Wednesday, April 1, 2020

Going viral

It's been nearly 3 months since my last blog post and the world seems a completely different place.  The daily case and fatality count of COVID-19 fills every space of my laptop screen, mobile phone, hours of meetings and even my dreams.  I wake up each morning unable to turn off the gears that make me contemplate each possible action I can take to protect my family, prepare our community for an outbreak and somehow continue to bring much-needed essential care to over 300,000 Jiwakans in the highlands of Papua New Guinea.

10 days ago, Papua New Guinea reported its index case of novel Coronavirus in an expatriate mining worker recently arrived via Europe.  I was asked to join the Jiwaka government's COVID-19 Preparedness and Response Committee.  This is a multi-sector task force currently working under a State of Emergency order by the Prime Minister.  Police, Justice, Health, Administrative and Education sectors are involved as well as representatives from UN and disaster agencies.

The Jiwaka COVID-19 Response Committee

Day 1

What happened next has been a surreal "trial by fire" into the field of Public Health that I never anticipated going through.

For the first two days, the effort was to enforce the State of Emergency directives from the Prime Minister which included limited mobility of persons.  I went with the police patrols to the various market areas clustered around the highway and gave a brief 10-minute overview of Coronavirus infection and the basics of how to contain the spread of the virus (Pasim Kus, Wasim Han, Noken Bung - "Cover your cough, wash your hands, do not gather in crowds").  Within a day, this basic message was codified by the various players in PNG health into leaflets and information that could be disseminated quickly.  We need this information to go more viral than Corona.

Briefing the patrol officers on COVID-19 basics - there is a lot of fear and misinformation which has preceded the arrival of the virus.

Riding in the police cruiser - it felt important to me that basic health information should be conveyed alongside the orders for limited mobility
Atop the Toyota Land Cruiser preparing to conduct some basic awareness teaching

The next step was to identify centres in our province that could accommodate patients, oxygen therapy, and isolation.  Our Jiwaka Health team had already identified three and I was asked to consult on making preparations for the facilities and the staff in the event of a surge of patients.  While I understand the need for ventilators in places like the US and Europe (and re-tooling manufacturers to create them), in our setting we need to do as much as we can to get the basics right.  Until a specific treatment or therapy is available for Coronavirus, we will need to mitigate its severity the best that we can, given our limited resources.

As a "triage" option, patients can be maintained on cylinder oxygen while awaiting admission to an isolation facility

Powered by solar and properly divided, this unit could provide 2 liters of oxygen per minute via nasal cannula to a maximum of 4 patients in need, who will be spaced 2 meters apart in an isolation unit.
Preparing an isolation unit

There needs to be a way to protect the workers at those facilities that both screen and treat patients.  The use of separate triage / staging areas for patients with fever and cough can minimize the number of personnel potentially exposed to the virus and can maximize the efficient use of the VERY limited supply of personal protective equipment (PPE).  I developed algorithms based on the current WHO case definitions to risk stratify potential patients and allow workers to identify those that might be a "suspect case" or "person of interest" - which includes travel history, severity of illness and the lack of other explanatory reasons for their acute infection.

Separate "cough tent" screening area at Kudjip where health workers screen patients using algorithms to identify any potential "suspect case"

In an ideal world, potential cases would be tested to confirm infection, trace contacts and recommend self-isolation during treatment for those that can be managed at home.  With limited testing supplies, we are over-aggressive on patient education and recommendations for self-isolation in order to create an environment where the restrictions on mobility can be upheld in an effort to contain spread.

So you think these are rare in the U.S.?

Infection Prevention & Control will, I think, be a significant weapon against any potential COVID outbreak in settings like ours.  Patients wearing masks / covering their cough is the first step to reduce transmission to others - including health workers.  Health workers with PPE (ideally mask, goggles, gloves and a gown) can also reduce risk to them.  There are not enough.  I get that.  There is a shortage of PPE supplies in the US, but it breaks my heart to see what truly limited supplies are like in the current environment around here.

3 boxes of basic PPE made available for our provincial health workers attending a population of 300,000 - praying for more to come!
In light of those limitations, hand-washing becomes very important for the community, the patients and the health workers.  Alcohol-based sanitizer?  Not so much.  Running water?  Sometimes.  What can we do?  We create basic wash-stations and use them ALL - THE - TIME.  There are a variety of options and thankfully, Papua New Guinea receives plenty of rain.  The difficult part is catching it, storing it and distributing it with sporadic electricity.  But I had time to bring a basic wash-station to one of our nearby facilities, instruct the personnel on using it and we plan for the provincial health leaders to create and distribute these things around the other centres.

Getting ready to see a patient in one isolation unit

So the rapid response to an outbreak in our setting follows the same basic principles in any other place: awareness, infection prevention and control (including PPE for healthworkers), surveillance and testing, isolation and treatment - recovery.  Unfortunately the challenges will be felt on an exponential scale if there is a significant surge in ill patients.  Praise the Lord there haven't been other confirmed cases - but with limited surveillance capabilities it is possible they are coming and we are taking an active and precautionary approach.

While this happens, the essential services that were provided before the outbreak need to be provided during it and be continued afterward.

The only place in Jiwaka that a patient can receive surgery, advanced maternal care or a blood transfusion continues to be Nazarene General Hospital at Kudjip.  We need to provide this care because we are the ONLY facility that can do it.  We can help other centres establish screening, work on hand-washing and protection, advise isolation and even, in some cases, administer oxygen.  But we cannot create operating theatres or blood banks rapidly.

This was brought home to me last night on call.  One of the other doctors and I were covering the Emergency Department and Maternity units.  I triaged a cough/fever patient in our screening area (donning and doffing one of our limited sets of PPE) before returning to the Emergency Room to perform a lumbar puncture on a patient with meningitis.  

Just after getting home, I received the call from Maternity ward, "Doctor, there is a patient here who has a breech baby stuck.  The baby has already died."  Patient X felt contractions at home during her 4th pregnancy and before she could get to her local health centre the baby was born, feet first, to the belly-button.  At the facility, the baby delivered up to the entrapped head, which couldn't be relieved there.  During transport to Kudjip, the baby died.

On arrival, the mom was in distress from a hyper-stimulated uterus which was contracting without pause in an effort to relieve the obstruction.  After establishing IV access and giving her some fluids and antibiotics, I performed a special maneuver to flex the deceased baby's head through the birth canal.  After the delivery, I examined the mother and realized that there was extensive damage that needed repairing in the operating room.  An hour later, cutting the last stitch, I was summoned to the Emergency Room again to attend a child with a diffuse infection in the leg threatening to penetrate into the bone.  After days of making preparedness plans for a potential outbreak of a deadly virus, I was reminded of the very real and equally deadly challenges facing my Melanesian neighbors in the here and now.

I pray that we do not see a significant outbreak of Coronavirus.  If we don't, we have made preparations and improved the resiliency of our health system for today's needs and future difficulties.  If we do, we will continue to provide the care that we can, for those that we can, in the ways that we can, for as long as we can.

Pray for our hospital, its staff, the community around us, our leaders - and for the financial provisions needed to support the ongoing work here - which will likely be significantly impacted by this global race to stem the pandemic.

Wednesday, January 8, 2020

Freed from optimism

A couple months ago, during my on-call night, a young woman came to the labor and delivery room at Kudjip.  The feet and legs of a baby presented through her birth canal, but the unborn head had been trapped in her uterus for several hours.  Sister Theresia, a dedicated nurse working at Kudjip, assisted in delivering a deceased baby boy.  Lo and behold, another baby quickly presented, head-first, and delivered – kicking and screaming – into Theresia’s waiting arms.  After addressing this healthy girl’s immediate needs, our nursing students, alongside the grandmother, turned their attention to her baby brother’s preparation for burial.  The bittersweet blend of joy and sadness, so pervasive in the highlands of Papua New Guinea, weighed down the room.

            Our family has been in Tulsa the past few months on furlough, giving me a little breathing room from the daily grind.  I have reflected on an important spiritual lesson that my mentor, IHI alumni Dr. Bill McCoy, taught me as we shared heartaches in the crowded hospital halls at Kudjip.  Hope is not the same thing as optimism.  Optimism posits that something good is going to happen, regardless of circumstances.  While something good may happen from any situation, I do not believe that, as Christians, we have any guarantee of good outcomes in this world.  Conversely, hope is a persevering belief that anything can be redeemed for good.  God can take difficult, even devastating, situations and redeem them for His purposes – not because those times are good, but because He is. 

Hope is one of the three abiding virtues (I Cor 13:13).  It is also an anchor for the soul (Hebrews 6:19).  The suffering of this world, that we battle daily, is not a piece of some optimistic jigsaw puzzle – it is a field of hopeful opportunity.  If I can appreciate this and leave the outcomes and results to God, my faith may be pressed – but it will not be crushed.  This faith, as David Bentley Hart says, “has set us free from optimism, and taught us Hope instead”. 

Some weeks ago, another young lady arrived into the labor and delivery ward at Kudjip with a referral note hastily scribbled onto scrap paper by a nursing officer working in a remote corner of our province.  This mother was barely conscious, having been struggling to deliver her baby for almost two days.  As the nurses scrambled to establish IV access and begin administering medications, I hastily performed a bedside ultrasound – with saddening results.  The baby was lodged in the uterus with its face presenting at the cervix, unable to deliver.  There was no heartbeat.  I mobilized our operating team, but knew that we were only performing surgery for this mother’s sake, since her little baby had already died.

In the operating room I worked quickly.  As I removed the lifeless form of this little one, I told the receiving nurse not to attempt any resuscitation – the baby was dead.  On her way to the basinet, she exclaimed – “Dokta Mark, em pulim win!”  “Dr. Mark, he took a breath!”  She got to work bagging the baby and, in a few moments, we heard cries of new life.  I repaired the uterus and finished mom’s surgery.  Over the next week, mom and baby recovered nicely and that fizzled spark of hope was fanned for me again.  This is what the Sovereign Lord says to these bones: I will make breath enter you, and you will come to life” (Ezekiel 37:5).  

            Now entering our seventh year working in Papua New Guinea, we see the challenges through hopeful lenses.  Our hospital has recently expanded to accommodate our growing maternity care services and surgical disease burden.  We have entered into a working relationship with the government to provide referral services for our entire province.  We are taking UPNG medical students and have taken our first surgical trainee.  Our recent Rural Health graduate has been elected President of the PNG Society for Rural & Remote Health.  Through it all, patients are being ministered to, both physically and spiritually – to the tune of about 70,000 each year!

            Our family prays to continue in God’s calling for us – in the ways that He plans.  Please consider joining us in prayers for perseverance, guidance, provision and continued Hope as we serve in the highlands of Papua New Guinea.