Sunday, March 29, 2020

Our Time is in His Hands

We have entered our fourth week in PNG, and every day presents new challenges, joys, and sorrows such that time frequently stands still and we experience two or three days worth of memories in a single 24 hours. 

With PNG following other countries in a nationwide shut-down, Dr Mark and Dr Erin have been on double duty organizing hospital and community COVID response efforts - appropriate education being the most important, followed by equipping hospital staff with PPE (masks mainly), and coordinating an entirely new hospital protocol for COVID screening with suspect patients being first seen in the COVID tent set up outside the Station fence at the primary school. This design theoretically keeps the Hospital free to run as normal without COVID suspect cases spreading the virus from within Station



https://drive.google.com/uc?export=view&id=14iW1MhWl42D4-Ttrngxv6sw6oXAd5gbnhttps://drive.google.com/uc?export=view&id=1tcQBVm8Fcf5yGK8nmfkKHlyvKMgv6xlw
Doctors are taking turns covering the COVID tent while the rest continue to cover the Outpatient and ER, but with non-essential domestic travel banned, only seriously ill patients are showing up (in other words, many fewer patients daily, but what we are seeing typically needs urgent intervention). While we have screened well over 100 patients in the Tent, only two have had sufficient reason for referring to another facility for testing. And as of today, we still do not suspect COVID has come to the Western Highlands of PNG.

As I mentioned, time slows to snail speed when so many new and different experiences are piling up on top of one another. Here is a list of cases I managed in a single day earlier this week (from Peds Ward rounds, to covering Outpatient Clinic and ER during the day, then Call that night): 


Pediatric Ward Rounds:

A handful of typical cases - Pneumonia, Malnutrition, and Gastroenteritis

Pyomyositis (massive abscess in her thigh), but thankfully no osteomyelitis on xray

Recurrent Febrile Seizures - monthly recurrence of unknown etiology

Lumbar Puncture for a child with undefined meningitis (Bacterial vs Tuberculosis vs Viral?)

Mastoiditis (infection in bone behind ear) - ended up needing surgery to drill a hole into the bone and release the pus


https://drive.google.com/uc?export=view&id=1wwTcVUavUDqCrlZYzSWU5mjX851uHCSn


Outpatient and ER:
A steady outpatient stream of High Blood Pressure, Diabetes, Acid Reflux, Muscle Pains, etc.

Breast Abscess (untreated Mastitis) - sedated in ER and performed an incision, washed out all the pus, and inserted two drains


Machete Chop to lower Leg, +Fractures - applied t
ourniquet, started IV fluids, cleaned wound, and referred to our Surgery team


Metal shavings in eye (from using a grinder without wearing eye protection ๐Ÿคจ) - sedated in ER and removed with Swiss Army tweezers (don't worry, I sterilized them first...)

Elbow dislocation - sedated, popped bones back into place, applied cast


https://drive.google.com/uc?export=view&id=1SybwDuyL2DwOZurgY-BjfXlNlwfZFN8ghttps://drive.google.com/uc?export=view&id=1tHHZyV2PzNqgdZKkCx3qm1RT8Vh_iCsU


Older man - wasted appearance with mass in lungs - TB vs Cancer - prayed & sent to start TB meds (no option if cancer)

Younger man with swollen/infected penis - due to a local tradition of injecting cooking oil into penis to make it bigger...๐Ÿ˜‘ 


Behcets Disease - known case - young gal with many years of painful aphthous ulcers in her mouth - given steroids and topical lidocain gel


Bell’s Palsy - half of the man’s face paralyzed similar to a stroke, usually viral etiology, recovers spontaneously


Coxsackie Virus Hand foot & Mouth - this is a more impressive presentation than the usual little blisters (oddly enough, at the time of writing this Solomon currently has had the typical HFM fever and red spots...coincidence? Or maybe I brought it home? In case ya’ll hadn’t heard, viruses are contagious... ๐Ÿ˜ฌ๐Ÿ™ƒ)



https://drive.google.com/uc?export=view&id=1CXivPkoMKzCPEZ6vcdMnuHhXZx7s9WE1


On Call - in the ER:
Two different women came in with machete chops to their arms - the first was accused of witchcraft and chopped by a man in her village (cut through flesh and bone), the second was chopped on her wrist by her angry husband and wore the deflated expression of “life as usual.” Sadly, this kind of violence against women is common in the Highlands. We sedated them, cleaned their wounds, and loosely closed the skin for surgery to consult the following morning.


https://drive.google.com/uc?export=view&id=1F6-X5udu95Mh4eI5D8AE3ikOEjsOtN5mhttps://drive.google.com/uc?export=view&id=1nP_9Bwfs-f_3wRR9xGeP7dEHOyLNhavmhttps://drive.google.com/uc?export=view&id=1aS3leMuWpF00S2JRkGsRUo2Z9IAIigtQ


Last night I was on call again and two different men came in with chops - the first with an impressive gash across the top of his skull, brain matter exuding from front to back (while interesting to me, I’ll spare you the gruesome closeup picture). I called Dr Nathan to come help and we sedated the patient, cleaned off the clotted blood and bits of mangled brain, sewed the skin back up over the wound, and sent him by ambulance to the surgeon in Mount Hagen. While he was able to answer a few questions prior to sedating him in the ER, his expected outcome is poor. 


https://drive.google.com/uc?export=view&id=1_4pyesgjY6PV_dp3aGrk1nBwsD8_egkghttps://drive.google.com/uc?export=view&id=1R6W5mVK0HY5c9zvJG5Sr0lU0YEPGbG4chttps://drive.google.com/uc?export=view&id=1E_-dTG_bXM93Cmzpjexo_WmnXmt1PTmi


The second man presented later last night, apparently from the same “domestic dispute”, with a chop to the right elbow that shattered his proximal ulna. I didn’t call anyone this time - just sedated him, cleaned the wound (gauze swab catching on bone fragments), tied off a couple small arterial bleeders, loosely closed the skin with a drain in place, applied a pressure bandage, and splinted with a backslab cast. This morning he couldn’t move a couple fingers (likely nerve damage), but the Surgeon put him on the schedule to have an operative repair. 

Apart from all this mind blowing medical immersion, I have filled spare moments playing with Pennie and Solomon (not as much outside as I would like due to mosquito overload at present), working on building a wooden footbridge in the workshop (will include pics in future Blog), playing volleyball and soccer with fellow missionaries, walking adventures with the family, reading Dante’s “The Divine Comedy” (have always wanted to read it, and enjoying it tremendously), and I have continued F3 boot camp style early morning workouts three days a week (slowly gaining momentum in attendance with some of the local guys - Brian Bosip nicknamed “Flex” being my primary partner in F3 victory). 


https://drive.google.com/uc?export=view&id=1C6KsRYk6A-LH9ZzqG3mNX35AcYRF9UfP

With current boarder closures and airlines like Qantas shutting down international travel through May, we are currently in limbo as to when we might be able to return to the US. Should COVID come to the Highlands, further restrictions may be imposed. Regardless, we are trusting God’s perfect timing and will begin to investigate travel options around Easter. My awesome primary care Peds clinic back home has radically altered their business model to reduce COVID exposure to healthy kids and account for a significant reduction in patient numbers - and as such are agreeable to my extended absence in the event we can not return as originally scheduled. In addition, my younger brother John recently escaped New York city where he works as an Environmental Engineer, and has happily quarantined himself in our vacant Richmond home - of course we are thrilled to have such a trustworthy full time occupant.


We are immensely thankful for all of you and the prayer support we feel every day! As we all are facing unprecedented changes and challenges, please join me in this prayer:



Heavenly Father, we praise Your Holy name! Creator of Heaven and earth, you hold us in your hand now and forever. We thank you for the breath in our lungs, and the salvation that frees us from wretchedness. Send to us your Spirit of wisdom and peace. Guide our hearts and minds in your Word, and protect us from physical harm and the temptation to serve ourselves. Remove fear and refocus our hope in Your son Jesus Christ. We are your hands and your feet Lord - fill us with your strength and Light, that we might obey Your will and bring Your message of Love to this dark world. All honor and glory are Yours Papa God and we pray all this in the name of Your son Jesus Christ. 
Amen!

Wednesday, March 25, 2020

Weekends & Wokabauts

I thought it might be nice to share a bit about something other than COVID-19... so here's a short summary of some things we've done over the weekends.

The weekend officially begins on Friday night - when we observe the long-standing Kudjip tradition of "Pizza Night!"  Because we are in the Western Highlands and one cannot simply order Papa John's, or buy a frozen pizza at the grocery store, Pizza Night preparations begin during afternoon nap time.  Dough is made, cheese is shredded, toppings are prepared/diced, sauce is cooked... it's quite the production, but always super tasty and fun!  This week's pizza was a white sauce base with sautรฉed asparagus, sausage & tomatoes.    




 




Besides homemade pizza, another food-first for the kiddos this past weekend was making our own popcorn - they LOVED watching the kernels pop!  

 



 Pennie joined Ted one morning for rounds on the Peds Ward.  I LOVE how inquisitive and bold she is - not timid at all about approaching sick babes and saying hello.  She enjoyed passing out some stickers and was a trooper waiting while Ted filled out paperwork to discharge a few patients.  


 


Laundry - nothing exciting here... it happens a few times a week, but almost always at least one load over the weekend.  




A couple of recent "wokabauts" (exploratory walks)... 

The first, down to the "rot bung" - street market just outside of the station selling local fruits & vegetables.  Ted was a trooper carrying Pennie on his back AND most of what we purchased!  

 

The second, a long trek around the outside perimeter of the station and down a muddy trail to the river... needless to say, we are quite the spectacle with our large toddlers in their Ergos wearing their bright blue sun hats!  ๐Ÿ˜†
The long walk was worth the time spent at the river's edge collecting and throwing stones.... though to be honest, I was a bit paranoid about the kids eating the rocks (Solomon) and/or getting any of the river water into their mouths.  The river is the dishwasher, bathtub, washing machine, and toilet for many locals.  






We have been attending "lotu" (church) on Sunday mornings at a chapel just outside of the station (sorry, no pics).  The entire service is in Tok Pisin and it's been nice to hear and understand some great messages preparing everyone's hearts for Easter.  On that note, I leave you with this verse as a reminder of our Hope during these dark times... along with a view of the beautiful Whagi Valley we are calling home for now.

Jesus spoke to them saying, "I am the light of the world.  Whoever follows me will not walk in darkness, but will have the light of LIFE."  - John 8:12







Friday, March 20, 2020

Covid & Cases

Dear Readers,
As of now, we write to you from one of only 14 countries in the World yet to have a confirmed case of COVID-19. (The PNG Government thought there was a case earlier in the week, but the man tested Negative). Life and work here continue as normal, but under the surface there is a bustle of readiness preparing the Hospital and educating missionaries and staff for the possibility of the pandemic spreading to our remote Highlands. We are well supplied and our administrative team has worked overtime to construct a comprehensive plan which will address each stage of a COVID outbreak in our community. As many countries are closing their boarders and travel is becoming more difficult, we are not taking the first available flight home. God has brought us here at this time for His work to be done, and we have great peace and joy to serve Him here, come what may. In fact, because some of the usual medical staff and volunteers are no longer able to return to Kudjip, our ability to remain here as able-bodied volunteers provides timely support to a medical staff already few in number. While we are praying for all of you who have already suffered pandemic changes to your usual routines, please continue to pray for us as we serve here and prepare for medical and social upheaval. 

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Now, to some interesting cases in the last week:

CASE #1:  This boy fell while playing, breaking the lower part of his Humerus. As you know, it has been quite some time since I have casted anything, so I was pleased with how straight his arm turned out after a little traction, positioning, and splinting.

https://drive.google.com/uc?export=view&id=1kZ6loXPya8MT8V9PszU9cnJMSDx8sZhyhttps://drive.google.com/uc?export=view&id=1Ci1lMBnB50-MLdz7GFCl6qqSE4BIyyUQhttps://drive.google.com/uc?export=view&id=1SCFiNUXsMboFOfWxJBHPEnz9Vq_Aofut

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CASE #2: This boy traveled with his father a long way from the Jimi valley to be seen. His spleen is 20x the usual size, which I explained is caused by repeated malaria exposure. Unfortunately we don’t have a solution for Tropical Splenomegaly, so I prayed with the boy and his father and sent him home. (Yes, patients who I see on the Peds Ward are often stickered. ๐Ÿ˜)

https://drive.google.com/uc?export=view&id=1YC1ASlf0I3GOU478pQo5gp6EtiSHqnKChttps://drive.google.com/uc?export=view&id=1TpXFhSNyG3m8zK_oR5rVOBY5Xn-u5Z1u

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CASE #3: This boy presented with extreme throat pain and inability to swallow, and on exam had a thick Grey/White coating all over the back if his throat. Even though rarely seen now, I diagnosed him with Diphtheria and started specific antibiotics to kill the infection. Diphtheria is a component of the DTaP vaccine usually given in a baby’s first few months of life, but not all children are vaccinated in PNG. After 48 hours on IV antibiotics, he turned the corner and today he was smiling and spoke for the first time. He is still at risk of developing other conditions (heart failure, paralysis, etc) related to the toxin released by Diphtheria, but so far he is recovering well and we are praying he continues to do so! (Second picture is the patient getting an Electrocardiogram with the most interesting system of spring clamps and suction cups I’ve ever seen).

https://drive.google.com/uc?export=view&id=1NBg6eFx5lUGr5tZazt2axWBfc03UP-pShttps://drive.google.com/uc?export=view&id=1skP8epb9UhUkcucnHk1mlNsXeD5XuwEahttps://drive.google.com/uc?export=view&id=1z2rz-zgcKp_b_OUcHjNhHlJ6CL2SO82n

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CASE #4: While I was on call one evening this week, I had three traumas present at the same time - an older gentleman with a machete chop to his right arm which our surgery team came in to help with, a man with a single small bullet hole in his low back (xray showed it to be shallow), and then this young man who had taken the bad end of a policeman’s shotgun to the legs. ๐Ÿ˜ณ I was concerned about pellets remaining in/near his joint space, and admitted him for surgery to manage further in the morning. 

https://drive.google.com/uc?export=view&id=1kMtFQsKkLA9TPnndwv930qpUF7J2bUA7https://drive.google.com/uc?export=view&id=1OtRIKiKXyrFI1KOYlgPuBLaQq3GJMd9J

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CASE #5: Finally, this little gal is on our Peds Ward healing from a fall into the cookfire. Burns are very common here as open fires exist in the middle of most homes. For this patient, and all of the sick patients we are caring for, please pray for rapid healing, and for our medical/surgical teams to have wisdom in providing the best care.

https://drive.google.com/uc?export=view&id=1kPClYVoHx00ISc29YZZ6C6vW6jf6a4cj

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May the God of hope fill you
with all JOY and PEACE as you TRUST in HIM,
so that you may OVERFLOW with HOPE
by the power of the Holy Spirit.
ROMANS 15:13


Tuesday, March 17, 2020

It's not all fun and games...

Don’t let all the sweetly playing pics in this post fool you...keeping two tiny people alive, fed, clothed, sort of clean, diapered/bathroomed, and occupied is exhausting in America...even more so in the Western Highlands of Papua New Guinea.  
Ted shared in his latest post about this past week feeling so long, and I wholeheartedly agree!  The kids and I have gotten into a good daily routine, which is great...but...we are ALL working through the difficult lesson that well established behavior back home does not necessarily apply in a different home in another country.  Culture shock for a toddler seems to look like throwing all the normal behavior expectations out the window and starting from scratch; testing every possible boundary there is to test - whether that’s trying to climb up on top of the dinner table, wandering into the road, or refusing to comply with a simple directive ... it’s all testing ... and it’s been happening ALL week.  
So while Ted is working to keep kids alive and healthy up at the hospital, I’m struggling not to lose my temper with Pennie & Solomon.  I could let this adjustment that the kiddos are going through get to me (and to be honest - I definitely do sometimes), but then I remember the humbling truth that we are all a bunch of “testy” toddlers in a way.  We know the path we should take and the choices we should make, yet we continue to “test” by stepping out of line and communication with our God.  Just like Pennie refusing to listen and obey when I ask her to do something, or Solomon opening the fridge when he’s been told not to.... we hear and know the voice of God... but we choose to ignore Him at times. Thank goodness our Papa God has a never-ending supply of love and patience with us!  He gently guides and corrects us, knowing that we very well may make the same mistakes tomorrow.  I grab on to this truth and hold it tight when I feel like I’ve said “no” / “listen” / “stop” for the hundredth time... 
So take a deep breath with me, and let’s thank our Father God for His ever constant love, guidance and grace!  

Now ... to all the fun playtime pics!  

Gideon, a local artisan & friend, made a flute & bow/arrow for the kids.


Climbing on the MK Elementary School playground


Running home for snack
Swinging on the rotary clothesline
Play-doh time!





Friday, March 13, 2020

Back to Reality

A dozen times a day I have become lost in the surreal awareness of being back at Kudjip Hospital. As though 5 years never happened, the same faces of hospital staff smile and laugh in passing, the same graphic odors and vivid images shock the senses, and Tok Pisin pours easily from my mouth from a source I didn’t know remained.  I have thought and dreamed of these images, scents, and faces thousands of times over the years - to be here now again is mind blowing, heart wrenching, and saturates a part of my soul Called to Serve here. I did not realize just how dry the well had become, but now my soul drinks deeply from these rich waters. So surreal is the experience at times, I have felt detached from reality - like I’m behind the camera of a documentary on Kudjip Hospital. Panning left we see a patient in the ER struggling to breath. Panning right, a bright lightbox on the wall illuminates xrays of broken bones. The camera zooms in at flies landing on a malnourished baby’s face, halfheartedly waved away by a thin tired woman. 

https://drive.google.com/uc?export=view&id=1xfTK_CXwDOEKMWPyM_i5ehN2MsAoPSLO

But then reality provides the pinch - “Dr Ted, please come, your patient is arresting.”

When we lived here 2014-2015, it took me about 3 months to get “used to” witnessing death. Now having one of my Peds Ward patients die the very first day back in hospital, the callous is not so hardened...and my heart cried out silently while the boy’s parents wailed over his lifeless form. His meningitis was bad before I ever took over his care. I’d even suspected he was brain dead that morning. But it doesn’t lessen the blow of a dead child underneath my stethoscope. I prayed with his parents for God to grant them peace. I filled out the death paperwork. I went back to outpatient clinic and put on a smile for the next patient. I held my children tight when I got home.

https://drive.google.com/uc?export=view&id=1xjgRhB6cpVJWE_QsQEQnk5sDNksuL-CX

My first day of call was on my second day back in the hospital. This time at Kudjip, I do not have any responsibility for OB patients when I am on call, for which I am very grateful. My friend Dr Mark Crouch was covering OB Call, and he had just headed home for the day. After clinic ended, I went to the other wards to familiarize myself with patients that might need attention overnight, then I went to the ER. A trauma patient had just arrived - he was hit by a car and it was immediately apparent that his left lower leg was malformed. As I checked the rest of the boy’s body for injuries, another trauma patient was bustled into the ER by a group of men - unconscious, labored breathing, and bleeding from a large laceration across his face. This man was reportedly hit head-on by a bus while riding his bike. Patient 1 was stable, so all my attention went to Patient 2. My first thought on examining him - clearly head trauma, maybe pneumothorax, maybe internal organ damage and bleeding. My second thought - I need help! So I called Mark. He came, he saw, he stuck a needle into the guy’s chest - that didn’t help. So we called Surgery. Ends up his labored breathing wasn’t a collapsed lung, but all related to the head trauma, and our surgery team drilled two holes into his skull to relieve pressure. So yeah, managing traumas is traumatic, and I am SO very thankful to have experienced missionary docs here to back me up. 

https://drive.google.com/uc?export=view&id=1Vp39T24b2GI03rq_NHG5NfKKjHwJDD3p

Day 3 on the Pediatric ward, I discharged a boy with a brain tumor, only to be replaced by another boy admitted with an abdominal tumor.  The child with a brain tumor needed a Head CT and a Neurosurgeon in order to survive - neither of which we have at Kudjip. If his family chooses, they will pay close to 1000 Kina to get the Head CT, then many thousands of Kina to get a brain surgeon to complete a risky procedure that may not actually resolve the problem. Between the exorbitant cost and poor prognosis, it is unlikely he will have any intervention, and his brain tumor will kill him. The other boy with the abdominal tumor, most likely a Lymphoma, is receiving a single dose of chemo here - if it helps, he will get more. If it does not help, with chemo options being VERY limited in PNG, his abdominal tumor will kill him. The apology and prayers I offer feel hollow and echo of routine. Then that hollow feeling sits in my stomach like a rock. 

On Thursday, I was greeted on the Peds ward with the news that Petrus had died a couple hours ago. I was shocked. This 11 year old boy with significant Congestive Heart Failure had been stable and communicative all week.  Yes, he was on oxygen and a bunch of CHF meds. Yes, his heart was barely functioning. But the report of “he was uncomfortable all night, then he arrested and died” seemed shallow. So many questions flooded my mind:  Why didn’t the nurse notify the Provider on call that he was worsening? Would it have mattered? Should I have done something different in his care? Would any intervention have changed the outcome? Probably not at this point. But did I adequately share the Gospel with him? No. I did not. I expected to have more time with him. Reminder of the day - tomorrow is not certain, take every opportunity to share the message of Jesus Christ. 

https://drive.google.com/uc?export=view&id=1XZDnCGK7T8svk-Nubtuv5dnUiFmW1MHr

It is Friday, and this week has felt like a month. While I am wading slowly towards remembering how everything works here, frequently I get stuck and need direction. How do I cast that again? What’s the right combination of hypertension meds? Does this abdominal ultrasound look OK to you? Tomorrow is Saturday and I am on Call again. Please pray for God to supply me wisdom in providing the best care, to know when to ask for help, and to have discernment for investing time & prayer with those who need it. Thank you!!! 

https://drive.google.com/uc?export=view&id=1V9rG_5TPfV24LfiKOB-7-TsUKjExJvLg

Monday, March 9, 2020

Mud Puddle Playdates

It has been an absolute JOY to bring our kiddos back to a place and people so near and dear to our hearts!
Yesterday, we had a blast splashing in mud puddles with some of the Crouch and Thompson kids (I obviously was not thinking clearly when I put Pennie in a white shirt!) ๐Ÿ˜†



 We also had a visit from our friend Apa, who was SO excited to meet Penniella & Solomon.  What a great way to start the week!