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.
Friday, February 27, 2009
Thursday, February 26, 2009
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
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
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.
Tuesday, February 24, 2009
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.
Saturday, February 21, 2009
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 :)
Thursday, February 19, 2009
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.
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.
Monday, February 16, 2009
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.
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.
Meconium Aspiration
Sorry for the lack of posts, but as I’m sure you can imagine, internet access is limited and the blog is blocked from the hospital. That, and we've been enjoying ourselves on some very necessary excursions and diving tours. So basically, I have quite a few posts to catch you up on…
On Wednesday morning, I arrived at the hospital (in the rain again) and went to the nursery to start seeing our pediatric patients. The doctor and most of the nurses were in the nursery around one bed, and I thought I noticed that they kept dabbing their eyes with tissue. As I entered the nursery, I quickly realized why they were all congregated around that one bed. On it was a newborn baby who had been intubated and strapped to a heart monitor; the nurses were manually bagging him. The doctor quietly brought me up to speed as she wrote her note on the recent events.
The mother was brought to the hospital on Tuesday afternoon by the midwife, who felt that the fetus was in distress after she had attempted to induce labor. The mother is a 26 year old G1P0 (that means that this was her first pregnancy) at a few days past 41 weeks (post-term). When she got to the hospital, they gave her fluids and strapped her to a fetal monitor which showed strong contractions but that the baby’s heart rate had flat-lined. They quickly put the mother on her side to ensure that the abdominal aorta wasn’t compressed by her uterus (to increase blood flow to the baby) and the baby’s heart rate returned but it still wasn't too promising. At this point, and the pediatrician didn’t know why, the OB on call decided to monitor the patient rather than perform an immediate C-section. A C-section was eventually performed later that evening, during which they discovered the baby had passed meconium in-utero, probably several hours earlier as the baby’s skin, mouth, and umbilical cord were tinged green. He immediately went into respiratory distress, was intubated, and put on a ventilator. A chest X-ray showed extensive chemical pneumonitis bilaterally, both his lungs were basically whited out. For those of you reading this blog that are not doctors or medical students, meconium is that sticky green stuff that comprises the baby's first poop. Normally, it is stored in the baby's intestines until after birth, but sometimes the baby passes it in response to fetal distress while still in the confines of the uterus or during labor. When this happens, the baby inhales the contaminated amniotic fluid and the meconium reeks havoc on the his lungs (among other things). It acts as a physical obstruction in the airway, causes surfactant dysfunction and thus impedes gas exchange between the lungs and blood, irritates/inflames the lungs causing a chemical pneumonitis, and causes pulmonary hypertension. It's very very bad.
The pediatricians tried suctioning the mouth and trachea to remove the meconium and used positive pressure ventilation to force air into his lungs, but there just wasn’t much improvement overnight. Repeat X-rays only showed minimal improvement of air movement in the bases of the baby's lungs despite all that work. It was such a bad case. Dr. Mungal said that the baby’s lungs were so stiff that at one point the ventilator machine wasn’t even working very well. When I arrived that morning, they had recently made the decision to stop all life support measures. It was an incredibly sad moment for the family and also for the physicians and staff who work at the hospital. Palau’s population is only approximately 20,000 people (most people seem to know each other) and its birth rate is pretty low (I've been quoted about 300 births per year). Because of this, the labor & delivery and nursery staff seem to become very emotionally attached to their mother/baby patients. It was touching to see how personally the staff took this enormous loss and how much they supported the family. While I know that the family is still mourning, I hope that they have found some measure of peace since that sad morning.
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