Professionalism

This is just a quick story about a patient encounter. Many if not most of the patients I saw on the largest Micronesian island of Weno had type 2 diabetes. This is largely a disease of obesity.



Now I am a healthcare provider and I’m a professional. If you come see me I will treat you with respect and do my best to provide quality care. But I am also a human being. To see woman after woman come up to my table all in varying degrees of obesity, and to have them laugh outright when I explain via translator that they need to lose weight was in some sense, well… comical. How outrageous that must have sounded to these island people coming from me.



One woman who must have weighed close to 400lbs approached my table. As with all those like her I had seen that day I wondered how the rented plastic lawn chair I had setup for patients could possibly hold her. Well, this time it didn’t.



About 30 seconds in to the encounter the chair made a loud cracking sound and the legs broke. Everyone in the room stopped to watch the woman fall (rather gently) to the ground with the crumpled chair beneath her. Someone later likened the scene to when Disney’s Bambi ventures out onto the ice, loses his balance, and his legs all go out in different directions.



I did my best not to laugh, helped the woman up, and gave her a new sturdier seat. But hey professional or not, let’s face it that was pretty damn funny.


--pete

FSM a hard day's work

This is my second off-boat experience in Micronesia. The destination is one of the “outer isalnds." The population is 700. No I didn't forget a zero there. We pull in to a crumbling concrete dock next to a beautiful, simple seaside church. Our clinic is again at a school, this one smaller than the last and having only 4 classrooms. My job today is not to be a provider but to work as a military corpsmen. I will take vital signs (blood pressure and pulse) from all the patients seen in the clinic. There is a navy corpsmen Ray working with me. I am actually looking forward to this, as I won’t be under any pressure to make any real decisions about patient care. It will be sort of a break for me.



The day drags on. After checking in what seems like 100 or so patients I check my watch and it is only 9am. Luckily the weather is cooler today and I sweat less. Many of the locals bring me fresh coconuts (which are delicious) and that helps me through. Also local women have prepared lunch for us. I avoid the fish and chicken but try the breadfruit. It looks delicious but it’s not very good. And so I make it through the day, having seen roughly half of the 400 patients that came through the clinic.



It surprised me how good I felt after having put in a hard day’s work. This was in stark contrast to how I felt after many of the days where I worked as a provider seeing patients for their medical complaints. Today I had a straightforward job to do and I did it well. I could see the line of patients waiting and I made it through all of them that were checked in. With each customer I had the sense that they would go on to receive good care from our team of providers. I had time to pause and look around. I took breaks to eat coconuts. I saw the Navy’s band play while the people danced. It was very satisfying.



I can’t help but wonder if this situation parallels the differing stereotypes of people entering medical school and those leaving it. Medical school applicants are characteristically excited, idealistic, motivated to learn, and very much wanting to help and make a difference. Meanwhile many (but by no means all) physicians are callous, weary, and well downright negative about things.



Maybe the work of being a physician is just plain tough. Maybe the long hours and eventually take their toll. That’s probably true, but maybe it’s something else. Maybe when the buck stops
with you and you are the one making the decisions that constitute a person’s healthcare that takes its toll on you in other, subtler ways. It’s a goal of mine to figure out what the subtle ways are so that I can avoid their effects and maintain my naïve premed idealism.



We are advised in med school to try and distance ourselves from our patients. “You can’t take your work home with you” they say. I think the culture of medicine does a pretty good job of making this so. Doctors don’t experience all the pain of their patients. They don’t wait for hours in a clinic for a quick 10-minute visit. They don’t lose sleep at night over the results of an HIV test. Well actually though sometimes they do.



Each patient is a challenge. That premed in you wants to save the day for that patient and give them the best care possible. But that’s tough to do. On the medical side it’s tough to remember all the questions to ask, all the signs to look for, and all the ways to treat it. Then on the practical side you are limited by the resources you have at your disposal and that the patient has access to. In the US, will the insurance company pay for this MRI? In PNG, can we get this woman onto the boat to get an Xray?



--pete

Genetics and Happiness

As soon as these two came in to see me, I was searching my memory for pediatric and genetic syndromes. When I asked what is wrong, the mom replied “oh she is fine, she is a happy girl.” The mother was the one with complaints of GI upset and musculoskeletal pain.

After addressing those problems, I switch gears to talk about her daughter and find out that the child is being well taken care of, meeting milestones slightly delayed but progressing well, is eating well, and interacting with others. She was such a beautiful girl, smiling at me from across the table. She was curious, inspecting the stethoscope as I listened to her heart and lungs. Her dexterity is limited to pincer grip on account of her fused fingers, nonetheless, she seems to do just fine with some adaptions. Throughout the exam the child was interactive, smiling, and happy as any other.

My first guess (and without the luxury of further testing or a textbook reference) was a genetic defect called Treacher-Collins Syndrome, also known as mandibulofacial dystocia (meaning multiple cranial and facial developmental abnormalities). Initially i thought this because of her macrocephaly (large head) and proptosis (bulging eyes), but that doesn't really explain fused fingers and toes. On further review back on the ship I'm thinking more along the lines of Apert Syndrome or acrocephalosyndactyly [read: hand and head bone fusions]. This is very rare syndrome (occuring de novo in 1 in 650,000) most often caused by a mutuation of immunoglobulin FGFR2 (fibroblast growth factor receptor 2), which maps to chromosome bands 10q26, and when altered and upregulated, leads to developmental increased bone matrix formation and premature ossification. The hand fusions create mitten-hands (or syndactyly) are easy to see as pictured, but there is also synonychia (or fusion of the nailbeds), and shortening of the humerus. Developmentally when we think of the bones and fissures of the cranium (like plate tectonics of the earth -- think in reverse chronology of the continents now moving towards Pangaea) fusing too early (remember the soft spot [ie. fontanelle] of a baby? that is a gap of the coronal cranial plates prior to their fusion, which allows the skull to grow in proportion to the developing brain--you wouldn't want the brain box to close while the contents are still expanding) we see the evidence of this in the morphology (shape) of the head. If premature closing does happen of some of the fissures, the growth of the brain causes expansion in other directions (usually of the unclosed fissures) which causes macrocephaly [read: large head] in one dimention (in this case coronal sutures probably fused first) and sometimes associated proptosis or exopthalmos (eye bulging) as there are actually 7 bones that fuse to make up the eye sockets.

I pontificate and regurgitate all of this into text simply out of curiosity. I wasn't able to give the mother a name to her daughter's diagnosis at the time, nor am I positive this is correct. In a lot of ways it doesn't matter. In the US, this child would be followed by multiple specialists from neurologists, surgeons, geneticists, pediatricians, ENT, opthamologists, dentist, orthopedist, etc, etc. Here she has only the family doctor that she hasn't seen in the last year or two. But sometimes its not about fixing every problem we see, taking every child and making them look and funciton like every other child. We could not dream to be able to provide such services and long term care to her, we simply will not be in PNG long enough, or have the resources to do all that would be done in the states. But we have to remember what is MOST important. For this girl a happy life with a supportive family and community is the best prognostic indicator that can be assessed. Her hope relies on the smiling faces that surround her rather than serial intercranial pressure monitoring or ventricular shunting surgeries that could be done.

Often times we see these children and think to ourselves in horror, “how horrible!” ...And it's true, it is a tough lot that was given her, being different from her peers. But she is in so many more ways more similar than different. Her metal abilities and cognition are delayed but likely positively affect her level of happiness. Its hard to look past appearances in life, and see through our first impressions. The outside world can be cruel and difficult, but this girl is growing up in an incredibly supportive and loving family that takes excellent care of her. She is luck to have such great parents, and they are just as lucky to have such a sweet little girl. I was so happy to see her today, to know that her mother was not embarrased to bring her into public, to know she is being well cared for, to see that the child is happy and interactive, to have gotten to know these two for the brief time that I did.

At the end of the physical, I was left with a dilemma. There are times when you don’t know what to prescribe. For me this happens quite a bit, but often I can pull out my pharmacopedia or Sanford antimicrobial guide and get a professional opinion. There are other times when there is nothing you can prescribe to make things better. This was neither of those times. This time it was a sour apple and watermellon Jolly-Rancher candy, which brightened this beautiful girl’s day.


Bon Voyage,
~Nic

On thoughtlessness

I didn't know what to blog about today, so I'll just write some random stuff about Micronesia that pops into my head.

There were a few times when patients needed to be referred to the hospital for follow-up care. The only hospital the people (on the islands we visited) have access to is the Chuuk State Hospital. Well, as it turns out, most of the islanders don't like going there for various reasons, but the one that struck me the most is fear. More than one person told me "My aunt went there for [appendectomy] but died from infection." And so they're afraid of dying too.
Now, I don't want to make all my posts about sad stuff, but that right there is pretty tragic. If the people are afraid of their own health care system, how can they be expected to seek care when they need it? I guess the answer is, they don't.

(right: unrelated cute picture to lighten the mood.  He's wearing the caution tape they had put up around the pharmacy to keep people from walking in)

Our Micronesian berthing-mate tells us that Micronesia is losing a lot of its population to Guam, Papua new Guinea and Hawaii. Something like 1/3 - 1/2 of the young adults are leaving to find ways to make money elsewhere, so they can support their families back home.
His own 2 oldest sons are in the States right now, but he tells me they haven't been sending money back. I wonder how common that is. I'm sure it's difficult to be an immigrant in a new country, and to make enough money to be able to support yourself and send money back home. If you are in that situation, would it be right to spend money on booze and living a comfortable life? How much is a countryman obligated to sacrifice himself for the poverty of his homeland... his family? I don't know what I would do, so there's no way I can make any judgements about it.

Oh, and there was a cool crab walking around. There's a surprising number of animals walking around some of these villages.  There's a picture of a Nic playing with a pig somewhere, but I couldn't find it.

(right: a crab.  Could be a coconut crab.  They eat coconuts.)

That's it.

-ryan

First time out in Micronesia

It’s day 9 of 12 at Micronesia and this is my first time off the boat. I actually haven’t even been outside in 4 days. The water is glassy and calm. The launch is nothing like PNG. We easily climb aboard a series of small (10-person) locally chartered “water taxis” which apparently are the mainstay of transportation in this area. There are 2-person teams to drive each boat. One sits in back steering and managing the twin Yamaha outboard motors. The other stands in the bow area holding a rope. I could never get an answer as to why they had a guy standing up front, but it did make for quite an interesting scene. For some reason it totally reminded me of all those old paintings of George Washington crossing the Delaware. And so we set out in a way that only America could.



We pass several islands on the way out. You can see small seaside huts or shacks dotting the otherwise undisturbed tropical landscape of beach and palm trees and steep volcanic hills. We pass some seaside caves where the Japanese hid during WWII. There are at least a few totally uninhabited islands, that would taken about 10 minutes to walk around on foot.



We pull up to a small concrete dock with a rotted out building frame that looks kind of like a greenhouse without the plastic. The water is ankle-deep and there is coral, rock, and seaweed everywhere. We unload the boats, passing the gear along a chain of people, and we are here. America is here. On shore there are perhaps a dozen 10x10 shacks made of tin nailed to a wood frame. There is a small graveyard with just 5 prominent mausoleums. Except for clothes hanging out to dry on one of the shacks this area doesn’t seem to be inhabited. 50 yards inland and we are in a grassy clearing half the size of a football field with an L-shape of simple concrete buildings forming 2 of the sides. This is a school and a schoolyard. There are about 6 or so classrooms, of about the same size one would expect in the US. There are large windows with wire mesh instead of glass, a decent amount of desks, and some rather filthy chalkboards. The only books to be found are a shabby looking pile in one of the rooms. We setup our various medical services in each of the rooms and it’s game time.



The weather today is hot. I tend to sweat a lot and it’s just outright embarrassing now. My shirt is soaked and I am just dripping all over everything. My body would adapt to these conditions if I kept living in this climate, but that doesn’t do me any good today. I unzip my REI convertible pants revealing my khaki dress socks and black shoes underneath. It’s a look that only really cool, yuppie white guys can pull off, and that’s definitely me. That’s the “doctor” these people get to see when they come to my table.



My most interesting patient of the day is my first. His complaint is “neck mass”. One glace at him reveals that it is a thyroid tumor. I plead his case to the commanding officer and several iridium cell phone calls later he is scheduled to go to the boat for an ultrasound and possibly surgery. As a footnote he eventually had the surgery and so was likely “cured” of his ailment.



I’m trying to keep the cynicism out of my posts, but I can’t help myself here. Clearly this guy was “sick”. Anyone off the street could look at him from 20 feet away and know that he needed medical care, and it’s awesome that we could provide that to him. However, I saw lots of other “sick” people that day who would look fine at 20 feet, or even at 2 feet. How about the lady who has been having heavy, painful menstrual periods for the last 2 years? I couldn’t check her for anemia (the weather was so hot our lab kits stopped working) but I bet $1000 it was probably pretty bad. She looked and acted fine, except for a little weakness and being rather fed up with the excessive bleeding. She did not get a trip to the boat. It would have been hard to convince people that she was “sick”.



So I guess my point is that we probably overlook the more subtle things in people when we decide who gets more extensive medical care. I bet we do this in the states as well but probably to a lesser degree because healthcare providers are educated about those subtle signs of disease and they are supposed to have an idea of what is sick and not sick.



The other interesting thing on this island is that the people don’t get along so well. I saw several patients with scars from stab wounds. I guess there are eight or so “clans” who don’t like each other and they are constantly getting in little scuffles. That’s really not so different than my family at a holiday get together, except none of us has stab wounds to show for it… well at least not yet anyways.



During lunch I realize there is really no signs of dwellings here. I know there are no roads. There is no electricity save for the occasional private generator. Apparently the island’s 2000 residents live scattered all over, mostly concentrated on the coastline because they “like to fish” as one local told me. Realizing the implications of this I am struck with another thought. Most of the patients I have seen are well-dressed and groomed. They literally walked through the jungle to get here but they managed to look very presentable after doing so.



The only other interesting medical stuff is how common infectious diseases are here. Lots of families complain of “worms in stool”. This is probably pinworms. These are 1 cm in length. They live in the intestine, not doing much else except eating some of the nutrients that would otherwise go to their host. It is estimated that over 1 billion people worldwide have pinworms. They are also common in the US. I give out the treatment, which is mebendazole. It will kill 95% of the worms in the body with a single dose. The problem is the eggs which may have been deposited in the skin around the anus can survive for 2 weeks so you are supposed to get a second dose in two weeks.



--pete

Nightime sounds

We are in Micronesia now. There are beautiful Hawaii-looking islands all around us. A group of twenty or so local people came onboard today to work as translators. Many of them are in my berthing area. They all snore at night.



Actually that’s really an understatement. Imagine that you took a tape recording of someone snoring. Then imagine you took that recording and made 10 more variations of it, varying the pitch, frequency, and overall character of the snores in each iteration. Now imagine that you played all those tracks at once, slightly out of sync with one another. That is kind of what my bunk room sounds like at night.



Medicine provides a perfectly good explanation for this impressive nocturnal serenade. Most of these people are overweight, or what we in the US would call obese. Why is that? Well it’s the whole nature vs nurture debate. Do these people have poor eating habits? Yes they do. I’m told that spam and sausage are staple items in the local diet. But part of it is just bad luck after taking a nice refreshing swim in the tropical gene pool. If your parents are fat you’re likely to be fat too, whether it’s the work ethic, eating habits, body habitus or whatever e else that you inherit from them.



PNG-ians come from Australia. To some approximation they look like the Bushmen you’ve seen on national Geographic. They are dark-skinned with thick curly hair. Their faces have prominent brows, so much that the eye surgeons on the ship say that removing cataracts on them was like “working in a hole”.



Micronesians come from the Phillipines. They remind me of Hawaiians, who derive from Polynesians, and Polynesia is just a few more hundred miles north and east of here in the Pacific. They are big, happy island people.


OK so getting back to sleeping. If you snore at night, you probably have what is called obstructive sleep apnea. You have the right combination of anatomy and floppy tissues such that your airways get blocked when you try to inhale at night. The fatter you are the worse the problem is. It’s usually not so bad that you actually suffocate but you do go for stretches of time where you essentially stop breathing. That’s bad for your brain because it needs constant oxygen. It also sort of wakes you up every time you need to suck harder to get air and so you never really get into REM sleep. It’s because of this subtlety that you do not get restful sleep. You feel tired all day. And this in turn makes your high blood pressure, your cholesterol, and your diabetes all get worse.


--pete

Underway

When a big ship is underway a lot of things happen, the first of which is you realize you are moving. As soon as we had pulled out of the protected gulf and made our way into deeper seas, the ship began to sway, roll, tilt, and rock. This is fun at first. If you walk outside and lean over the rail (for which you get yelled at) you can see the plowing effect of the bulbous bow makes as it surges through the uneven swells of the sea, making a continuous running bow wake alongside us. If you take the time to walk the 6 flights of stairs to the top of the aft deck (a place called the sun deck, which is conveniently nestled between the two smoke stack billows) you can see the side to side rocking of the ship, with the flat tarmac of the ship crisscrossing the horizon. At other times the ship rocks and bows, with the nose digging into oncoming waves, only to rise back up again. On the open seas your visibility is directly related to how high above the water you are. Being only 60-90 feet up on the top deck you can only see about 26 miles in any direction, regardless of the clarity of skies. So you feel pretty isolated looking out hour after hour and seeing only blue water with the occasional white cap lacing.

Another thing that happens is that people begin to have more time on their hands. Without patients to care for other things can be done. The ship gets cleaned, items get repaired, folks get to rest, people interact with each other more, and they get to have emergency preparedness drills. These are silly drills where they “pretend” there is a fire somewhere or a man overboard or the ship is sinking. Someone gets on the intercom and sounds the alarm, then they narrate the event as if it were happening, “fire located on 01 floor aft side zone 6, it is uncontained and emergency crew personnel are arriving on the scene” or something to that extent. Meanwhile everyone has to put on a life jacket and muster (assemble) on the top deck tarmac. Each and every 1400+ people on the ship. It becomes a sea of ridiculous looking orange people. Then the alarm is called off and we go back to our normal business.

With all the time available underway the “Fun Boss” is hard at work making sure we have, well, um… fun. She throws movie nights on the top deck with a big projector displaying the movie onto the helo hanger. There are exercise classes (spin, cardio, abs, etc). Bingo nights complete with 1,500 jackpot prizes. Poker and dominoes tournaments. And something referred to as steel beach, which is essentially a beach party on the top deck all day long. There is the Navy Band plugged into full set of amplified speakers blaring music, several inflatable kiddie pools filled with water, super soakers galore, a basketball hoop, and bbq food cooking on the grills. It’s a great time up there. I never thought I would shoot hoops on a huge Navy ship, or kick a soccer ball around, throw a Frisbee, or sit in a kiddie pool.

On the more educational side of things, we kept ourselves busy by going to CME lectures held daily, spent time with the radiologists learning how to perform ultrasound exams, and cherry-picking interesting cases from the pathologist’s collection of slides from the trip.

Of course the more days you spend at sea, the more you are ready and restless to get of the ship and see some patients.

Bon Voyage,

~Nic

Crossing the Line

On Wednesday at 8:30 PM we crossed the Equator at Longitude 153.40 degrees (our latitude was, of course, 0.0 degrees). Papua New Guinea is now to lapping in our wake en route to Micronesia. We have been underway for almost 2 days now, charging into the blue ocean, crossing this imaginary line we use to segregate the poles of the earth.

There is an old Navy tradition of sorts that goes along with onboard equator crossings. Essentially there are 2 kinds of people, those that have crossed the equator on a ship (they are called shell backs, and those that have not—these are called pollywogs). Somehow the (its not as scientific as you might think—in 5th grade science we learn a pollywog turns into a frog, not into a turtle).

Nonetheless, once you have successfully been hazed and cross the equator you care dubbed a shellback—someone who is tough, tried, and true, knows the ways of the sea, and is a true sailor. A pollywog, on the other hand is a slimy, limey, slithery nothing, who is too afraid to leave the shallows of the mucky-muck pond.

On your virgin voyage across the equator on a ship you are eligible to join the ranks of the shellbacks. But it comes with a price. The hazing involves sitting all the pollywogs together in the m idle of the deck wearing ridiculous clothing, tying you up with ropes, making you eat strange kitchen remnants, slither around while hosed down with water, and belittling you while you are expected to answer tough maritime and nautical questions. Passing this arduous pollywog flogging you get your shell.

Fortunately today they didn’t do the hazing bit (this was reserved for the FIRST time they crew passed the equator) so I guess we earned our shellbacks the easy way—or maybe we are still pollywogs? Anyway, we didn't get one of the 11x15 poster sized certificates.

As an interesting aside, once we pass the International Date Line (180th meridian) on a ship, we get inducted into the Order of the Golden Dragon. Whoo whoooo! That's definitely going in my resume!


Bon Voyage,
~Nic

On Lingo

Navy / USNS Mercy  vocabulary, according to Ryan

MEDCAP - Medical Civilian Action Plan.  This is the name of the daily trips we take to various islands and things, for the specific purpose of helping people and/or s

aving lives.  Transportation can take various forms, but usually involves a boats and buses.  Services we provided include Primary Care, Pediatrics, Pharmacy, Dental (DENCAPS), Optometry, Physical Therapy, Women's Health.  Typical

ly we would see something like Other "CAPS" included SURGCAPS (self-explanatory) and ENCAPS (when engineers would fix/build schools and hospitals).

p.s. I suggested to Nic that we should have a "lives saved" counter on the blog.  I was not taken seriously.

(On left, a view from inside the transport a.k.a. the bus. On right, a NapoleonCAP)

VETCAP - Veterinary Civilian Action Plan.  When our awesome veterinary team would go out to help our animal friends.  Usually dogs and cats, but a lot of other interesting things.  Wallabees, alligators, cuscus, pigs, birds, etc. Wallabees, cuscus, and pigs were eaten when they are grown.

(Right: Cuscus)

Berthing - Where you sleep.  Our berthing was called "Enlisted F Berthing" and was the second floor down on the red stairs.  It could house 99 people in bunks that were in colums of three.  Pete insists that he fits in his bunk, but me and Nic are pretty sure he has to bend his knees to lay down. During some of missions, they would have nationals sleep in our berthing.  A good way to make friends in these countries, but the frequency of snoring would greatly increase during these times.  It was almost like the cacophony of lots of really large frogs.

Mess deck - Where you eat.  We would get three squares a day, every day, when we were on the ship.  Breakfast is 6-730, Lunch 11-1245, Dinner 430-530.  Miss one of the meals, you would go hungry, no exceptions.

We all volunteered for helping out serving food.  These guys work hard, and the heat in the kitchen was worse than the heat outside.  And that's saying something.

Prevmed - Preventive medicine.  I think this is the most important part of these missions.  They would go out and survey the water supply, sanitation, etc.  They would make tours through the slaughterhouses and beer factories and make recommendation.  They killed the disease-carrying mosquitos.

OIC - Officer in Charge.  During a MEDCAP, this guy was in charge.  

MA - Master at arms.  The guys with the guns.  They were in charge when things get out of hand during a MEDCAP.  They usually sent out three-four guys per team.

Muster - Where you meet every morning.  Muster would be at 5 or 530 for a MEDCAP.  Muster would be at 730 regularly.  We'd often be late for muster, in which case we were forced to read the "Plan of the day" and "Menu for the day."  

Colonel Muster - Where you meet in the dining room with the candlestick.  (Running joke).

Flight quarters - When I would get yelled at for being outside.  Apparently being around a spun-up helicopter is not the safest thing to do.  Who knew?

-ryan

My New Haircut

I went to the barber shop today. I was getting a bit hirsute in the facial department and my hair was out of control to the point where I had to buy a jug of hair gel to keep it under wraps. So you could say I was overdue for a trim. I walked in, sat in the nearest barber chair and the guy turns to me, “okay boss, what would you like?” “Just a little off the top to tame it down a bit, and the sides can be trimmed quite a bit,” I replied. He turned to get his equipment ready and I strained to get my head in the line of sight with the mirror across the room that didn’t quite line up with the chair. He started with the sides; hair was falling onto my shoulders and sliding down the drape with each stroke of the shaving shears. I strain a bit more to see the mirror—it looked great. He started making his way up to the top of my head, “hey boss, you want me to even this out for you?” He asked. I replied in the affirmative, while thinking to myself, “well, of course, I’m not really looking for a lopsided or asymmetric haircut here.” That must have been code for something that was lost in military to civilian translation because the next thing I knew he took a swift and broad stroke with the clippers in the mid-sagital plane. I couldn’t object… it was too late. A negative mohawk was created in one fell swoop. He must have sensed my terror, “is that okay, boss?” “Yeah, sure. That’s even alright,” was all I could say. He continued to mow down the rows of long hair remaining, and in doing so he rotated my chair about its axis about 90 degrees.

At this vantage point I was staring directly at a sign no further than 3 feet away that had in big block letters “MILITARY HAIRCUTS ONLY.” I couldn’t help but laugh.


In the end it didn’t look bad at all, I mean he did a good job and all. I was just taken off guard a bit. Anyway the haircut was free, like most services on the ship… I guess you get what you pay for.


Bon Voyage,
~Nic

Photos Uploaded... finally!

Finally, we were able to get enough bandwidth (0ff the ship) to upload our pictures thus far. Have at em! They are quite phenomenal. We will try and upload our pending posts as well to get you all up to speed. As an update, things are still going great, and we still cant think of a better way to spend 2 months... I mean is this real? We are getting elective credit for this, and hitching a ride on a boat around the south pacific. Epic is a word that simply falls short in describing this trip.

Gaire farewell

Again I’ll skip the medical stuff and talk instead about how the citizens of Gaire sent us off in style. We finished relatively early that day, around 3pm. As the final patients were ushered from the pharmacy and out the gates, we were treated to a dance performance in the street by a troop of local adolescent males. I don’t really know how to describe this scene except to say that the music consisted of a whistle and rhythmic grunting and it had some obvious sexual overtones. I was unable to get an explanation from anyone about the significance of the dance, so I’ll have to let the photo speak for itself.

Then we got a speech from the mayor and the local health department official, both praising the Mercy and its efforts. Next our commanding officer spoke, returning the gratitude and thanks. And once again our group was invited into the pastor’s home for refreshments. We were greeted on his porch by a crowd of women, a table piled with gifts, two trays of potato chips, and some ice-cold colas.

As we boarded the buses one last time, the mood in the village was more excited than ever. The local police cleared the residents out of the streets to make room for our vehicles. Excited adults ran up to the buses exchanging last minute words with mercy crewmembers whom they had worked alongside for the past several days. Email addresses and phone numbers were hurriedly scribbled on scraps of paper and passed through the open bus windows. People were singing. Children ran after the buses as we pulled away. People along the road waved excitedly all the way back to the port.

--pete

Inspiration from the Little Ones

Pediatric patients are the kind that can in one single instance of brilliance and simplicity brighten your day. Their naivety, sincerity and curiosity can turn any situation into a smile. They will play with you even though they don’t know your language or customs. The following are stories of the little ones:


“Mr T” was one that made you smile without him even doing anything—I mean how can you not when you are looking at a papua new guinea kid replica of Mr. T?. His mother came to the ship for surgery and while recovering he found it fit to wheel her around the ward, a feat that he was not that good at, yet he persisted. At the helm of the wheelchair “Mr. T” scooted his mom into many a table, bed, or pillar before she finally brought him under wraps. Mom said that she finally caved in and gave him this haircut because Mr. T is his hero.


The twins (in green) and their little sister (in red—that’s not ptosis you’re seeing) are a feisty lot. Their dad is a big burly guy who runs the boxing club in Port Moresby. They came to me for a physical examination to “see if it was okay for them to box.” These girls were in great health, and at the end of the exam I decided to have one final test. They each wound up and were told to take a hard swing at my shoulder the way their dad taught them to do. After the second punch I was nearly knocked off my flimsy plastic chair.


I was walking down CasRec when I saw this little girl scooting around in circles, shuffling her feet and cooing with excitement. She had commandeered her mom’s sandals and was parading on the newly waxed floor. You can’t help but stop and watch her regal procession. Soon there was a crowd of 4 or 5 of us. The picture doesn’t capture it all, but sufficed to say she is a cute one.


Sometimes the kids don’t come with smiles and excitement. Sometimes they are scared, apprehensive, guarded, and crying. You learn very quickly that the child is in control of the visit and will only let you do what they are comfortable with. Your job is to earn their trust and confidence. This is one of my favorite challenges in pediatrics. The first thing you have to do is establish trust and an amiable relationship with the parent. Ignore the crying child, and focus on the parent first. Children are smart and very observant, even when they are crying. Establishing rapport with the parents, talking with them, shaking their hands, examining them, all tell the child that you are a safe “stranger” that mom and dad are okay with. Next you address that child. Tricks of diverted attention, systematic desensitization, magical wizardry, and of course bribery are employed at this point. For example, I always show them my stethoscope and have them hold it to show them it is not dangerous. If they are old enough I ask them to put it on their heart. I’ll show them what I’m going to do first on mom so that they see its safe. I’ll give them things to hold and inspect while I hold and inspect them. I’ll show them my pen-light and shine it through the nail of my pinky finger, turning the tip an orange-pink, making an ET effect. If this fails, there isn’t a kid around that doesn’t finally crumble their outer shell to accept a nitrile-glove-balloon-man gift.


Bon Voyage,
~Nic

Hailed like gods

The last day of the MedCAP visit before we are done seeing patients or even packing up the people began to shower us with gifts. One thing that was consistent throughout every day of the MedCAPs was how appreciative and thankful the people were. Even when I could do nothing to help a woman’s breast cancer, or was baffled with the old man’s Parkinsonian-like symptoms without any evidence of Parkinson’s disease, or the child with what looked like treacher-collin’s syndrome; even when all I did was give Tylenol for a wife with lower back pain from carrying water, multivitamins and cough syrup for a child with cold symptoms, Aleve for a man with osteoarthritis of the knees, the people were grateful beyond belief. They shook my hand fervently saying thank you with a look of relief on their faces. Some of my patients came back later in the day with gifts to give me: hand-made bags, shell and seed necklaces, and even a model of a traditional trading boat called an “Abotouey,” which is their traditional trading boat previously used to trade throughout PNG (ie fish and shells for sego palms, yams, coconuts, tarro, etc). She seemed to have a bit of a crush on me. I am told that on independence day they parade around with these boats. A few of the volunteers asked for my contact information so that they could write me at home. Some came up with a pen and asked us to sign their t-shirts. Others wanted pictures with us (they did not have a camera, but wanted to be in a picture with us on OUR camera). And one girl shyly approached me as we were packing up and asked me to have her volunteer translator name tag—I gave her my American Flag pin from my shirt and said thank you. Her friends were huddled to the side of the walkway watching the transaction, giggling. We finally got everything packed and exchanged final thank-you’s as we got back in the busses. I sat in the back row looking backwards as the crowd chased after our bus smiling and waving. I can’t help but think that we were being revered higher than our credentials, I mean it sure felt like we were hailed like gods. A warm sensation of accomplishment and satisfaction glows from within. We helped a lot of people, we saw even more, and we showed a small community in the corner of the globe that we care about them, so much that we traveled this far with so many people to make their lives just a little better.


Bon Voyage,
~Nic

On International Aid

One of the obvious reasons for coming on this trip... obviously... was to provide some medical care to the people that otherwise had no access to "standard" medical care. And hopefully, the care we provide would be quality medical care that we would be proud to give back in the U.S.

Of course, I now know my expectations were too high, and my assumptions were wrong.

One typical scenario would be a patient that had been seen by the local doctors many times, perhaps even at the general hospital. Although the treatment was at times inexplicable, i.e. antibiotics for osteoarthritis, the diagnosis was usually correct. The problem is that they would come to us for help, and we would have no treatment to offer. Torn meniscus, endometriosis, hepatitis, schizophrenia, on and on. The American doctors that have come from thousands of miles away, who were assumed to be better than their own local doctors, had nothing to offer.

The other scenario is a patient with a chronic and very often serious problem, who would come for treatment. At times, they have walked for 10 hours, and stood in line since the night before to see us. Not only did the patient have high hopes, it was a lot of pressure on the provider to help someone who comes to you at such great cost.

But as it turns out, it's difficult to treat ALS or a cerebellar stroke with NSAIDS and antibiotics.

How do you, in essence, turn away a patient who comes to you as their last hope? How do I tell a patient to go to the general hospital when they have no resources or support?

Maybe one day someone will be able to come back, and really help these thousands and thousands of people that desire so strongly for relief from their, at times, treatable ailments.

But how could you really help these people substantially without a complete overhaul or even creation of a medical system? One provider couldn't even make a dent. And how can you create a complete medical system without a complete overhaul of the social and economic systems already in place?

Someone please figure this one out. Thanks.


~Ryan

The gifts we bring

The translator who worked with me all three days brought me a handbag on the last day. He said his wife made it, but I later heard rumors that many of the locals bought the gifts they gave. A handbag like that goes for $25 American. The average monthly household income in PNG is $100. As for me, I brought no gifts for anyone. To be honest I didn’t even think about it. When I was frantically packing back in San Diego, the thought never crossed my mind. For the rest of my outings while aboard the Mercy I made it a point to bring at least some small item to give as a gift.


The San Diego congresswoman Susan Davis visited the ship during the earlier part of the mission before I arrived. Apparently she had gotten many calls and complaints from her constituents who were upset that they could not get appointments because their doctors from Balboa Naval Hospital were away on this trip. She said she wanted to see for herself how American tax dollars were being spent, given that they were pulling resources away from her community of taxpayers and voters.


My point is how easy it is to lose perspective. I don’t think the naval hospital patients in San Diego, myself, or our Congresswoman are bad people. No one could fault any of us for how we acted. However, when we look at the larger view our actions seem perhaps less than noble. Maybe it’s OK to wait to see your dermatologist or to see a different one for a while if it means some people in a village in PNG can get basic medical care. And maybe it’s better to bring gifts instead of extra workout clothes and protein powder when you visit a new part of the world.


--pete

Tatana Village

MedCAP [read: Medical Civilian Assistance Program] to Tatana, day one. Tatana is a small island community connected to mainland PNG by a small land bridge not very far from Port Moresby. It is a mountain shaped island with most all inhabitants living on the water's edge on stilted houses. Interestingly there is no fresh water is available on island as such they must trek water in, a job done solely by women, hauling 20L tanks of water to and from the water tank/well. People are very close with each other, they are forced to be close, living on a small island necessitates that. So they all talk about ecah other like gossip you might hear at lunch in high school. Children flock together and play like as if a kabbutz. It is a beautiful village with a great view. The people were exceptionally nice, many of them make what money they have by fishing.
I set up shop on a table up stairs in the church hall next to the window with a view of the water and windows that let in light and a cool sea breeze. The day went by so quickly, it seemed like I had hardly started seeing patients when the end of the line found its way inside.
The next day I returned to Tatana, getting a warm greeting from the community just like before. Outside, next to the line of people looking for medical care is a group of people who needed no further healthcare... I say this because they were strong young men playing a very competitive game of volleyball, the likes of which would hold its own weight even on the sand courts of Mission or Huntington Beaches. This day my personal goal was to give everyone smoking and betelnut cessation advice. This is on top of the ergonomics, exercise, and stretching counseling I would give everyone I wrote NSAID treatment for. Ergonomics is a big problem here--the woment stay hunched over for long periods time doing repetative tasks such as washing clothing. They do so on the floor, sitting crossed-legged, leaning forward rubing the clothes inside a big bowl of soapy water in front of them. What you will never see is them put the bowl on a table so that the whole operation is at elbow level.
Later that night we tried betelnut with Sonia--it was her last night. Betelnut is chewed with much ritual. first you shuck the betelnut, exposing the seed which you can pack in your cheek. Next you grab a kava (member of the pepper family) seed pod and lick it, dip it in Lyme (Calcium Carbonate) and add that to your mouth's mixture. Once the chemicals combine you start looking much closer so someone with red paint in their mouth than anything else. The stuff gives you a quick buzz, lightheadedness, flushing, and increased heart rate--but most of all it causes you to perpetually spit nasty red looking stuff. I know its terrible for you. I saw people all day long who had dental and oral medical problems, even cancer, from chronic betelnut chewing. Nonetheless, we couldn't leave PNG without trying it once. (I understand the irony of this in relation to what I wrote in the previous paragraph) Needless to say, I'm quite sure that this was the last time we tried the stuff, it tasted like stink and left your mouth feeling like you just chewed on a piece of chalk.

Bon Voyage,
~Nic

PNG: Lost in Translation

My goal for today was to see greater than half as many patients as the ER doc I was working alongside. I was really in the flow and rhythm of seeing patients, when a man with an unusual problem came to my table. He was very short-stature, probably no more than five feet, and his body was childlike while his head was normal-sized and fully-matured. In medicine we would say that he looks “syndromic” meaning that he probably had some sort of genetic or congenital disorder like Down’s or autism. If you’ve ever seen anyone with Down’s you would probably agree that they have a characteristic look. However, since there are hundreds of these syndromes and they are tough to remember, only a few physicians whoa re experts in identifying these disorders remember them all. The rest of us just say the patient looks “syndromic.”

So anyways the patient sits down and I ask him if he takes any medicines. He does not respond, at which point the translator intervenes and tells me that, “This patient is deaf and mute,” and so he cannot speak or understand me.

“OK fine” I say. Then reflexively I switch to using the translator mode. “Can you ask him what medicines he takes?” I say.

The translator then proceeds to act out my question to the patient without using sounds, as if he were playing charades. He motions about putting things in his mouth, presumably to mean taking pills. Satisfied that he was understood next he points his index finger at the patient indicating that he wants to know if the patient takes pills.

The patient nods in understanding and shakes his head “no”.

“He doesn’t take any meds,” says the translator.

--pete

On Silence

A citation from Pathologies of Power:
"Dr. Plarr was a good listener. He had been trained to
listen. Most of his middle class patients were accus-
tomed to spend at least ten minutes explaining a simple
attack of flu. It was only in the barrio of the poor that
he ever encountered suffering in silence, suffering
which had no vocabulary to explain a degree of pain,
its position or its nature. In those huts of mud or tin
where the patient often lay without covering on the dirt
floor he had to make his own interpretation from the
shiver of the skin or a nervous shift of the eyes."
Graham Green, "The Honorary Consul"

I have often found that many of the patients in the poorest situations have been difficult to communicate with because of they would not volunteer information, would not express their complaints. I never knew if they lacked communication skills or they simple did not wish to speak or complain. In the case of non-english speakers, it could have been the language barrier.

This has also been very true in this part of the world. In Papua New Guinea, one of the pharmacists remarked about how "stoic the people in this country are." People will have suffered incredible injuries or illnesses, and will not express what I would have considered "the appropriate amount of concern." One lady complaining about a headache didn't even want to mention to me her huge draining abscess-looking-thing on her index finger. I, of course, freaked out. Her response was something like, "yea, it hurts."

Initially, I thought: I guess these people would have to be stoic to put up with all the difficulties they deal with. This includes having to walk everywhere for hours at a time, the resulting knee and back pain, not having enough fresh food available, a failed social services system, the terrible terrible heat and humidity, lack of sanitation, high crime rates, etc.
However it has come to my attention that this subject has been thought about before, and I can put it no better than the eloquence of Paul Farmer (sorry it was so long its paraphrased):

You don't have to be a doctor to know that the degree of injury, of suffering, is unrelated to the volume of complaint. I have seen the sullen, quiet faces in waiting rooms in Peru, say, or in prison sickbays in Russia.
Members of any subjugated group do not expect to be received warmly even when they are sick or tired or wounded. They wouldn't expect Dr. Plarr (from above) to invite a long disquisition about their pain. They wouldn't expect the sort of courtesy extended to the priveleged.
The silence of the poor is conditioned. To describe as stoic is not to be wrong, but rather runs of the risk of missing the great eloquence beneath the silence.
~paraphrased from Pathologies of Power

I could say something here, but I will just leave this with the power of those sentences.

~ryan

PNG Key Points

This is an excerpt from my PNG Gaire experience. I included it here because it makes several points. On my first day I saw a woman with sarcoidosis. Briefly this is a rheumatologic condition (like lupus or arthritis) that has no cure, gets worse with time, and imparts rather sever disability on those afflicted with it.

This woman was in a wheelchair. She traveled two days from a neighboring village to be seen by us. She had to be pushed along the concrete floor in our clinic so I have no idea how she made it several miles from another village.

Point 1: many patients traveled several days and/or waited in line for many hours to be seen, but not a single one of them complained.

She had her medical record with her. She had been given the correct diagnosis at Port Moresby hospital. I thought she had received the correct treatment with prednisone, but the dermatologist in our group said methotrexate was better. The dermatologist showed me the relevant physical exam findings for this disease and then she took photos of the woman. These were to show the dermatology residents she taught back in the US, most of whom would never see a live patient with this disease in their 8+ years of medical training. The dermatologist did some education for the woman about her disease, left several therapy recommendations in her medical record, and sent her on her way.

Point 2: Many of the people here had a small notebook that had their medical history in it. This aided greatly in helping to get their story right, and (I think) it sometimes helped to move their case forward because we could leave recommendations from our experts for therapies that local doctors could carry out.

So in the end we didn’t do much for this woman except to give her information about her disease and to facilitate her getting the optimal therapy for her terrible illness. She thanked us and left with a smile on her face, ready to set out on her multi-day journey home.

Point 3: The people of PNG were so grateful for whatever we could do for them. No one complained, not even once. And many of them brought gifts which they gave at the end of their encounter to their providers.

--pete

Koki Village, PNG

Medcap to Koki village, my first trek into PNG. What nice people they have here. Everyone is very nice, appreciative, and giving. We were greeted with cheers, USA chants, and a seemingly endless line of smiling faces and waving hands. It was like driving through a gauntlet of people. We wound our way up to the top of the small hill to the church which was set on the top of a rocky purchase that dropped off into a small cliff down to the beach below where plenty of stilt houses stood. I worked side by side with the captain in charge of the sight, which was a great experience because I could curbside him with a quick question whenever one arose. Had my first real MRE today for lunch, and shared it with the translator. All in all it was a great day. At the end they gave us gifts of a hand knit bag and a shell necklace. This is why I came half way around the world, for this experience, to exchange handshakes with people from a different culture and do my best to help them as best as I can, getting a crying baby to smile, or maybe improving their lives on occasion.

Bon Voyage,
~Nic