Outpatient Clinic

So this past week was my turn to work in the outpatient clinic (OPD). Like Justin, I was given my own room and free rein to see and treat patients as I thought appropriate. Occasionally, I would present the patient to the staff physician working in the clinic that day (usually Dr. Malsol), but I quickly realized that wasn't necessary. After that, I usually just gave her a quick rundown of the patients I saw before I left for the day.

Generally, I saw the usual mix of people that I would have expected in any urgent care type setting - a few diabetics, asthmatics, hypertensives, and your ever present chronic pain patients. But what interested me is the absolute separation of the OPD from OB/GYN. The main reason why this strikes me as odd is because the OB/GYN team works primarily on a schedule full of appointments; they don't squeeze patients in. So what happens if a female patient comes in to the OPD with female related problems? Apparently, not much unless I'm there.

In the first day I saw two patients with OB/GYN related issues - a first pregnancy at 18 (she didn't know, I diagnosed it) and an abnormal vaginal bleeding case. After asking around for the things/tests I needed for the exam and work-up, I realized that my exam room wasn't stocked with those things because they don't normally deal with them in the OPD. The first patient came in with a complaint of vomiting that morning. The nurse brought me the chart and plopped it on my desk verbally assuming I was going to diagnose gastritis and send her on her way with instructions to drink plenty of fluids. As I delved more into her history, I found out that she had just started to be sexually active and hadn't had her period in 2 months. She tried to convince me that her periods were always irregular and there was no way she could be pregnant. I told her I wanted the test anyway to at least rule it out and went in search of a urine pregnancy test. This proved harder to get than I would have thought. I had to ask several nurses and they then had to pull one out of their supplies for outreach clinics on other islands. It was the quickest positive result I think I've ever seen. At this point, I talked to the patient about what that meant and got her in the system for prenatal appointments with the OB.

The abnormal bleeding case was worse in my mind. You can always get a pregnancy test from a pharmacy or grocery store, but there's not much you can do about bleeding except see a doctor. Granted, it wasn't an emergency and she probably could have waited for an appointment, but something like abnormal vaginal bleeding is disturbing enough that I would want it checked out quickly and at least be reassured that I can wait for a more thorough exam by a gynecologist. They even registered her complaint as abnormal vaginal bleeding at the OPD triage center, knowing that vaginal exams are not done in the OPD. Well, they are when I'm there. I noted the patient's history, ordered an ultrasound of her reproductive system to look for overt causes like fibroids or polyps, and went and talked to Dr. Olmo (the doctor I worked with last week) about my patient. I was gathering all the supplies I would need for the exam, but we decided that I would just bring her back to Dr. Olmo once the ultrasound results were back. My patient got her initial exam to reassure her that there was nothing obviously wrong on her ultrasound or on her cervix and was given some medication that will hopefully stop the bleeding and an appointment for a more thorough follow-up in a couple of weeks. I'm not sure what would have happened if I wasn't given her chart. I assume that the OPD physician would have just told her that she needed to make an appointment with the OB/GYN and that's it. She might have given her the prescription for the medicine, but I'm not sure. To me, that would not have been enough....

A Crazy End!

For my very last week of med school!! Whoohoo I thought I would check out the Behavioral Health unit in the hospital. Palau has one of the highest rates of schizophrenia in the world toping out at somewhere around 2-2.5 people/100, and has been the focus of several international behavioral health studies trying to figure out why. The behavioral health unit is kind of an isolated wing alone on the north side of the building. Ward 5 as it’s known as consists of a central office, a small nursing station, a females only room with 3 beds, along with a male room with 3 beds. There are also three other “isolation rooms”, that are the exact same as a concrete prison cell, bars and all. In the isolation rooms they sleep on a wood platform with no mattress. I can’t understand how this would be productive to someone’s state of mind. However, that was the worst part of Ward 5. There were a lot of things I thought they did right, and actually I would say better than in the states. Clearly with only 9 beds, most of behavioral health in Palau is outpatient. They approach the outpatient mission from several angles (please read my post in Dermatology, about how I would vow to never say that again..Damn). Patients are scheduled to come into the clinic every so often to meet with Dr. Wally, who is the one and only doctor who staffs the clinic, and rounds on the patients in the mornings. When she meets with the patients in the clinic she takes about 45min to an hour with each one. She talks to them, gets them to open up, they usually cry and then she offers advice. It was what I wanted to see on my Psyc rotation at Tulane and never did, true behavioral therapy. The clinics I worked at in New Orleans were nothing more than cattle calls for people coming in to get meds, and I always wished we could just talk to people instead of refilling their Prozac without ever making eye contact. Dr. Wally would try to speak a mix of Palauin and English so that I could at least catch some of it. The first patient we saw was a lady in her mid 40’s who was having trouble controlling her aggression at home. She had a pretty tragic history of physical abuse when she was young and had been through a good amount of therapy back in the day and generally doing well for the last 10 years. This year however was the year her daughter turned 11, which was when she was abused, so it was all rushing back. She also had this history of her oldest daughter who was in her 20s sleeping with both of her former husbands. I’ve learned that there seems to be a lot of that going in Palau.

After the first patient, Dr. Wally told me to start seeing my own patients. The first guy I talked to had been having personality issues ever since he was in a car accident a few years ago and suffered some kind of brain bleed. From what I could tell his personality issues had pretty much resolved, and he seemed stable to me. His only complaint was this massive headache that he couldn’t seem to shake. After talking to him for a bit I learned that he met just about every criteria for diagnosing a migraine. I presented this to the doctor and she was a bit taken back because she had been seeing him for a while but had never thought of a migraine. She later thanked me, and admitted that she really never thinks about medical conditions, that are outside of the behavioral therapy realm. It was a bit concerning, I’m not going to lie. What I found more concerning is that when she is “on call”, like she was that night, she is the one running the ER. I will say though that she does an amazing job of connecting with her patients, and is a rather brilliant therapist, so she has a well defined and needed place.

In the afternoons the nurses or social workers head out into the island in search of patients. Some of them never followed up with their appointments, some of them just get daily home visits to receive a shot. This is something else I thought was pretty amazing. If someone in the states falls through the cracks of the mental health system, they are gone, and more often then not wind up on the streets. In Palau they are making an active effort by basically going door to door and making sure that doesn’t happen. I rode around with a nurse named Georgia who was happy to have me along. She took pride in not only telling me about the patients, but showing me around Palau. I was getting a tour where the tour buses would never go. Off the main road most Palauins live in conditions you would expect from the third world, which is mostly run down tin shacks that are barely able to support themselves. Georgia having grown up in Palau under such conditions either knew everyone, or was related to everyone. I also learned that everyone generally just knows everyone. Often we couldn’t find a patient and she would just start asking random strangers, and it didn’t take long. Georgia was also giving me a bit of a dark history about Palau. The only recent violence they have against tourists happened a few years when a Japanese couple was brutally beaten. She explained that most Palauins especially the older ones really dislike the Japanese. She told me about how Japanese soldiers used to torture and harass the native palauins during WWII. I wonder if all the Japanese honeymooners at Palau Pacific Resort are concerned that people might be spitting in their food? Georgia also showed me where the one and only brothel was, which was a restaurant as a front. Funny, because Vanessa and I passed by it and thought about eating there once. Georgia said they definitely didn’t serve any food. She told me one of her schizophrenic patients bragged once that he went in there and had sex with a Chinese lady for $5. To think I had to pay $10, what the hell. On one of our little road trips we went to the Palau Jail to deliver meds to the prisoners. The prison cells weren’t much different than the ward 5 rooms. I guess the guards used to give meds to the prisoners, but of course they weren’t without corruption and soon enough starting selling the drugs or just keeping them for themselves, so the ministry of health cut a deal with the jail to go inside and do it themselves.

Most of the severe schizophrenics in Palau obviously aren’t in the hospital, and the small but courageous efforts of Georgia can’t keep tabs on all of them. What they have come up with is a day program where these people come to the hospital everyday and do yard work and have therapy sessions. The men tend to the grounds, while the women make lunch. They also branch out into the community to do yard work so they make enough income to keep their program afloat. It’s pretty amazing to see a group of mentally unstable people coming together and create a self sustaining therapeutic program. Dr. Wally said it has really been helping them.

The final tentacle that the behavioral health department sends into the community is a 24/7 help line. But this isn’t a normal help line. When it first started a lot of the teenagers asked if they could text message in their problems. Dr. Wally has the responsibility of looking through the transcriptions of these txt conversations every month to make sure the social workers are doing an adequate job. She gave me one of the files to read. It was late in the day when she gave this to me, I had already been dismissed, I was hungry and tired, but when she gave this to me I couldn’t put it down. Most of the txt messages clearly came from teenagers, mostly girls asking for advise about everything from depression to boy problems. One in particular read “how d u get a boy to lyke u?” The response from the help line was “just be yourself and it will happen”. Dr. Wally offered me the invitation to run the help line for a day if I wanted. Unfortunately I ran out of time and never got the chance, but I imagine it would have been a lot of fun. What I found really interesting is that all of the txt messages that came in were serious. Nobody pranked the line, everyone had a real issue, some more serious than others. I told Dr. Wally that I didn’t think it would work in the states because people might not take it serious, she said that people have such limited options here when it comes to reaching out for help that they respect whatever they are given. I also learned that people in Palau due to cultural restrictions never really show any emotion and tend to bottle everything up. With no outlets they eventually fall into some state of misery. It’s starting to seem that parts of this sunny paradise might only be superficial after all.

In my last couple of days Dr. Wally was sick, she called me because she knew I was in her office abusing her internet privileges. She asked me to round on the ward 5 patients, write a note, and call her if there was any issues. So for two days I was the only quasi doctor managing the mental health unit. Most of the patients were stable and my plan was either “continue plan”, or “see orders”. I called her once with a list of things I wanted to change, she agreed and that was really all there was to it. Perhaps it was a nice swansong to med school that my last act was holding down an entire ward of crazies, and that I never actually wound up there myself.

Following The Wind

Last Friday we finally ventured out to a bar. It’s a shame really that we have been here for nearly 3 weeks and haven’t really gone out, but in all fairness every day we have been waking up early to either go diving, or go to work. The bar of choice was this joint named Kramer’s, which apparently is the place where all the tourists/ex-pats go (people that used to live somewhere else and moved to Palau). Our waitress was one of my patients and she introduced us to a couple of people. This one Pilipino girl named Teng pretty much held the social light and decided where to shine it. She was very good friends with this guy we met named Gary who for the last four years had been living on his 45 foot sailboat that he parks in the harbor. Gary is in his mid 50’s, and probably one of the most outgoing people I’ve ever known, one of these people that always has a smile on their face and is laughing at something, or someone. Teng tends to organize small day excursions on Gary’s boat, and I was pretty thrilled when Vanessa and I were invited to tag along for a day of sailing/snorkeling/and boozing on Sunday. We were scheduled to go diving on Sunday, which I quickly decided to cancel for a chance at some real sailing.

After talking to Gary more that night I learned that he has been sailing the pacific for the majority of his adult life. Most of the time he will port somewhere for an extended period of time, sometimes years, find a job either building boats, or whatever carpentry work he can land, when he has enough money he tends to move on to the next island. The only reason I could get out of him that he has been in Palau so long is because it only costs him 300/year to put his boat in the harbor. Gary likes to mention that when he was younger all of his friends and family were pretty disappointed in him for not getting a job/going to college/getting married like he was supposed to. Now that they are all close to retirement Gary has become the envy of just all his friends and family. He has successfully lived a life of leisure sailing wherever and whenever he feels like, and just generally enjoying life.

On Sunday we showed up at the dock at noon. There were about 8 people coming out on the boat, most of whom had already been at the bar for quite some time. The boat could comfortably sit everyone and had a cabin where about 2 people could sleep comfortably; there was even a little kitchen. As we started lifting the sails and getting underway the mood was light and the beers were cracking open. Soon enough everyone was laughing and having a great time. Most of the people on the boat worked around Palau in various bars, or dive shops. Everyone was pretty much a regular when it came to weekend sailing with Gary, we were the only true out of towners. Gary sat back and directed as a couple people drove the boat. I was given a brief lesson in the physics of sailing from Jay, who was in town from Guam for the weekend. He also explained to me how Gary was the master of sailing, and told such stories how he has once sailed for 9 straight days of the Japanese coast in fog so thick he couldn’t see the front of the boat. It was true that when the winds changed he put his beer down, switched hats and started barking orders at people, but quickly went back to laughing and drinking when we were repositioned.

Eventually we pulled up to Palau Pacific Resort, the same resort Vanessa and I bought a membership at, only now it was a bit of a different angle. We anchored in about 30 feet of water and just hung out for a couple of hours, drinking whatever we could get our hands on and eating some pizza. I brought a bottle of Bacardi as a peace offering that quickly disappeared. After an afternoon of snorkeling and swimming and thankfully nobody drowning we turned the boat back to the dock just as the sun was setting. As fate would have it that was the only sunset I’ve seen in Palau that was perfect. Every time we had been at the beach it was too cloudy or raining. What better way to watch a nice round sun melt into the ocean then off the starboard side of an antique 45 foot sailboat as we cruise down the coast.

Back at the dock which was a dive shop, which of course had, you guessed it, a bar. We had a few more drinks. I met Gerald, a German probably about the same age as Gary. Gerald although not as social as Gary, seemed to maybe have more of a fire and need for exploring. He had made the decision when he was very young to be a sailor. In his younger days he had a similar boat to the one he has now which I think he mentioned was about 35 feet. He used to work shipping jobs across the Atlantic and travel wherever he could. He has been doing this his whole life, although he sails now more for leisure then work. He made the case that in Germany perhaps back in the day it was more socially accepted for someone to take a path in life like the one he had lead, unlike the stigma someone would experience in the states for following such a cavaliering mentality. He equated choosing a life of sailing and exploring instead of having a house and a steady job to something as simple as picking a college degree. To him it was pretty simple. I asked him if he would ever stop, or if he had a goal. He smiled and said he would only stop if he died, or met some woman. Meeting people like this that are so free spirited, that have taken the steps and successfully broken free of any social pressures ever put on them fills me with hope and fear. Hope that I might someday live a life like that, and the fear that I actually will

Team XX

This past week, I have been working with Dr. Olmo, one of two physicians that comprise the OB/GYN team at the Belau National Hospital. Despite the small population size of Palau (and thus the low number of annual births), the two OBs are spread pretty thin with all of their responsibilities in the hospital, especially when one goes on vacation or sick leave.

They have a different clinic every day starting at 8am (theoretically) that is dedicated to a certain group of patients. The only exception to this is Thursday morning which is set aside for elective surgeries. Often, the clinic doesn't start exactly on time because the physicians are seeing other patients that have been admitted to the medicine ward or L&D overnight. Mondays and Tuesday mornings are set aside for GYN patients. During these visits, they see women for their annual exams, follow-ups for abnormal paps, or for abnormal symptoms like bleeding or discharge. Tuesday afternoon is dedicated to post-partum visits during which they examine women who delivered 2 or 6 weeks ago and discuss contraception planning and breastfeeding. Wednesday mornings they see high risk prenatal patients - women with gestational diabetes, preeclampsia, a history of miscarriages, etc. Wednesday and Thursday afternoons are for regular prenatal visits, and Friday mornings are dedicated to women who have scheduled their first prenatal visit for the pregnancy.

At any point during the day (i.e. during clinic), the physicians can be paged for emergency admissions, surgeries, or deliveries. Luckily, I haven't seen this too often during my week, but I can easily imagine how that must completely throw off their schedule. It is also very difficult for them because other employees such as the clinic nurses or OR techs do not comprehend the scope of their responsibilities. The world of these ancillary employees is centered around their one responsibility (the clinic, the OR, etc.), so they do not understand why the OBs might be late or why it is absolutely imperative that things start on time if they are available (particularly the surgeries). I have heard many stories over the week in which the OB shows up to the OR for her scheduled elective surgery only to find that the patient has not been wheeled back and the OR nurses/techs are hanging out eating breakfast. The cascade then begins - the surgery starts and finishes late, the OB is late to clinic, the clinic nurse pages her overhead with patients waiting, and so on. What a difference a larger group of physicians (especially residents) make when running a clinic and L&D ward!

As you can imagine, their days are pretty busy and I have used this week to work on my speed with patients, particularly during annual exams, while maintaining comprehensiveness. Lots of pap smears, Leopold maneuvers, and recording of fetal heart rates. Surprisingly, I'm not sick of it at all.....I guess that's a good sign for residency!

Storyboards

One of the traditional Palaun buildings is known as a bai. It is a completely wooden structure - no metal is used at all during construction - that served as a men's meeting house. The walls, both inside and outside, and interior beams are decorated with colorful stories and motifs that depict the legends from all over Palau. Generally, each village would have one that served as the meeting place for the clan chiefs of the village. In the bai, they would congregate and discuss important matters affecting their communities.

In 1929, a visiting Japanese artist and anthropologist became enamored with the carvings and paintings on the bais and was very sad to learn that the Palauns were no longer building them. He then introduced the concept of carving similar scenes on pieces of wood and selling them to the Japanese in Palau (Palau was under Japanese administration at that time). These carvings became known as storyboards and are now considered a traditional art form of Palau. Today, they are carved by master carvers and their apprentices (or prisoners in the Koror jail if they've been good) on local wood - usually mahogony or ironwood - and display images of the local legends and myths. They can take anywhere from a couple of days to several weeks depending on the size. Sometimes, the piece of wood is carved into a shape like a turtle, manta ray, or fish before and then the legend is carved on the body of the animal (like a carving within a carving). To finish the storyboards, they are sometimes painted to add splashes of color or they are left with their natural wood finish. Shoe polish is usually applied to protect the wood and make it shine.

Justin and I have been keeping our eyes open for some storyboard to bring home and we finally found some. We went to several places, but our favorites were from the Tebang Wood Carving Shop, where you can watch the carvers work. We looked at the Koror jail gift ship where inmates who've displayed good behavior can carve and sell their storyboards, but surprisingly, they were more expensive and usually not as good. To be fair, some of them were quite good with a lot of detail and depth in the carvings, but those were usually in the thousand dollar or more price range. Anyway, we found three that we liked and managed to bargain for a price of $115 each (down from $150 each). Admittedly, I didn't do much of the bargaining - that doesn't seem to be a forte of mine but I better work on that since I've been told that absolutely everything in Southeast Asia is negotiable. Justin bought two carvings on wood that was shaped like a turle that tell the legends of the Ngibtal Tree and Ngemelis and the . I bought a rectangular one that also has these same two stories carved on it. Mine has both a turtle and a manta ray carved in the rectangular piece of wood with the legends carved within the bodies (I guess that becomes a carving within a carving within a carving). Now, we just have to figure out the best way to ship them home!

Paradise Interrupted

Many of the clinics on the remote Islands were built within the last decade or so. Much of the disease they have seen within this time has been what you would expect, a steady diet of hypertension, diabetes, coughs and colds. But just imagine if these clinics were older, much older. What if these tiny clinics had been around for 100 years? What kind of stories would the walls tell? If I could choose to be a fly on the wall in such a clinic it would be in Peleliu during September of 1944.

Peleliu marks one of the bloodiest battles in the history of the US armed forces. Peleliu is at the southern end in the Palau archipelago chain. When the Japanese took over during WWII they utilized Peleliu for its harbor and airstrip making it a vital point for the Japanese command. As the US pushed into the Philippines there was concern about the stability of their flank to the east. It was speculated that the Japanese could move ships from Palau into the Philippines to intercept US forces. Several Generals disagreed with this threat, but the decision was made to invade Palau anyway. On September 15th 1944 Marine divisions landed on Peleliu. They expected a three day battle to take the island. What they didn’t expect was how dug in the Japanese were. Through an intricate series of caves, tunnels, hidden machine guns, and booby traps, the Japanese had rewired Peleliu into a nightmare for any invading force. As the marines landed on shore the Japanese opened steel doors on the mountain side revealing a wide arsenal of motors and 47mm guns that cut whole marine divisions apart, some losses are quoted to be as high as 70%. The expected 2 day battle dragged on for over two months. Losses were astronomical on both sides as guerrilla warfare was being redefined.

So just imagine the doctor sitting in this clinic. He is used to the same diseases that we see today on Peleliu as mentioned before, but over the last few months he has been treating more and more Japanese. His practice is doing well. He remains neutral in the war, and ultimately enjoys the infrastructure the Japanese have brought to his Island. One rather calm night in September is quickly interrupted with the sound of crackles in the distance that he assumes are local kids playing with fireworks. Suddenly he hears a blast and the whole building shakes, knocking medicine off the counter. He knows something isn’t right. The sky starts to light up with shells and he knows what’s happening. Just then a Japanese solider pounds on the door. When the unsuspecting untrained Palauin doctor opens the door the horror of war is literally brought to his footstep as this 19 year old solider falls into his clinic holding his intestines as they try to escape from his body. The next 48 hours are sheer mayhem for him. Every floor space of the clinic is full with bodies, some with cuts and scrapes, others long deceased. Now as if you had a remote control, hit fast forward. The wounded Japanese are soon replaced by Americans, after several more months things calm down. After several years the clinic is forgotten about. Decades later the indigenous population starts to repopulate and rebuild as it once had. In the 1990s The Palauin Government restores the same clinic. Years later a 4th year medical student from the United States gets on a two hour boat ride with an Air Force PA to staff the clinic for the day that is now only open once a week. They see the same diseases that the now traumatized doctor saw in 1943, only a year before he knew how much blood the human body could hold. The clinic is actually quite well maintained as far as drugs are concerned. The PA is from the Air Force Civil Action Team, or CAT for short. He is the medical element to this small deployment of engineers, but once a week he leaves the unit and works in some of the distant indigenous clinics. He brings a supply of drugs that he is given through the Air Force and the ministry of health. So actually the remote clinic in Peleliu to some extend has better access to drugs than the hospital in Koror. There are of course quarks in the clinic. I had to blow the spider webs out of the otoscope before I could look in someone’s ear. The diseases for the most part were fairly benign. The most interesting of the 10 patients we saw being a huge ganglion cyst, a case of viral arthritis, and of course fungal infections.

The island is peaceful, the island people seem happy and fat. The battle of Peleliu code named “Stalemate II” is now only held in memory by a small but significant war memorial museum. The museum’s hours of operation are based on calling the rangers to come open it up. There is a single shelf lining a series of hallway that holds rusted pieces of artillery, random articles of clothing, and gear found in the woods. Most impressive are the stories that line the walls. Mostly from news paper articles or the personal memoirs of marines that fought on the island. They tell a graphic depiction of how what seems like a tropical paradise now was at one time the bloodiest battle in the pacific. The battle of Peleliu is also remembered by the unexploded munitions that are peppered throughout the dense jungle all over the island. There has been very little excavation work to uncover some of these caves and battle sights. The jungle has reclaimed most of it anyway. A few years ago a tourist came to the island retracing his father’s footsteps in the war. He found caves full of human remains and Japanese relics of war. I think the Japanese government still has a standing request on the island that if any relic is found to ship it back to Japan. It would be a fascinating experience to explore the jungles of Peleliu searching unexplored caves for these artifacts. Too bad I don’t have more time.

Update on Meconium Aspiration

I’m now working in the OB/GYN service so I had the opportunity to find out more about the Meconium Aspiration case from my first week here. As it turns out, there was a lot that the pediatricians didn’t know.

As I said in my earlier post, this was the patient’s first pregnancy and she was a little over a week post term. The OB had performed a biophysical profile (a detailed ultrasound) the week before (week 40) to evaluate the baby, the placenta, and the amniotic fluid level. At that point, the baby was measured at 8lbs 8oz with a good heart rate. The amniotic fluid level was 15 (this is considered normal). Everything seemed to be ok, so the OB scheduled the mother for repeat non-stress tests (NSTs – monitoring contractions and fetal heart rate) every 3 days to make sure that the fetus was ok while she waited for the onset of labor. The patient missed her appointment on Tuesday – what would have been her second NST. Instead, she presented to the L&D with strong contractions.

When she got to the hospital, she was strapped to the fetal monitor which showed lots of decelerations indicating that the fetus was in distress. They administered oxygen, IV fluids, and put the mom in the lateral position to increase blood flow. At this point, the fetal heart rate returned to normal. The mother was still have regular contractions and was dilating normally. The OB planned to rupture the amniotic sac when the mom was dilated to 4-5cm (this is sometimes done to augment labor). When she performed the amniotomy, she noticed that there was scanty amniotic fluid despite a bulging amniotic sac and a normal amniotic fluid level one week before. She also noticed that the amniotic fluid was stained green. She knew immediately that the baby had passed meconium in-utero. She immediately scheduled the mom for an emergency C-section, but the baby had already aspirated the meconium. He was 9lbs 15oz at birth (quite a growth spurt!).

So, based on the patient’s presentation and the information obtained, the OB did everything appropriately. One could still ask why a C-section was not performed earlier (at initial presentation and signs of fetal distress) but the fetal heart rate returned to baseline with normal accelerations after the administration of oxygen and fluids. Would an American OB have gone straight to the OR? Maybe, but we often say that American OBs are too quick to rush patients back for C-sections rather than letting them labor down. Which is the right way? Unfortunately, there isn’t one – it’s a call based on clinical judgment and either one would be criticized for different reasons. Sadly, the cost in this case was high.

What New Posts?

Just wanted to let all of our avid readers know that there will be more new posts soon. Justin and I have been using our internet time over the last few days organizing our flights out of Palau and into the mainland of Southeast Asia. We've decided to make a brief detour to Bali for a week....I know, what a hard life we lead. Anyway, now that it has all been organized and the tickets bought, we will be posting about our recent escapades both in and out of the hospital shortly.

Micronesia Anesthesia Society

As of last night, Justin and I successfully completed the Micronesia Anesthesia Refresher Course that has taken place over the past week. Last night was the conference dinner during which laminated certificates were given to all the participants who completed the course and prizes were handed out to the person who performed the best on the daily quizzes. To our surprise, Justin and I were included in the recipients of said certificates. The fact that we've never taken the introduction - or "freshener" course as we like to say - was of no consequence.

As Justin mentioned in an earlier post, it was a very informative conference on many levels. My exposure to anesthesia is minimal at best, so I feel that I've actually learned something about the medications used, why these particular medications are selected, and what can happen in an OR that anesthesiologists need to be prepared for. The lectures were geared toward people with similar skill levels to mine despite the fact that they've already been working as anesthesiologists or nurse anesthetists (like Justin said, the retention level between conferences seems to be low). It was also an eye opener to the limitations that these people have to work with. Their training is inadequate, their drug supplies are abysmally low, and their facilities are disastrous. They don't perform nearly as many surgeries as more developed areas, and, thankfully, they easily recognize when they are over their heads and need to refer patients to places like Manila or Hawaii for better care (which they do without any second thoughts). They do the best they can with what they have, though, and I find that very admirable.

On the last day of the conference, the Aussie physicians organized a little game of Jeopardy as a fun way to end a long week. They picked an assortment of categories - some related to the topics they had been lecturing on all week and others completely unrelated. There were categories on history, geo-politics, and the history of anesthesia as well as more medically oriented ones. In an effort to let the others focus on the medicine they had just learned, Justin and I tended toward the history and geo-politics topics, especially the geo-politics category. I soon realized that I was going to be useless because every question had to do with either some obscure historical fact about Micronesia or it involved the military. Thankfully, the Aussie judges were very liberal with their hints (and their scoring) and all the other teams tried to help each other out as well. One of the questions had to do with the location of the US star wars program and all that came to mind was the skit in Edie Izzard's Dressed to Kill about the Death Star. I didn't think the Death Star was the right answer so I just stared at Justin until he made a guess (with a lot of help from the representatives from Yap). Needless to say, Justin and I had a strong finish in last place :)

The Anesthesia Minimum

At the start of this week there was very little direction with concern to what I was actually supposed to be doing. Not terribly wanting to commit to one service for the week and risk being bored to death by a small uneventful patient load or being trapped in an OR, I headed over to the clinic where I could more or less pick and choose what I wanted to do. I started working with this Doctor named Jonathan who I found out was actually a Pathologist. He was functioning as a Family Physician helping out in clinic for the day. If I was in the states and a pathologist was working in a general clinic seeing patients that would be like, well, actually that would be like a pathologist seeing patients, its about as absurd as anything I can come up with. He informed me that he usually works in the clinic for a couple of hours every day and has been for the last 9 years. I asked him about the path lab before we started seeing patients, he told me they ran out of stains and the only thing he can look at are gross specimens. As we started in the clinic I was expecting a train wreck and I would have to bite my tongue so hard it would come off. To my flabbergasted surprise this pathologist was heads and tails the best clinician I have yet worked with in Palau. He was able to take his knowledge in pathology and apply it clinically. Everything he diagnosed he was able to go through the mechanism of how the disease worked and how the patients present. It made me wonder that although pathologists never interact with patients I wonder if most could work a clinic if they really had to, granted they remember which side to listen out of a stethoscope.

That afternoon I was planning on going back to clinic, but was informed that there was an anesthesia conference going on in the library that might be worth checking out, Vanessa was already there. The conference was actually a week long event, it was actually pretty cool. These two Anesthesiologists and Surgeon from Australia were running the thing. The concept was to bring other Anesthesiologists and Nurse anesthetists from other islands in for the week and run through a training seminar. There were about 10 others there from places like Yap, Chuuk, and as far as the Marshall Islands. They represented all of Micronesia. This conference is actually held every other year on different islands. One of the Australian doctors Arthur said he had been doing it for several years, and the faces are usually the same. The main concept of the week was more about establishing a system of professional support for these people rather than truly trying to educate them. Most of them work in these rather remote islands in rather awful medical conditions in complete isolation. They are also under educated and under equipped for the jobs they are doing, this became apparent very quickly. Islands like Yap and Chuuk can’t do simple things like blood gases, nor do they have anything outside the most basic of drugs and gases. Often times the doctors from these first world countries would start talking about a tube or drug that is basically considered standard of care in many other places, they realized that no one in the room had access to what they were referring. They couldn’t really do anything else besides look at each other and move on to another topic. Palau is no exception, and they lack just about as much as the rest, occasionally they have a couple things that no one else has.

I learned that conditions in Chuuk are the worst; they don’t even have running water in the hospital. But, I was shocked to find out that Chuuk has 60,000 people, which is three times more than Palau. While Palau is a fairly safe place where you can walk around at night with no issues, the same night time walk in Chuuk and you might find yourself with what they called a “phillipinni” through your chest. It’s basically a tire iron straightened out and sharpened and then they launch them at each other with these sling shot like contraptions. Now imagine this thing sticking out of you and being rushed into a hospital with no working utilities, and a skeleton staff that has no capabilities to handle such a trauma. The anesthesiologist that never did any official training in the field comes to prep you for surgery. You see him push some drug into your IV which is the only kind they have, in your last image you see what the drug was and knowing a little bit about drugs you think wait I shouldn’t get that drug because… and you pass out. In Manila you might wake up, in Chuuk you just saw your last cockroach scurry across an operating room floor. The World Health Organization is well aware of the health care disaster is this area, and like most areas of the world the problem revolves around corruption and money. The WHO and Federated States of Micronesia pour money into places like Chuuk but the local government is so corrupt that hardly a dime gets to where it’s intended. You just flat lined on the operating room table, but their defibulator broke about a month ago.

I was actually impressed with how the Australians had organized the week. Every modern well proven method of learning module was somehow in play. We did review questions, had problem based learning sessions with fake scenarios, watched DVDs, and of course death by powerpoint. At one point they asked Vanessa and I to act out scenarios and the participants would each take turns working us up like a trauma patient and running through the basic ABCs of trauma (airway, breathing, circulation). It was fun, the Aussies hammed it up and all had a good laugh with some of the scenarios. Although it was a bit scary at times when some of these Anesthesiologists who were MDs did not understand the simple concept of how to access the Airway, Breathing, and Circulation in that order. Arthur told me later that he teaches basically the same course every other year to what is basically the same group of people and little is retained. So these guys do what they can to teach the trade. If nothing gets through at the end of the week they have at least helped the group establish some kind of professional comradely, and at a very minimum give an email address or two so they can ask questions later. But I think Vanessa and I have enjoyed it because we actually are learning a good deal about anesthesia and getting a lot of review at the same time. We are also getting another lesion about the challenges in this region.

Les Poissons, Les Poissons

On Saturday, Justin and I went to Fish’n Fins for our final two dives before becoming certified divers. As per routine, we joined a boat of much more experienced divers headed to whatever destination had been planned for them. Actually, Justin and I have decided that there isn’t much planning when it comes to the destinations…..just a vague outline. This method seems to work pretty well since the diving instructors know the dive spots like the back of their hands and this freedom allows them to change destinations if there is anything unsatisfactory about the original one (current strength, direction, high vs low tide, etc.). That day we were headed to (conditions permitting) the New Drop Off and Blue Corner, which is considered one of Palau’s best but most difficult diving spots. At Blue Corner, you can see the widest selection of aquatic life, but there is also an extremely large current which requires you to use a reef hook. A reef hook is essentially that – a hook that you catch on the reef (a non-living section of it) that also has a long cord attached to it which you clip to your diving gear. This allows you to remain in a hovering position despite the current so that you can watch the sharks, fishies, turtles, and other animals swimming by. This time I came prepared with a good quality mask that I purchased at a local dive shop. As we all know, I have an incredibly small face (thanks mom) and had to use a child’s size rental mask on the first few dives. Width wise it was decent fit, but it was a bit too short and was starting to hurt my nose.

We set out at about 9am under a canopy of ominous looking clouds. Alain, our diving instructor, assured us that bad weather on the surface meant calmer conditions underwater. I’m still trying to figure that one out, but somehow he was right as the currents at both locations were supposedly not as strong as they sometimes are. Our first stop was the New Drop Off, also called West Ngemelis Wall, with a steep drop off (as the name suggests) starting around 5-10 meters. We stayed pretty close to the wall and got a good look at the colorful soft coral and hordes of fish swimming around it. There was a huge school of Redtooth Triggerfish, dancing in the water against the current. They are incredibly beautiful but can be quite dangerous if they feel threatened or protective. Alain actually had a piece of his ear bitten off by a triggerfish (not the redtooth variety) on a dive several years ago. He said that the big ones can even bite through a scuba fin, which is fairly solid rubber. We saw a variety of brightly colored fish – lots of butterflyfish like the Threadfin Butterflyfish and the Yellow Longnose Butterflyfish, some clownfish, yellow and blue surgeonfish, a giant turtle, more schools of barracuda, and of course more reef sharks. This list doesn’t even begin to really cover all the different species of marine life that we saw, but, despite Alain’s frequent use of his white board to write their names down for us, there is no way that I can remember them. We did manage, however, to take pictures of some of them. Justin made sure to charge his batteries and bring his camera, regardless of how boring Alain said the dive would be. Of course the pictures don’t do the fish justice. The water is amazingly clear and blue – in shallower water you can see to the bottom quite clearly – but the colors just don’t seem to come out as bright when you’re deeper, even with a flash (which isn’t that strong on a Cannon powershot apparently). We would have needed additional lighting, or the several thousand dollar underwater housing to Justin’s really nice Nikon camera, to make the colors as bright in a photo as they really are.

Our second dive was at Blue Corner – a site that is on almost every single “top 10 dives of the world” list because of the sheer volume and variety of fish that you can see in just one spot. That and the fact that the dive can be different every time you dive it. We dove down and slowly made our way to the coral shelf that then drops off at about 17 meters or so, fighting what I thought was a decent current (but apparently wasn’t very strong at all). Alain helped us “hook in” with the reef hooks and then we just hovered against the current watching the most awesome array of fish swimming harmoniously amongst each other. Some were the same from the previous dive, but there were a few others that we hadn’t seen yet. I saw a beautiful fish that was brown on the upper half of its body and had perfectly formed white circles on the bottom half. It turned out to be another triggerfish – a Clown Triggerfish. I also saw an eel hiding in the coral as some fish swam around his small opening. There were, of course, more sharks, but this time one of them had a couple of baby reef sharks swimming underneath her, trailing her every move. There were some huge variety of tuna, giant trevallies and an enormous green looking fish called a Napoleon Wrasse that seemed to take a liking to us. Even after we unhooked and swam away, it seemed to follow us. It was definitely a popular spot among the divers. There must have been several dozen of us hooked in to various areas of the reef, mesmerized by the scene playing out before us.

After we surfaced, we went to the “swimming pool” where we had practiced our underwater skills the week before to eat lunch. By this time, the weather had definitely taken a turn for the worse. It was windy, rainy, and cold. Thankfully we didn’t stay there very long since they had also planned another trip to Jellyfish Lake, which is somewhat shielded with calmer waters and less wind. Justin and I decided not to go up this time (we were both cold and he wasn’t feeling well – he had a massive headache). Alain stayed back with us and we hung out with the rangers in their little office. They felt bad for Justin – he was shivering – so they gave him some hot ramen and tea to try to warm him up. When the rest of the divers finally came back down, we headed home. I have to admit that the boat ride back was fairly miserable. Riding uncovered in a speedboat through the rain is less than pleasant. The rain drops feel like tiny needles hitting your skin and you can’t warm up. On top of that, each wave we went over (and there were a lot of them when it was that windy) made Justin’s headache even worse. Thankfully, we made it back to dive shop fairly quickly (with one short interruption where we ran out of gas and had to look for the spare gas tank stored on the boat) and Justin was able to get some medicine from one of the dive pros who suffers from migraines. The medicine has codeine it, so Justin soon felt better - or at least he didn’t care about his headache anymore. After we had rinsed off and returned all of our rented gear, we had our last little meeting with Alain during which we got our temporary diving cards. We are now certified divers!!!

Despite the conditions at the end, it was an awesome day. I think that New Drop Off is my favorite dive so far; the coral and fish were just so beautiful. We’re not sure when our next dives will be, but I’m sure that we’ll try to squeeze in a few more before we leave Palau. And be patient with us on the pictures….we have them and you will too eventually.

アンガウル(Angaur)

Once a month a team from the hospital ventures out to one of the remote islands in the Palau archipelago know as Angaur. They do a variety of different things each time they go. Sometimes they do general checkups, other times they administer vaccines. Last Thursday a boat departed on a cold raining morning heading to Angaur to do cancer screening for prostate and cervical cancer. A couple days before Vanessa and I got invited to tag along if we wanted. I jumped on the chance to break the already redundant routine at the hospital. We were told very little before we left, we only knew it was about a three hour boat ride, and we would possibly be sleeping in some kind of clinic. We assumed things like food and water would be taken care of, we turned out to be only semi correct.

When we got to the dock it was raining with no signs of letting up. There were 15 of us going in total and about 10 of the women were clustered around some of the gear we were taking not looking very enthused about the impending boat ride. It turns out they were actually debating about cancelling the trip because apparently our boat captain had never been out to Angaur, or had never navigated in rough seas, not sure which one, maybe both. The boat finally pulled up and it was a shell of the boat I thought it would be. It had a fiberglass hull and could sit maybe 8 or 9 people comfortably, there was a canopy for rain, but it wasn’t much, it didn’t matter anyway as the rain likes to come down sideways here. For two hours I sat there curled over my backpack inside my green poncho trying to stay warm and dry. I learned that it wasn’t really that waterproof after all.

The clinic we were working at was right next to the dock, it was no more than a couple random 2-3 room buildings by the sea. The town itself was a intermesh of backstreets that cut through the jungle, somewhere between 200-300 people lived. I got mixed reviews every time I asked how many people lived there. The only one thing I got was that there are 23 families on Angaur. As we sat on the dock an ambulance approached to pick us up, you have to pretty much let an western idea you have of an ambulance go to understand this thing. It was some kind of minivan from maybe the early 90’s with two folding benches in the back that could comfortably sit about 5 people and lay someone down on the floor. There was of course a working siren and light. I kept thinking, but never asked what they would do with an ambulance here. Where are they taking someone besides down the street to a clinic that has no supplies and is usually ran by a nurse practitioner. The ambulance took us to a house were all 15 of us would be sleeping, it was a decent size ranch with about 3 bedrooms, naturally there were mattresses scattered everywhere.

The clinic was run out of both buildings, female exams in one, while the other was going to be used to question the males about prostate cancer and STI screening. Naturally the male side was only staffed by males and vice versa. We set up a series of tables were patients would come in have their history taken, get blood drawn for Prostate specific antigen, pee in a cup to screen for STIs. Lastly they would come see me off in a separate room where I would ask a series of yes or no questions that addressed prostate cancer risk factors. Some where pretty personal like does it hurt to get an erection, or can you still get it up, while others were basic like how many times a night do you pee. Most of their English was pretty good, but of course the one word they didn’t understand was erection. Using tactics learned from world traveling I ventured into charades, making my finger limp then straight while saying “during sex?” They understood this, but I found it much easier to learn the palauin word for erection which is Deorse, bringing my vocabulary to two words. I’m not sure what kind of native conversation I can have if all I know how to say is erection and thank you, or at least I don’t want to imagine the conversation.

During these questions I noticed some actually pathology a couple of times and attempted to play doctor rather than defender of the prostrate, or erection linguist. One guy had some simple contact dermatitis which I gave him, or to my disbelief sold him a tube of hydrocortisone cream. Another guy was complaining of shoulder pain. It turned out that it was actually coming from his neck and his left arm was starting to go numb in the pattern of one of the nerves. This can happen if any of the tunnels that your nerves travel through going from your spinal cord to there final destination are narrowed. It suggested that this guy might have a real neck injury that could get much worse and might have some permanent nerve damage if not careful. Once I discovered this I knew the text book answer about what needed to be done next, what imaging he should get and what other fancy tests and drugs to give. But, I was on Angaur, we had Advil and the best diagnostic machine we had was limited to the sensitivity of our fingertips. The guy of course didn’t want to go to Koror where he could have got maybe half the tests he needed, for the other half and possibly surgery he would need to be shipped to Manila. So I did what I could, instructed him to take the highest dose of Motrin, use warm compresses (he did have some real shoulder stuff going on as well), and that if it got any worse he had to take action for himself, I did my best to scare him. Outside of that I had nothing to work with. I’ve learned that the lesson is always the same and it stretches from the jungles of Nicaragua to some lonely Island in a tropical paradise. No matter how much advancement are made in Beaumont hospital or what new procedure is thought of at Methodist in Houston, most of the third world will never experience such care. The true challenge we face is not advancing technology or our puppeterring of drugs, but figuring out how to spread existing treatment and technology across the globe. Access to health care, be it New Orleans or Palau is and always will be the paramount world health issue. Ok, enough ranting.

After the clinic was over at 5pm there was a break before the women’s side opened up again to see if any women came in after work. Everyone was hanging out and some of the nurses told the story how they had a problem with sex education in Palau because they used to show people how to put on condoms in school by using bananas, much the same way they do at home. I guess something was lost in translation because kids started thinking all they needed to do before having sex was to put a condom on a banana which I guess they then put by the bedside. It wasn’t until they hired one of the local wood carvers to build a carving of a penis that they could use in sex Ed. I guess there aren’t too many carvings of penises in the grocery store, so the message caught on.

For dinner that night people from the village brought us traditional Palauin seafood that had a wide variety of edibility. There were crab cakes, whole crabs, rainbow runner fish, fresh tapioca, and some other things like sea cumber bathed in vinegar I didn’t quite get.

That night two of the public health workers, the two Korean medical students that came along, and Vanessa and I all got in the party ambulance and went to the one local bar. This place was more of a fabricated patio then a bar. About 30x30feet, someone just built a wood structure that could function as a bar. It was however very well done and the attention to detail was impressive, there was a pool table, a karaoke machine with speakers that could reach to the far sides of the Island and some pretty nice patio furniture. The two Palauins that came were desperate to get the karaoke machine running, and it was a celebration followed by 3 hours of misery when they did get it working. I promised Vanessa I wouldn’t go into too much detail about how she sang karaoke sober, or how for one magical night she kept half the island up with her pipes.

The ride home from Anguar was the opposite of the way there. It was a rare sunny day without a cloud in the sky. I sat at the front of the boat, and even though the ride was only about two hours and I put sunscreen on once, my face burnt to a crisp and I learned my lesson about equatorial sun.