Broken and scattered

“All these pieces broken and scattered

In mercy gathered, mended and whole.

Empty-handed but not forsaken,

I’ve been set free”

-Broken Vessels

 

I regretfully collected some papers from the Surgery office.  They contained the records of a boy we will call Will that I had cared for last week … a boy whose family was now grieving over his under-sized grave in the north of our valley.

Will presented to the emergency room with a distended abdomen and vomiting.  The family said he had been like that for over a week.  With the health system (including Kudjip) getting derailed by a wave of COVID in recent weeks, this was the first chance they had to seek care for him.  Though he was awake, it was obvious that he struggled to remain so.  On our pediatrics ward, our nurses were placing a tube into his stomach to drain the contents there and giving intravenous fluids to support his circulation.  Blood tests and an X-ray revealed an intestinal blockage and, surprisingly, a pneumothorax - probably from an infection eroding into his chest wall.

Dr. Ben came to the hospital promptly when he detected the concern in my voice.  We both have children about Will's age.  A drainage tube placed in the chest removed foul-smelling fluid and a significant amount of air.  We placed tubes about everywhere we could - to relieve his struggling body and to monitor the effects of our treatments.  He never really improved and less than a day later he died in spite of our efforts.

 

I went into the nursery and discovered that a premature baby I had been caring for had also passed away overnight, not unexpectedly.  Susan's first twin had died last week, suffering from ailments all-to-common for tiny babies in this setting and her second baby had deteriorated over time.  I looked over the other dozen babies under my care - all improving, all feeding, all growing, some going home to grateful and relieved families.

After finishing rounds in the nursery and pediatric wards I met our resident, Dr. Sheila, in the operating room for a cesarean section.  Maggie's baby was “sotwin” and couldn’t tolerate her labor.  Although she was only 8 months pregnant, we felt her little one had a good chance to do well if delivered.  Dr. Sheila performed the majority of the procedure as I assisted, and a vigorous little boy went to his “bubu” (grandmother) while we closed Margret’s incision and her anesthetic wore off.

Not long after, we were asked to see Anna - a fifth-time mother who had presented the day before with some mild contractions and edema.  A scan revealed twin babies nearly term but with the second one “slip-across” or in transverse lie.  Her blood pressures were severely elevated, a dangerous condition called pre-eclampsia.  Blood tests showed that her kidney function suffered as well which could jeopardize her ability to receive the resuscitation and medications she needed or to tolerate surgery.  We debated the best way to manage her and decided that we could attempt a vaginal delivery.  When the moment came, she did well.  Our midwife delivered the first baby, I guided the second baby into a good position and Dr. Sheila broke water and delivered a second small but vigorous baby girl.

Before leaving the hospital for dinner, I went to our COVID ward to follow-up on Wendy.  Wendy has worked at our hospital for about thirty years.  Her presence on station is a mainstay of our community.  In recent years she has struggled with some health problems.  She was one of the first to receive our COVID immunizations when they became available earlier this year.  Six days ago when I saw her in the emergency room with shortness of breath I was worried.  Testing confirmed that she had contracted COVID in the midst of our current spike in cases, likely from the delta variant.  While she looked good for a couple days, she later de-compensated at home and was promptly brought to our emergency department.  I had heard a reassuring update from Dr. Erin - but wanted to see how Wendy was doing today.  When I arrived my concern rose immediately.  Wendy was struggling - to breathe, to speak, to sit and to recognize those around her.  We changed out concentrators (recently mended by our amazing maintenance team), adjusted flow rates, added a couple of medicines.  Esther, the kids and some of our extended missionary family gathered on the porch outside our COVID ward and prayed together.  Wendy’s daughter, another of our nurses and also suffering from COVID, joined us in lifting up this faithful servant into the hands of God.  I know that whatever comes next is beyond me.

“You take our failure, You take our weakness,

You set your treasure in jars of clay.

So take this heart, Lord - I’ll be your vessel -

The world to see Your life in me”

During our recent furlough one of the most common questions I got went something like, “How can you do that?  It must be so difficult to see that kind of suffering.”  Some will ask “How can we help you in that?”

 

There is a renewed interest in caring for the spiritual and emotional health of missionaries in difficult situations and I think it is important.  The thoughts, prayers, words and deeds of our supporters give a palpable strength to our ongoing efforts here.  In attempting to be whole and healthy to best serve others I have heard something like, “You can’t pour from an empty cup.”

That is certainly true and I have had to be deliberate in setting aside times of rest, rejuvenation and fun to maintain myself and my family in this environment.

But I have also grown to appreciate the workings of the Holy Spirit in spite of my own weakness.

 

There are times when I am just empty-handed.  A jar of clay with pieces cracking off and scattering.

But there is a treasure in there: God’s heart for a broken world, which awaits its redemption through the groaning of the lost and dying.

   

Perhaps, sometimes, my job is not to gather the pieces but to let the glow of that treasure spill out the cracks.  Maybe my tears can be redeemed when joined with the heartaches of the vulnerable and desperate around me.  As I read the Gospels, it seems that those places are precisely where Jesus brought his mercy - mending and making His children whole.

 

“I can see You now -

I can see the love in Your eyes,

Laying Yourself down

Raising up the broken to life”

 

 

 

The fairest Son

"As we walked through fields of green,

it was the fairest sun I'd ever seen.

I was broke, I was on my knees.

You said yes as I said please"

-Mumford & Sons

 

"Dokta Mark - we need you in the O.T."   

"Auntie" Margret has worked at our highlands mission hospital for about forty years.  Why I hesitated when she called is beyond me.  I had a rough night, had just turned in my thesis and was preparing for a brief nap before going to our high school to teach.  I wasn't on call and I knew we had surgical back-up at the hospital - why was I being summoned?

"Dokta Daniel needs you - we have a complicated C-section and she is pouring out blood."

I felt a bit of a jolt of adrenaline, grabbed some scrubs and made my way up.  Why did I delay when a colleague needed me?  I have been that position, too.

Throughout the past year and a bit, the demands on our mission doctors escalated dramatically.  We shouldered more and more - chops, trauma, difficult obstetrics cases, tropical disease - without the usual supply of volunteers to ease the load.  Funding issues weighed us down as well.  Over time, every call from the hospital felt like another straw on this camel's back.  We were down to the bare bones and were carrying the same the load.  Though I felt moments of immense satisfaction during that time, it left a scar.

 

"I have no strength from which to speak - when you sit me down and see I'm weak."

Then earlier this year, multiple prayers were answered.  Doctors arrived - some for a few weeks, some who have moved here to join the ministry and bolster our depleted ranks.  Two new PNG doctors joined us to serve and receive training.  I remember distinctly: for the first time in months, I went to our clinic and tried to use our ultrasound machine but there was another doctor using it that I needed to wait on.  I teared up while my patient and I waited - I'm sure she was very confused.  It felt like a renaissance.  Now, the load is much the same - but the shoulders of those lifting it are broader in number and united in community.

Our surgical resident was busy in a bowel resection when I got to the hospital, so I urgently made my way to the operating room where Daniel was having trouble.  I almost instantly teared up again at the sight that met my eyes.  Another colleague had received a similar summons and arrived ahead of me.  She was scrubbed in helping Daniel.  Three young physicians who had responded to God's call and the world's crushing needs were diligently working to save a mother's life.  Dr. Daniel, Dr. Laura and Dr. Spencer had each served at Kudjip for a brief time in the past as students or residents, and all joined us this year in the midst of one of our greatest seasons of need.

As I looked around them into the operating field, I could tell that they were making progress in a good direction.  I didn't scrub in.  This woman's trouble, her very life - which would have been another agonizing call just a year ago - was in the capable hands of three new doctors who now shouldered the weight of this ministry with us.

For more than a year and a half, our little rose bush has struggled.  It is long and spindly and still growing but has produced nothing but thorns for a while.  There had been times that I felt we should just dig it up and get rid of it.  Why a rose bush that only made thorns?  Earlier this week, as Esther and I walked down the road in the evening she pointed out a new bud that was just beginning to open up.  As I admired a blush of pink petals pushing their way through, I noticed three smaller green buds that would soon turn this thorny plant it into a florid tapestry.  All that time, there was a life beneath the thorns waiting for an appropriate time to bloom.

 

 

At times I have really struggled to understand God's timing.  Why don't we get funding sooner?  Why don't we get more doctors quickly?  Why all this waiting?  

There are thorns everywhere without a rose in sight.  

But I realize that there is a difference between laboring to see God's redemptive work in the world in a patient way and hastily pushing through my own agenda on my own strength.  One could tear out something of great potential.  The other could bring impressive beauty from a seeming heap of ashes.

"We will be who we are,

You will heal our scars,

Sadness will be far away.

Do not let my fickle flesh go to waste,

As it keeps my heart and soul in its place.

I will love with urgency but not with haste"

No expeditious road

I moved through the crowded emergency room toward bed 4 where a young man lay with his leg wedged in improvised pillows made of tattered old clothes. He was disoriented and his eyes drifted in and out of focus. His young mother, similarly clothed in a torn second-hand t-shirt, wasn’t sure exactly how old he was but I guessed 11 or 12. 

For a brief moment I thought, “We should be playing soccer together with my son.” 

 

 But the impressively swollen leg made that impossible, and his delirium told me that the infection in his leg was rapidly progressing through his bloodstream. With a crowded emergency room and outpatient clinic still full of patients to be seen, I hastily told the mother he would need powerful medicines through a “blood-tube” in his arm and to stay in the hospital. She looked a bit lost - as though she had never seen a permanent building before – but there was an implicit (and terribly beautiful) trust in her eyes as she committed her son to my care. I grabbed a nursing student to begin the IV antibiotics, wrote orders for an X-ray and made my way back to the clinic. 

 

The noise of a helicopter made me pause. Time to get changed into scrubs. Our provincial health team notified us earlier that a sick mother was being transported due to delivery complications. As I went to delivery bed number 1, our Papua New Guinean medical resident Sheila was already working with the nurses on emergency stabilization. Her lifeless form was pale and her eyes she searched the room for anything familiar, but quickly rolled into the back of her head again. While she wasn’t actively bleeding now, she had been for the past 3 days when her baby was delivered at her home in one of the most remote corners of the globe. A nearby aid post attempted to deliver the placenta the next day but the cord broke, oozing blood. After another day’s journey to the health center, the nursing officer at a small Anglican clinic at Koinambe managed to radio out for a helicopter and she arrived at Kudjip clinging to life with a hemoglobin concentration of 2.8 g/dL [normal range 12-14]. 

Dr. Sheila aggressively resuscitated her with IV fluids and 2 units of emergency type “O” blood in addition to strong antibiotics. But we knew that shortly we would need to remove the decaying afterbirth and pray that she responded.

 

 

Our family of six will soon attempt the journey back to the US for a short furlough after one of the most grueling terms of service I imagine a medical missionary has faced. And once again, I am terrified. 

 

Due to airline-imposed restrictions, we will need to pull off 18 negative COVID tests between the six of us to actually board our planes to get home. Airports are skeletons, planes are devoid of food service (never helpful with 4 young mouths to feed) and we are praying that we don’t land ourselves in a traveler’s purgatory of hotel quarantine. But none of those are the reasons I am scared to go back to my passport country. 

 

During our first furlough in the US some years ago, Esther phoned me to ask if I could stop at a store on the way home to pick up a few items (milk, butter and chocolate chips if I remember correctly – it sounded promising). We had only been in the country for a day, and I was still convincing myself to drive in the right lane. I got to the store and found my purchases but thought I would pick up band-aids. One step into the pharmacy department and I quickly turned around, made my way through the self-check-out, then bustled to the car and stared through tearing eyes at my dashboard for about 10 minutes before going home. The much-anticipated cookies helped calm me down. 

 

Now, as I glance into the pages of news sites or Facebook, I am similarly stunned. 

 

Just a year ago, those pages were flooded with the gestures of sympathetic people throwing together programs and projects to help amidst this new COVID “pandemic”. Health workers were applauded, meals were delivered to them. Everyone was encouraged to “look for the helpers” as Mr. Rogers taught us. I remember feeling a strong sense of global solidarity. Finally, the affluent world is having their eyes opened to the kind of reality that affects the 2/3rds world every day. Maybe this is the moment in which those nations decide to embrace the places of the world struggling to keep children and mothers alive against the miserable odds created by their poverty. 

 

But the vaccine arrived and is now available to pretty much any (rich) person who will take it … so we are instead trying to decide if our pets need to get COVID vaccines while opening clubs, bars, restaurants and movie theaters. 

 

Don’t get me wrong. I hope to enjoy some of our old favorite stomping grounds while getting a bit of a break and seeing family. I just hope I don’t say or do anything to get myself into too much trouble. 

 

“I could tell you my adventures – but it’s no use going back to yesterday, because I was a different person then.” -Lewis Carroll 

 

After two units of blood, Dr. Sheila and I addressed our now conscious mother. I explained to her and her cousin (the only relative that lived nearby) that she was incredibly sick – her placenta was rotting inside of her sending a cascade of infection throughout her body. Without removing it she would die. If we removed it, she had a chance to live. They agreed to go ahead. 

 

We saw the desperation melt from her face as the anesthetic took hold. Over the next grueling hour, my resident and I removed necrotic afterbirth and repaired lacerations in the birth canal as the septic smell assaulted our senses. Once finished, she returned to the ward with additional blood transfusions hanging and an anxious family member praying her through the night. 

 

My young patient with an infected leg looked worse the next day. His X-ray did not show infected bone, so I drained fluid from his joint and attempted to find a purulent pocket to aspirate in his leg – without success. I hoped that whatever germ was running amuck would respond to our antibiotics. 

 

As the on-call doctor, I drifted from the emergency room to the labor and delivery unit throughout the day. Reducing and casting limbs broken in heated tribal fights, counseling cancer patients, failing to resuscitate a newborn baby, repairing difficult birth trauma, admitting a COVID patient, completing miscarriages that threatened to take a mother’s life, balancing feeds and fluids in babies with malnutrition, and myriad other now-routine tasks that would seem quite exotic to many doctors in my home country. Lives were saved and lost. Prayers were said. Hearts were changed (including mine). 

 

“There is no expeditious road to pack and label men for God, and save them by the barrel-load” -Francis Thompson 

 

Like many young Christian physicians, I set out feeling like I had been called into this. I felt that God’s broken world could use the efforts of more doctors attempting to bring Christ’s redemptive healing and hope in the deepest dark. I have come to realize that, while I am called to be a minister of medicine, none of my patients are called to be sick. They are created to be whole – redeemed and rescued out of ferociously hostile enemy territory. While I cannot provide that, I can partner with the One who does. Not because I am a miraculous healer, but because I am not. I have not, yet, physically restored anyone with a simple touch or a word. But I have touched and spoken into some of the deepest miseries I could imagine. And each time I see that He’s already there. At times giving strength for the groaning road of restoration. At others, providing a safe haven for tears. But there in all.

The Hope You Hold

"Awake my soul to the hope You hold, Your grace is all I need."

-Mercy Mercy

 

As we waved another doctor off of Kudjip station I thought about the days, weeks or months ahead.  

The damage of the Coronavirus pandemic on our mission so far has been decidedly collateral.  While we have established triage protocols and increased our use of PPE in specific areas of the hospital, our entire highlands region has confirmed only 28 cases at the conclusion of 2020 - none fatal.

Meanwhile, the burden from pediatric pneumonias and diarrheas, vaccine-preventable-disease, premature newborns, trauma, difficult obstetric deliveries, HIV, tuberculosis, typhoid, cancer and myriad other ailments continues.  The workload which was previously managed by our missionary and PNG physicians and supplemental volunteer doctors has now been funneled onto a dwindling "Gideon's Army."

As part of that ongoing effort, we are adjusting the workflow so that the most demanding cases, surgeries and deliveries are reserved for the doctors.  While it empowers our nurses, it means that nearly every patient I see, every day, might be facing a life-or-death condition that I am supposed to help them with.  And I know my powers and my profession are limited in the light of such miseries.  Even my prayers are wearing thin.

 

"Heaven's story breathing life into my bones -

Spirit lift me, from this wasteland lead me home" 

As I scuffled from the emergency department to the clinic to the delivery rooms on Thursday morning, I was interrupted by our labor and delivery nurse still wearing bloody gloves (never a good sign) nearly running across the corridor to find me.  "Dr. Mark, mipela nidim yu!"

I entered delivery bay 1 and saw blood-soaked clothes and bedding being removed while IV lines were hung.  Unable to palpate a radial pulse to match what I heard through my stethoscope, I asked the woman her name.  A feeble voice answered, "Maria."  So she was semi-conscious and knew who she was - better than I had thought.  Her heart rate pounded out at 130 beats per minute and the blood pressure cuff could detect nothing.

Maria had delivered her seventh child in the bush of the Jimi Valley - one of the furthest habitats in the world.  Her placenta did not deliver and she bled for hours until she could manage transportation to Kudjip.

As we rushed to get unmatched type O negative blood for a transfusion I hastily scribbled some orders for antibiotics and went to retrieve the anesthesia and instruments I would need to remove the placenta and stop her bleeding.

With the assistance of our midwifery student I removed the afterbirth and gave strong medications to contract the weakened uterus.  A unit of blood infused during the procedure.  The cuff read out a systolic blood pressure of 80 millimeters of mercury ... my heart nearly sang.  As I left to attend to the outpatient department patients, I hoped that we did enough to prevent seven new PNG orphans.

Our senior clinic nurse said that they had already used up their quota of doctor clinic visits for the day but people were upset.  I looked at the line of patients and charts still awaiting me and said that I would work as quickly as possible, but if they were truly emergencies to send them to the ER and I could see them when I finished in the outpatient clinic.

 

An hour or so later I picked up the record book of a man named Gideon.  He had paid no physician fees.  He had not been entered in the list of patients to see the doctor.  But his wasted frame sat on bed 7 of the ER and I immediately knew his diagnosis.  After sedating a pediatric patient for our nursing student to repair a laceration and setting a fractured bone, I walked Gideon to the now-closed outpatient ultrasound room.  A quick scan confirmed my suspicions - a massive hepatoma, a slowly growing liver tumor, now consuming his body and impeding his ability to eat.

We took some time to discuss his illness.  I answered his questions.  I reassured them that our medicines could help his pain, but would do nothing to cure him.  

What was his faith like?  Gideon and his watchman, Glen, had been baptized in the church as kids, but walked away.  Gideon engaged when I shared that we would all face a burial in this ground ... but that a new life awaited those who trusted in Christ's redemptive sacrifice at Calvary.  His misty eyes told me that he wanted and needed to hear that. 

They both prayed to receive Christ in that moment.  

And we all agreed to place whatever the next steps were in His hands.

 

"Now I find my life in Yours -

My eyes on Your name."

Eyes to serve

"Keep my eyes to serve, my hands to learn."

-Below my feet, Mumford & Sons

My colleague, Dr. Dave, approached me as I concluded my rounds on medical ward to get some guidance on a lady who had just come from the Jimi valley.  After just a few words I knew we were in trouble.  I wrapped up seeing my patients, made a few notes for the nurses, and prayed with our team before going down to the maternity unit.

In Labor Bed 6, a pale and nearly lifeless woman breathed fast while Dr. Dave oversaw nurses placing IV lines and starting antibiotics and then went to notify our surgical team that we needed the theatre ready urgently.  Her unborn baby had become obstructed in the uterus.  After strong contractions for a day, a hand and the umbilical cord presented through the birth canal and the baby asphyxiated.  

 

"And all I knew was steeped in blackened holes." 

As a blood transfusion was prepared and nurses placed a foley catheter, I asked where the woman's husband was.  They had just arrived - having traversed some of the most hazardous roads on the planet - and he sat nervously on bed D-5, the only man in a sea of young women and speaking only a little of the lingua franca, Tok Pijin.  

I explained, as best I could, that his child had died inside his wife's womb and that she was also in significant danger of dying as well.  "Mi laik karim i go katim na givim chance we em bai inap laip yet" - "I want to do an operation on her to give her a chance to live."  He agreed and the team prepared for surgery.  I went back to her bed and uttered a hasty prayer - "Papa, giv stea long mipela inap ken sevim laip long dispela mama" - "Lord, guide us so that we can save this mother's life."

 

 

Our hospital has been operating with a "skeleton crew" of doctors for nearly a year.  The usual supply of volunteers has dried up thanks to  COVID restrictions on travel, and our dwindling physician work-force has been stretched.  We have poured sweat and tears into this work and wearied ourselves.  Thankfully, God's grace has continued, and our doors have remained open to the sick and hurting in our highland jungle - whose daily miseries continue.  I have asked myself where the ongoing strength will come from.

 

"I was still, but I was under Your spell.

When I was told by Jesus all was well - so all must be well.

Just give me time.  You know Your desires and mine.

So wrap my flesh in ivy and in twine - for I must be well."

Dr. Sheryl opened the abdomen and a large haematoma presented itself to us.  The uterine artery on the right had dissected creating massive blood loss.  We quickly removed the deceased baby and set to work stopping the bleeding and removing the severely damaged uterus.  Each clamp and stitch needed to be placed quickly but appropriately while blood was being squeezed in by our anesthetic officer.  After a diligent operation, the monitors showed the heart rate lowering and the blood pressure rising.  She returned to the ward to recover - while her deceased baby was wrapped up by our nursing staff to await one of Papua New Guinea's many under-sized graves.

Near the tail end of clinic that day a young woman walked toward my clinic room.  Her gait and girth told me we needed to stop short of my exam room and we detoured to the ultrasound machine.  As she lay on the table I glanced through her record book.  An astute nursing officer in a health center at one of the corners of our province felt that this first-time expectant mother might have a baby lying sideways.  With the potential ramifications of such a dangerous condition fresh in my mind, I scanned through her abdomen and discovered that she was, in fact, in breech presentation - also a dangerous condition, especially for a woman who has never given birth before.

We went to the maternity unit - to the same bed on which my dying patient lay so recently - and I gave some intravenous fluids and an injection of medicine to relax the muscles in her uterus.  Using the ultrasound machine to guide me and check on the baby, I was able to turn her little one into the cephalic or "head-down" position.  After thirty minutes of monitoring they both appeared well and I sent them home with instructions to come back and check the position of the baby again in a few days.

 

"Keep the earth below my feet.

From my sweat my blood runs weak.

Let me learn from where I have been.  

Keep my eyes to serve, my hands to learn"

We don't know when our world will open up again.  News about vaccines emerge and it seems life may get "back to normal" soon.  But "back to normal" for the majority world doesn't mean family gatherings, the Olympics and movie theaters.  It often means a continued struggle against the majority killers.  Please pray for the health workers of the world - that we might continue to learn and serve and be well.

For the love

"Brighter than the sun, more beautiful than words could ever say."

-Nothing Like Your Love

 

I got the call from our PNG medical student late at night on a Friday.  "Dokta - we have a young girl here with an open fracture of her arm."  Though our eager student wasn't on call that night, he was working in the ER in an effort to get some additional experience.  I made my way up to the hospital to help administer sedation and attempt a reduction.  When I got there, the 10-year-old girl thrashed about on the trauma bed.  Her ulna protruded at a disheartening angle through a break in her left forearm.  But her chaotic demeanor concerned me more at present.

She and some friends were walking across the roof of a large building near one of the coffee factories in our area.  I didn't stop to ponder what they might have been doing up there ... perhaps they had been promised some much-needed cash if they kept the roof clean.  In any case - she suffered a fall from the roof onto the cement floor some 8-10 meters below.

While the obvious fracture created a bit of a squeamish upset in my stomach, the bruising around her eyes and her altered mental status worried me most.  She had suffered a significant closed head injury.  I put her to sleep and our nurses established IV access, got suction available for her airway and brought the ultrasound machine over.  Over the next 30 minutes we stabilized her neck, ruled out significant internal hemorrhage, and ferociously reduced her open fracture and applied a splint.  But then came the hard part.

I took her mother aside and explained that her daughter likely had a significant head injury.  She was resting now, but if the damage was severe, there was a chance she would never wake up.  As the fear grew in her eyes, our little patient - her child - was taken to the pediatrics ward.  We prayed together and as I made my way home I wondered what would happen to this little girl - scared that she would breathe her last before I could come back for morning rounds.

On March 11th, about a month after our return to PNG for our 4th term of service at Kudjip, the WHO declared a pandemic of COVID19 - the illness caused by a novel Coronavirus which first emerged in China at the end of last year.  Shortly after that, a case was detected in Papua New Guinea in a traveler from overseas.  A state of emergency was declared, travel was halted, the health system made every effort to prepare for this infection which seemed to be ravaging Italy and parts of Europe at the time.  And my spirit entered a season of fear I hadn't known previously.  What would happen to our facility?  Our patients?  My family?

I went to my usual service in the hospital - performing C-sections, delivering babies, handling emergencies, stabilizing AIDS patients, hunting out Tuberculosis and caring for malnourished infants.  I washed my hands until my fingers were raw, put on my medical mask, and kept my "Peter Parker" glasses on in case of getting coughed on.  But something was different.  I wasn't grabbing my patient's hands to pray with them much.  I was "efficient" in my exam - trying to minimize my exposure.  I was keeping my distance because I was afraid.

Weeks went on.  Our hospital physician staff dwindled - overwork and travel restrictions taking their toll on us.  It felt like this new illness would push us past a tipping point ... not because we were overrun with its victims, but because of so much collateral damage.

 

In the garden of Gethsemene, Jesus' soul was grieved to the point of death - he was sweating blood.  He was afraid of His coming execution - with a fear that could easily have crippled Him and left Him incapable of fulfilling His mission to endure and defeat sin on the cross.  What could move Him past that and give him the strength to pursue a shameful death?  

As I sat on my porch swing looking out over the mountains as the sun rose, it hit me.  "Perfect love casts out fear" (1 John 4:18).  

His love.

And I was free.

The next day, my little patient showed no sign of change.  She was completely unresponsive.  Her mother's fear gave way to a couple hours sleep, but the emotional toll was evident in her entire countenance.  I set a few things in order regarding her fluids and medications and again prayed for her life to be spared - but more convinced that we would soon see an empty bed there.  But the next morning, a little girl sat in that bed with a bulky splint covering her arm, two significant bruises around her eyes and a small smile that her doctor and her mother had nearly given up hope of ever seeing.

 

 

I still put on my mask.  I still wash my hands.  I still wear my ugly glasses and come home with a checkered face for a couple hours.  But I can, once again, embrace the mission.  Not because it is free from risk or fear, but because there is a way to drive that out - replacing it with the Love that put me here in the first place.

"Your Love amazing - fills my heart and I sing out.

There is none like you.  There is nothing like your Love."

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.