Final Day

My last day was a bit more relaxed. I had a big moment of weakness in the morning, though. As I went to collect Xrays and lab results I heard some commotion in the emergency room. Dr. Jim was already giving instructions, including some instructions on collecting resuscitation equipment. I knew he could handle whatever happened in there, so went on to my pediatrics ward. In full honesty, part of me couldn't stomach the idea of seeing another ill-fated resuscitation to start off my last day at Kudjip hospital. I rounded fairly quickly in the pediatrics ward, knowing those would be the last patients I saw the next morning.

I saw a little boy named Nixon. This was the second time I laid eyes on Nixon, and both have been miraculous. He is about 10 years old and was helping to push a broken down vehicle a week ago when he fell, the vehicle rolled and (according to bystanders) went over his lower back as he laid belly down in the dusty road. When we first saw him, I couldn't believe this story. He had some back pain, but no evidence of serious damage, and was able to walk out of the emergency room with some tylenol as his only treatment. Friday I saw Nixon in our outpatient department. His back was a little sore, but he was walking fine and had no major injuries evident in followup. I assured his mother that God had something for this boy's life because he should probably have died from his accident and came away without any serious injury.

Nixon doing very well at followup

I spent a bit more time the outpatient department on that Friday. There was the usual assortment of complaints, and the occasional trip the emergency room to cast a bone, sedate a patient for the nurses to drain an infection, perform a procedure, etc. Oddly, none if it felt dissimilar from any other day there. I found myself more comfortable in that environment. I could see patients largely without a translator. I knew where supplies were. I knew what treatments were available. I even knew how many pediatric beds we had in case a very ill child came in and needed to be admitted (and one did). A stark contrast to my first day at Kudjip.

Dr. Erin casted a broken bone in our orthopedic room. I noticed afterward her giving instructions to the patient's "wasman" (watchman). This is very common, but it is not common for the wasman to be a small child. It caught me off guard and I took a photo. The wasman is extremely important at Kudjip - they bring the patient in, get the instructions on how to care for them, give medicines, etc. They also care for the patient's hygiene and meals if they are admitted to the hospital. It struck me that this little boy was taking on such a big responsibility. But the children here grow up quite a bit quicker than they do at home.

Dr. Erin instructs a "wasman" on cast care

I saw a few final patients in the ER and got to do my last Kudjipian Csection before heading home for dinner. I was on call in the evening but only made a couple of trips to the hospital. One stood out. I met an elderly man who seemed extremely frail and, even in my limited Pigin, slightly demented. His family complained that he had been coughing and losing weight for months and left the hospital only 2 weeks ago (in a remote area) with no improvement. We couldn't admit him to our hospital, but within a few minutes I could tell this man was dying from heart failure. I told the family my thoughts, gave him some additional medicine to help him breathe better, and let them take him home, most likely to die. As they left they made a comment to the nurse that the "white" doctors were smarter and knew more than the other doctors. I thought two things about this. 1) It isn't true. The PNG physicians for the most part, if our Registrar Raymond was any indication, are on par with the medical knowledge they need to treat the illnesses they face. 2) There is a grain of truth in their concerns. Many patients come to Kudjip unaware of how sick they truly are. They will be told repeatedly at government clinics or hospitals that their surgery is just around the corner, the specialist will see them when they are here next week or that their illness has been treated and they can go home. They are very rarely told, it seems, if they are dying. I don't have a solution to that issue, but I do know that this family was almost relieved to hear the honesty of even a fatal diagnosis.

I went home and slept until the next morning with no additional interruptions. I rounded in the pediatrics ward on Saturday morning and walked back home a little more keenly aware of the uneven stones in the road, the smiling faces scattered around the street despite another body being added to the morgue that morning, the beautiful tropical mountains covered in cool fog all around me and the sense that my work wasn't over. Even though I had my bag, my water bottle, and my surgical shoes packed up from the hospital, I couldn't help feeling that it wasn't really the last time I would put my hand to work at Kudjip. We have a lot of reflecting to do on our time there, especially as we consider what God has for us next. But something about the people, and the place itself, makes me think that we'll be there ... and back again ... sometime.

Footsteps

Today I was able to follow in the footsteps of one of my heroes.

Dr. Paul Brand was a British orthopedic surgeon who worked at a leprosy hospital in India for many years. During his time there, he developed a technique of serial casting to treat contractures and other bony deformities that occur from disease or congenital defects. Esther and I read about his time in India and his reflections on his lessons learned in a phenomenal book that everyone should read called The Gift Of Pain.

His work led to the development, about the same time, of a set of manipulations and serial casting techniques called the Ponseti method. This practice has led to dramatic changes in the lives of children born with congenital club foot.

Today was my chance to see this, and practice it, first hand.

2 patients came to the clinic today with club foot. One was a 3 year old boy who had no previous treatment and had already developed an ulcer on one of his feet from walking on his overly adducted tarsal bones.

A 3 year old with untreated club foot

The other was a 2 year old who is on his 10th week of treatment with some good results toward correcting his deformity. Dr Rosie let me watch and assist with this child's casting, and perform the manipulation maneuvers and cast the 2nd leg. It was a definite treat - probably one of the highlights of my being here. These patients will now be able to walk - and create footsteps of their own for their children to follow in.

Casting a boy with club foot - an exciting first for me

After work today, I discovered that Anna is becoming a little more adept at tree-climbing. At least, she can now hang suspended from a branch momentarily. There were several instances today that I couldn't believe how grown up she is. We now have a 2nd baby on the way and it is hard for me to imagine her being a big sister ... even though I know she will be great at it.

Anna goes spider-man on the tree outside our house

Unfortunately I did a pretty good number on my ankle today while playing soccer with some of the college of nursing students. The missionaries usually play American football, which I did for a while. I like to have a few minutes of soccer though if I can get it, and today I really should have gone straight home for dinner. My ankle is not swollen, but it's hard for me to remember a sprain that was this painful during the first day after injuring it. It wouldn't bother me much, except that we are going to be making the long trek home in about 3 days and I will need to be able to bear weight, and extra weight, for that journey. If you are running out of things to pray for here, please add my ankle to the list.

I may have another post to add before leaving. It will probably be something of a debrief. So much has happened, and it amazes me to know that it will go on happening here after we are gone. I don't know if Kudjip is part of God's plan for us in the future, but we will treasure our time here forever and have very fond memories of it.

Enough

I tried to share on facebook this morning about a little boy that had a very bad accident and came to our hospital. The image and message wouldn't upload, so I will share his whole story now.

John was playing outside like any typical 12 year old would, but was hit with a thrown stone. It caught him just under his ribs and he went home in pretty bad pain. Night before last he had severe pain and started vomiting so his parents decided to bring him to Kudjip.

On the way, John stopped breathing. He came to the emergency room not breathing and without a heartbeat. We thought John had died, but an ultrasound showed his heart was still pumping weakly, so Dr. Bill and I resuscitated him for 15 minutes in our emergency room. After being intubated, having CPR and getting adrenaline through an IV and blood started, John had his own pulse, a blood pressure and had some breathing - but Tiffini (a visiting PA student) and I took turns bagging him until the operating room was ready for him.

John before surgery

I got to perform surgery with Dr. Jim to explore what had happened to John. It turns out that this stone did quite a bit of damage. John had 2 lacerations to his liver and some of his intestine had perforated. We repaired the damage, and when he left the operating room John had a good blood pressure, was breathing on his own and had a very large incision newly closed along the length of his abdomen. It seemed like we did just enough.

Unfortunately, shortly after the surgery, John started breathing heavily, developed a fever and had a seizure. There may have been some damage during his resuscitation, but more likely the damage from his belly had already sent his body into a cascade of reaction called peritonitis. He died a few hours after surgery.

John's bed the day after his ultimately unsuccessful surgery

Today, the second of the twin babies that I performed a Csection for got very sick. It looked like she had neonatal sepsis (severe infection). This baby also has some underlying congenital anomalies (we think) and did not respond well to our treatments for her. Her twin brother is alive, healthy and doing very well. I wept with Betty, her mother, as we stopped ventilating her and let her pass on.

There were a couple of victories today, though. More than a couple I'm sure. One mother who had a placenta that was invasive into her uterus delivered at our hospital. She had severe bleeding after her delivery and Dr. Bill and I gave her blood transfusions, performed a small surgery to stop her bleeding, and stabilized her after the procedure. If she had delivered at home she would not have survived her delivery.

Two babies that I've been taking care of for two weeks were looking fantastic today. They are twins and both came with severe pneumonia and dehydration needing IV fluids and oxygen. Now, their lungs sound great, they are feeding well, off oxygen and going home.




My patient with diabetes, Anna, is doing much better. She has put on a little weight, has much more energy and is not having the vomiting and pain that brought her to us. As she prepared to leave the hospital, I got a quick photo with a fantastic smile that looked nothing like the frail girl that came to us just a week ago.

Anna ready to go home (I'll forgive the Chelsea jersey)

I wrote before that the blend of joy and grief rub against one another so frequently here. Over the past few weeks, I realize how terribly true that is. I consistently find myself thinking that we've done just enough for our patients here. It seems like we are in the nick of time to perform surgery, resuscitate a child or a baby, stop someone's infection or treat their heart failure. When one of our patients die, I find myself asking if we did enough. Did I know enough? Was I careful enough? Did we use enough of our resources and time for them? Do I care enough that they are gone?

I know now that the answer to each of those questions is no. If I am looking to myself to be 'enough' for the people here, I will invariably fall short. There is not enough of me for the great challenges here. Where, then, do I turn for hope? If the doctors and nurses, the staff and families that spend their time and energy in this place is not enough for these patients to live on, where is their hope? There is no natural hope. I would find it impossible not to trust God in a place like this without losing my mind to grief. If I didn't know that God's sovereignty was more than enough, I am sure I would despair. Amazingly, our hope (and because of that our peace) doesn't depend on the situations or circumstances we find ourselves in if we have something outside of us that we put it in.

I already wrote that I don't feel I have to explain the things that happen here, to justify why things are this way. I know that God is sovereign and that we simply find our roles to play, great or small, in how He chooses to work. Tonight Anna, Esther and I read about the Israelites in the Old Testament during a battle in the wilderness. When Moses, their leader, lifted his hands up they prevailed, when his arms came down they began to lose the battle. Moses' actual hands had very little to do with the battle. But as God's instrument, he was imperative to what God wanted to do for the Israelites. So much so that Moses had others alongside him that supported him when he was too weak to play his part alone. I am certainly no Moses, and I don't pretend to play a pivotal role in the things happening here as a visiting physician. But I recognize that I have a role to play, that my strength is not enough, that God is ultimately going to decide the outcome, and that the people around me are a large part of what successes I have in this place.

Thank you, again, to those of you that make it possible for us to be here with your support and your continued prayers.

Wokabaut

Catching some Z's on the couch in my retro quilt while waiting for calls

Thursday was another day on call. Slightly less traumatic than my previous. In fact, I only had a couple times to go down to the hospital. One for a young man who collapsed somewhat out of the blue ... who looks to have some form of heart disease. An echocardiogram (ultrasound of the heart) would be very helpful. Well - an echo with a cardiologist to read it. We also got a lady who came into the OB ward in labor, roughly 34 weeks along (about a month early). She was not far into her labor and was able to complete a dose of steroids which will help her baby's lung mature.

Friday was a busy day but in many ways very good. Our pediatric ward saw 3 or 4 patients improve and go home. A young lady named Sandy who has a brain abscess was stabilized this week. During my last call a week ago we came to the ward because she stopped breathing, but recovered during the week. She is still very sick and will need a miracle to return to the cheerful girl that said "Apinoon, Dokta Mark" a couple weeks ago.

I have been doing more Csections this week and Friday I got the icing on that cake. I performed a Csection on twin babies without complications and with two pretty health looking babies at the end of it. That procedure gave me a nice shot in the arm after such a difficult day in the nursery last weekend.

Twins a-la Crouch
Pray for our little girl on the right who may have some congenital defects

Saturday I experienced a wokabaut. Dr. Bill has been into the mountains around Kudjip a few times, but not in the past year or so. He agreed to take me on a "hike" through the mountains despite the fact that he just finished call the night before and had a sinus headache. He also put me to shame on the mountain - bounding and running on slopes that I thought might be the death of me. We started out near the station and went up the Kane (pronounced Kon-yuh) river into a gorge and up Las Mountain (Last Mountain). The terrain didn't remind me at all of some hiking I've done in the Rocky Mountains. Imagine the TV show Lost - thick jungles covering steep mountains. There is no way the characters in that show would last more than a week. We went through some serious bush country. As I write that, I have to admit that our "guides" for this hike were 4 boys from the local village who couldn't have been older than 10. They made this mountain look easy enough - but when two of their girlfriends showed up I was even more embarrassed to be huffing and puffing along this jungle path into the mountains. But once we reached the summit and had lunch looking out over the station in the distance, it was definitely worth it.

Las Mountain
That speck of tin next to my eye in the background is Kudjip Station

On our way back, we had a nice dip in the Kane which turned out to be freezing cold. We also discovered an outdoor prayer chapel up one of the nearby ridges.

One of our guides taking a dip in the river

It was such a refreshing trip. At times it felt we took our lives in our hands going up narrow jungle paths along the mountainside. But looking out over the valley and discovering the serenity of the chapel with naught but the sound of the river disturbing the quiet was very comforting. Many of the difficulties and failures of the previous week seemed to roll down the valley along with the clouds as we looked down from our perch. It reminded me of David in the wilderness being pursued by Saul. He had every reason to forget God, to dismay and become a recluse never inheriting the promise of God's kingdom for him. But he turned his moments of solitude into moments of refuge and composed some of the most thoughtful reflections on God's feelings towards us in scripture.

Prayer chapel near Las Mountain

I'm very grateful for the time that we've had in this place. The hospital and the medical experiences are one thing, but being able to "un-plug" for a while has been very good also. Admittedly, I miss the chances to spend time with friends and family, to watch a good soccer game, to "run down t'pub" for fish and chips or a brew - but this place has other treasures that are hard or impossible to find at home.

A new day

After my last call, I was beginning to feel extremely discouraged. The third baby that I admitted who was born prematurely ended up dying overnight, and a 16 year old patient I'd been taking care of since I got here also died in the early morning hours. Needless to say, my Monday was not the most encouraging of days. Tuesday was a new day.

I'm on Pediatrics ward for the next couple weeks, which I find more challenging and a little less stressful. I wasn't able to see anyone leave the hospital, but I did see one patient that I operated on a couple days ago doing a little better. She has osteomyelitis (bone infection) of her tibia and fibula and Dr. Jim and I opened up her leg (for the second time) in an effort to get rid of her infection. She seemed a little better today - but our Xrays were not encouraging. It looks like there is more infection in that leg that will need to come out at some point. The prayer now is that she won't lose her leg.

On the way to the ER, my beautiful wife and daughter came walking toward me. Esther and I went to have a prenatal visit with Dr. Bill, who took an ultrasound of our little one, ETA December 3rd, 2011. Things are looking good for this little one so far, which blesses us tremendously after our challenge during a miscarriage last year.

Baby Crouch 2.0

Later in the morning I went to OB ward after the nurse came to get me for a laceration repair. It was easily the most complicated laceration from childbirth that I've ever seen, and required sedation and some pretty involved stitching. But in the end, I think the injury will heal well. Wednesday I had a similar laceration, but again mom did well and was feeling better today.

After lunch Tuesday, I saw several patients in the OPD (outpatient department) including a very weak looking young lady. She had been to several doctors over the past 2 years because of generalized weakness, body and joint pains and losing weight and stopping her monthly menses. She had been tested for HIV, Typhoid, Malaria, and had an ultrasound scan of her abdomen for cancer of an unknown source. In talking with her, her diagnosis seemed impossible, but for the fact that she woke up every morning dreadfully thirsty. Our one and only test in the clinic that afternoon involved 3 seconds of checking her blood sugar - 561. This patient probably has untreated diabetes leading to weight loss and emaciation. That made for a small victory in clinic, she is now getting a little better slowly with insulin injections in the hospital.

This patient was 20 years old and weighed 32 kg (about 80 pounds)

Tuesday night we had dinner with Erin, Becky and Tiffini - a visiting PA student here. It is great to spend time with people our age and get to have a good time joking together. It makes this place feel that much more like home - but we are definitely missing our friends and family there.

Wednesday I saw several patients in the OPD after peds rounds. One couple was coming for infertility - though they had only been trying to conceive for 2 months. There is pretty significant pressure culturally to have children here, and the father wasn't happy with the idea that it might take up to a year to conceive. I also saw a lady with bacterial meningitis in the ER and did another LP with Dr. Bill. Her CSF studies came back today mildly concerning for Tuberculous meningitis, which I pray she doesn't have.

Another Csection Wednesday with a baby that came out looking quite distressed. After our day Sunday, I didn't think I could stand another baby dying. This child wasn't breathing and, again, Dr. Stephanie resuscitated the baby while I worked on Mom - a little less chaotic than the last one, though. Baby turned the corner quickly and went to our nursery. Thankfully, prayers were answered and the child looks great so far.

One of my C-Section babies - doing well

I'm on call tonight again and may have more pictures and stories for tomorrow and this weekend.

Losing

Anyone who knows me knows that I don't like to lose. But today was a day of losing.

I'm halfway through my call and I've already had more than my share of loss and frustration. Most relates to the recent departure of Dr. Scott Pringle, our visiting OB/Gyn physician. Now that he's gone, the OB calls are coming fast and furious. At Kudjip, the doctor is not called for routine, happy deliveries. They are called for problems. I guess that's what I get for wanting more OB exposure.

My first call to OB brought me to a young girl who was about 5 months into her pregnancy (21 weeks). She had contractions through the night and was already dilated in active labor. Dr. Stephanie was already in the OB ward so we gave salbutamol. But she was already on her way to delivering. Her baby was born prematurely and lived for a couple hours in our nursery.

A little later a woman presented to the OB ward in labor. This woman had 9 months of pregnancy completed (fantastic) and was fully dilated ready to deliver (also very good) and had 3 previous successful deliveries (great). But her baby's heart rate sounded out at 70 bpm (normal is 110 to 160). Ugh. She did better on her side, but would not tolerate pushing so we took her to the OR for a Csection. Then all of those promising signs from her arrival vanished.
Her baby had hydrocephalus and frontal bossing when I delivered the head, and turned out to have dwarfism when I delivered the rest of the baby. As Dr. Stephanie went to resuscitate the baby, I was left with a uterus that seemed to bleed with no stopping in sight. As the mother's heart rate climbed towards 140, Dr. Stephanie was instructing the nursing staff caring for the extremely sick baby. I'm very grateful that God gave me steady hands, even when very nervous or scared. I was able to finish the Csection while Dr. Stephanie helped intubate and ventilate the baby. (I am convinced this little one's heart had a significant defect, because the baby did not survive beyond 2 hours after delivery). My heart sank as I scrubbed my hands and left the OR.

These things tend to happen in 3's, and today was no exception. As soon as I returned to the ER the ER nurse showed me a baby that just arrived. She had been delivered at home 3 days prior when the mother was about 6 months into her pregnancy. The baby did not feed well and had only shallow breathing and a faint heartbeat. I felt compelled toward this child, having seen two pass away already. This baby is now in our warmer with oxygen, a feeding tube, IV fluids and sugar, antibiotics and respiratory medicines in an effort to stave off what increasingly seems inevitable around here.

One of our newborns who did not survive day one

One story that has been extremely important to me in the past has been the story of David's first child born by Bethsheba. Because of David's sin, the child became ill and David prayed and fasted for his recovery. When the child died, his servants were afraid that he would become despondent. Instead, David cleaned himself up, ate, and worshiped God. They asked him how he could do this and his reply has been an important life lesson for me as I take care of the sick and hurting:
"While the child was alive, I fasted and wept; for I said, 'Who can tell whether the Lord will be gracious to me, that the child may live?'" (2 Sam 12:22)

We often ask how God could be good, powerful and care for us in the face of suffering like this. I used to wonder that also - and theologically, I have my ideas. But when I see the grief of mothers who have lost their children, my theology seems less important. I find myself asking what David asked, "Who knows? Perhaps the Lord will be gracious." I've come to appreciate that I don't have to explain God's doings, the "why's" behind the things that happen in our world. I believe that He is good, and because of that I trust Him - in spite of my own failures at times in bringing healing to those He directs my way. Because of His goodness and that trust, I can have peace. That doesn't mean it is all taken lightly. Quite the contrary. My burden is to see the suffering without having to justify it, and to hope that I may yet, sometimes, be an instrument of His grace.

Lepto can wait

Dr. Bill likes to give me various topics to investigate on my own that relates to illnesses we see at the hospital. This happens in the States all the time but it's usually, "Does an ultrasound to rule out DVT help decide whether to not to use medicine for a clot." Here, it's more like, "Find out what the heck Leptospirosis is." But today (/yesterday) was Anna's birthday so, as Uncle Bill said, "Lepto can wait."

What a great turnout at her birthday party. Everyone here has welcomed us with open arms, which is an absolute joy when you are thousands of miles from home and your little one has a birthday. We enjoyed "hobo dinners" around the fire before heading to Uncle Bill and Aunt Marsha's for cake, games and presents. Anna's new best friends the Goossens kids were there, as well as at least a dozen other people who celebrated with her. We're grateful that Anna has so quickly got an extended family to make the day memorable.

Anna, Lexi and Mama around the campfire (it was a little rainy)

I'm sure Esther will put up a list of her presents. She got her own bilam and a highland traditional hat ... though she doesn't look all that Papua New Guinean to me yet.

Anna's highland hat

Some interesting work in the hospital yesterday as well. One patient, Paul, has been sick for a couple weeks now. It seems like he has an infection and he hasn't been able to communicate or walk and is totally disoriented. We are not sure what illness is causing it and I can only imagine how challenging it is for his family right now. Dr. Bill and I did a spinal tap in an effort to find some culprit but as of now we are at a loss.

Trying to find a reason for a patient's illness on the ward

I've also been really happy with the progress of one of our patients who has pericardial TB (TB fluid around the heart). She is improving with medical treatment and probably won't need surgery - which would be very involved and dangerous. She has been a joy on the wards and has a smile every time we see her. I'm amazed because I had a very similar patient (an immigrant from Africa) during my Intern year at Hillcrest. That patient was in a negative pressure cardiovascular intensive care unit and had serial echocardiograms, a pericardial window guided by Xray, a cardiologist, cardiovascular surgeon, intensive care physician, infectious disease specialist and a family practice resident taking care of him. This patient has prednisone, lasix, anti-TB drugs and a family practice resident taking care of her. And she may be close to going home. I don't wonder any longer why our care in the US is so expensive. Obviously, we would love to have those things for this patient - but she is healing well, I think, because of a very positive attitude.

Me, Nursing students and my smiley TB patient

Next week I switch to Pediatrics and will start to work a little more in the OB department when I'm not in the ER. I'm really looking forward to working in OB and getting some additional C-section exposure. It is a little intimidating with the different techniques used here and, like most things in PNG, I'm sure it will be a quick learning curve.

ER

I am starting to really like the emergency room at Kudjip. At first I felt intimidated every time I went there. Now I feel a little at home.

There are 6 ER beds, each separated by about a foot of space and (If the situation demands) a curtain. There are usually one or two patients standing around or sitting on stools waiting to be seen in various corners of the room as well. The supplies in the emergency room remind me a little of our trip to Haiti ... things you need for cleaning wounds, reducing, suturing, splinting fractures, IV fluids (though we are currently experiencing a shortage - did you know you can make normal saline by injecting 30mL of 23.5% saline in 1 liter of fluid?)

The presentations to the ER are usually more acute than those in the OPD. I've mentioned that I have trouble seeing patients with chronic conditions with very little command of the language. I still have trouble in the ER, but not as much so. Abscesses, broken bones, necrotic wounds, pulmonary edema, asthma exacerbations - they are fairly easy to diagnose without a lot of dialogue. The times I struggle are the times that someone comes with something I'm very unfamiliar with (TB, Typhoid Fever, Malaria and the like). But today was filled with infection.

A young man came to the ER today with an infected wound on his foot. Last week he was running from the police (I don't know why) and a bullet grazed his foot. He got a shot of penicillin from the local health center, but got worse. I put him to sleep with my fast favorite Ketamine/Valium combination and cleaned out the infection threatening to leave him without a right foot. This story was repeated ad nauseum during the day.

One patient stood out to me this morning though. A lady roughly in her 60's has been in our hospital for a few days now because she had a tracheostomy (breathing tube placed in the neck) at Hagen Hospital last week that fell out at home. This was done because she had a tumor in her voicebox, but the family wasn't sure about whether they wanted to have the cancer removed or not. The visiting ENT specialist placed a tracheostomy and told them to come back in 2 weeks with their decision. At Kudjip, we've replaced the current tube with one a little easier for the family to manage. In reviewing this patient's records and talking to her, it appears that her feelings regarding the decision about her cancer have been largely unsought. In a way, now that her voice is gone, she has very little input into anything that happens with her. I find this a problem that exists at home but greatly magnified here.

I saw a man yesterday about 70 who had pancreatic cancer and looked like he would not live more than a few months. I mentioned treatment to keep him comfortable, but his family said that he didn't know about his illness and they didn't want to tell him. I'm amazed that someone they care about could face the end of their life and they would want to keep it a secret. I'm pretty sure, and told them, that he would be able to figure out soon enough he wasn't getting better. His options, medically, are limited. He is an elder in his pentecostal church, though, and the family is praying for a miracle. I've seen a miracle in this very situation, and told them as much. It makes me very sad, though, to think that they will pray for his healing without letting him know that it will take a miracle for him to recover.

But life in general, I feel, gets treated very differently here. There doesn't seem to be as much value to a person's life while they are with us, yet culturally there are enormous obligations on family to express grief and mourning when they pass away. This is a "house-cry" which goes on for days after someone dies and relatives do not eat, sleep or drink but mourn vigorously. (One girl in the ER fainted twice at a house cry and was severely dehydrated today). I'm told that there is some animist influence to this tradition - but having recently lost a relative, I wonder if we don't fall into that tendency at home also. We are filled with remorse and regret when we lose a loved one, but we often don't have the same degree of affection while they are with us. I'm reminded of Jesus referring to his own disciples. He says that they are to celebrate with Him while He is there in the flesh because their mourning will be difficult after He departs. I wonder if I celebrate those around me as much as I would if I knew that I may not have them to see again in this life.

Tomorrow I go back to the medical ward, but will transition to Pediatrics next week and try to be more involved in Obstetrical care after Dr. Scott (our visiting OB/Gyn from the States) heads home. I'm still scared of sick children in this environment but very much looking forward to having more exposure to obstetrical care here.

Produce

Dr Bill pulls in the day's haul of bananas

Apparently Monday is the day of plenty in Papua New Guinea. Today we were given: berries, lemons, bananas, pineapple and got a chance to buy asparagus (a treat around here). Our kitchen looked like a grocery store. We are definitely eating more and more fresh fruit, and some vegetables. Sometimes I find myself craving a bag of potato chips, though.

I found the hospital a little less daunting today. Some nursing students came on hospital rounds in the morning. A large number of them gravitated toward Becky, but two came with me. Apparently we are expected to teach them, which is fine with me, though I have no idea how to do that cross-culturally and cross-language. Rounds were much faster, though, and I got to the outpatient department by 10.

3 or 4 of my patients spoke English remarkably well. They complained of symptoms a little more along my usual clinic patients also. Stress, back pain (x2), arm pain from an old fracture. I think it helped me to feel less daunted by the OPD.

In the ER, I admitted 2 infants with pneumonia. Sick children are becoming the most intimidating thing to me here. I handle the trauma, broken bones, cuts / stab wounds alright because I need no interpreter for those, in general. I find it very difficult to tease out a diagnosis in a child when I can't speak the language. It doesn't help that Papua New Guineans are ridiculously poor historians when it comes to illness. "I think she was in the hospital last year. I can't remember why. No, maybe that was last month. Was that my other child?" (Sigh)

I did treat an elderly man with cough for 4 years and weight loss. In this place, I now know, that represents TB unless you have a great reason for something else. He looked somewhat frail and came to the ER with his nephew. The nephew was adamant that it couldn't be TB, "It's probably just his winbox (lungs)." I remember seeing a very strong sense of denial towards diseases like HIV and TB in Africa, and I wonder if the same is true here.

Last night Esther and I spent time contemplating our plans after residency. There are several options that we've been looking at, and we wanted to see this place before we started to make that decision. Working at Kudjip is exactly the kind of medicine I went into my training thinking I would do. I spend 95% of my time taking care of patients here. I spend 0% of my time worrying about billing or malpractice. I see broad pathology and have the responsibility of treating it all. Yet the past 2 years at IMAGE exposed me to several other templates for medical missions, and I enjoy all of them. Village clinics and community health, public health, disaster relief medicine, medical education. All of them represent serious needs and have big answers for some of the neediest places in the world. Figuring out where I fit in that puzzle will likely take longer than a week working in a rural mission hospital. But I wouldn't trade our experience here thus far for anything else. I hope and pray that God will use the rest of our time to crystallize some of our goals, our heart and our path down the road.

Weekend

Preparing to go down a rock slide

Weekend. Just as good (if not better) in Papua New Guinea as anywhere else.

After my night on call Friday, I expected to spend most of my weekend sleeping. But Saturday morning, after wrapping up on the hospital ward, we joined several families from the station to visit a nearby river in the mountains. This cascaded in a certain area creating "rock slides." It took a bumpy, muddy ride in a land cruiser across a bridge literally made from fallen tree trunks, plus a slightly more treacherous hike through the jungle and up and down muddy slopes to get there. But I'm glad we decided to go. Anna was a little less excited about the entire ordeal than we were, but I managed to get her down one of the slides with only mild crying on the way down.

Saturday afternoon saw all three of us take naps. Mine stretched longest into the evening and I woke up only just in time to have dinner with the Goossens, a family living next to us on the station with 2 little girls and 1 boy. Randy manages IT for the station and Joni works in the field office as an accountant. We enjoyed spending the night there with another young family somewhat recently arrived.

Today we took in a local Nazarene service. There were 2 English worship songs, but the rest of the service took place in Pigin. Marsha McCoy wrote some translated notes for us on the sermon, though.

Back at home, we've been relaxing most of the day away. We went to see Dr. Bill's garden which boasts pineapple, mango, banana, papaya and several other more familiar crops. I took a stroll to the far end of the station to get some lemons and was nearly roped into a game of rugby with the locals. I'll likely be taking up that offer in the near future.

After bringing Esther some belated Mother's Day flowers, we sat down for a relaxed dinner and have spent the rest of our night playing in the living room, intermittently grabbing flashlights due to the frequent power cuts.

The general feeling I get from today is one of rest and relaxation. Not just for us, but for the other families living and working here at Kudjip. I feel this is how our days of rest ought to look. I suspect that the challenges of daily life here make these days particularly special for everyone on the station. Sometimes I wonder if our Sundays at home could use fewer checks at the clock or watch to make sure we're on time for church, for lunch afterward, for dinner with the family or just watching our last moments of weekend tick away. The time moves a little more slowly here, which is fantastic.

I'm still convinced the weekend just wasn't quite long enough, though.

Post-Call

A ward (Pediatrics) and B ward (Medical)

Day # 2 at Kudjip hospital challenged me more and more - mainly because I spent that night on call after seeing patients at the hospital during the day.

The call requirements at Kudjip remind me a little of call at home. One responds to calls from labor & delivery, the hospital wards and the emergency room. The similarities end there, though. A typical call at home generally results in admitting a patient to the hospital after they were stabilized in the emergency department, or at least given a very cursory glance by a physician somewhere along the way. At Kudjip, call means you are taking your patients lives in your hands somewhat independently. I am very thankful for the doctors here who are helping me along - though I feel bad having to rely so heavily on the team during a night that I'm supposed to be "holding down the fort."

My first call was to the emergency room for a young man who was drinking and fell off a 2 story building. He landed on his right side, fractured his humerus, clavicle and a couple of ribs, and was pretty much unresponsive with a blood pressure of 70. I planned on admitting him after stabilizing his vital signs and splinting his arm. As I notified the staff physician, one of the nurses started doing compressions on an infant in the bed across the room from me ... and things got serious. The next 2 hours passed in something of a blur and I felt way out of my league. I was so grateful for Dr. Becky's help. After a few more harrowing moments in the emergency room, we wrapped up and I headed home.

I lay down on the couch and fell asleep, but received a call back to the ER for another trauma victim. While orienting myself (and realizing I had only slept a disappointing 30 minutes) I got a call from the OB ward about a newborn that was having seizures. My head started to hurt - what am I doing here?

I went to labor ward first, discovering a very well looking baby that had 2 convulsions during the night but was otherwise doing well. In this country, Paraldehyde mainstays the treatment for newborn seizures, but I'm far more comfortable with diazepam - so gave that instead. I left OB ward reassured that the baby was not in immediate distress. As my trauma patient was returning to the ER from Xray, the enormous bandage covering his forearm soaked with blood and the strong scent of alcohol made me a little nauseated. He was in a car accident, smashing his arm against some part of the car when it rolled on its side. As I unwrapped him, it was obvious there was serious danger to his hand. His fingers were paralyzed and I couldn't appreciate a pulse in his wrist. When I got to the skin the reason was obvious. Both bones in his arm were broken, one quite visible. After recruiting some additional surgical help, we "reduced, stitched, and splinted" his limb (a pretty common procedure around here I'm discovering). Again, I had been largely overwhelmed and heavily dependent on Dr. Jim and Dr. Raymond in treating this young man. If they weren't there, I worry he may have lost his hand.

Both of these experiences left me a little discouraged. At home, I feel I function fairly well as a young physician. I have a lot to learn, but have made serious progress in the past 2 years as a resident, gaining confidence in treating heart attacks, strokes, delivering babies, performing the occasional resuscitation in the hospital. So far, in this place, I feel overwhelmed.

The hospital is my comfort zone. It is the most familiar part of doctoring here. My patients smile when they see me and I've seen a few make strong recoveries and leave for home. I have seen a couple die, though. But not, I believe, because of some inadequacy on my part. After just 3 days, my rounds are more efficient and I'm learning what tests and treatments are in my arsenal. Things are falling into place.

Call was another story. It was intimidating as an intern to face my first night on call. I remember a similar feeling when going for my first drive in the car having a new license at 16. Something you've wanted for so long that contains a strange mixture of excitement and terror wrapped into one. This call was more like that. I am so dependent on the nursing staff, the emergency physicians, specialists, monitors, lab results, xrays and CT scans of American medicine that facing a broken, suffering patient without them feels impossible. Yet the doctors at Kudjip do that consistently - and do it well. Several lives were saved last night. They weren't saved by expensive laboratory equipment, million-dollar machines and consultations. Somebody's child, somebody's arm, somebody's life was saved because a physician some time ago put their ambitions aside and struck out to the mountains of Papua New Guinea in an effort to relieve the suffering of the people here. God gave them that call, and they responded. Now, they've created a place where His saving efforts toward us are reflected by the doctors and nurses who work here. Each of them has a fascinating story to tell, and I'm sure each endured their own difficulties and challenges before they felt confident in this place.

I pray that in my time here I will be able to absorb a little of that medicine, and a lot of that heart.

And I wonder what their first night of call was like.

Day 1

The view from our porch

Big nem bilong yu means "honor to you" in tok pisin. Dr. Bill concludes his prayers with patients that we see with this phrase.

We arrived in Papua New Guinea 3 days ago. Now I've decided to try to keep some account of our time here ... for those who have put time, money and energy into making this trip possible. Without you, we wouldn't have this opportunity - thank you!

At 6 in the morning, I've been up about an hour already today. I can level the blame for that on the time change, but working steadily throughout the days in a new country with challenges I've never faced before means that I'm ready for bed far earlier here as well. Getting up at 5 this morning still meant a good 7 to 8 hours of sleep last night.

The ambient sounds of Papua New Guinea don't lend themselves to lullabies. Cicadas (spelling?) smashing into the screens and yells in the middle of the night don't help. There are no calls to prayer at 4 am though, which is decidedly better than many of our previous trips. The steady rains of the afternoons and evenings with their rolling thunder coming out of the mountains is relaxing, though.
Last night we heard a procession in the middle of the night and I'm sure I heard Jesus' name used several times, though I couldn't tell if there were sounds of joy or sadness. It seems that those two are inseparable in a place like this. Something that I've learned is true at home, but perhaps contrasted a little better here.

I wrote in my journal yesterday about my first encounter with caring for the needy here at Kudjip:
"Today I watched a 15 month old boy die while Dr. Bill and I tried to resuscitate him. I delivered a baby in a csection. I repaired a woman's elbow after she had been stabbed in a knife attack by a rival tribesman (who was looking for her husband). I drained an abscess, praying that there was no bone infection, on an infant who now lies in our ward receiving IV fluids and antibiotics to stave off sepsis. I did all of this without falling apart. But I wonder if that, too, is close at hand."

We have a rare privilege and burden here. I don't see patients looking for a reason to suffer. I don't see patients "using the system." I don't see patients with the wrong insurance, on too many pain medications or insisting on seeing a specialist. I see patients who are lost and hurting, with insurmountable odds stacked against them trying desperately to care for themselves, their spouse, their families.

The day we got to Kudjip, a pregnant woman arrived at the hospital at about 5 months along. 10 days before, she went to surgery from our emergency room. Her husband's other wife, who couldn't conceive, attacked her and stabbed her in her abdomen. That injury was repaired in the operating room, as was a small hole made in the uterus from the penetration of the knife. She recovered well and went home. But on the 3rd of May, her water had broken and she delivered her boy prematurely weighing 400 grams. There was a hole piercing the side of the baby, leaving his abdomen exposed and open. The baby died 2 days ago, having surpassed all expectations in living almost 48 hours.
I was reminded of Zechariah 12:10, "And I will pour on the house of David and on the inhabitants of Jerusalem the Spirit of grace and supplication; then they will look on Me whom they pierced. Yes, they will mourn for Him, as one mourns for his only son, and grieve for Him as one grieves for a firstborn." This is the prophecy that John writes was fulfilled when Jesus was pierced on the cross, with the flow of blood and water that followed an illustration of the sacrifice and redemption we undeservedly gained in that moment. I am struck and humbled to be in a place where the imagery of God's rescuing us is so vivid and alive. Whatever shortcomings I have in this place pale when compared to God's sovereignty and care of the people here. We are all control freaks, I realize. At Kudjip, even the idea of control has been torn away from me. Without it, I realize that God lets no moment go by without recognition, even if it doesn't turn out the way He intended long ago. Who am I to ask Him what He is about?