Professionalism

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



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



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



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



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


--pete

FSM a hard day's work

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



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



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



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



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



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



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



--pete

Genetics and Happiness

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

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

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

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

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

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


Bon Voyage,
~Nic

On thoughtlessness

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

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

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

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

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

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

That's it.

-ryan

First time out in Micronesia

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



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



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



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



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



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



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



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



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



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



--pete

Nightime sounds

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



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



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



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



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


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


--pete

Underway

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

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

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

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

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

Bon Voyage,

~Nic

Crossing the Line

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

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

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

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

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

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


Bon Voyage,
~Nic