Tuesday, December 30, 2014

Peril and promise

I thought we might have an easier clinic day than most, being Christmas Eve.  Although our patient numbers were down a little, in the afternoon I limped across the line after encountering one patient in particular.  

As he made his way toward me, shoulders slumped in a defeated posture, I could tell his face was swollen and his breath was short.  I looked at the clinic book he just handed me with his name printed on the front: Luke.  The same as my twin brother.  Not even in my room yet, I knew I would struggle through this visit.

One year prior I enjoyed reading a book next to a roaring fire in my parents' living room with a beautiful Christmas tree, preparing to move my young family to Papua New Guinea  But Luke began struggling for breath on his daily walks up and down the mountains of his village.  He got medicine from the local aid post, but it didn't help and he went to a hospital a few weeks later getting slowly worse.  Worried about his cough and shortness of breath, they treated him with six months of Tuberculosis medications.  Nothing helped.  Doctors and medicines weren't making a dent in Luke's condition - and he got weaker and began losing weight.

His sister came with him into my room, bearing the body language of someone who has seen countless doctors that couldn't give them a proper answer.  Reviewing his symptoms, looking at his thin but swollen frame and going over his X-ray and ultrasound with Dr Bill, it became obvious that Luke had cancer in his chest.  Not inside his lungs, but outside of them - compressing their ability to expand and breathe and limiting how much blood his heart could pump to the rest of his body.  Luke was dying.

I explained that I couldn't cure him.  I couldn't give a medicine that would take away this cancer and a surgery to remove it would kill him in this place.  Dr Bill might, I said, be able to take away some of his shortness of breath and help him be more comfortable - but it would take several weeks of strong medicine that could leave him weak and tired, or even kill him sooner.  Luke didn't hesitate - he wanted medicine to try and shrink his tumor and maybe help his suffering.

My job in the States at this point involves sending him to a specialist, who then administers medicine in a carefully calculated and controlled fashion while closely monitoring Luke's blood counts and other possible side effects.  In the U.S. he might even get a long shot at a surgery to remove some of his tumor, enabling him to breathe easier and live longer in comfort.  But in this place, Luke gets a little IV fluid and two different kinds of poison injected into his veins, with the prayers and hopes of his doctors that he will return feeling slightly better and not worse.


Kudjip chemotherapy

Barimo came to the Kudjip emergency department about one in the morning and our nurse, Mr Thomas called me concerned about him.  I wish I could say I immediately got myself out of bed and up to the hospital - but I did not.  Barimo experienced epigastric pain, but his vital signs were normal so I gave Thomas his admission orders over the phone which he carried out.  "After all," I thought "what could I do differently if I were there?"  I tried to get some sleep after what had been a busy call.

An hour later, Lucy from medical ward calls me to say that Barimo is confused, short of breath and clutching his abdomen in pain.  When I arrived, Barimo looked every bit the heart attack patient, hooked up to oxygen but still cool and sweaty with a thin and thready pulse.  In a brief lucid moment, he shook my hand and said, "Hello, dokta."  I gave him morphine and prepared to give aspirin and nitroglycerin, but his heart gave out first.

I compressed Barimo's chest while Lucy and Simeon, who just returned from taking a patient to the morgue, gave him artificial breaths and adrenaline to no avail.  He died just a few minutes after saying "hello" to me.  As I made out Barimo's certificate, and his family wailed in agony, I reflected on his death.

In the US, Barimo would have received electrical monitoring of his heart, an ECG, admission to an intensive care unit and, most likely, a percutaneous procedure in which a doctor threaded a small scaffold into the artery supplying his heart that was choked off, restoring the blood flow.  He might stay two or three days in the hospital, then be discharged home with medications and activity precautions, probably to live another five, ten or even twenty years.  This kind of life-saving procedure occurs many times a day at my old hospital, which serves a population of about 200,000.  And there are multiple hospitals in Tulsa that could do the same.

Somewhere in there a patient sleeps while getting life-saving care

But for seven or eight million Papua New Guineans, that kind of care might as well be on the moon.
They can't get to a single hospital or doctor with that technology or those skills.


I'm not one to get involved with political debates - free health care, socialized medicine, mandatory coverage, etc.  But how many of those fiercely discussing such issues in the US give a second thought to bringing more healing to the developing world?  It's not perfect, but Americans can get immunizations reliably, clean drinking water at will and emergency life-saving medical care almost anywhere in the country.  But Papua New Guinea can't get a single hospital to perform at that level for its millions of inhabitants?

With so much need and such an imbalance in the distribution of resources needed to combat it, what kind of world do we live in?

A world of peril and promise.

The perils are real and the illnesses are advanced.  The poverty is extreme and the living is hard.  The stakes are high and people are dying.

But some small things can make big differences.  Some hold great promise of health and life for millions.  Like giving the right foods, having enough measles vaccination, keeping babies breast-feeding, or giving care and medicines to AIDS patients.  Every day I participate in these seemingly thankless tasks.

In the hospital, I mostly encounter patients like Barimo to whom help comes too late.  But I believe that the promises of what we can do are just as real as the perils of what we cannot.  Babies are growing, HIV patients are thriving, mothers and their children are living better because of Kudjip's staff and their efforts.  Doctors and nurses who work hard - sometimes sending healed patients back to their villages never to be seen again - but taking bodies to the morgue daily.

How long can that promise keep the perils at bay - and preserve the hope of those combating it?

Please pray for the staff at Kudjip, whose tireless efforts make big, but often unseen, differences in the lives of their patients.

Tuesday, December 2, 2014

Many graves

"You call me out upon the waters
The great unknown where feet may fail
And there I find You in the mystery
In oceans deep
My faith will stand

A mountain range lies north of Kudjip station, just across the highlands' only serviceable road.  Beyond the mountains sits a valley filled with tropical jungle and people living in one of the most remote parts of the globe.  The name of this area is the Jimi valley.

Three weeks ago, Beron made the trip from her home in the Jimi to the local aid post for a routine checkup before her delivery.  An incredibly astute nurse, probably working in one of the most remote clinics in the world, palpated (touched) her abdomen and thought that Beron might have twins and they might not be in a good position.  He or she suggested Beron come to Kudjip.

Beron and her husband made the journey over a couple of days, and walked into our labor ward where I met them.  It turns out Beron had twins and neither of them were in a position to deliver vaginally.  I kept her on the ward, gave her vitamins and administered steroid injections to mature her baby's lungs.  Two weeks later, I performed a Cesarean section on Beron and presented her and her husband with two healthy twin boys.  Thanks to the efforts of one nurse dedicated to working in the Jimi, Beron's family is safe and whole.

 Beron and her twins - Mark & Luke (after my brother and I)

"He will bring justice to the poor of the people;
He will save the children of the needy"

About a week ago, a young lady living in the Jimi, and expecting her first baby, went to the local aid post with contractions.  After several hours, her water broke, but the baby wouldn't come out.  She pushed and pushed but could not deliver her baby.  In fact, not until three days later, after pushing with her body's contractions for almost 72 hours, could she hire a car to bring her to Kudjip hospital.  Her name is Kum.

At the time Kum arrived in Kudjip, I sat in reflective prayer during a Monday morning chapel devotion.  I enjoyed the message shared by one of our staff members but a nurse from the Obstetrics ward summoned me out.  Fighting back my frustration (our obstetric service interrupts me nearly every hour during my day), I went and discovered a very pleasant young woman on the delivery bed - but nearly fell over from the smell.

Kum forced a weak smile as I entered, but her abdomen was locked into a strong contraction creating pain.  A baby's head was lodged in her pelvis, but there was no heartbeat and the ultrasound confirmed that the baby died, probably one or two days prior.

After stabilizing Kum with intravenous fluids and antibiotics, I applied a vacuum extractor to the baby's head, but could not relieve the obstruction of her labor.  Kum needed a Cesarean.  Dr. Kevin Kerrigan, a selfless surgeon volunteering from the US, performed her surgery and delivered her deceased baby.  Kum went back to the ward, surrounded by women with their own healthy babies, to recover from her operation.  But now she leaks urine, meaning she has probably developed one of the most isolating conditions in the world, a fistula.

Lately, my heart has been breaking for the people of the Jimi.  Nearly every day I see women with obstetric complications - bleeding, infection, malaria, prolonged labors, high blood pressures.  But when the nurse tells me, "Doctor, she is from the Jimi" - my heart sinks.

I think of Lavinah, whose baby's arm presented in her birth canal during labor, then died while it took her two days to come to the hospital as her mother suffered from septic shock.  I think of Mana, whose first twin died after being born in the Jimi, and whose second (also deceased) twin wouldn't deliver until I was able to resuscitate her with a blood transfusion and apply a vacuum to the baby.  I think of other patients who arrive too late - with metastatic breast cancers, heart and kidney failure, advanced cervical cancer, or osteomyelitis (infection of the bone) needing amputations.  And I wonder what could have been if they had access to care where they lived, or if they could make it through the jungle to see us sooner.

In short, I think of the graves in the Jimi - many unnecessarily filled by the babies, children and parents of that remote area.  Some graves whose occupants I will never know about and never even have a chance to help.  Some whose occupants I know ... but knew too late.

"And I will call upon Your name
And keep my eyes above the waves
When oceans rise
My soul will rest in Your embrace
For I am Yours and You are mine

As difficult as I find it, dealing with the problems of the Jimi, I know that my emotional struggle is nothing compared to that of its people.  I weep over the babies I can't save.  But their mothers spend a few days recovering and then make the long trek back over the same path through the mountains to their bush houses of grass and sticks.  They return to their husbands, who may or may not blame them for losing a child, and have to resume tending their gardens to have enough food to eat or sell or trade.

Where will their hope come from?  Are they condemned to an existence full of suffering and death? 
How many more graves will they dig?

Mana and Kum's babies died before they ever had a chance to hold them.  Beron's babies both survived and she is recovering well from her surgery.   A long time ago I gave up trying to figure out why things happen like that here in Papua New Guinea.  Certainly I still wonder, and I still get frustrated.  But I choose to look into the face of the suffering here every day not because I know why, but because I believe that God gave me the skills and knowledge I have for a specific reason.  I table my tears, because I have more work to do as I walk the ward.  And though I struggle to prevent my patients' suffering from paralyzing me, I know that I can only help the next one if I keep it together.

I don't ask God why these things happen.  I ask that He would send more and more people like Beron's nurse into the Jimi to care for the neglected people living there.  Slowly, I believe that those living there can receive what they need.  Until then, I pray that I would have strength to save those I can, the heart to comfort those I cannot, and the endurance to do both every day in spite of the numerous mothers and babies who are dying there.