Legacy

"It started out as a feeling, which then grew into a hope.

Which then turned into a quiet thought which then turned into a quiet word.

And then that word grew louder and louder, until it was a battle cry."

-The Call

In 1890, a Swiss physician named Courvoisier noted that patients who had a painless yellowing of their skin and eyes along with fullness in their abdomen most likely suffered from a cancer in their pancreas.  His name accompanies this particular constellation of findings to this day, and it represents an ominous sign for a patient, and usually precipitates heart-sinking in their doctor.

In January of 2003, this particular finding was burned into my memory.  I remember vividly the night that my mother and father sat all of us down in their living room and explained that it looked like my father had pancreatic cancer.  He underwent a procedure to relieve some of his discomfort, but faced radical surgery.  Even then, before starting medical school officially, I knew enough to be very scared.  Few survive pancreatic cancer, even with the best care.  I prayed furiously leading to the day of his surgery, and when the surgeon sent word that the surgery didn't go exactly as planned, I cried.

I looked at my father on his hospital bed as he recovered from his operation.  I cried with my sister, Christy, at his side.  I remembered the things I learned from him - a strong work ethic, respect for others, appreciating a job well-done, compassion for the sick and service to the poor and needy.  I remember him saying, while we each tugged on various fencing around our property, trying to rip their concrete bases from the ground, "You should learn to respect working with your back and sweat, because many people you meet won't have the chance to make a living with their brains like you do."  Then he would climb onto our 1953 Ford tractor and we would work until after sundown on the remaining posts.  Lessons that shaped who I was then and who I remain today.  I remember his great passion for teaching medicine - and feared that I would never get to learn that art from him.

Miraculously, every biopsy report from his surgery came back all clear.  Samples sent to the military research hospital confirmed - no evidence of cancer.  Some months later, he went back to medicine and teaching and we never bothered about his cancer again.

Fast forward 13 years.  It's Monday morning at Kudjip, and a man in his late 50's enters my room.  His abdomen is mildly swollen, his eyes are bright yellow and his skin has a sallow appearance, even for someone with dark complexion.  

I put my hand on the right side of his abdomen, and that heart-sinking begins.  Joseph had pancreatic cancer, and no options in the remote mountains of Papua New Guinea.  I sat down and explained his illness to him in no uncertain terms.  He took in every word, asked a few questions.  The space between us felt thick with discouragement.

Earlier this month, my father arrived at Kudjip hospital to visit us, along with my mother.  They hadn't seen their grandchildren in over a year and spent five glorious days enjoying them.  My dad came to work alongside myself and Dr. Bill McCoy - his first ever student in medicine and my medical mentor.  Dr. Bill attended my birth nearly 33 years ago as a physician-in-training under my dad.  Last year he delivered my child, using the skills my father taught him decades ago.  He has mentored me as I take these steps into serving as a physician amongst the people of Papua New Guinea.  And for an incredible week the three of us attended patients together and discussed dreams of healing the world's ills.

Then the opportunity I secretly prayed for arrived.  As I took call for the hospital, a nurse called from our Obstetrics ward.  "Doctor, we have a fetal distress"  I arrived in the ward to find a mother struggling with labor pains and a baby who, by listening to its heartbeat, seemed stressed from the process.  I quickly gave her IV fluids and placed a catheter to drain her bladder.

"Let's go to the OR"

I telephoned my dad who had probably just fallen asleep at our neighbor's house on station.

"Dad, we have a C-section, are you up for it?"

"Of course, I'll be right there"

Before I could even get the car down our road, he met me near the hospital, having walked up in the black of night.

We went to the OR and scrubbed as the nurses prepared mom and our anesthetist administered a spinal block.

I wondered, after more than forty years of doctoring but almost a decade without delivering babies, if my dad would be up for a C-section.  But it seemed second nature to him and within a few minutes we had a crying baby out on the nursery table.  Stunned at first, he quickly picked up.

The whole time my father stayed here, I couldn't shake the concept of legacy - passing on the baton of medicine as a ministry to the sick, poor and vulnerable.  Carried down through three medical and two biological generations.  

Back in my office, I prayed for Joseph and prescribed some medicine for his pain and nausea.  As he prepared to leave, he stopped himself at my door, put his hand on my arm and said, "Doctor, if God decides to take me home, that is OK.  But I am glad that I met you, and that you explained everything to me so that I don't have to be worried."  He turned out the door as tears welled in his eyes, and promised to come see me again in a few weeks.

 

I have no idea if Joseph will receive the same kind of miraculous healing that my father did.  I've long since given up trying to piece together the ins-and-outs of God's sovereignty in the face of this suffering.  But I know that my time and prayers helped him, and the memory of his hand on mine expressing his thanks keeps my heart tender to those around me.  And that, too, I believe is a part of the great legacy I inherit and hope to pass on.

 

So what kind of character, values and faith do I want to give to my children?  Younger doctors I might one day teach or mentor?  My patients?  

The same kind I received, I think.

Consolation

A while ago I blogged about several of my patients who suffered from placenta previa.  Three babies born small who died in our nursery before they reached a month of age.  I struggled during that time to see how my efforts here made a difference.

Then I met Getruth.  Getruth experienced bleeding during her pregnancy at about seven months.  When I scanned her abdomen, I thought I might fall through the floor.  Like Dambo, Grace and Moreen before her, Getruth's baby was too small to survive and the placenta obstructed the birth canal.  I kept her in the hospital, and fought the urge to avoid her bed during daily rounds.  Fears of failure and another little life lost surfaced.

Then she bled again, and it was time for Getruth to have a C-section and deliver her baby.  The baby was small, smaller than one of my previous patients who died.  And I shadow-prayed for this little life to be spared, but harbored all kinds of pessimistic thoughts about him.

"I called, you answered and you came to my rescue.  And I want to be where you are."
- Hillsong

But fast-forward a couple months and Getruth's baby first survived and then thrived.  After gaining enough weight and breastfeeding well, they went home together.  A couple weeks after that, Dr. Susan brought this little miracle to my exam room, proving that at least this one had been rescued.

Wednesday afternoon, just as I prepared to leave the hospital for home, one of our emergency room nurses found me in my clinic room and said, “Dokta, plis hariap, emergency”

I got my stethoscope back out of my bag and went to the ER. One small patient occupied a bed at the end of the room, with two nurses trying to start intravenous lines. As I approached, no obvious injuries appeared but the child didn't move and her chest barely rose and fell with her labored breaths. When I turned her toward me, my un-gloved hand found the reason for her condition – a significant head injury in her left parietal bone that left blood on my palm. I put my stethoscope to her chest and realized her breathing motions were ineffective, agonal, and she didn't have a pulse. I started chest compressions while asking nurses to bring equipment to intubate and medicines to try and restart her heart.

4 year old Esther walked along the side of the highway about a kilometer from the hospital when a passenger van turned on its side in one of the many unsafe stretches of road. The vehicle collided with her. Having seen the accident, her very young mother was the first to be brought immediately to our hospital with her, but I was told more would be coming.

I placed a breathing tube and gave Esther medicine to try and restart her heart. After several minutes without any response, I quit resuscitation efforts on Esther and focused on patients arrived in a second vehicle - clutching limbs and heads, dressed in bloody clothes. Jacklyn with a large hematoma in her flank, Rebecca with a head injury and Bobi with chest pains I quickly gave intravenous fluids to and checked Xrays. Then two more children arrived, a one-month-old baby who appeared very well and a child in mental shock who wouldn't move his right side. After assessing both of them, I realized that no other victims had life-threatening injuries. I admitted three to the hospital, and sent others home after repairing some lacerations and removing glass from injuries. Only after an hour or so did I realize that sobs still sounded from outside. Esther's family prepared to take her body home. I made my way to the road and put my arms on their shoulders as they sobbed over the tiny draped figure in the back of a pickup truck. They departed to return home, still crying, and I crossed the dusty path back into the hospital to check on a few of my obstetric patients.

Eight accident victims, three recovering in our wards, four home already and one who I couldn't save.

During my time at Kudjip hospital, a visiting physician talked about how to avoid “burnout” This phrase gets used in medical schools and residencies, as well as amongst practicing physicians. It describes the idea that the compelling forces of compassion and sacrifice which propel one to train as a doctor become eradicated by various things – insurance companies, paperwork, long hours, demanding patients and loss of family and quality time.

Interestingly, one of my mission field coordinators called this idea “compassion fatigue.”
It made me think more about the idea of “compassion” What is it?

Compassion in its Latin root means to suffer with. But what does that look like? I can't suffer with my malnutrition babies because I am not malnourished nor a baby. I can't really suffer with their parents when they die from dehydration, because they aren't my child, though I can imagine what it would be like to lose one. I can't truly suffer with Esther's mother, because it's not my child that was killed by a tragic accident. My heart breaks for her, but certainly not in the same way.

Compassion propels me into medicine, doesn't it? So what does it mean?

Because I see the suffering with those around me afflicted with disease – I want to take action. But how can I really suffer with my patients? I'm a western-born, highly educated and comparatively affluent white person – while they are remote villagers for the most part, subsistence farmers who hack their way through a tropical jungle to see me in the hopes I have medicine for their illness, or that of their family.

So I'm not really suffering with my patients. I see their suffering, and I want to act.

All too often, in my setting, my action doesn't help. Or I guess wrong, since I have no real diagnostic testing to work with. Or I don't have the medicine, the surgery, the specialist that I need to relieve the pain I see.

Bai mi make wanem? (What will I do?)

I console.

Of course my compassion would fatigue. I see suffering perpetually and I have limited tools or answers to bring to bear. If I perpetually felt the depth of loss my patients feel I would quickly despair. I feel the suffering of those around me in general terms, but I acknowledge I will never have the ability to truly experience it.

Instead, I console. I stay with the lonely ones. Those left behind after the baby dies from obstructed labor, or the child inevitably loses the battle against tetanus which ought to have been prevented by an immunization, or the elderly man passes away because I didn't appreciate his surgical abdomen quickly enough. I stay there, in the loneliness of those left, trusting that God will give the peace I can't see or feel. Because of His limitless and perfect compassion.

I am compelled to care for the patients here at Kudjip because of compassion. When I don't see their healing, I recognize I cannot feel the true depth of their suffering – but I can remain with them and offer the consolation that I would want in their place. And I believe that whether I relieve suffering or console a lonely heart, God blesses both.

“Though the fig tree may not blossom, nor fruit be on the vines; though the labor of the olive may fail, and the fields yield no food; though the flock may be cut off from the fold, and there be no herd in the stalls -

Yet I will rejoice in the Lord, I will joy in the God of my salvation.”

-Habakkuk 3:17-18

The greater miracle

"All those people goin' somewhere
Why have I never cared?"
-Brandon Heath

A couple days ago, when one of Ted's patients deteriorated, his mother's sobs broke aggressively into the routine of examining babies, writing orders, and checking drip rates.  He was admitted the night before with severe acute malnutrition and bleeding, probably from septicemia.  Ted saw him first, changed what seemed the most likely circumstances to try and save his life, but told the mother that most likely he wouldn't survive.

The rest of ward rounds felt surreal, as she sobbed into her baby's bed and Ted and I monotonously gathered more charts and saw the rest of the patients.  After rounds, he went back to comfort the mother and Chaplain Lucy arrived to share in her grief and pray with her.

Later in the morning, as the pile of waiting patients' health records grew, I stopped myself at patient number eight for the day.  His book showed the picture of a child, hastily scribbled out with the word "adult" written next to it.  James told me it actually belonged to one of his two sons, and I mentioned he did a good job getting them their immunizations.  James went on to describe the feeling of "fullness" in his abdomen for months.  

This bothers me.  In PNG, people may have an illness for a week or two, in which case it is most likely Malaria or some other acutely reversible phenomenon; or they have it "long-time true" meaning it is something which won't kill them.

If someone is sick for "some months" I start to think of Tuberculosis or Cancer, and I pray for Tuberculosis because I have medicine for that.

I took James to our ultrasound machine and my fears were confirmed - a large tumor in the right side of his liver, an extremely common condition owing to the high prevalence of Hepatitis B infection in Papua New Guinea, usually acquired at birth.

We went back to my exam room and I outlined his illness for him.  I told him he had cancer, that I didn't have medicines or surgery to offer him, that his illness would kill him, and that I didn't want him to spend all of his money going to witch doctors promising a cure for him.

James took it all in and asked two questions that took my breath away:

"What did I do that made this sickness happen?"

and

"Will I make my family sick with this?"

What could I say?

What made you sick?  The fact that you were unfortunate enough to be born in a mountainous island country with neglected people and a health system that can't guarantee immunizations to its people.  Instead I told him "Nothing you did made this happen."

Further, having just received the body blow of a terminal cancer diagnosis, James' first thoughts went to his wife and two sons.
"No you will not make your family sick." 

"Thank you - I didn't want to go home and make them sick"

I prayed with James, prescribed some medications to help with his pain and nausea and told him to return to me in a few weeks.  After I showed him out and closed the door, I went back to my desk and pinched the tears from my eyes as I prepared for patient number nine.

After a long day full of draining fluid from lungs, lancing abscesses, refilling medications and ultrasound scanning pregnant patients, I was again stopped in my tracks in the late afternoon on patient number 44.

Jim came from another province with a "chronic sore" in his leg.  He walked clutching a stick in his left hand and smelled of infection.  His condition started nearly four years prior and he had been to many hospitals around the highlands.  His sister brought him to Kudjip.

I said he might need surgery to remove some infection in his bone.  Could he come back in the morning for an X-ray when the hospital opens (we had stayed late and our X-ray technician was already home).  His sister explained they were from far away and couldn't make it back anytime soon - could I admit him to the hospital?

At the end of a long day, I wanted to stand firm on hospital policy and I knew that our medical ward had recently been filling up a lot.  I said sorry.  He would have to find somewhere to sleep and return.  In other words, go away.

"Give me Your arms for the broken-hearted
The ones that are far beyond my reach
Give me Your heart for the ones forgotten
Give me Your eyes so I can see"

I went on to patient number 45, the last patient of the day. But halfway through speaking with her, my heart dropped into my gut.  I couldn't focus on what she was saying and the words on her health book blurred a little.  All I could see was an image of my last patient, clutching a walking stick and struggling his way back down the stoney roads - turned away again, in a time of deep need.  The tears came in earnest and I excused myself.

I went quickly to the front of the hospital looking for Jim.  I scanned our patio area and business offices.  He wasn't there.  I checked at the dispensary but, I realized, I hadn't prescribed any medicine so he wouldn't be there.

I had lost him.

But I knew I couldn't send him back to the jungles of Papua New Guinea, simply hoping that he could return for his testing and treatment later.

I went past the emergency room and the outpatient waiting area.  Finally, I saw him hobbling toward the gate to exit the compound, still clutching his stick and struggling to walk.  His sister, Josephine, stood talking to one of the security guards asking about places to sleep, but with a worn expression on her face.

I choked as I told them "Wait - don't go away.  Stay, sleep in a bed at the hospital and see me in the morning for your tests."

"Which was the greater miracle?  The suspension of natural law for the sake of physical healing, or the conversion of the human heart by absolute love?"
-Michael D. O'Brien

The next morning Jim's X-ray showed infection of his femur.  He might get some help by taking an extended course of antibiotics, but I would need to see him in a month and check his leg again.  Josephine and Jim both thanked me and she added "God bless you" in English.  They gathered their things and began again the slow walk toward our security gate, this time with medications and a day to return written into his book.

I've seen some miraculous things at Kudjip.  Patients who shouldn't live that were rescued from the brink of death.  Pregnancies or babies that should have been lost but survived.  Patients with Luekemia that received life-saving medications and left cured.
But I've also seen a devastating amount of heartache and physical healing that never came.

I will admit that the thing I'm impressed by the most are the moments in which a human heart is changed.

Sometimes in the patient, like James, who gracefully accepts the terminal cancer diagnosis well beyond their control.  Sometimes in the calming touch of a nurse or chaplain toward a grief-stricken parent whose child dies in the hospital.

And sometimes, painfully, in the merciful conviction of this doctor's heart when my fatigue or frustration would otherwise deprive a suffering person from receiving what small help I might give at the end of a long day.

I know I haven't got enough strength to care for all of PNG.  And at times I long to live and work in a place where doctors have the time, medicines and technology to meet the needs of their patients.  But other times I feel God's impression on my heart so clearly - to show compassion on broken lives in spite of my failing strength.  And then I know the heart that really needs changing is mine.

Kinder tomorrows

"Black clouds are behind me,

I now can see ahead.

Often I wonder why I try - 

hoping for an end.

Sorrow weighs my shoulders down

and trouble haunts my mind.

But I know the present will not last,

and tomorrow will be kinder."

-The Secret Sisters

At eight in the morning on Saturday, I began rounds on our postpartum ward.  I prepared for a hard day of call, anticipating a lot of work after a very busy week following the holidays.  I wasn't disappointed in that aspect.

After seeing a few patients a nurse summoned me to our pediatric ward to evaluate a patient "going off" - a phrase the nurses use here when it seems that a patient is close to dying.

Waity came to Kudjip with mouth sores creating pain with eating.  Unfortunately, Waity was adopted a few months ago and didn't breast-feed, leading to a vicious cycle of infections and diarrhea causing malnutrition.  Two days prior, I thought Waity would die in the emergency room - the nurses couldn't get any intravenous fluids to him and he wasn't conscious.  After placing a metal catheter into a bone of his leg, I was able to give him antibiotics and fluids.  The next day Waity looked miraculously better.

But it wouldn't last.

Waity's frail body couldn't tolerate the infection, despite our best efforts to fight it off.  Now, as I looked at his family gently patting his hand I knew the worst was coming.  The nurses resuscitated Waity but without success - he passed away and the all-too-familiar sounds of howling grief filled the ward.

A little boy further down the ward from Waity named Franky also struggled through the day.  He had Down's syndrome, as well as a congenital heart defect causing his breathing to be labored.  His six-month old lungs and heart worked hard to get him enough air, even while receiving medicines and supplement oxygen in the hospital.

I explained to his family that his condition was incurable.  He might improve a little by getting medications and oxygen for a while in the hospital, but eventually he would die from his heart condition.  I prayed with his mother almost every day.

Every tomorrow I hoped would be kinder for Franky - but every day he struggled to breathe unless connected to his oxygen.

After rounds a couple days ago, as I packed up my stethoscope preparing to go to our outpatient department, I took a last glance down the ward.  Several families whose children were sick came from a long distance away and didn't have friends or relatives to get them food during their stay.  I saw Franky's mother gather additional food from her bag in the corner and walk up and down the ward, handing it out to parents who, like her, hoped that their children would improve.

Some hours after Waity passed away, Franky took a turn for the worse as well.  I had nothing else to offer him.  I couldn't bear to stay in the ward listening to another mother let loose her grief.

Now Franky is in an eternal peace, breathing easily without any pain, but his mother feels his loss as she makes the journey back home without him.

 

Yesterday I went on to lose two more patients: Ruth - whose leukemia got the best of her, and Elizabeth - who suffered a tragic death after developing Guillan-Barre syndrome, a condition normally survivable with the use of ventilators.

My first few months at Kudjip, I looked at my call days as learning experiences.  So many of the diseases were new.  I performed multiple procedures and even some surgeries.  Calls concluded and I felt I learned a good deal.  But then the adrenaline rush of practicing in a mission hospital wore off.  And I got to the end of my calls remembering the faces of the patients whose last moments I could only watch and pray through.

And I just hope for the next day to come - so I can recover from the realities of the hurting people here in Papua New Guinea.  And one of my colleagues arrives to face whatever the hospital has for them.

"For we will surely die and become like water spilled on the ground, which cannot be gathered up again.  Yet God does not take away a life; but He devises means so that His banished ones are not expelled from Him."

-2 Samuel 14:14

Yesterday, Rachel struggled through the labor of her first child.  Her body's contractions weren't effective and after a few hours without progressing, I gave her oxytocin, a drug to help strengthen them.  After some time on this, it seemed there was no way for her to deliver her baby.  I went to talk to her about performing a non-emergent C-section because of her failure to progress.

But her baby wasn't happy with the labor.  Heart tones that sounded out at 140 a few moments ago suddenly dropped to 60, and stayed there - a bad sign.  I turned off her oxytocin, gave her fluids and oxygen and checked her cervix, praying that she was ready to deliver quickly.  Seven centimeters - not enough to help her with a vacuum.  We mobilized our OR team but I knew it would be at least fifteen or twenty minutes before we could operate - and Rachel's baby may not have that long.

 Sister Vero got the OR ready while brother David raced in to provide anesthesia, I placed a catheter to drain Rachel's bladder.  The movement helped the baby come down and she could nearly deliver.  I pushed the remaining cervix around the head of the baby and told her to push.  The baby was coming down but its heart rate was still just 60, far too low.  I took a risk and applied a vacuum extractor to the baby's head, pulling skyward while Rachel pushed.  In a minute, the baby was out on the bed, screaming and crying - beautiful sounds on the obstetrics ward.

 

 

 

"Mother, listen to my heart,
Just as one beat ends, another starts.
You can hear no matter where you are"

-Punch Brothers 

Three other babies delivered safely at Kudjip yesterday, and I couldn't help but consider that though we lost four lives there are four new healthy babies in our postpartum ward.

They won't be a comfort to the families who have lost loved ones.  But for this missionary doctor - I think of those four babies, I look at today's beautiful sunshine, I enjoy the presence of my wife and children.  And even though I won't forget the faces of those lives I couldn't save yesterday,  I continue to hope for kinder tomorrows.

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.

Why?

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.

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"

-Oceans

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.

Fears and New Days

 

"There's a rhythm in rush these days
Where the lights don't move and the colors don't fade.
Leaves you empty with nothing but dreams
In a world gone shallow,
In a world gone lean"

 -Stay Alive, Jose Gonzalez

Ten months ago I left my home country and comforts to serve in a mission hospital in the islands of the south Pacific.  There are moments I absolutely love this call.  Throughout the Gospels, Christ went to the poor and hurting places of the world to reach out to the most miserable and suffering people He could find.  In the jungles of Papua New Guinea, nearly everyone I see struggles with providing for their families and surviving in their culture and suffers from severe hardships accumulated in their lives.

But a few days ago I realized how far I am from the selfless model of Christ's example.

Margreth came to Kudjip hospital on October 31st - Halloween - though it meant nothing to her.  She had a steady back ache.  Nine months pregnant, she felt it was time for her baby to come.  Her last baby took a couple days to deliver, but arrived safely.

But in the time since her last delivery, Margreth contracted HIV.  She knew she might give this fatal illness to her little one, so she came to the hospital at the first sign of labor.

For a day she had a steady back ache but no real labor.  On her third day, I saw her in the morning and felt it was best to help her baby come rather than wait - she already looked tired.  I used medications to bring more contractions.

However, by the next morning Margreth made little progress.  I looked at her chart with scorn - a nurse overnight had not performed a vaginal exam for fear of her HIV status.  This might have delayed intervening for her or her baby.  She could have been delivered by now.  Who would avoid their duty of helping someone because of fear?

I couldn't break her water or I could expose her unborn baby to a greater chance of contracting HIV.  The baby's heart rate was too fast - a sign of trouble.  I didn't want to give her further help because it could stress the baby.  She developed a fever.  Margreth was getting sick.  Her baby needed to be born now.

It hit me.  I would soon be performing a bloody surgery on Margreth - using sharp instruments to remove her baby from her womb.  My hands would be covered in blood infected with HIV.  And the fear of that overnight-nurse grabbed my heart.

About 0.7% of the population of Papua New Guinea are infected with HIV.  In our area, Jiwaka, the number is closer to 1-2%.  Our HIV department manages the care for thousands of HIV patients, some of them moving to Kudjip from other areas to receive the best ongoing medical care they can.

Many, if not most, of the women infected with HIV acquire the virus from their husbands or partners.  Once discovered, though, they are sometimes beaten and abandoned.  Stigmatized because of their illness, many places refuse to treat them and family members neglect them.

They are left empty in a shallow world, expecting a baby - and their dream is that it won't end up "like them."

Imagine having a deadly disease, needing medical checks and daily medications, as well as being pregnant without anyone to support you through it.  You are trying to be responsible for yourself and your unborn baby, but even at the hospitals or clinics, everyone puts on extra gloves before they even touch you.

This was Margreth's reality as she labored at Kudjip.  Yet I, a healthy and respected missionary physician, still hesitated in taking the necessary action to deliver her baby safely.  What does that say about my efforts here?  Did I travel thousands of miles, leaving friends and family, to fail in the most critical final moments of God's call for me?  She did everything in her power just to stay alive and deliver a healthy baby.  I didn't want to perform surgery on her - and that taught me how far I've still to go on the road to serving like Christ.

"One of the ways the mission of God ... chisels away at us in the work of sanctification is when we engage with the hurt, the pain, and the sorrow of the world around us.  When we do that, God shows us our inadequacies, our shortcomings, and our fears."

-Matt Chandler

I prayed with Margreth for her and her unborn baby before we started.  Then I made the initial incision into Margreth's abdomen.  Every time I picked up the scalpel or a needle my heart skipped a momentary beat and I watched its point carefully.  Her baby boy delivered after some difficulty removing him.  Blood washed over my hands as I cleaned out her uterus.  Her surgery went as smoothly as I could have hoped.  All of the paper drapes and gowns were thrown away (we normally save and re-sterilize cloth ones).  I wiped the thin line of sweat from my top lip and began to make out her post-op orders.

Missionary surgeons, doctors, nurses and others take these risks every day - and most take them more frequently than I do.  I wonder if they struggle each time.  Do they still ask themselves if they are willing to take the risk?  Are they just reckless?  Do they think they'll be supernaturally protected from harm?

I think not.

I believe they are motivated knowing Christ embraced risky situations if it meant He could touch someone in great need.  Especially the marginalized and forgotten.  The truth is that engaging the neglected or isolated people of the world represents no more or less than God's call on any of us.  In various places and with varying degrees of risk and sacrifice, God's people are told to care for the hurting world.

With that knowledge, I look past my fears and see the beautiful child and mother, safely united, looking forward with hope.  I see new days beyond those difficult nights.

"But there is a truth and it's on our side -
Dawn is coming, open your eyes.
Look into the sun as the new days rise"