Hopes and fears

“The hopes and fears of all the years are met in thee tonight”

-JJ Heller

I was seeing patients alongside a visiting resident in the clinic when we were summoned to the delivery room by a nurse to assist a mother who was struggling to deliver her first son. She had been in labor for some hours and hovered on the verge of exhaustion. An aunt was there attending her, along with a couple of our nurses, each giving encouragement. But etched in her face was a look I have seen hundreds of times. A look of fear – that this child would not come, that she didn't have the strength.

I instructed Daniel, our resident, in preparing a vacuum extractor to assist with the delivery. She looked doubtful as we made the instrument ready, but a brief explanation seemed to allay her fears. She pushed. Daniel pulled. A vigorous baby boy soon rested in the arms of his exhausted but obviously joyful mother. The hope of those nine months now breathed against her chest.

When I see expectant mothers in our antenatal clinic or outpatient department I notice the mingled hope and fear of the new life growing within them. Hope of a child with all of its innocent promise and the expanding joy of their family. Fear of all that may happen in a place challenged by difficult maternal and perinatal mortality figures.

I am perpetually wonder-struck at Christmas. I have grown up knowing that God chose to become man for our sake and that his arrival was marked by a humble birth. But until I saw the challenges of childbirth in Papua New Guinea, I don't believe I appreciated the incredible courage of Mary and Joseph. I did not fully comprehend a God who was willing to take any chance to safeguard His children. Nor did I grasp His love – that would put his own Son in harm's way from his first breath. But when I see the faces of those mothers, full of concerned anticipation, I take a moment to ponder the miracle of Christ's coming.

“Awaken your forsaken hope and look upon your king.”

Nevertheless

"Launch out into the deep and let down your nets for a catch"

-Luke 5:4

I got the phone call at about midnight late Sunday.  The previous day I was bumped and jostled up the highlands highway returning from the national medical symposium 9 hours away on the coast, so I was a little sore.  The calmness of the voice on the other end of the line clashed with the message delivered.  "Doctor, your C-section patient is in arrest."

I flew out the door and up to the hospital.  It didn't make sense - her surgery had been fairly routine a few hours before.  Her baby simply wouldn't come vaginally so I took her to surgery and delivered a big, vigorous baby.  But when I arrived in the ward, there she was without breathing or pulse, receiving chest compression from a nursing student while an anxious family looked on.  I quickly placed a tube in her airway while nurses prepared drugs to try and restart her heart.  After several minutes and rounds of exhausting CPR, she had a pulse.  One of our anesthesia officers arrived to help but she kept losing her heartbeat so we started a continuous infusion of adrenaline to keep her alive and took her back to the operating room, allowing our ventilator to provide artificial breaths while we tried to reverse whatever happened to her.  Did she get too much anesthesia or pain medicines?  We reversed it.  Did she bleed too much?  An ultrasound of her abdomen suggested no.  What happened?  After many hours being kept artificially alive, her body eventually wore out and she passed away - her cause of death shrouded in mystery.

I got some hurried breakfast and went back to the hospital.  Only hours later another mom came to the delivery room who had been laboring in a bush health center without any progress, awaiting a car's availability to bring her to Kudjip.  Her baby was clearly obstructed in her pelvis and she needed surgery.  The nurses had reported a strong fetal heart beat before surgery, but it became apparent they had detected the mother's pulse.  I delivered a baby that seemed to have died some time before.  I put the last stitch into my patient's skin and went on to clinic, preparing to work my way through a steady steam of the destitute sick of Papua New Guinea.  I was mere hours back into work and I was already feeling drained.

After an invigorating time teaching at the PNG national medical symposium, I returned to the maternity ward at Kudjip.  For the past several weeks, I have experienced the highs and lows of helping deliver babies in a country that struggles with some of the worst maternal and perinatal mortality rates in the world.  And it felt like I was losing the never-ending battle against them.

Some years ago my mentor, Dr. Bill, shared about his journey through the perils of trying to save the world through medical missions.  He points out the story in which Jesus encounters Simon.  After a long night of fruitless toil, Jesus asks him to help him teach the people.  Simon likely didn't need to be there, but I believe our Lord saw something that he needed to learn.  Scripture doesn't actually give us the sermon - but his message comes through loud and clear when he asks Simon to go out into the deep waters.  The waters where had just spent hours of work with nothing to show for it, where he had just failed - where he lost.  Although he was ready to give up, his response motivates me every day:

"Nevertheless, at your word I will let down the nets."

 

"Doctor, the baby's head is stuck."  Once again, I raced up to the hospital, convinced that this baby would die in those hurried moments as I made my way up the stony road.  When I arrived at the delivery bay, I saw a nurses clutching the body of a baby in her arms, the head still inside its mother's womb.  Without any antenatal care, this breech (feet first) presentation had not been detected until the mother arrived at Kudjip ready to deliver, with the baby being partially born immediately after she laid on the delivery bed.  As I worked to relieve the obstruction of the head, I felt the body in my arms grow limp.  After what felt like hours, the baby's head delivered and its lifeless form lay on the bed.  I wanted to cut my losses then, to give up - to clean my nets.  But there was a slow, faint heartbeat still.  Seeing an opportunity to teach newborn resuscitation (but without any real hope), I instructed our nursing students in doing CPR for this baby boy.  In a minute or two, that heartbeat was a little stronger.  I placed a breathing tube while a small spark of hope nestled in a corner of my heart - the corner where so many fizzled out in the past.  But the baby "pinked up", began to move, took his own breaths and tried to cry.  A short time later, we removed the breathing tube and that baby lay resting comfortably at its mother's breast.  A couple days later, they went home to his big sister who had been eagerly waiting for him.

As I make my way through our maternity ward every morning, I must choose to let down the net.  There are days that it remains empty, when it seems like it will spoil.  There are days when perhaps I haven't pushed out far enough into the deep.  Nevertheless, there are days when when it nearly breaks with the new lives that we are part of bringing into the world here at Kudjip. 

"Never again the shallows.  Never again the same."
-Bill McCoy

Hearing the brokenhearted

"He hears the brokenhearted

He binds their wounds"

-Estherlyn

Not for the first time, my vision blurred as I examined the patient in front of me.  This baby, less than a few hours old, appeared healthy.  Pink skin, good muscle tone, breathing well, crying strongly.

It was the crying that went to me and brought my own tears, clouding my vision.  I knew what this child couldn't yet comprehend - that she would never know her mother.  Only a few minutes prior, I removed the breathing tube I had inserted in our attempts to resuscitate her, and helped prepare her body to give to the new grandparents.

"Josephine" had delivered her baby at home.  After the delivery, as her father explained to me, she bled heavily and simply wouldn't stop.  She collapsed, and the desperate family scrambled in the early morning hours to find someone with a vehicle to bring her to Kudjip.  When they arrived, our newest doctor, Matt Woodley, and I saw them carrying her limp body onto one of our exam tables.  An anxious relative walked in behind her, with a new baby bilum over her head.  We attempted CPR and placed a breathing tube, giving medicine to try and restart her heart but she likely had died before ever arriving in our hospital and I couldn't bring this baby's mother back for her.

Josephine on the left behind curtains, her mother and baby on the right at bed 4

USA Today recently ran an investigative article looking at the maternal mortality rate in the US, bemoaning how high it is and highlighting a few stories from the 700 cases of mothers who died around childbirth there last year.  The piece makes for compelling reading, a call for action on the "abysmal" safety of delivering a baby in the US.  But it also captures something else ... the impressive ability of our human condition to focus on us ... our country, our people, our problems and what we can see.  What it neglects is the tragic reality the rest of the world faces - that becoming a mother often truly represents the most dangerous thing for a woman to do.  The reality of orphans around the world, crying fruitlessly for their first feed at their mother's breast.

“We’re not talking about a Third World country, we’re talking about us, here.  This shouldn't be happening here."
-Trainer, The American Hospital Association

Josephine's grandmother watched attentively through muffled sobs as I examined her new granddaughter.  She said that another woman in their tribe recently had a baby and could breastfeed this hungry child.  Her father was already helping some of her brothers to lift Josephine's body back into a vehicle that would take her home for burial.  In less than thirty minutes their grief and struggles became the overwhelming reality that swallowed the heart of this medical missionary.  Then she disappeared out of sight again, back to a family that is tragically all too familiar with this kind of loss.  And much of the world could care little less, only occasionally remarking on depressing numbers.  Numbers that it has somehow chosen to accept as inevitable for orphans in the "third world."

"Crying is all right while it lasts.  But you have to stop sooner or later, and then you still have to decide what to do."

-CS Lewis

For nearly five years I have absorbed some of the challenges of the PNG highlanders whose crumbling health services remain conveniently shadowed in the remote jungles of this Pacific island.  But as many as I can touch, help, suture and resuscitate I know that there are important ways to move upstream.  For me, teaching is an important step in this process.

During our last furlough, I became an instructor for a course that teaches practical obstetrics skills in an effort to curb the suffering of mothers and babies in childbirth.  In a few weeks, a team from In His Image in Tulsa, Oklahoma will join me in conducting the first of these courses here in Papua New Guinea.  We are aiming to teach staff from many hospitals throughout Papua New Guinea during the PNG Medical Symposium.

While I trust that skills we teach can make a difference in the lives of mothers throughout Papua New Guinea, my other prayer is that we could raise the awareness of their struggle.  A struggle shared with mothers around the world who deliver babies in surroundings that have no access to services that are often taken for granted in other places.

While I look to teach others some skills to make a difference in these women's lives, I hope that those challenges may one day catch the attention of a world sometimes spinning too fast to take notice.

-----------------------
Update
-----------------------


In the last 2 weeks we have hosted the first 2 ALSO courses for Papua New Guinea physicians.
What a privilege to be part of the Society for Rural & Remote Health and to meet and
work with great doctors who want to make a difference for the mothers and babies
of rural Papua New Guinea.

A day's work

Typical queue outside the hospital in the morning

Many of my blog posts focus on a particular patient's story – one that captures and speaks to me. I hope that those stories bring a fresh perspective to those who read about them. But I recently came across the journal of another medical missionary who outlined his typical day. I want to do the same, in an effort to make “a day in the life” of Dr. Mark a little more real to those who have partnered in our journey - this amazing ministry of medical missions. Perhaps this can also help those considering a similar career for their future.

So recently I kept a log throughout my day. As a general outline, we usually get up around 6:30. I make some coffee (french press if the power is off) and usually try to sit on the swing on our back porch looking out on the clearing of the fog from the misty mountains around us. The children are up at 7 and we get them fed and Anna ready for school. By 7:45 or so I am off on a walk with Anna to drop her off at school on my way to the hospital.

Lately I have had some protected times in the morning from 8-9am to study for my upcoming tests, but I usually will see patients on a ward (Medicine, Pediatrics or Obstetrics). During this particular day I saw patients on our pediatrics wards with a variety of childhood ailments ranging from heart disease to pneumonias to diarrhea and malnutrition. After ward rounds, about 9am, I go to the hospital's out-patient department (clinic) and see patients there as well as covering the emergency room or delivery ward.

On this particular day, after ward rounds, I saw cases of:

Pericardial tuberculosis, tetanus, severe asthma requiring IV aminophylline, typhoid fever, a follow-up of pneumonia in a pregnant HIV patient, an undescended testis in a 4-year-old which I confirmed with an ultrasound examination, hypertension, a follow-up of a supra-condylar fracture in a child I reduced and splinted the day prior, splenomegaly from portal hypertension caused by congenital hepatitis B infection, and a bronchitis in a patient with hypertension. 

It was then time for a meeting with the provincial malaria officer to discuss a case of artemether-resistant malaria I picked up in a young boy living in a remote part of the province. We needed to organize a community outreach to confirm any additional cases and put plans in place to deliver bed nets and alert the national malaria control program. I also met with our provincial TB officer to talk about staff from WHO that were planning to come to our province and conduct a survey of our TB patients.

I went home for lunch with Esther, Levi, Lucy and Gabriel – Anna takes her lunch at the school. Lunch breaks are great ... an hour every day that I can take just a 5-minute walk to escape the pressures of the hospital and see my family. I know that if I were practicing in the US, the odds of getting lunch with my family would be pretty slim, and I'm grateful to have that chance here.

In the afternoon I was back to the clinic to finish a busy day, including cases like:

Gastroesophageal reflux, vomitting in a newborn, a 10-month old with pneumonia, osteoarthritis in an elderly lady, and then a summons to the delivery room to assist with a severe shoulder dystocia that needed very involved maneuvers to deliver – thankfully after resuscitation efforts both mother and baby survived, then back to clinic for a forearm fracture in a 6-year old, persistent diarrhea and weight loss secondary to enteric fever, a new supra-condylar humerus fracture needing reduction and splinting, carpal tunnel syndrome, rheumatic fever, a 12-hour old foot laceration, a child with nephrotic syndrome and finally a young woman who likely had infertility from polycystic ovarian syndrome.

About 10-12 pediatric inpatients

10 clinic patients in the morning and two meetings with provincial disease control officers

12 patients in the afternoon along with a severely complicated shoulder dystocia delivery

Every day at Kudjip is different. Each one brings its own challenges and rewards. Each one is tiring. But each one holds work that needs doing and, often, a patient that needs special care and prayer.

It would be impossible to capture one day and call it typical. But for those who would like to imagine what medical ministry looks like at Kudjip hospital, perhaps this can provide a glimpse into it.

“Throw away, in the first place, all ambition beyond that of doing the day's work well.”

-Sir William Osler

Kindly light

"Lead kindly light, amidst the grey and gloom

The night is long and I'm far from home

Here in the dark I do not ask to see

the path ahead, one step enough for me"

-Lead kindly light

A couple weeks ago I walked into our pediatrics ward to begin my morning rounds.  A new patient and her parents awaited me on bed 10.  Maria had recently been taken for surgery for a possible abscess in the back of her throat.  Her surgery revealed very little, if any, infection there - but her neck still tightened and she complained of difficulty swallowing.  After examining her, I adjusted her antibiotic coverage and IV fluids, moving quickly on to dozens of other patients that needed my help that day.

The next day I saw a note from the on-call doctor who had been called to see Maria because of a "fit" - which turned out to be a muscle spasm, commonly encountered in one of the diseases I've seen working here in Papua New Guinea and have grown to abhor - tetanus.

Over the next few days, Maria's body contorted itself in frequent, uncontrolled spasms - through which she remained conscious and alert but paralyzed.  She could not eat or drink and pain etched itself more deeply in her young face.  I remembered Lesley whose drawn out battle with tetanus ended when the spasms and subsequent paralysis overwhelmed his breathing and he died.

In a hospital with ventilators, the treatment of tetanus is difficult but largely successful.  The patient is put on a respirator and strong medications given to halt the spasms while antibodies are given to help clear out the infection.  Here, we haven't been able to get the antibody treatment supplied for a while and we have no ventilators.  So we focus on "supportive" care - an IV antibiotic against the Clostridium organism, IV fluids for hydration, medicines to decrease the spasms - balanced against the need to not completely tranquilize the patient and halt their breathing.  We also place the patient in the darkest room we can contrive, blacking out windows and minimizing stimuli which are known to trigger spasms.

Several days into this treatment, I entered Maria's room where her mother typically slept on the floor next to her bed, to avoid touching her and triggering the illness.  As my eyes adjusted to the tiny ribbon of light allowed through the side of her window I noticed that Maria, who had each day been lying on the bed, was now sitting up slightly in her mother's arms.  She forced a weak smile on her face and after I reviewed her IV drip and medicines, glanced at her mother who asked me a question that inspired this post:

"Em i askim inap i go autsait na lukim san"

"Can she can go outside today for a few minutes to see the sun"

In the darkness of that room, the tears that instantly rimmed my eyes were hidden, but my breaking voice choked out, "yes."

Often my patients are looking for a glimmer of hope in their struggles.  A kindly light to lead them out of utter darkness.  Sometimes that little hope goes against all medical reasoning, but I believe it is no less crucial.  Maria's question taught me this in an instant.

"Each stumbling step where other men have trod

Shortens the road leading home to my God."

The next day, Maria's mother told me she was so happy to be outside that, despite having another fit in her room, she relaxed enough to eat a small amount.  Over the next two weeks Maria waged war with tetanus - occasionally being thrown into muscle spasms, occasionally glancing at the ribbon of sunshine in her room, kindling hope and gaining strength.

After a month in the hospital, I finally put my pen to Maria's chart for the last time - not to sign her death certificate as I so often do, but to write her discharge order to go home.  

Through a rough and stumbling road in that darkened cave, the Light had brought her home at last.

Risen indeed

On this Good Friday, I made rounds in the hospital on the pediatrics ward, tending to about thirty children with ailments ranging from HIV and malnutrition to pneumonia and diarrhea.  As the on-call doctor, I also checked the other wards, emergency department and labor & delivery unit.  In the bustle, a nurse summoned me to the medical ward to assist with a patient who had just arrested.  I recognized him as a young man I admitted to the hospital a few days ago for a central nervous system infection of unclear cause.  Over the last couple days his condition worsened and although we eventually identified the tuberculosis in his spinal fluid, our interventions were too late.  As we gave medications and attempted to restart his heart and breathing, his brother looked on.  After several minutes, I instructed our nursing staff to stop their efforts and told him, "Em i dai pinis" - "He is dead"  He collapsed onto his brother and wailed in grief.

To lose a patient, a young man perhaps half my age, on the same day that I remembered Christ's own death and suffering on our behalf made me ponder how much further we have to go in order to see His completed work in our world.

After checking on our nursery, I went to the emergency department to see a baby of four months struggling to take breaths with a low pulse - barely alive.  The baby was born at Kudjip in December and was diagnosed with multiple congenital abnormalities affecting the brain, heart and other systems.  Although the mother knew her son would not live long, she lovingly cared for him until Friday.  I counseled and prayed with her, and tears flowed freely as the pain of her son's death sank in.  I was struck by her example.  That she spent every day for months in a bittersweet reality of enjoying this life but knowing it was coming to a steady end.

In the book of John, after Christ is crucified, Mary goes to visit the tomb in which his body lay.  Seeing the stone removed she quickly tells the disciples.  After seeing that their friend's body has been taken away from them, they return home.  But Mary chooses to endure the grief.  She remains in the garden, weeping. 

Why did she stay there?  Jesus was dead.  The disciples left.  Even the body of her Lord was gone.  Why remain in a place where reminders of loss, tragedy and grief surrounded her?  This moment in scripture has powerfully shaped my ongoing work in the rugged highlands of Papua New Guinea.  I think that Mary gives us an example, like my patient's mother, that God may use the times that seem  darkest to make even small lights appear bright.  Because of Mary's willingness to simply weep, she became the first person the risen Christ chose to reveal himself to.  Perhaps God wants those who suffer to endure those times of loss because it highlights the Resurrection.  Not to minimize the suffering - but to contrast it against a sharp relief of hope.

On this Easter Sunday, when I celebrate a risen Christ, may the dark and empty places in my world not frighten me away.  Instead, may they foster in me a patient expectation for the resurrected Lord.

Phantoms

"May it be an evening star

Shines down upon you

May it be when darkness falls

Your heart will be true

You walk a lonely road

Oh! How far you are from home"

May it be

At about 3:40 in the morning on Monday I got a call from a medical student visiting Kudjip about a patient in the Emergency Room who needed prompt attention for a hand wound sustained during domestic fighting.  Just as I hung up the phone, the ground started to shake.  Several minutes later, after taking shelter with the kids under a sturdy bed, I went up to the hospital.

After clamping some arteries and stabilizing the hand for later surgery, I got breakfast back at the house and then returned to the hospital.

After a few minutes a nurse asked me to come to the ER to evaluate a child just brought in.  When I arrived at the bedside it was obvious the child, a boy of about 5, had passed away some time before.  His mother was upset but alongside her grief she wore a face searching for answers.  In fact, the reason they came to the hospital was not to get care, but to ask, "why"?  What had caused her baby to suddenly stop breathing and die so suddenly?

I could have given many answers.  He had a distended abdomen - perhaps there was a congenital malformation that caused an intestinal rupture.  Perhaps there had been an unknown injury that worsened in the night.  From a big picture, the absence of routine well child care and preventive services could be to blame.  Ultimately, why would any child of 5 die, other than the lingering effects of a fallen world still groaning for its final redemption?

But what that mother really wanted, I think, was for her child's life and death to have a reason.

Throughout that week we heard news on the quake.  A strong 7.5 on the Richter scale that hit west of us with reports of homes being swallowed in avalanches.  Much of the international news media covered the quake for a day or so before quickly moving on to other topics.  After the initial "unconfirmed" death toll it seems that, sadly, the lives of those affected by this catastrophe will resume being "invisible" in their struggles to most of the world.

"How many are sicker ... of whom, the first takes knowledge, is the sexton that buries them, who buries them in oblivion too!  For they do but fill up the number of the dead in the bill, but we shall never hear their names till we read them in the book of life with our own"

John Donne

Wasana Village, Photo MAF

My mentor, Dr Bill, wrote a book some years ago titled Until We All Have Names, chronicling the stories of just some of the thousands of patients he has seen.  Stories and lives that have no birth certificates, no forms of identification, no accolades other than the powerful testimony of lives colored by incredible endurance.  As a hard world went by, like those who were swept away last week in numerous avalanches, they made no headlines.

I used to think my blogs and stories from this mission hospital represented a battle against this anonymity - that I could give names to the people that much of the world saw only as phantoms.  But I think I understand things differently.  Each of them has a name, a purpose, a reason and incredible value that may not be fully known this side of Heaven.

When the night is overcome

You may rise to find the sun

So while the world takes a fleeting glance at an earthquake in one of its remote corners, numbering the dead briefly, we press on trying to know and, at times, bring healing to those whose names will one day be accorded their rightful place.

A patient evacuated to Kudjip by MAF from the earthquake area

Black and white

“I used to think I needed all the answers

I used to need to know that I was right

I used to be afraid of things

I couldn't cover up in black-and-white”

Thanks to the generosity of an individual sponsor, for the past five weeks I have been able to study courses at the London School of Hygiene and Tropical Medicine. This represents part of my ongoing work toward getting a Master's in Public Health there.

The experience exceeded my expectations. Those at the School emphasize providing realistic public health care in settings of conflict or development – things that I feel complement my work in the hospital at Kudjip.

But for all I have learned I feel that my perspective has been unique. As the eighty-plus students around me take notes and the well-versed professors give insight into challenges I have personally faced the past four years, I am periodically drawn to look out the windows. My mind wanders back to my exam room, the delivery unit or the TB ward at Kudjip. I see clearly the faces of patients whose earthly burdens I've witnessed. Many seem so far removed from the walls of my school that my heart breaks – wondering how many have lost their earthly fights in my absence.

I am a life-long learner and I love black-and-white answers. Perhaps that is part of the reason the Lord put me in Papua New Guinea. Things so rarely declare themselves in black-and-white and the answers are even more complex. Perhaps he needed me to let go of that mindset.

I believe my studies will help me, and help those who come to Kudjip for care. More than that, I believe they have shown me that, even surrounded by the high ranking public health minds of academia, the most valuable contribution I can make as we serve in PNG is to truly care for and love those that put their trust in our hands. To consider how I can go “upstream” and make bigger impacts, but never lose sight of those individual faces.

“So I just want to look

a little more like love.”

-Ben Rector

Joly ol' England

Our crew just arrived in the UK this morning to visit with Esther's family for 5 weeks before returning to Papua New Guinea in February.

We are so grateful for those who came to hear about our work in PNG and who have joined our team in bringing hope and healing to the highlands there.

In the next few weeks we plan to connect with Esther parents, brother, sister and in-laws as well as her church family at Long Crendon. We are staying with Esther's family in a beautiful village called Studley Green. I will also be attending classes on Wednesday, Thursday and Friday each week to continue working on my MPH through the London School of Hygiene and Tropical Medicine. I'm excited about this opportunity and have already felt like my studies enhance my work at Kudjip.

Thank you again for being part of our journey!