Tatana Village

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

Bon Voyage,
~Nic

PNG: Lost in Translation

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

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

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

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

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

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

--pete

On Silence

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

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

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

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

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

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

~ryan

PNG Key Points

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

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

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

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

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

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

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

--pete

Koki Village, PNG

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

Bon Voyage,
~Nic

Gaire lunch break

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

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

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

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

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

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

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

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

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

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

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

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