Peril and promise

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

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

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

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

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

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

 

Kudjip chemotherapy

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

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

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

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


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

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

Why?

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

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

A world of peril and promise.

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

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

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

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

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

Many graves

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

-Oceans

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

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

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

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

"He will bring justice to the poor of the people;

He will save the children of the needy"

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

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

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

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

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

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

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

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

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

Where will their hope come from?  Are they condemned to an existence full of suffering and death? 

How many more graves will they dig?

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

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

Fears and New Days

 

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

 -Stay Alive, Jose Gonzalez

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-Matt Chandler

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

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

I think not.

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

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

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

To find each other

"To see the world, things dangerous to come to, to see behind walls, draw closer, to find each other, and to feel. That is the purpose of life."

-The Secret Life of Walter Mitty

About six weeks ago, Nellie's parents brought her to Kudjip hospital in great distress.  She experienced high fevers for several days and then began to drift in and out of consciousness.  Once she arrived, Dr. Erin Meier treated her for meningitis but she failed to show significant response.

Around here if a patient looks infected but doesn't respond to our usual medicines, we quickly suspect Tuberculosis.  Rare in the United States and other developed nations, Kudjip hospital registered 565 new TB cases last year alone.  The average person with Tuberculosis exposes about ten additional people per year.

Nellie's condition worsened - she went comatose and couldn't communicate or eat or drink.  Dr. Bill McCoy place a feeding tube through her nose into her stomach to administer treatment for Tuberculosis of the brain.  Over some days and weeks, Nellie showed gradual improvement.

This week I've been working in our Primary Health Services department, helping in programs from Antenatal care and immunizations to TB and HIV clinics.  Our devotional on Wednesday morning happened on the TB ward.  Nellie sang in broken tones our hymns and said "Tank yu" to Tolbai who led the devotions that morning.  Her mother lovingly calmed her when she had fits of agitation in her wheelchair.

I realized as I watched Nellie and her mother what a common bond exists across the world for family.  Nellie will never have a normal life.  While she shows some improvement, she will likely have serious mental deficits forever.  Yet her mother cares for her tenderly, thankful that she is alive.

Later that day I cared for a young girl, Rose.  Rose had a cough that wouldn't go away.  I thought she might have asthma or a simple pneumonia, but unfortunately seven-year-old Rose has been living with HIV since her birth, acquiring the disease from her mother at the time of delivery.

Rose's father showed concern for her and affectionately led her around the hospital to get her X-ray taken and collect her records from our HIV department.

Rose's X-ray appeared to show a pneumonia, and her HIV seemed well controlled on her anti-retroviral therapy, so I prescribed an antibiotic and told them to see me again in a week or so.

Although Rose's pneumonia may get better, her reality means she most likely won't live beyond the age of ten or twelve.  Knowing this, her father still cares for her diligently, assures she gets her medical checkups on time and gets her supply of ART regularly at Kudjip.

Getting around in Papua New Guinea isn't always easy.  Frequent mudslides, storms and even tribal wars can make roads difficult or impassible.  However, every day pregnant mothers come to Kudjip to get checkups for themselves and their babies.

While most pregnancies will proceed without problems, the poor nutrition, difficulty in accessing medical care and risk of malaria in most women here makes the neonatal mortality one of the worst in the world.

But these women come to get antenatal vitamins, HIV tests, counseling and malaria treatment to give their unborn children the best chance of survival.

I find it easy to distance myself from patients at times.  There are one hundred and fifty new patients every day in our OPD.  The hospital beds fill up with new people every few days.  The ER sees dozens more each day.  With so many people coming through the doors at Kudjip, many faces get lost in the shuffle.

Yet each person has a unique life, a unique voice and a unique story to find.  At times, I have to slow myself down and really listen for at least one patient every day that I'm supposed to touch, hug, pray for or just cry with.

And in those times, though thousands of miles from home in a new culture and language, I feel like I find someone specific that God sent me here to help.

Co-laborers

"I beseech you therefore, brethren, by the mercies of God, that you present your bodies a living sacrifice, holy, acceptable to God, which is your reasonable service."

-Romans 12:1

When I first came to faith I used to imagine myself like one of the ancient martyrs.  Losing my life for the faith of Christ seems, to most, the pinnacle of service to God.  Not until several years later did I realize the importance of this verse in Romans.

God indeed calls some to lay down their earthly lives for Him.  However, I realize now He calls each of us to give up our lives, even if we enjoy many ongoing years on this earth.  Why should I be confident that I would lay down my life and die for my faith if I'm not willing to lay it down and live for it?

At Kudjip I enjoy the privilege of working with incredible physicians who live their lives in a sacrificial service.  Having met, learned from and loved them - I want to share them with you.  I can never put enough words to the testimonies that their lives represent to me, but I will try to give you a glimpse into how they've affected me.

Dr. Jim Radcliffe currently recovers from open heart surgery in the US, but plans to return in about three months and resume caring for the sick and needy as a surgeon at Kudjip - a position he's filled like nobody else could for the past thirty years.  He life and ministry, praying with all of his patients, speaks to his endurance.

Dr. Bill McCoy I cannot say enough about.  Bill attended my birth in Tulsa, Oklahoma thirty two years ago and has remained close to our family.  He is a large part of the reason our family moved to Kudjip and his mentorship and now friendship, along with his wife Marsha, has smoothed our transition here in humbling ways.

Dr. Susan Myers left practice in the United States and moved to Kudjip with a young family over a decade ago.  She now serves as the director of medical services and her patience with me as I learn to function in the Kudjip system reassures me in times that I wonder if I can continue here.  She has a special ministry for our children with congenital heart disease.

Dr. Andy Bennett loves on his patients and gets to know them outside of their illness.  He also works every week to correct club-feet in young PNG children who would otherwise spend their entire lives crippled.  If you need help remembering the fourth verse of an old hymn, ask Andy.  Andy's heart-felt care and encouragements remind me of my dad.

Dr. Scott Dooley runs the whole show.  I don't get to work with him much in the hospital, but it is great to have a fellow "visionary" to discuss grandiose and entirely speculative ideas with.  I'm very pleased my neighbor is back from his home assignment.

Dr. Erin Meier never let an eye-lid droop while she watched over Levi in our scariest time since moving here.  Erin works hard, plays hard and lives on purpose and I enjoyed having her as my stand-in mentor during Bill's absence.  She also sees about half of the patients at the hospital on any given day which makes for the occasional early afternoon off - thanks Erin!

Dr. Imelda Assaigo has the best smile on station.  She works toward a Master's degree in rural medicine and seamlessly became an integral part of the team here, even though she is technically still "in traning"  She also keeps me honest in my Tok Pijin.

Dr. Scot Pringle and his wife Tyronza have been here for 4 of the 9 months that we have.  He retired from OB/Gyn practice in the states and comes at least once a year to Kudjip and takes OB call every third night, relieving the pressure on the rest of us.  Scot makes me laugh and Tyronza perpetually hosts people in their home, often making us classic home-cooked meals!

Dr. Ted Henderson arrived in the last week.  I've already enjoyed a hearty basketball and soccer game with Ted.  I blog-stalked Ted before he came and in a way he has felt like a part of our team for a while.  It's great to have he and his wife Rachel as new neighbors.

Dr. Ben Radcliffe, a surgeon and Jim's son, and his wife Dr. Katherine will be here in January.  Ben and Katherine received the same Steury scholarship that Esther and I did in medical school.  Though I've not met them yet, what I know of their family and their hearts makes me think there couldn't be a better recipient.  Ben and Katherine and their young family will become our newest neighbors, rounding out station life on the "north end" and putting a couple more playful boys down here in the middle of all the girls.

A moment of hard grace

"I’m tired I’m worn
My heart is heavy
From the work it takes
To keep on breathing
I’ve made mistakes
I’ve let my hope fail
My soul feels crushed
By the weight of this world

And I know that you can give me rest
So I cry out with all that I have left" 

Imagine that your wife nearly dies after a complicated surgery to deliver your unborn child.  Imagine that you lose that child in its first weeks of life.  How would you approach the doctor that cared for them?  How would you feel about going back to the hospital where it all happened?

Imagine that you are a young doctor in a foreign land taking care of diseases you've never seen before.  You have witnessed more suffering in just a few months working there than your last eight years of medical training.  Imagine that you've delivered three small babies in the last four weeks for the same nearly fatal problem in their mothers.  All three have died despite your best efforts - the last after nearly two weeks of fighting for life, buffeted by your prayers and tears.  How would you feel looking that child's father in the eyes?

Moreen came to Kudjip about three weeks ago with placenta previa, the third patient I saw for the same problem in as many weeks.  She bled heavily, nearly losing her life and that of the child inside of her.  She was only seven-and-a-half months pregnant.

Moreen, like Dambo and Grace before her, got blood, steroids and tocolytics to keep her uterus from contracting.  She stayed in the hospital a few days.  Then she began bleeding again and her baby girl was delivered by Cesarean section to protect her mother's life.

Dambo and Grace's babies came under my care in the same circumstances and within a week they both died.  As I listened to Moreen's baby, I struggled to control myself, wondering if I could emotionally tolerate losing another tiny baby to this malady.  This little baby's heart sounded wrong - a strong murmur, potentially a sign of congenital heart disease.  For a day or two she did well enough and I thought she could breastfeed.

Then Moreen got measles.  She never looked good after surgery and had fevers that didn't respond to antibiotics.  On her third post-operative day her eyes turned bright red and an extensive rash appeared on her face and chest.  I had to move her to another ward to protect the babies around her, and she never established breastfeeding for her tiny baby.

Over the next ten days, her baby's weight plateaued - and she struggled to breath while also suffering jaundice.  I gave her all six things I had to offer (IV fluids, IV antibiotics, Oxygen, Phototherapy, Nasogastric Tube feeds and IV aminophylline to protect her breathing)

Two days ago she lost her fight.  When I found out, I felt dead inside and my inadequacies as a doctor stared me in the face.

This morning a man came to see me in the clinic, bringing his three year old son with him.  The son fell and hurt his elbow.  When I took a second glance at them I asked the father, "Where have I seen him before"

The man said, "A couple weeks ago we came here and you took care of his mother.  She had surgery.  Our little baby died two days ago and when I went back to my village I found my son had fallen so we are back."

"Her name was Moreen"

"Yes, that's us"

I wanted to leave the room.  I thought this man would surely want another doctor.  His wife struggled to survive, his baby died under my care and now he brought his remaining child to me.  But we both stayed in that moment for a short time and he smiled at me.

Isaac had indeed broken his elbow.  I gave him an anesthetic.  I pulled on his arm, attempting to straighten the bone and then put a splint on.  The father looked at me without contempt.  Indeed, if I saw anything on his face it was gratitude - even affection towards me.  He smiled several times.  

Did he know how conflicted my heart was at that moment?  That I wanted to make his entire family well, but also wanted to run away and hide from my failure as their doctor?

I left the room, gathered my things and headed home.  Twenty meters out the door I stopped.  The only thing I could feel was overwhelming love from this man, and I had no idea his name.  His wife nearly died under my care, he lost his child despite my trying everything I could to save her.  Yet all he gave me were looks and words of thanks.

I turned around and went to their bedside.  Isaac lay still with a new splint, sleeping under his anesthetic.  

"What is your name?"

"Kikiow - or just call me John" he said and smiled again.

"Can I pray with you?"

"Yes, please"

I prayed and he said "Amen" and then "thank you."

I walked home, avoiding looks from passers-by.  I changed clothes and literally ran into the jungle.  I ran past the station, past the reservoir, past the grass huts and up the river in the mountains.  I added tears to the water passing by for a few minutes, remembering Moreen, her baby, her son Isaac and her amazingly tender and gracious husband, Kikiow.

What a mysterious opportunity our lives are.  I never asked him if he felt I did the right things for his wife and child or if he was upset.  I could see in his face that he didn't blame me.  In this moment, when a father could have let loose his anger or frustration at me, he chose instead to show kindness and grace.  A powerful grace not to comfort me, but to teach me something.  Perhaps the moment of hardest grace in my life.  A "severe mercy" as Sheldon Vanauken might say.  A grace I felt I didn't deserve, could never earn and had no means to repay what he had lost.

What minister or saint can show the kind of grace that Kikiow showed to me today?  But there won't be any remembrances put in religious calendars for his child, nor feasts named after him.  He and his family's hardship might go unnoticed by all but a handful of people.

Yet his example of grace just might change one person's life forever.  His story might endure.  And tomorrow, that suffering might be just as real for another needy patient.  And the hard grace that goes with it might be brought to bear on the broken doctor caring for them.

"Let me see redemption win
Let me know the struggle ends
That you can mend a heart
That’s frail and torn
I wanna know a song can rise
From the ashes of a broken life
And all that’s dead inside can be reborn
Cause I’m worn"

-Worn, Tenth Avenue North

Life and death

"We were so utterly burdened beyond our strength that we despaired of life itself.  Indeed, we felt that we had received the sentence of death.  But that was to make us rely not on ourselves but on God who raises the dead."

-2 Corinthians 1:8-9

 

 For the past month or so, I've been working on our obstetric and nursery ward.  OB is challenging here.  In the states, doctors attend nearly every delivery.  90% of them are a straight-forward, joyous occasion and mostly I just "caught" babies and congratulated parents.  At Kudjip, the nurses attend uncomplicated births and the doctors are only called if there are problems.  After a month of these complications, my heart begins to ache for the babies I can't save.  I could say my emotional and spiritual pulse ebb away at times as I see babies die and mothers suffer.

 

Two weeks ago, Dambo came during her third pregnancy with bleeding.  Dambo suffered from placenta previa and a hemoglobin of 4 (normal 12-16) requiring multiple blood transfusions when she got to Kudjip.   Her blood loss stopped, her baby survived and we watched her closely, knowing that at only 7-and-a-half months pregnant her baby might struggle if delivered.  

On my last call, Dambo began bleeding again and her little baby's heart rate raced along at 170 beats per minute.  I decided to deliver her baby by cesarean section immediately.  Once I got him in my arms, though, I wondered about his chances - he only weighed 1.6 kg (3 pounds, 8 ounces).  I sent the baby to the nursery while Dr Mike and I finished Dambo's procedure while giving her yet more blood.

The nurses working on my obstetrics ward summoned me in the middle of rounds to evaluate a patient who had just arrived from a rural health center.

Sharah delivered her baby at three in the morning at home.  Lo and behold, a second baby needed delivering, but it was lying sideways.  The officer at the health center felt a hand in the birth canal and immediately sent her to us.

I couldn't doppler the baby's heart beat so put an ultrasound machine on.  It was difficult to see and I worried the baby had died already.  Bill joined me and we both felt that perhaps there was a faint pulse after all but not convinced that we could appreciate it.  But the baby was still lying sideways unable to deliver quickly and with only a very faint and slow pulse.

According to the Advanced Life Support in Obstetrics manual, an Internal Podalic Version is probably the most dangerous procedure allowed in modern obstetrics.  It involves reaching into the uterus, manipulating the unborn child so that its feet present in the birth canal, and then delivering the baby in a breech fashion.  Complications including separating the placenta leading to bleeding for mom and baby as well as head entrapment during the breech extraction, both of which can be fatal.  Sound complicated?

Dr. Bill manipulated the baby into a feet-first position and I helped our registrar Imelda deliver the baby breech.  However, the baby didn't breathe.  Imelda stimulated the baby, suctioned its nose and mouth and I gave artificial respirations through a bag.  The baby gained a pulse and her color went from ghostly pale to pink, but she wasn't moving any of her limbs as I carried her to our nursery.  I fought back tears because we still had work to do, but inwardly, I was convinced we had delivered a baby who would soon die.

I've been thinking a lot lately about the discrepancies between life here and my life back in the States.  I took so much for granted there.  Mothers and babies didn't die.  In fact, if a complication came up during a delivery, even though everyone usually came out well, doctors panicked and parents worried.  I worried myself sick in residency because a baby I chose to deliver ended up in the (excellent) NICU at our hospital.

What about the rest of the world?  Who may or may not survive their birth, grow up in poverty, give everything they have just to get an eighth grade education and still gladly take on the dangerous blessing of bearing and raising their own families.  Can I not trust that God will look after the concerns in my life knowing that most of the world has to rely on His grace for their food, health and survival every day?

For two days, Dambo's baby did well in our nursery.  Dambo, however, continued to bleed from her surgery and needed multiple transfusions of blood again.  It looked as though her baby would out-live her.

The morning after Sharah's twin birth, I went to see her baby girl.  Amazingly, she moved all of her extremities, breathed well and even startled at the touch of my stethoscope on her chest.  I took a chance and removed her oxygen (we've run out a lot lately) and let her breastfeed.

On day three of Dambo's ordeal, her little boy took a dramatic turn for the worse while his mother improved miraculously.  Within hours, Dambo had turned her corner, but her baby deteriorated.

Sharah's baby girl and her twin brother are going home.  From a breathless and pulse-less baby to a new life with untold potential in front of her.

However, Dambo's baby died two days ago, likely from complications of being born too early due to his mother's unstable condition. 

On foot

"He departed from there by boat to a deserted place by Himself.  But when the multitudes heard it, they followed Him on foot."
Matthew 15:13...

Some nights on call I pray for nothing to happen.  Some nights so many things are happening that I find myself getting irritated when the phone rings, yet again, summoning me to another ill patient that I may or may not be able to help.  Sometimes I just want to get to a nice deserted place.

Lavina went into labor with her third child on a rainy Monday.  She felt pain come and go for eight days.  At that point, her baby presented its arm into her birth canal.  The baby was laying sideways and couldn't come out, so she went to her local health center in the Jimi valley outside of Kudjip. 

The Jimi sits north of Kudjip across a mountain range.  Most patients who come to Kudjip from Jimi spend two or three days walking through the mountains before getting access to a car that can take them the rest of the way here.  Though not deserted - it is certainly remote.

Kudjip to Hagen is 50 kilometers, on a road it takes an hour

At the health center, the nursing officer recognized that Lavina's baby had probably already passed away, and that it could not deliver vaginally which put Lavina's life in danger.  He referred her to our hospital.  Three days later she made it to Kudjip arriving in the middle of last Friday night, the 11th.

30 miles of this terrain, on foot, between the Jimi valley and Kudjip

I've recently started performing my own C-sections without surgical assistance from the other doctors on station.  On meeting Lavina in our delivery bay, my heart raced as I thought of managing this difficult operation for a baby that had already passed away and a mother whose life might be in jeopardy as well.  During Lavina's surgery, her blood pressure hovered precariously low.  Her baby had died, but Lavina survived her surgery.  I scrubbed my hands clean and went home after what was an exhausting night of call.

The next morning, Saturday, I got a call to evaluate Lavina before rounds.  She was gasping for breath with a low blood pressure.  I couldn't for the life of me come up with the reason she had done so poorly since her surgery.  I gave her medicine to reverse narcotic overdose and adrenaline to increase her blood pressure.  I left Lavina in the care of Dr Erin for the remainder of the day.

Two days later, on Monday, I quickly scanned the ward to Lavina's bed and dreadfully saw a different woman there.  Convinced she had died despite my best efforts, I started rounds.  When I got to bed number five, I was stunned to realize that Lavina, in fact, sat before me looking an entirely different person.  Her husband Daniel was at her side.  Rachel, one of our nurses, explained.  "Dr Mark, she never woke up on Saturday, but God touched her like magic.  Sunday morning she woke up and felt fine."


Lavina and Daniel, a miraculous healing

 I will, I hope, never pretend to understand why Daniel and Lavina have lost their child.  But I also hope that I never presume to take credit for the miraculous healings that happen in this place.  I don't feel God called me to heal everyone who walks through the doors at Kudjip.  However, I believe He moves His people with compassion - and that I have a responsibility to give my efforts for those He directs here.

Thank you for joining us and being part of the medicine and ministry here.


"... and when Jesus went out He saw the great multitude, and He was moved with compassion for them, and healed their sick."
Matthew 15:14

Lionheart

Last week a young woman came to Kudjip hospital in the very late hours of the evening.  She began having labor pains at home, but after an hour or so she was bleeding and her pain increased dramatically.  When she arrived our nurses assessed her and could tell something wasn't right.  After they notified me, I went to the hospital for what I hoped would be a quick vacuum delivery so that I could still get some sleep.

I parked Herbie (our thirty-year-old Suzuki) near the emergency room and covered the short distance from there to Obstetrics ward bringing the ultrasound machine with me.

When I walked into Jenny's room my heart rate went up abruptly.  She was pale, barely conscious and a collection blood was expanding on her bed.  I quickly checked her pulse and had the nurse helping me give her IV fluids rapidly.  Once I had the ultrasound on Jenny I could see that the baby's heart rate was only about sixty, which should normally run over one hundred for a baby in utero.

In the United States, most labor wards are perpetually ready for a "crash" C-section.  That means an anesthetist, operating room, scrub nurse, supplies and instruments can be ready in a matter of seconds to minutes, in the event that a baby is in big trouble and needs to be delivered emergently.  This means that an entire operating room, an instrument kit, a scrub nurse an anesthetist and a doctor capable of performing a C-section are within the hospital walls.  It's an expensive setup to maintain, but it does save lives.

This one room probably costs more than our hospital

As soon as the ultrasound showed Jenny's baby to be in distress, my hopes for the baby plummeted.  The only thing I could feel presenting in the birth canal were blood clots coming out of a cervix that wasn't ready to deliver a baby.  I quickly took more thought for Jenny.  The nurses began a second IV site with additional fluids and I called our laboratory personnel to get emergency blood.  I also mobilized our operating room team for an emergency C-section, having to send a security guard for one of them who lived across station because several phones have been broken lately.

Having received fluids, Jenny looked a little more awake, though still deathly pale.  I scanned her again to see if I could identify where and how she was bleeding so badly.  The placenta was not low (placenta previa) nor could I find an obvious abruption, but the baby was not engaged as well and the heart rate was about twenty.  I watched in agonizing defeat as Jenny's baby experienced its last heartbeats and died before we could get to the operating room.

"For the Lord will not cast off forever.  Though He causes grief, yet He will show compassion according to the multitude of His mercies.  For He does not afflict willingly, nor grieve the children of men."

-Lamentations 3:31-33.

Thankfully Dr Andy Bennett helped me with the surgery.

During labor, Jenny's uterus ruptured.  That means a part of it tore and the baby came out through that opening, rather than descending through the birth canal.  Uterine rupture might be the most catastrophic event that can happen to a laboring woman and her baby.  Though rare, it is the main reason that very few doctors will allow a woman to have a vaginal delivery after a previous C-section because this weakens the uterus, increasing the chances of a rupture.

Jenny's deceased child was delivered from her abdomen and Andy and I went to work on repairing the damage that had been caused by her rupture.  Had Dr. Jim been here she would have had an emergency hysterectomy.  I have no idea how many stitches we put across Jenny's uterus in our efforts to stem the bleeding.  At last, after four units of blood, her blood pressure normalized and her uterus seemed to be clamping off the remaining bleeding vessels.  We closed Jenny's abdomen and left the OR.  I have no idea what time it was.

I told Jenny's husband what happened and he and his brothers wept to think of the baby they lost.  He and Jenny had one daughter and I had tied Jenny's tubes to prevent further pregnancies after the extensive work we did on her uterus.  Her husband told me, "I don't know what this is, but I trust it is God's plan"  I couldn't believe the strength of his faith and prayed with him and their family.

 Family members praying on the ward

I have found that the people in Papua New Guinea much more readily accept God's authority over our lives.  Perhaps because so many things happen here that they can't control.  Maybe that lack of control makes them appreciate God's sovereignty.  It reminds me of a man in scripture.

A centurian's servant was deathly ill so he sent for Jesus.  But before Jesus arrived, the centurian sent messengers saying their master felt he wasn't worthy to receive Jesus into his home. 

"But say the word, and my servant will be healed.  For I also am a man placed under authority, having soliders under me.  And I say to one, 'go' and he goes and to another 'come' and he comes and to my servant 'do this' and he does it."

Luke 7:7-8

Why wouldn't he see Jesus, if he believed he could heal his servant?  He obviously recognized his great power.  Who wouldn't want Him in their house?  What if saying the word from afar wasn't enough?  Didn't he want to be absolutely sure that his servant would get well?  Wouldn't it be better if Jesus was actually present performing the miracle - had more control over it?

"When Jesus heard these things, He marveled at him and turned around and said to the crowd that followed Him, "I say to you, I have not found such great faith, not even in Israel!"

Luke 7:9

I believe that the only people who really know the magnitude of this story are Jesus and this un-named centurian.  This foreigner to the faith put Israel to shame because he recognized that Jesus had authority and power and that He could use that power to save the sick servant without ever setting foot in the house or seeing the sick man.  Are there other instances in scripture in which somebody managed to marvel Jesus, the son of God?

In this place I am unfortunately reminded of my lack of control frequently.  But I pray that I won't forget about God's sovereignty, and that I would spend more of my time asking for His help and less worrying about my own modest efforts.  I want to be someone that recognizes God's authority and takes confident action on it.

"And as the world comes to an end
I'll be here [within] Your hand
'Cause you're my King and I'm your lionheart"

-King & Lionheart

Vast beyond all measure

Normally I find writing in my blog about the experiences here therapeutic.  This time, though, my hands nearly shake as I try to put words to what happened at Kudjip last week.

On Thursday morning Levi woke up with a bit of a runny nose and wheezing.  He did this a couple times before we left the States, needing a visit to urgent cares and some nebulized medicines to calm him down.  I gave him a treatment but worried more later that morning when Esther asked me to bring my pulse oximeter (used to measure oxygen levels in the blood) home from work at lunch.

When I got home he wasn't doing too badly, but Dr Erin came to check on him as well.  I went back to work believing that his medicines would enable him to turn the corner.

After work, Levi looked drained, sitting alone on the couch watching a cartoon on the laptop while getting his medicine.  He could only speak in one-word answers to my questions so I called Erin again.  She recommended IV fluid to get him some energy since he was breathing so fast.  The next ten hours were probably the longest and scariest of my life.

Getting oxygen and IV medicines at the hospital

We got our fluids in the ER and planned to return home.  But I noticed Levi having more difficulty and had to give him breathing medicine every hour or so.  His heart rate hovering at 180 and his breathing labored and coming about 60-70 times per minute, I needed this illness to be managed by someone else.  Erin graciously came back to check on him.  Her level of concern told me that this was getting serious.

She brought Esther, Levi and I back to the hospital while our neighbors took care of Anna and Lucy.  When we got to Levi's hospital room, our field coordinators were there and so was our Anesthesia officer with pediatric intubation (breathing tube) supplies.  Levi was getting continuous nebulized medicines, oxygen, IV aminophylline and a dose of IV magnesium but still breathing about 80 times per minute, struggling to get enough air and wheezing so loudly you could hear each one of his labored breaths from across the room.  Erin got information about having him evacuated to Australia.

Would we actually need these for a breathing tube?

Esther needed to go home to take care of our girls, so I held Levi to keep him calm while he received drugs to keep his airways open.  I couldn't believe what was happening, but I felt the effects of dozens if not hundreds of people praying for us.  I also saw that Erin had no intentions of going anywhere - she stayed awake at his bedside all night, adjusting IV drip rates, giving nebulized treatments and praying at his bedside.  (Levi noticed this at one point and said, "wake up!" which made us both smile - partially out of relief to hear his voice)

About six hours later, in the early morning, Levi took an interest in Erin's iPad, and began playing a game on it.  I believe the pediatricians might make an exception on the idea of limiting computer and movie exposure in kids if such devices calm them down enough to keep them breathing.

From that point on, he showed gradual improvement.  We spaced out his breathing medicines to every hour, gave him additional oral medicine and took a chest Xray which showed pneumonia.  I was able to take the oxygen away and Esther showed up with some breakfast and to give me a break.

As he got better, we transitioned him back to the house to receive the rest of his IV medications but kept him on breathing treatments every two hours.

Trying it out at home

Just 72 hours after this ordeal, you would barely know that he was sick.  He's back to running, playing with Anna, talking excitedly but also to being a bit moody (from loss of sleep and steroids, I hope)

Was this kid sick?

One of our family members back home admitted the day after we left the hospital that their first reaction to hearing about his illness was "You get all three of those babies on a plane and back here now!"  In my heart, I confess I too knew that thought and felt the anxiety leading up to it.

Now Levi is on a host of medications to prevent flare ups of his condition.  They're not easy to get here.  There's also no guarantee that he won't have another episode like this one, or that it might even get worse.  How do I approach that knowledge?  I asked Bill via email if it made me a bad missionary that I was considering the wisdom of living somewhere without the advanced medical care he could potentially need.

I blogged in the past about the concept of following God's call even when circumstances or outcomes might be challenging for me.  Now I face that idea in a new light.  That night in the hospital with Levi shook everything I felt to be secure around me.  Does that change where I live - who I serve - how I see patients - my calling?

"The heavens and the earth will shake; but the Lord will be a shelter for His people."

-Joel 3:16

We've not felt compelled to change our plans for staying here.  Esther and I are both prayerfully considering these next weeks and months while seeing how Levi does.

I remember a couple years ago speaking with a friend about the incredible love a father has for their children.  Obviously, there are Biblical parallels to this concept.  That Christ would give up his own life to make things right for his children (us) resonates easily with me.  I would give my life in a heartbeat for my children.  But another amazing love is that God would give His son for us.  I find it harder to as readily say I would give one of my children's lives for others.  I don't know what that means yet.  But I do know that I can very slightly understand the great pain that God the Father must have felt as He saw His child suffering.  And I pray that I'll use that as motivation to continue to share His love with those brought under my care here.

How deep the father's love for us

How vast beyond all measure

That He would give His only son

To make a wretch His treasure