The Voyage Mercy

Professionalism

2008-09-16T17:34:00.000-07:00

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

2008-09-15T07:49:00.000-07:00

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

2008-09-15T02:53:00.000-07:00

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

2008-09-14T17:07:00.000-07:00

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

2008-09-14T07:27:00.000-07:00

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

2008-09-13T07:13:00.000-07:00

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

2008-09-12T13:54:00.000-07:00

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

2008-09-10T21:28:00.000-07:00

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

2008-09-08T01:21:00.000-07:00

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

2008-09-03T22:37:00.000-07:00

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!

2008-09-03T21:02:00.000-07:00

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

2008-09-02T23:35:00.000-07:00

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

2008-09-02T17:18:00.000-07:00

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

2008-09-02T17:09:00.000-07:00

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

2008-09-02T16:44:00.000-07:00

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

2008-09-01T02:28:00.000-07:00

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

2008-08-31T21:52:00.001-07:00

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

2008-08-30T02:33:00.000-07:00

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

2008-08-29T02:40:00.000-07:00

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

2008-08-28T02:23:00.000-07:00

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

2008-08-27T21:53:00.000-07:00

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

Gaire lunch break

2008-08-27T02:09:00.000-07:00

Today is more of the same, so I'll cut to the chase and talk about my lunch break. The local women have made food for us at the pastor’s house. I am let out of the fence around our church basement clinic by armed policemen. I cross the street, and go up the stairs of an oceanside house made of sturdier material than the other homes in the village. There is a huge porch in back on the beach and another in front facing the church. There is a spread of food out on the table with many women in floral print dresses offering me food. I pass on the more exotic foods and head outback to enjoy my MRE (meal ready to eat, see prior post).

The view is spectacular. It’s no less beautiful than the waterfront I’ve seen in California or Florida. Dozens of kids play on the beach below. They again perform antics when I take pictures of them. Foolishly, I ask one of the women where the bathroom in the house is. After some confusion is resolved, she points outside.

There are makeshift walkways extending into the ocean, about every fourth house. I had seen these before but just assumed they were docks for getting a better view of the ocean or for pulling a boat up next to. (Go ahead and look at the picture up above and you probably thought so too.) But upon closer look, I saw that that at the end of each was not a boathouse but an outhouse. I watch for a minute for the next customer to arrive. A woman goes in, and a minute later something drops out of the outhouse and into the water below. Not even twenty feet away is a group of 3 children running naked playing in the ocean.

I remember a patient from that morning. It was a mother claiming that every time her 3 children go swimming they get an ear infection. Good thing I gave her antibiotics.

I walk back through the house and the women on the front porch have broken out into spontaneous song. The sound is truly magical. They are harmonizing and singing in counterpoint. Invigorated I head down and finish seeing patients for the afternoon.

--pete

The Numbers Are Staggering

2008-08-26T05:35:00.000-07:00

It is striking how loving and appreciative the people of Papua New Guinea are. As we get near to the MedCAPS [read: medical civilian assistance program sites] people from all around begin to line the streets, some are locals, others travel for miles—usually by foot. They are waving, smiling, even running with the bus. It is the biggest event that has ever happened for these communities in quite some time. They have seen our huge ship in the middle of their harbor, anchored in the deep water with boats constantly transporting us back and forth, and now we are finally here in THEIR community.

There is a palpable excitement that is contagious throughout the community, from the children to the elders. As we get closer to the site (usually a church, school, or public building) a line materializes amongst the crowd that is as much as a few thousand people strong. When I first saw this I looked around the bus: 10 doctors, me (a med student), 5 nurses, 2 dentists, 4 dental assistants, 4 optometrists, 1 chief of operations, 5 security guards. How were we going to see all these people?

I turn to the doctor sitting next to me, “don’t worry, you’ll be able to see more patients than you ever have before” he reassured me.

The reason for this is that these encounters are not exactly like those in the US. We are giving goal-oriented medicine, that is we are 1.) looking for the truly sick individuals in the community so that we can get them to the ship for treatment where we have a full staff, equipment, medications, ancillary services, and surgery rooms, 2.) keeping an eye out for people with infectious diseases like TB and HIV (so that we can refer them to public health at Port Moresby General Hospital where they have free resources and medicines to help treat them), 3.) limited by a formulary that consists of a handful of antibiotics, NSAIDs, OTC’s, some topicals, multivitamins, and a handful of other meds, 4.) not looking to cure chronic disease as we will only be here for a week longer, 5.) trying to educate patients on better health practices, hygiene, and nutrition. With these constraints and goals in mind, encounters for lower back pain can be rather quick, whereas the truly sick patient or surgery consult patient may take a bit longer.

We make our way through the masses of people as they reach out to touch us, give us high-fives, and occasionally a USA chant is heard. I can’t help but smile. We set up and open the doors to the patients to come in. We are pumped up and ready. It turns out he was right, by the end of the day our medicine group saw 864 patients, dentistry saw 112, and optometry about 409 (1385 in all!). I worked as hard as I could, barely eating lunch, and contributed a meager 64 to that number, but wow what an impact!

Bon Voyage,
~Nic

On Caring

2008-08-25T02:00:00.000-07:00

The question has been proposed at times, "How can a temporary mission like this really make a difference?" Even worse, how can 1-3 week whirlwind missions really provide any permanent medical change to communities and countries?
Do the medical visits, surgeries, preventative measures done by the USNS Mercy team really help anything?

The following story does have a point:
After the church service yesterday, one of the community announcements was regarding one of the Navy officers who had just lost her brother, and must return home.
At the end of the sermon, we sung a song about how we are cared for. Some lyrics:

And He walks with me, and He talks with me, And He tells me I am his own,
And the joy we share, as we tarry there,
None other has ever known.

After the song, she stood up, tearful, and shared her story:
Growing up, she lived on an island 2 miles by 16 miles long, much like some of the small islands we have been visiting. Her parents would be at work all day, and she and her brother would stay with her grandparents. There was no electricity, no television, a small handheld radio.
One day a "big American" came, and at their local school provided some basic dental work, pulling teeth, handing out toothbrushes, as our dentists during this mission have been doing.
And even though they didn't do any fancy surgeries, their visit changed her life and affected all the people on the island.
What made the difference wasn't so much the medical assistance, which was minimal, but was the knowledge that someone out there cared about her. The knowledge that there are people in another country who would travel such a long distance to come help their little island.

And so she said, even if you think you didn't do anything, even if you think we didn't make any grand changes, I am living proof that you did make a difference, by coming to help because you cared about these people.

In the end, it seems that I've been thinking about this all wrong. It's true, sometimes we can make a medical difference, and sometimes we can't. But there is isolation and hopelessness everywhere you look in the world. And perhaps one of the roles of a physician can be to bring some caring and hope to people who may have neither.

-ryan

first day out.... Gaire village, PNG

2008-08-24T23:15:00.000-07:00

I’ll try not to duplicate material from the other posts here. What I have tried to do is give you a play by play of what it was like to go on a "away mission" off the Mercy and into a foreign country to see patients under the protection and supervision of the US Navy. I’ve put pictures and descriptive words to help you see the sights and hear the sounds. My experience is ideal for this because I was at one of the most remote locations. This was, literally a seaside village of a few thousand people.

It’s my first day off the ship… finally! Up at 5am. The water is rough as I climb aboard the band-aid 20-person boat (shown at left). On shore we open up the storage lockers and load our pallet of supplies onto two pickup trucks. Then we climb aboard 2 buses (shown right) and caravan our way to a seaside town 40 minutes away. Our team is composed of 20 or so healthcare providers: doctors, nurses, dentists, physical therapists, and military hospital corspmen along with a 10-person security force complete with guns in hand.

Soon we are in town. The houses are approximately 20x20 feet, and all are built up on the second floor. My best guess is that this is because of termites because even the hilltop ones are built like this so it can’t be on account of the rain. They are made of wood and tin. All have cooking pits on the ground beneath them. (That explains all the burns we have been seeing.) There is a great deal of excitement and bustle as we ride in. Kids run up to the buses in the street yelling and cheering. Everyone waves. There is a lot of cheering and a general feeling of excitement hangs in the air.

Our clinic today is the open-air first floor beneath a church. We exit the bus and start setting up shop while a man with a loudspeaker gives a grandiose speech first in the native language and then in English. After hearing stories of thousands of people lined up I am surprised that we have just a small crowd of maybe 100. I wonder if we will have enough business for the day. My intuition turns out to be wrong as we have a steady stream for the next 3 days. There is a small wire fence around the church basement, and all around are the houses of the village.

Children are playing and peering through from the fence. Small, scrappy dogs are running around. When I take out my camera, all the children cry out to get my attention. They perform antics and make funny poses trying to get me to take a picture of them. I see what I think is a mosquito and immediately slap on my REI bug juice. Malaria, which is transmitted by a bite from a mosquito, is endemic here.

I am excited but also nervous. I get one of the “provider” spots at a table, with an experienced doc right next to me in case I need to solicit any advice. She is a dermatologist, an indispensable resource for this situation due to the abundance of skin complaints. She flies through patients. Interviewing, diagnosing, explaining, prescribing, and then sending them off as she yells “next patient.” I get off to a slow start. I do everything I’ve been taught. I smile as I introduce myself. I ask lots of questions. All this is done through a local man who is serving as a translator and so the process takes lots of time. I am glad to have my dermatologist for backup.

Soon I realize that this isn’t the same breed of medicine that I am used to seeing in the US. My job is to find the truly sick people and do what I can to help them out. If someone sounds like they have TB, I tell them adamantly that they need to get treatment at one of the free clinics on the island. If I think they have malaria, HIV, or are pregnant they get tested by our lab and receive an answer on the spot.

At least two-thirds of my patients are there for back pain. It’s no surprise given that the women carry huge jugs of water atop their heads from wells and streams back to their homes, and men go out and gather firewood and return with it on their backs. I give the “low back pain” lecture countless times. Keep your back straight when you bend down. Use your knees to lift the weight. Stretch your hamstrings. Keep your stomach muscles strong. Don’t work so hard. Wear shoes when you have to walk long distances. I warn them to stop using Motrin if they have stomach pain. (A well-known side effect of that drug is stomach ulcers, something Vioxx tried to fix but that caused other problems.)

I am surprised that almost all the patients are happy at the end of the encounter. They thank me graciously, even when I have to conclude with “I’m sorry that we can’t do more for you.” It’s a very different experience than treating people in the US.

And so I make it through my first day, having seeing fewer than half as many patients as the dermatologist at my table. Then it’s back onto the buses, a caravan back to the port, and a ferry boat onto the Mercy. I eat a ton of food for dinner and immediately go to bed.

--pete

Zebras and the Kokoda Trail

2008-08-23T21:57:00.000-07:00

Last day of on the boat service. Our direct report is finally back from his week-long mission ashore running daily medical clinics. We casually stroll into his office at 9am. He is a pleasant surprise. Smart, professional, and frank.

I hang out in the area of the boat known as CasRec (short for Casualty Receiving). You can probably guess what this room is used for when the Mercy is serving as a military hospital ship. On this mission, however, this area functions sort of like the ER would in a US hospital. Every patient that comes on or off the boat goes through here. Some are straightforward. Most are not. All are very pleasant and grateful. An easy patient would be one scheduled for a surgery. They have already been seen by their surgeon-to-be back on shore. A history and physical has been done. Admission orders are in the chart. They are just of here for an appointment. Their vitals are taken and they are taken to the Pediatric or adult floor beds.

Many of them have no appointment but have managed to talk their way into being seen in CasRec. I see one of these. He was part of a tour group of national government employees that is onboard for a tour, one of the mainstays of the diplomatic side of the boat’s mission. He is a 33 year-old man who is a driver for the national embassy in Port Moresby. His chief complaint is knee pain. Approximately 100% of the adult patients here have knee pain. This is not surprising. They walk everywhere. They have no cars and no buses. They often have no shoes except for simple flip-flops much like the pair I brought along on this trip to wear in the shower.

His story is classic for osteoarthritis, the medical term for wear and tear of a joint. His pain is worse at the end of the day. My interview is interrupted by my Attending. I think this patient should get some Motrin and perhaps a nice pair of athletic running shoes with lots of cushioning. My attending orders a knee X-ray, writes a script for Aleve and Tylenol, and arranges a visit to Physical therapy on the boat. Aside from merely observing surgical procedures this is my first clinical encounter yet on this trip, and it doesn’t feel all that much like international medicine.

I see that patient later in the afternoon after he has received his battery of services on the boat. He is very happy. I guess that shows what I know. Maybe we did make a difference for that guy.

We see another woman from one of the tour groups. She complains of headaches. She is given a referral to optometry. (As anyone with an outdated prescription on their glasses can tell you, blurry vision can cause headaches.) She also asks that her bloodwork be analyzed. Her request is granted. A vial of her blood is drawn by a Navy corpsman and sent to the onboard laboratory. The levels of sodium, potassium, chloride, and calcium in her blood are analyzed. Her red blood cells are analyzed, counted, and sorted. Their shapes are characterized and statistics generated to report all this information. In the end her vision is fine and her labs are all normal. I do not catch-up with her in time to see what my attending does for a discharge plan.

The rest of my day is spent trying to catch wind of the cases that need more than vital signs taken and see those patients before my Attending gets to them. Near the end of the day I see a girl with an obviously deformed face who is heading to ophthalmology. My medical training provides almost no exposure to ophthalmology so I am eager to get some exposure to that while on the boat. I run to catch up as she is taken there with her mother and father.

I leaf through her chart. Her working diagnosis is right cranial nerve 6 and 7 palsy. That means she cannot move her right eyeball in 4 of the 6 cardinal directions (CN 6) nor does she have use of any of the muscles of facial expression on the right half of her face (CN7). She cannot close her right eye. She cannot smile. She cannot hold her mouth closed so that she constantly has drool falling from the right side. She was brought to the boat primarily for CT imaging of her head and neck. The most likely diagnosis is a brain mass. Now I’ve skipped a few steps to arrive at that conclusion so I’ll digress for a moment to explain.

Medicine is a game about most likely’s. They say if something has four legs and grazes in the field it’s probably a horse and not a zebra. Don’t look for zebras is what we’re taught, unless of course you’re taking an exam in which case the zebra is probably the answer.

If this girl’s right eye worked fine she would not be on the boat. An isolated cranial nerve 7 deficit is called bell’s palsy. That would be the most likely cause. It could be diagnosed by most any competent 2nd year medical student. It is very common. It can happen from disease, infection, or simply spontaneously. Sometimes it gets better; Sometimes not. The treatment is steroids, not like baseball players take but hydrocortisone like my Grandmother takes for her rheumatoid arthritis. But this patient also has a CN 6 deficit. That’s a different story entirely. Now the most likely pathology (problem) is a single lesion that is affecting both CN’s 6 and 7. Harkening back to anatomy, the only place where those two structures share a common pathway is inside the brain, and in particular the brain stem.

So now we are talking brain lesions. That means tumors, infections, and bleeding blood vessels. This is all pretty serious stuff with big-time consequences. Getting an image of this girl’s brain to see what is going on in there could save her life, even if we don’t do the surgery or treatment she will need during this mission. It could mean the difference between catching a tumor when it is small and easily operable versus catching it too late when it has grown and even spread. In fact, this kind of imaging technology is one of the ways the Mercy can really make an impact in a short time.

A patient found on one of the away missions who needs medical imaging to further the workup is a great candidate for a referral to the boat. The cost of doing a CT or X-ray series on the boat is relatively cheap. Well that’s not really true. The true cost is high, but the incremental cost of doing an additional image is small. We already have the machines, the people to service them, the people to operate them, the nursing staff to prepare the patients, and the radiologists (physician’s who trained for 5 years post-medical school) to interpret the images we capture. That money has been spent. So ferrying out one more patient from the shore to the boat, checking her in, taking her vitals, and doing one more CT scan is, so to speak, inexpensive.

However, the CT scan of this girl is a surprise. There is not identifiable lesion. Now what? The pediatrician is unsure so she sends for an ophthalmology referral. That’s when I joined the case.

She is given a standard vision exam, exactly like what you get when at Walmart when you see the optometrist. The difference her is that her father is translating and she apparently doesn’t recognize the letter Z which comes up very frequently on the exam. I’ll have to remember later to check whether that is in the PNG alphabet. The exam shows she needs some low-power reading glasses, but that the sight functionality of the right eye is 100% intact.

Several phone calls later and we are speaking to the head eye surgeon. First of all, his OR schedule is full for the remainder of this mission. That’s not so bad, though because even if it weren’t, even if this girl were say in the US instead of a boat in Port Moresby harbor, the optimal management of her case would be to wait at least 12 months from the onset of her symptoms before considering surgery. This is because in a significant number of cases the symptoms spontaneously improve, and thus the patient is spared an unnecessary trip to the operating room.

So this patient needs an MRI. It captures images with a magnet. No radiation. But even with all our technology we haven’t found a cost-feasible way to house a 2-ton magnet strong enough to detect images down to fractions of a millimeter on a metal ship that traverses through 20-foot open ocean swells. In fact, many smaller hospitals in the US don’t have an MRI machine on-site. They cost over $1million. It is very common to see mobile MRI trailers parked outside a hospital, hitching up to a big-rig and bringing their imaging power on the road as needed. Unfortunately for this patient there is no MRI machine in the nation of PNG. 7 million people. No MRI machine. The pediatrician goes to work filling out the necessary forms for the Australian rotary club. This is a non-profit group that works to obtain medical services for PNG-ians using the resources and infrastructure from nearby Australia. The patient’s medical history is taken down in great detail to fill out the forms with 100% accuracy lest some oversight be a cause for denial of her request.

So that’s it, the patient is ready to go. But first, something that is very common on this trip happens. The doctors and nurses take pictures of this patient. I always found this part of medical culture to be a bit odd, this fascination with the most deformed and grotesque manifestations of disease. Yet medical types love it. They seek it out. They have chosen careers dedicated to the alleviation of human suffering and yet they are obsessed with witnessing the most terrible forms of disease that can be found. I wonder what these people will do with these pictures. Certainly they will download them onto memory cards and onto iPods and laptops. Perhaps they will share them with others on the boat as the captain did this morning with me. Maybe it’s good. Its part of the teaching culture of medicine. It helps educate everyone else about something that happened in a distant part of the world.

The patient’s parents are very thankful at the conclusion of their visit. Not to mention that they had perfect manners throughout their encounter. Despite waiting for the better part of the day for the various tests to be conducted on their daughter they never complained. Had I not asked whether they were hungry at 4pm they most certainly would not have mentioned that they had not eaten the entire day.

I run into one of the general surgeons after dinner. He was ashore today. He describes the multitudes of people he saw and their deformities: broken bones that were not treated properly and so they never healed right; arms that bend in three places instead of just at the elbow; a shin bone that is poking through the bottom of a heel ever since the patient fell out of a tree years ago. All of those patients would require multi-stage surgeries to correct their deformities, and this is beyond the scope of this mission. They would need highly skilled nursing for months following their procedures. That is also out of the question. He concludes saying how he was impressed that all those patients were still very grateful for whatever medical services were provided to them. He says that people in the US don’t know how good they’ve got it. I agree.

The briefing is more exciting for me tonight. Tomorrow is my first day off the ship. I pay more attention to what’s being said. I check and double-check my wakeup time and muster [read: assembly] location.

The feel-good message of the briefing tonight is about the Australian hiker again. She has made it past the critical stage of her illness (she suffered severe hyponatremia with sodium levels as low as 118). Apparently the story has caught on in the press. We are shown the Google screenshot that boasts an impressive display of news articles for her name as the search term. Congratulations to the boat’s crew are again extended. (Capt. Wiley has a good summary of what happened in his blog)

The commodore’s speech makes sense to me. I like him. I think he really gets the big picture. His message tonight is about how all the diplomatic efforts from the early part of the mission are paying off. The country’s head of state toured the boat today and had nothing but the highest praise to offer. He said we are making a difference and leaving a positive impression on everyone on the island from its highest ranking official to some of its poorest citizens. He is right. I have the thought that this mission is not attempting to solve the medical needs for all PNG’s citizens. It’s about paving the way so if someone cares enough to come back later, they will be welcomed with open arms.

~Pete

Tattoos

2008-08-22T18:24:00.001-07:00

Talking to some of the student and church volunteer interpreters I get a glimpse and perspective on the culture and traditions here in PNG. One such tradition is a right of passage for women in which they receive customary tattoos with designs from their family and tribe upon their first menses. I met many women with these tattoos in various locations with intricate, but now fading designs. Facial tattoos were the most striking, but tattoos on the hands and arms were also common. The interesting thing was that rarely were there any young girls that had tattoos.

The youth (whom I would have thought would embrace tattooing as they do in the US) rarely if ever had tattoos. I asked an interpreter why, and she said that many of the younger generations do not want to be associated by the tribal customs. “Nobody does it anymore around here,” she explained.

A grandmother who had tattoos along her arms told me that the patterns in her tattoos represent her family and community where she comes from. I asked her why her daughter doesn’t have similar tattoos, to which she replied, “I tried to but she had too much pain. Nowdays people are not as strong as before.”

It seems that wherever I go, American culture, ideals, and traditions are mowing over and often replacing those foreign nations. It’s a shame and it seems like we are tainting the world with our capitalism. But when you talk to people, they embrace it, want and yearn for US culture. Maybe it comes from the “grass is greener” phenomenon, or the idea of mimicry and emulation that propels people to improve or assimilate. But there is a subtle tragedy regardless if it is forced or not, in the sense that slowly these beautiful traditions and cultures are loosing what made them unique, that which took years and generations to develop. Almost the same way you hate to hear about endangered species slowly being erased from the senses of species. Maybe it’s a survival of the fittest mentality that improves success and living standards, and maybe for the individuals it’s for the best, there is just something that irks me about this trend. But who am I to judge, my father immigrated and assimilated in part to America and the culture for a better life for him and his family.

Bon Voyage,
~Nic

On Crowd Control

2008-08-22T18:24:00.000-07:00

At both of the MEDCAP [Medical Civilian Assistance Program] sites I've been to, I've noticed a peculiar thing. At the end of each of the days, the children would, perhaps understandably, go nuts. They would either storm into the site and try to play "touch the American" or "please take a picture with us" or crowd around the buses and try to get our autographs (crazy but true).

However, there would always be a man who did crowd control. He would have a very large stick, usually a large tree branch, and swing it at certain kids he decided were unruly enough to warrant such a punishment. It would be at random kids too, since almost all of them were almost out of control.

The best part was, this guy wasn't associated with us. He didn't have security uniform or a volunteer t-shirt on. It was just some guy from the local town, who came by with a big stick and decided to start swinging. At another site, someone observed a woman fulfilling this role, only she was using a banana peel rather than a stick.

Maybe we should've hired the guy, hahah.

You know you're in an interesting place when its okay for a local man to run around trying to hit kids.

~Ryan

Settling In

2008-08-22T17:53:00.000-07:00

I wake up late and rush to catch the end of breakfast. I run into Sonia. We talk for an hour or so, mostly about medical specialties. Then she is off to meet someone and I head to the OR.

The plastic surgeon I worked with the day before is there. I reintroduce myself and soon I am suited up assisting with a cleft palate repair. During the procedure all sorts of medical and dental folk wonder into the room, They ask questions of the surgeon. The push to get a good view of the procedure. They talk shop. Because this is a more involved procedure than a cleft lip this patient will spend another 2 days aboard the ship where she can be closely monitored for post-op complications like bleeding, or breakdown of the sutures.

Then onto lunch. Sonia informs me that we have permission to leave the ship. We catch the next ferry boat to the dock, where there is one guy selling stuff out of the back of a pickup truck. I buy some stuff figuring this might be my last chance at getting any souvenirs. Then it’s back aboard the next ferry and onto the boat again.

At dinner I meet more people. Military personnel. Project Hope doctors. Pre-dental volunteers from San Diego. The hot topic from everyone is their experiences from the away missions. Hundreds of patients seen by 5 providers. Arriving at a clinic site and being greeted by thousands of waiting cheering patients, such that it feels like finishing a marathon. Stories of regret for the hundreds of patients left waiting in line at the end of the day that did not get seen, some of whom had been waiting since 3am that morning.

All of the returning away mission personnel look tired. But they are all happy. They are living the dream. They just spent a day toiling at the thing in life that they are passionate about. The thing they spent thousands of dollars in airfare and months of time away from their families to be a part of.

I will not be participating in any away missions for 4 more days. I am frustrated. I am disappointed. Then I am mad at myself for thinking these things. This isn’t about me. It’s about all those people waiting in line to be seen. I resolve to prepare myself as best as possible for when I finally get to go off-ship. Someone from dinner said they saw 60 patients. I will see 70. Hell I will see 700 if they would let me.

~Pete

About Papua New Guinea

2008-08-22T03:35:00.000-07:00

Here are some factoids I picked up along the way, just to give you a lay of the land and a perspective of where we are:

Population: 6.7 million (largest, most populous single island nation in the Pacific)
Port Moresby is the capital with 255,000 ppl
Western 1/2 of island is part of indonesia, while Eastern half consists of PNG
Government: Constitutional Parlimentary Democracy (previous British declared protectorate 1884, Australian administration 1906, Independence with ratified Constitution in 1975)
Life Expectancy M-63.4, F-67.9
Currency is PNG Kina (previously used shells for trade until 1933) which trades at ~2.5 Kina to $1 USD
English is the official language of business and government, while Melanesian Pidgin (Tok Pisin), lingua franca, and Hiri Motu can be heard by locals. 57% literacy rate.
One of the most culturally and linguistically diverse and heterogeneous ethnic nations in the world, with over 750 dialects and distinct tribal cultures and communities
Main Ethnic Groups: Papuan means "frizzy haired", Melanesian, Micronesian, Polynesian, Foreign missionaries
Common Tok Pisin Phrases: Hello-Gude; Thank you-Tenkyu; No-Nogat; Goodbye-Gutbai
Religions: majority Christians, animism (attributing souls to animals, plants, phenomena, ancestor worship), up to 1930 headhunting and cannibalism
Finances: $2,400 per capita income, mainly from farming, fishing, hunting/gathering, and tourism industries
Diet: staples of starchy vegetables, wild greens, bananas, coconuts, mango, meats of fowl, pork, fish, turtles, and marsupials, tea at all times, Kai Bars (fast food stands becoming more popular as people become more sedentary)
Kava Drinking (member of pepper family) medical or social purposes (grounded, pounded, mixed with water (kavalactones concentrated in rootstock) for sociability, relaxation, & sleep. Is described as a sedative hypnotic.
BeetleNut chewing is widespread here, considered a stimulant. The beetlenut is de-husked and the seed packed in the cheek. Calcium-carbonate powder is added to the mouth along with a Kava seed pod in order to add flavor and essentially “free base” the beetlenut for improved bioavailibity and speed of absorption. The mixing of these ingredients causes the mouth to turn bright red, the evidence which you can see just about anywhere as red spit marks. The use of beetlenut in men, women, and children for prolonged periods of time causes teeth decay and oral cancers which becomes a huge health problem.
PNG has the highest HIV rate in the Pacific
Traditions: Hand drum called "kundu", Ceremonial dancing "singsing", competitive feasting "fighting with food" between important men known as "big Men." Competitive gift giving is a form of symbolic warfare arising out of tribal one-upmanship with the goal of prestige by the "big man" to crush his rival with large gifts and impress onlookers with the brilliance of his oratory. Tattooing "Bilas", piercings, face painting, and skin scarring serves ceremonial and social purposes for initiation ceremonies.
Superstitions: sorcery, black magic, traditional "witch doctors", one can achieve another's bravery and strength by eating that person's flesh, bones of the deceased are buried under the house for protection. Ancestral masks bring spirits of the deceased. Savi masks represent most powerful spirit, discouraging enemies. Tambaran carving houses powerful spirits, elaborate hooks or food hooks attract good spirits and keep food from spoiling. Do not give flowers in even numbers or 4, 7 , 9, and 13 as they are bad luck
Clasping of hands is a widespread greeting.
Polygamy with "big men" and only approx 10% of men.
The "Pacific Way" is a general term referring to the behavior appropriate for pacific islanders, emphasizing shared cultural values.

Lukim Yu! (see you later),
~Nic

Surgery Mercy-Style

2008-08-21T06:56:00.000-07:00

Up at 6am. Most of the other bunks are already empty. Breakfast. Awesome as usual. Then I head to the OR, determined to find some action there. The big case of the morning is a takedown of a wrist contracture from a burn injury. Ironically its the same child that was sitting next to Nic on the band-aid boat onto the ship. In the room is the surgeon, assisted by an Army Gen Surg resident. An Army Ortho attending is watching as is another surgeon. I talk shop with the Ortho attending who apparently arrived a few days ago and has been denied permission to operate.

I wait out the case and then seek out another, hopefully less crowded room. I enter a submandibular and sublingual gland removal. In the room is a Peds surgeon from the US. assisted by a Aussie Peds surgeon. They don’t pay much attention to me being there, so I again wait out the case, not seeing much.

Lunch, then back to the OR where I introduce myself to the project SMILE team. Their organization is entirely self-sufficient. They bring their own supplies, instruments, surgeons, anesthetists, and nurses. They have a corner of the PACU to themselves, which is a 20x20 play area with kids and parents milling around. These are all pre-op patients. Each is wearing a hospital gown with tape declaring their NPO status on it. “Don’t give me anything to eat or drink after 8am”

The next case is a cleft lip repair. The surgeon is from New Zealand. He flew in this morning at the last minute to replace another surgeon who was ill. The anesthetists are from the Philippines, the nurses from Australia. Quite an unusual OR team.

A bit about cleft lips. At 6-10 weeks into a pregnancy, the face of the fetus is formed. The last step is when the eyes and nose come down from the top of the head to meet the mouth and also pull together to meet in the middle. It’s kind of like the motion you would make if you came up behind someone and reached around with 2 hands to cover their eyes. About 1 in 1000 times something goes wrong and the continental plates don’t meet. 1 in 500 if you’re Asian. From there nature does its best to fill in holes or defects with scar tissue.

The final product can be slight (a minor scar on the upper lip extending towards the nostril) or more severe (the roof of the mouth does not close in the middle and communicates freely with the nasal cavity). The severe cases cannot breastfeed (try sucking on a bottle with a hole between your nose and mouth). Minor ones have cosmetic defects. Nearly all will have a corresponding defect with their speech, let alone the social implications of their deformity.

Ok so how do you “fix” a cleft lip (the more minor case)? The basic idea of the procedure is to excise a wedge of tissue where the defect is. It’s like cutting a piece of pie that extends from where your gums meet your cheek above your front teeth, out over the lip, and up to just inside the nostril. Then you line up the two halves and stitch them back together. Of course there are lots of plastic surgery techniques (C-cuts, and Z-cuts, and Mallard incisions) to help make the final product look pretty. The surgeon informs me that when you reconnect the two sides that if you get the border between the skin and lip (vermillion border for you medical types) if you are off by just 1mm the result will be noticeable by an average human observer at 3 feet, which is about conversational distance. Getting the 3 points that constitute the “Cupid’s bow” on the upper lip are also important.

This is the first time I’ve ever seen a plastics case. The result is nothing short of amazing. A terribly deformed face turned into a totally normal one. This patient will be checked at the end of the day, stay another night on the ship, and then be sent home. Their sutures will dissolve over the next week, and they can start eating as soon as their post-anesthesia nausea clears.

In the US or Australia cleft lips are repaired by 6 months. Palates are done by 1 year. Later at about ten years of age, a bone graft is sometimes then put in the palate if nature didn’t do a satisfactory job catching up its growth. All cases get intensive speech therapy.

Our patients today range in age from 7 months to 14 years old. For speech therapy they will receive some teaching during their stay aboard the boat and a handout giving them exercises to do at home.

More cases follow. All the exact same defect with the exact same repair until the very last one. The patient is 13 years old, and she bravely gets on the table in the OR as she is put to sleep. Her defect is still on the lip only, but there is a great deal of scar tissue in the area. The surgeon’s best guess is that she had some manner of repair done, but there was a complication such as a post-op infection. The same sort of wedge excision followed by reapproximating the two edges is done, but the result while a major improvement is less than perfect. If this was the US, the patient would be allowed to heal and her swelling to subside. She would then be brought back for one or more subsequent surgeries to improve the cosmetic result. There will be no such follow-up for this patient.

I catch the tail end of dinner, then on to the gym and the nightly briefing. The highlight of the briefing is a case presentation. The patient is a 30-something woman who had both of her distal forearm bones broken in a car accident years ago. She adamantly refused amputation. The bones never healed back together so she has been carrying around a hand held attached to her arm by soft tissue only. The fingers only move when she holds the hand out at length.

In the US she would get multiple surgeries by orthopedists and plastics to reapproximate the bones and make them heal together, all the while making sure to recreate the correct tissue planes for the nerves, tendons, and blood vessels of her wrist. Here she received a specialized brace crafted after several days of trial and error by the physical therapy department.

The woman is brought up in front of the whole room of people. She tells her story. She is genuinely thankful and very happy with the treatment she has received. This segment of the briefing concludes with a happy Birthday (her birthday was yesterday) sung by the whole audience.

I know this presentation was put on the briefing schedule as a feel-good morale booster for the audience. I’m a skeptic at heart. It didn’t make me feel good. I wondered why she has to walk around her whole life with her hand suspended by skin and muscle waving from the end of her forearm when we have this boat here with the manpower and the tools to give a better result. I know the answer. I know why they didn’t do those operations for her on this mission. It’s too risky. The procedure would have to be done in multiple stages. She would need very close follow-up for many months. We are leaving in 8 days. I am frustrated. At this ship. At this mission. For this woman.

Then I think to myself, that there is always a line like this that needs to be drawn. Even if the boat were to stay here for a month, or a year, or 5 years there would always have to be those cases where you had to look a patient in the eye and say, I’m sorry that’s the best we can do.

Maybe that’s just the nature of healthcare. You can’t “cure” every ailment, and you can’t prolong life indefinitely. In med school we are trained how to break bad news to a patient. “Mrs. Smith I’m afraid I have some disappointing news to tell you. Your cancer has progressed. The last round of chemo did not work. We have exhausted all the options. We have no further medical treatments to offer you. I’m sorry.” But its one thing to tell an actor or talk about it in a class in med school, its another thing to say it to someone with no other hope.

~Pete

On Timing and Travel

2008-08-21T06:06:00.000-07:00

It takes us about 20 minutes to get anywhere on the ship. Okay, that's exaggerating, but it does take a lot of time and effort to get where you want to go. for example, you wake up at 6:30 and you're groggy. All you want is food. But first you have to try to fiddle with your combination lock (in the dark). After it's open, you try to change and wash up, but oh no, you've forgotten your toothpaste. Time to fiddle with your lock again. Now you're out the door of the berthing, and climb up 4 sets of stairs to get up two floors to Main. On Main, you walk across 1/2 the ship's length to get from the purple stairs to the red stairs. At the red stairs you walk up 4 more sets of stairs, through some double doors, down two hallways to get to the chow line.

I always leave at least 5 minutes early. And my watch is set 2 minutes fast.

~Ryan

In the NAVY Now

2008-08-21T06:01:00.000-07:00

Wow, this is one incredible floating, working, functioning town. I entered this town as an outsider, not knowing the slightest of nautical terminology, military protocol, or how a ship this large functions. So i'd like to take a bit of time to share some of the things I've learned along the way.

First of all the concept of the USNS MERCY (T-AH 19) is not novel, in fact there is a long line of predecessors that lie in the veritable wake of this white washed hospital ship with a red cross stamped on its hull. In fact, there were two previously commissioned Mercy ships as early as mid 1918. The first Mercy (AH 4) was first an army troop transport during the first nine months of WWI, then renamed MERCY and converted to a hospital ship and commissioned in 1918. Upon commissioning, the ship made 4 round trips to France, returning 1,977 casualties in that first year. The second Mercy (AH 8) commissioned in 1944 and deployed to the Battle for Leyte Gulf in the Republic of the Philippines, embarking 400 casualties, transporting wounded to New Guinea. Later it aided in service in the Okinawa campaign, arriving in Hagushi Beach and transferring wounded soldiers to Saipan, Marianas despite heavy air fire and kamikaze attacks. Later on it was The tradition traces back to the first commissioned ship for hospital purposes, the USS Red Rover which sailed from 1862 to 1865. This hospital aid ship proved to be a benefit in the field and subsequently spawned a whole series of ships. Inspired by the "Prayer From the Navy Wounded" that Navy Commander J. M. Stuart wrote while stranded and wounded on a tropical island, each ship then on was named from words within this prayer. It reads:

I am wounded, lying in the tropic of darkness.
Who will deliver me, oh, God? Is there no HOPE?
Is there no present SOLACE from the flame that burned me?
No Heaven-Blessed RELIEF for aching steel-torn flesh?
Surely the All-highest in His SANCTUARY,
He who is my ever-present CONSOLATION,
My REFUGE who is BENEVOLENT indeed,
Will send me one SAMARITAN to bind my wounds,
For I have sang His MERCY log as Christians should,
Have known him BOUNTIFUL, yea, my enduring life,
Have dwelt before Him in old Faith's TRANQUILITY,
Rescue me, Lord, COMFORT me in my deep stress.
Salve my wounds, bear me up to some sailor's HAVEN
On to the sweet REPOSE that Thou has promised me!

The following are the dates and names of the 22 hospital ships deployed:

1862-1865 USS Red Rover

1898-1921 USS Solace (AH-2)

1908-1910 USS Relief (AH-1)

1918-1921 USS Comfort (AH-3)

1918-1934 USS Mercy (AH-4)

1920-1946 USS Relief

1942-1946 USS Rescue (AH-18)

1941-1946 USS Solace (AH-5)

1944-1946 USS Refuge (AH-11)

1944-1946 USS Hope (AH-7)

1944-1946 USS Samaritan (AH-10)

1944-1946 USS Bountiful (AH-9)

1944-1946 USS Comfort (AH-6)

1944-1946 USS Mercy (AH-8)

1945-1946 USS Tranquility (AH-14)

1945-1946 USS Sanctuary (AH-17)

1945-1947 USS Haven (AH-12)

1945-1947 USS Benevolence (AH-13)

1945-1950 USS Repose (AH-16)

1945-1955 USS Consolation (AH-15)

1987-Pres USNS Comfort (T-AH-20)

1986-Pres USNS Mercy (T-AH-19)

Originally the Mercy was an Oil Tanker originally built in San Diego in 1976, was later purchased and converted into a hospital ship by the Navy in 1984. Thus the design of the boat is divided into 7 "zones" which are, for the most part, non-communicating vertical compartments that span the ship from bow to stern. This make travel laterally a bit difficult because you have to climb the stairs to the 'main' floor in order to travel the length of the ship, then take your desired zone stairwell from there.

Prior to its current mission in the Pacific Partnership 2008, the current Mercy T-AH 19 ship served in 1987 in the Philippines and South Pacific as a training and humanitarian aid ship. Next in 1990 the Mercy was activated to support Operations Desert Shield/Desert Storm in the Arabian Gulf. The Mercy supported allied forces, admitting 690 patients, performing 300 surgeries, and and 21 US and 2 Italian POWs. In January 2005 the Mercy reached Southeast Asia as an aid relief vessel after the tsunami caused damage throughout the coastline, treating 9,500 patients, and 19,512 medical procedures in Banda Aceh - Sumatra, Alors - Indonesia, and Dili - Timor Leste. Quickly thereafter in March the Mercy was able to lend its services to Indonesia after the 8.7 earthquake devastated Nias island, performing 123 surgeries, 19,000 medical procedures. On its way home a stop was made to Manam islanders who fled to Papua New guinea after a major volcanic eruption on their island. In 2006 the Mercy again did a humanitarian tour, stopping in the Philippines, Bangladesh, Indonesia, and Timor Leste, taking care of 60,000 patients. With such a positive track record and impressive numbers in terms of the ships abilities to take care of people internationally it is no surprise that the Mercy yet again was commissioned for another mission.

The only other hospital ship still in commission is the USNS Comfort (T-AH-20) which resides on the East coast, with a similar resume of service.

On this mission the Mercy left San Diego on April 30 with the itinerary to from San Deigo, CA stopping in Manilla - Philippines, Dili - Timor Leste, Port Moresby - Papua New Guinea, Chuuk - Micronesia. And yet again the mission includes providing healthcare, preventive and environmental medicine, engineering services, veterinary medicine, and education to each of these partner nations.

Goals:

Primary Mission: rapid, flexible, and mobile acute medical and surgical services to support the department of defense.

Secondary Mission: provide mobile surgical hospital service for use in disaster or humanitarian relief or limited humanitarian care incident to these missions or peacetime military operations.

Some statistics and random info:

The ship is under the command of Commodore Kearns.

Motto: "Steaming to Assist"

Time to activate: 5 days

Staffing: 61 civilian and 1,214 military

Length: 894 feet

Displacement: 69,360 tons

Maximum Speed: 17.5 knots

Propulsion: Two turbine, two boiler, 24,500 horsepower

Facilities: 1,000 hospital beds (80 Intensive Care, 280 Intermediate Care, 500 Limited Care, 20 Recovery, 120 Light Care), 12 operating rooms, 2 CT scans, radiological services, medical laboratories, optometry lab, medical laboratory plus satellite lab, pharmacy, oxygen and nitrogen producing plant, Isolation ward, physical therapy and burn care, emergency room, sterile processing, morgue.

2 helicopters, 2 "band aid" boats, multiple soft person mover boats

Chapel, Computer labs, Library, game rooms, movie theaters, post office, barber shop, 3 gyms, etc

Berthing [read: dorm] Rooms contain 2 things: racks [read: bunk beds] and lockers. There are 37 racks, each 3 beds tall = 111 beds per berthing. There are 8 such berthings in the purple stair case zone. The beds cramped to say the least, with dimensions approximately 65" x 30" x 30" (or 6.5' x 2.5' x 2.5').

This ship is larger than ANY shore-based naval medical facility.

Water is distilled in evaporators when underway, giving the boilers fresh water first over the crew.

Bon Voyage,
~Nic

First Impressions

2008-08-21T06:00:00.000-07:00

From the plane ride in the town looked like the 3rd world. Whatever that means. I guess it’s some different world from the one I live in. Maybe that’s not such a bad description though. It was the same in the airport. They really tried to make it like the airports I had seen in the US. Lines with clear signs for customs. A security guard. I paid my $50 for a Visa and in the lobby there is a guy standing with a sign with our names on it. I feel like a VIP.

Outside more of the same. Lots of barefoot people walking around. On the sides of the highway. In the streets. In alleys. Whole piles of them riding in the back of pickup trucks. The driver plays a tape of Christian rock and starts the windshield wipers as a light rain begins to fall.

We come over a hill and the ocean is visible. The driver points out our boat anchored in the middle of the bay. We are waived straight through the security checkpoint of the seaside base. The rain is picking up, and it is windy. There is a makeshift tent setup with people seated in plastic chairs and a few people in military uniforms milling around them. One of the soldiers/sailors introduces himself and leads us onto the dock where we are to board the next ferry boat. We climb in with our heavy luggage followed by several PNG-ians. They are mostly middle-aged. There is one elderly woman, and two small children. No one looks sick or in distress. In fact they look excited. The ride out to the boat is a rough one, and when we do finally pull up to the docket it is no small task to get everyone off the boat with life and limbs preserved.

We climb a ramp for several stories and at the top the PNG-ians go to the triage waiting area while we are checked in by a friendly young sailor. Paperwork is filled out, several phone calls are made, and soon we are being shown to our berths by another sailor.

We get a basic tour of the ship at its conclusion we are told that there are some GI endoscopies going on if we want to watch. I forego that opportunity and use the afternoon to find the computer lab, catch up on emails, and hit the gym. I also stumble across the ship’s barber shop, which was alerted to me by the lit barber pole outside its doors. I few minutes later and I am in a chair being given a rather crude civilian haircut by a Navy barber from Maryland. He uses an electric razor for the whole thing. I doubt he ever gets the chance to use scissors. All of this is, of course, free. Imagine that. I free barber shop on a navy boat docked in port in PNG.

Then on to dinner. There are lots of people to meet and I soon learn I have to be on my best behavior because you never know who that person you’re shaking hands with is.

We run into another med student. She is an upcoming second year student, having just completed the first 9 grueling months of UCSD’s archaic curriculum. In a year’s time she has never had an encounter with a patient as part of her formal medical training. But she has spent the last month on the boat seeing things that most practicing physicians never experience. She is elated. No that’s not right. She is literally walking on air. Smile from ear to ear, and she begins what can only be described as a verbal information dump, detailing her many exciting experiences on the mission.

I get a little more insider tour from Sonia. Apparently there is an area on the side deck of the boat where everyone hangs out. People go there to smoke; others—to make-out.

Then it’s back inside for the evening briefing. It’s a very feel-good, go-team atmosphere. The helo [read: helicopter] crew did a Medevac and there is a lengthy presentation about “the mission”. It culminates with the commodore pinning medals on the entire crew. Very military. There are reports about all the activities going on with the mission. Trips to shore for medical, veterinary, dental, education, and engineering projects. How many patients are onboard. What stories the press covered that day. The upcoming schedule for the boat’s band. The weather forecast. It finishes up in one giant orgasmic release of feel-good juice with the admiral reading a letter from a local governor. It describes, in seemingly genuine manner, his gratitude for the professionalism and caring shown by the mission’s satellite team to his hometown.

~Pete

Communication and the Internets

2008-08-19T22:30:00.000-07:00

We wish we could be better about communicating with everyone from over here, but it seems a few things are keeping our hands tied. As mentioned before there is a bit of a delay with our posting. Furthermore, it is almost impossible to upload photos that we have taken from our 6 & 10MP cameras, which is going to make this blog look pretty drab, but we will try our best.

But on a different side of things, there is also delays in our ability to use the internet. We connect on a separate, but parallel NGO (non governmental organization) network which brings us the internet via satellite at the blazing speed that I can only compare to 1440 speed dial-up. This is because, as we all know, the internet is "a series of tubes. And if you don't understand, those tubes can be filled and if they are filled, when you put your message in, it gets in line and it's going to be delayed by anyone that puts into that tube enormous amounts of material." Thus navigating the internet or getting email is a bit tough, so please bare with us if we are slow to reply.

We do have phone access, again via satellite, but since our time zones are off by 7 hours and a day, there is a long waiting line and thus its difficult to talk.

So that leaves good ol' snail mail. I brought a photo-printer for some ridiculous reason (and gladly hauled the thing through New Zealand and Australia), and the ridiculous reason was to create photo-post-cards and send them off. Maybe not that ridiculous because getting on board I found that both the post office and the ship store don't carry or sell post cards. If you would like to send anything our way (before Sept 15th) you can reach us at:

Last, First: Civilian
Dept. DMS
USNS MERCY (T-AH-19)
FPO AP 96672-4090

Bon Voyage,
~Nic

May the Voyage Begin

2008-08-07T21:36:00.000-07:00

Today we touched down in Port Moresby, Papua New Guinea on a flight from Cairns, Australia that was excessively early in the morning. The three intrepid voyagers slung our carry-ons and walked up the walkway to our twin-engine prop plane ride to PNG. The views of the Great Barrier Reef were spectacular, and on decent, seeing the rain-forrested landscape of PNG for the first time piqued our excitement.

A man carrying a sign with our names on it greeted us at the airport and we were driven to the dock and boarded the USNS Bandaid (a small boat that shuttles people and equipment to and from the Mercy Ship which is docked within the marina and not accessible otherwise). We jumped on along with about 14 locals who were boarding the boat for medical care.

A 4 year old boy with the biggest grin on his face sat next to me on the bow of the boat, giggling every now and again when we got rocked by a wave. He had the normal look of a boy who played in the dirt a bit more than his parents probably wanted. He was short and skinny with a continuous amount of snot that rolled along his sun-chapped cheeks that he wiped off occasionally with his sleeve. He didn't say a word, just looked up and smiled at Pete, Ryan, and myself, seemingly intrigued by our light skin and "American-ness". His left hand, I noticed, was severely constricted with scars and contractures to the point where he essentially had no functionality of it. It lied in almost a fist-formation that he tucked deep into his over-sized jacket sleeve. I heard that many of the surgeons have already made their pre-op visits, so he must be coming on board for hand surgery to improve his hand's functionality. He was just one of 14 on the Bandaid boat, with dozens of trips back and forth to the boat like this every day.

His father sat by him. Dark skinned, tangled hair, his shirt stained and with evident wear and tare, yet he had a look of pride on his face. Pride and hope. His child was going to get the care he might never get in PNG, and he would be there for his child, making sure he can have the best life possible. It was a priceless moment, one of silence and the exchange of only smiles. Around us was the din of the boat engine and the shifting of passengers as waves crashed against our hull, plowing ever forward towards the Mercy. Once we docked alongside the ship the father hopped out of the boat and I lifted his child up to his arms. I wanted to say something, like "good luck" but nothing came to my lips. And before I knew it, we were directed by people in uniform where to go and what to do, and I lost sight of the father and son.

We received our "berths" [read: bed/room assignments] and are now trying to get situated. Soon we will be briefed on our specific roles and responsibilities on the ship and which teams we will be working with. In the mean time, just trying to keep ourselves from getting lost within the winding corridors and colored stairwells of this huge ship!

May the voyage begin!

Bon Voyage,
~Nic

Posting Delays Expected

2008-07-29T17:31:00.000-07:00

Today we had a briefing here in San Diego before embarking on our trip, and I just learned that there will likely be some delays in our ability to blog from the ship. Bandwidth is reportedly slow at times, but more detrimental is that we will need to get our photos and text "approved" for content before public dissemination. So here is an apology in advance, but we will do our best to keep on top of things.

In the mean time, we are frantically trying to tie up loose ends and get ready for our bit trip. From spring cleaning, to residency applications, we are trying our best to knock off some things on the To Do list before we depart.

Pre-Mercy Itinerary

2008-07-21T12:06:00.000-07:00

LAX 22:30 PM AUG 1 NZ5
AUK 06:15 AM AUG 3 NZ5

AUG 3, SUN:
-- Airbus to Downtown Ferry bldg, Fullers ferry (depart Pier 2, Ferry Terminal, 99 Quay Street) to Waiheke Island (Arrive Matiatia Wharf). Hourly starting 7am.
-- Oneroa Beach at top of Goodwin Ave; 5 min walk (HeKerua Rd #11).
-- Sleep HeKerua Lodge
-- Wine city bus: Saratoga, Te Motu, Stonyridge, Topknot Wineries. See map for locations.

AUG 4, MON:
-- Take Ferry Back to Auckland
-- Stay Base Auckland Central Backpackers Hostel (229 Queen Street, Level 3)
-- 192m on Sky Tower

AUK 07:15 AM AUG 5 NZ171
CRN 10:55 AM AUG 5 NZ171

AUG 5, TUE:
-- Taxi to Hostel: Cairns City Backpackers Hostel (274 Draper St)
-- Cairns Esplanade Lagoon, massive pool shape of Queensland w/ fountains

AUG 6, WED:
-- Depart for GBR @ 8AM pickup, stay 2 day 1 night, Scuba/Snorkel x7 dives.
-- 9.00am 90 minute transfer to Outer Barrier Reef with 2 dives
-- 2:30 OceanQuest transfer and travel with afternoon dive and night dive, sleep on boat

AUG 7, THUR:
-- 3x dives b/w breakfast and lunch, Depart outer reef @ 3pm, Return @ 5PM
-- Cairns City Backpackers Hostel again. Taxi to airport.

The Voyage Mercy: Trip Description

2008-07-20T12:25:00.000-07:00

Pete Bluvas, Nicholas Kanaan, and Ryan Yoon will be representing UCSD Medical School during the United States Pacific Partnership 2008 aboard the USNS MERCY (T-AH 19)—a 900 foot oil-tanker converted 1,000 bed hospital. This partnership will be staffed by the coordinated efforts of multiple organizations (U.S. Navy, Marines, Army, Air Force, and Public Health Service; Armed Forces of the Philippines, Australia, Canada, and Japan; Regional Health Officials and Local Health Care Providers, Operation Smile, and 13 local NGOs—of which UCSD is one). This collaborative will be providing humanitarian aid in the form of surgical, medical, dental, & ophthalmological care, as well as provide onshore building & infrastructure support, improve foreign relations & diplomacy throughout the South Pacific. This will be carried out in the following destinations: Cotobato, Samar, Manila (Philippians), Nha Trang (Vietnam), Singapore, Dili (East Timor), Darwin (Australia), Port Moresby (Papua New Guinea), Chuuk (Micronesia), Guam, Pearl Harbor, & San Diego (USA).

As fourth year medical students, they will be taking care of patients and helping achieve mission goals in the South Pacific during their leg of the journey (August 1st to September 19th), beginning in Papua New Guinea, through Micronesia, Guam and Pearl Harbor. As part of their participation, they are hoping to establish long-term relationships with the USNS Mercy and participating NGO’s to carve the way for future UCSD medical students to participate in upcoming humanitarian missions. Furthermore, the three participants will be keeping daily journals which will be uploaded when available at sea to an online blog to share experiences, express opinions, initiate discussion, and keep connection to UCSD medical students, faculty, and staff.

As participants, they hope to gain exposure to international and humanitarian health care delivery, better understand medical problems and management in the third world, and learn about new cultures. Being on a multidisciplinary care team as well as working with military personnel, they will gain insight and expertise in complex health care operations.