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