us to PNG where he will also be working at the hospital, though he will only be there 3 weeks. He was scheduled for 5, but also encountered visa trouble and is not fortunate enough to have flexibility with his return date. For the next week and a half we'll just be reading as much as we can about the culture there and the major diseases we'll be seeing: malaria, typhoid, tuberculosis, pneumonia, and HIV. Oh, and we'll probably manage to get in some time with his new Wii!!

Day (-)12

Hey guys! Time for post #2. We had hoped to be in PNG by now getting over our jet lag, but alas, we are still here in the States. Our rather expensive hang up has been obtaining our visas, which finally seems to be getting on track. Unfortunately, that means two less weeks there and some hefty charges to change our tickets. Se la vie.

I just wrote an incredibly boring update on my situation which included some obligatory statistics regarding the country, the people, and the hospital. The only thing worth noting, I think, is the crazy amount of good the people at Kudjip Nazarene Hospital do with what American hospitals would consider chump change. You can check out all the statistics here at their website of how many people they see, babies they deliver, and surgeries they do. Suffice it to say that it is pretty freaking amazing, especially considering they do it all on $750,000 a year.

Coincidentally, that is just under twice the amount it cost for Stephanie and Caleb's stay at the hospital when he was born. Stephanie had preeclampsia, which basically means her blood pressure (as a result of the pregnancy) was so high it was trying to kill her. As a result, Caleb was born at 30 weeks, and spent a month and a half in the NICU. I'm definitely not going to go all utilitarian and say that we shouldn't use expensive treatments/resources to save lives. Far from it! The money spent on both of them was more than worth it, and I don't like to think about what life would be like for me now if we had been in some third world country when it all went down. Selfish... maybe. It is just crazy to think that our one hospital bill could fund an operation that serves a province of half a million people for the better part of a year. I think that speaks to the differences in both the capacity for complex care and the level of resourcefulness in our respective systems. Hopefully I'll be able to pick up on some of that resourcefulness while I'm there.