Papua New Guinea is a land covered in mountains and rainforests.  Typically the monsoon rains roll out across the Pacific from southeast Asia and keep PNG soaked.  Our year here is marked by two seasons “rainy” and “dry.”  Dry season usually meaning it only rains 2-3 times per week instead of twice a day.  This year is quite different.  The monsoon season that usually will run through June ended early with very little rain in June-September. This included a five week stretch without a drop.  This abnormal weather is being caused by one of the most significant El Niño weather patterns in recent history.  While other parts of the world are flooding PNG is on pace to have one of the driest years in its’ history. Similar droughts having occurred in 1964 and 1997. In a place where almost everyone relies on their gardens for most of their staple food this is starting to become a real hardship with many families going hungry. The staple food here is kaukau, very similar to yam or sweat potato, which is harvested four times per year. One growing cycle has been completely lost and another is in jeopardy. Imagine how this affects a place that has no familiarity with drought and where most homes are still without electricity. This country’s ability to cope with drought and famine is not present.  We need rain and need it badly.  I can not recall every experiencing first hand how important water is. We’ve begun seeing increasing numbers of infectious diseases related to the worsening water supply.  As small streams are drying up and people are utilizing the bigger rivers nearby much more heavily the contamination in these water sources is mounting. The Kane, our river, is now so low that even with the new reservoir the hospital’s hydro is not able to produce enough electricity to keep the station and hospital powered.  We have resorted to running on generators for long stints when the water level is too low.  The hospital’s backup generator is in the process of being replaced as the current one is well beyond its’ lifespan.  Usually the generator kicks on in a few seconds when the power goes down but today the auto switch was not working. The lights were out for several minutes in the operating theatre. Today, I was thankful for battery powered headlamps and a battery backup for the anesthesia machine.  I was also reminded of one of my favorite quotes from a seasoned missionary surgeon, “Anyone can operate with the lights on.”

When you turn on your faucet and water comes out, flip on a light switch and the lights come on or enjoy the luxury of flushing a toilet,  remember to pray for rain in PNG.

In my short career as a physician I have offered to pray with countless patients.  I remember feeling a bit apprehensive about this in my early years of medical training.  Would he be offended?  Might she say ‘no’?  What if a nurse (or worse yet, my preceptor) walked in while I was praying with a patient?  But very quickly, those moments of solitude and connection with patients and their families became my own refuge.  I would look forward to opportunities to provide this gift of prayer to those who desired comfort and peace in some of the most lonesome days of their lives.  And since that very first day that I, a timid medical student, sat at the bedside of a terminal patient and prayed a quiet prayer, not one patient or family member has ever declined my offer.  I believe there’s a message there!  Particularly in the medical world, prayer opens doors and creates a space that is safe, accepting, whole and impartial.  Prayer allows for the most unique opportunity to commune with the One who makes all things new, whether in body or spirit.  Now that I’ve transitioned into this life of medical service in a mission hospital  you’d be correct to assume that the opportunities to pray with patients are countless and precious.  My challenge at the start was to learn how to pray in a new language and meaningfully express what I could easily articulate in my own language.  I still find myself paying close attention during prayers in church or when I’m working with one of our hospital chaplains as they comfort a patient.  There are certainly times when my Tok Pisin words are not enough, but thankfully, God hears prayers in all languages, including those of the heart.  In the last two weeks it seems that I’ve encountered some of my more sweet moments of connection with patients and I hope that these glimpses into my clinic exam room will serve as a reminder to pray for our work in the hospital as we minister to both the physical and spiritual needs of our patients.

Maria came to my clinic room with her son one morning.  As she entered the room, I hoped that she might share that she was here for an antenatal visit.  Unfortunately, this was not the case.  She was not pregnant.  For several months now she had slowly been accumulating fluid in her abdominal cavity and she also complained of right-sided pain.  She had been seen in several other medical facilities and at the last hospital where she was evaluated, she was told she likely had abdominal tuberculosis.  As I heard her story and examined her full-term-sized abdomen, the diagnosis of abdominal tuberculosis rose to the top of my differential diagnosis.  However, as I got her comfortable on the ultrasound table and moved the probe over her right-upper quadrant, the abnormal appearance of her liver suggested that her diagnosis was unlikely Tb and more likely chronic liver disease.  I had hoped it was tuberculosis, because we have treatments for this very prevalent disease.  Chronic liver disease in this middle-aged woman will come with many doctor visits and likely hospitalizations as well.  She’ll be on diuretic medications for the rest of her life and eventually this disease will likely claim her life.  I prayed with Maria that morning after sharing this news with her.  I prayed a prayer that I pray with most every patient.  “Papa God, stap klostu Maria. (Father, be near Maria.)”  In my own heartache and desperation, I’ve found that closeness and communion with my God is the only thing that brings peace beyond measure.

Nenspe is a sweet old papa who was led into my exam room by his two adult children.  He used his bamboo walking stick to lower himself onto the chair.  Nenspe’s daughter shared his story. For two months he’s been having increasing difficulty swallowing.  At first it was hard to swallow rice and kaukau, but now water won’t seem to stay down either.  He vomits after most meals and says food seems to get stuck in his chest.  He has been losing weight and can hardly climb small hills, let alone the mountains that he could easily manage before.  The rest of his story, my exam, and his chest x-ray confirmed what seemed most likely from the start.  Nenspe most certainly has esophageal cancer.  His children were realistic about his diagnosis and his daughter even said that Nenspe himself felt certain he had cancer.  I referred him to a nearby hospital for a barium swallow study to help confirm the diagnosis and I prescribed some mild pain medication.  The family is Lutheran and Nenspe has given his life to the Lord.  His son, who was present, is a pastor and felt so privileged that I would offer to pray with them.  They all prayed aloud with me and I believe the Lord heard our prayers and will answer our request for peace that passes understanding.  I asked if I could take a photo of Nenspe to share with my family and friends who will also be praying for him.  I’m grateful for the lack of privacy laws in PNG that in any developed nation would prevent me from sharing these stories and photos.  This family was thrilled to know that others would pray as well.  After I took their picture, Nenspe’s son insisted that I get in the photo as well so that he could take one with his phone and share it with their village.  Nenspe knows that this cancer will claim his life one day, but he testified that God claimed him first, so he’ll rest easy in that promise.  What a beautiful story of the surrendered life!

Matlyn was especially quiet as she made her way into my room with her grown daughter and brother. As I asked about her symptoms and what brought her to Kudjip that day, her daughter asked if she could tell the story for her mom.  About seven months ago, Matlyn felt a small lump in her tongue.  She ignored it at first because it was small and not all that bothersome.  But over the last few months her tongue has become more sore, firm and now she can hardly talk or swallow.  As I listened, I wondered to myself what I would find when I donned my gloves and asked her to open her mouth.  The few times that Matlyn spoke were mumbled and she had difficulty controlling her saliva.  My exam revealed what I feared…advanced tongue cancer.  The entire right side of her tongue was a solid mass which had grown into the soft tissues below, tightly tethering it.  She could not move her tongue more than a centimeter at the very tip. Unfortunately, Matlyn was not from our province and any biopsy or treatment (which was unlikely) would have to be done at the next provincial hospital. Her prognosis is dismal, but once again, I was allowed to enter into a beautiful time of prayer with this family.  As I began to pray, the daughter asked if she could share one more thing.  Matlyn is a mother of eight children, but only five are now living. Matlyn’s oldest daughter proceeded to share that Matlyn’s 17-month-old daughter passed away last week after complications from tuberculosis.  I could hardly contain my sadness as I allowed this piece of news to sink in.  In those moments, I prayed for God’s infinite grace to settle over this family and for His spirit to comfort the deepest reaches of their souls.  And what a blessing to know that those words are not empty, nor do they fall on deaf ears.  In this place, where death and tragedy are daily occurrences, I often remind patients (and myself) that God does not promise to bring complete and miraculous physical healing (although He is able), but he DOES promise to abide with us and weather the storm with our hand tightly grasped in His.  The storm may rage around us and threaten to swallow us, but our God remains a firm foundation, the hearer of our prayers.

As a surgeon I often get to care for patients who find themselves in desperate need. One time it may be from advanced cancer, another from severe infection, and yet another due to a car accident or an act of tribal or domestic violence. These individuals come to Kudjip looking for healing as well as something or someone to ease their suffering. One of the most challenging lessons that I am learning is that not every patient can be helped. Sometimes my best as a surgeon just isn’t good enough. Too often what we have to offer in this resource-limited place just doesn’t cut it. I knew that this would be the case long before I moved back to PNG to serve. I don’t think I was naive about the reality of being a surgeon in Papua New Guinea. In the past five months I have witnessed more death on my watch than in my five years of surgical training.  I’d like to think that each of these deaths has been from advanced disease or lack of resources.  But I know there have been instances when my inexperience as a young surgeon has led me to operate when perhaps I should have waited or maybe not even gone to surgery at all. Thankfully I have an experienced, invested, and supportive senior partner who on many occasions has gotten me out of a jam or kept me from getting into one in the first place. To have my father as a partner is an incredible resource and thrill for me. He has helped me to see which patients we can help and how best to do it. And at times, he’s shown when it is best to do nothing. I am coming to realize the truth of the surgical adage that states, “The best surgeons are the ones who know when not to operate.” Its becoming clear that this wisdom comes from experience…experience that sometimes teaches unpleasant lessons.

As a physician I feel that I’m called to go to battle with death and disease. But as a follower of Jesus I am compelled to believe that we were not brought into existence for death and disease. The Creator’s intent was never suffering, but rather life…and life to the fullest.  Two poems have been on my mind as I have been wrestling with these concepts of life and death in this setting where they are so very tangible. These poems have crossed my mind frequently at the end of the day or in the middle of the night after a particularly difficult case or when I’ve done all I can for a patient on the ward. I’ll share portions of each that have been especially present on my mind in these days. The first is Dylan Thomas’s, “Do not go gentle into that good night.”

And you, my father, there on the sad height.                                                                                     Curse, bless, me now with your fierce tears, I pray.                                                                                 Do not go gentle into that good night.                                                                                                 Rage, rage against the dying of the light.

The second that has become so meaningful to me is Annie Flint’s, “He giveth more grace.” The second stanza has become my testimony in recent days.

When we have exhausted our store of endurance,                                                                           When our strength has failed ere the day is half done,                                                                   When we reach the end of our hoarded resources                                                                               Our Father’s full giving is only begun.                                                                                                     His love has no limits                                                                                                                                   His grace has no measure,                                                                                                                             His power, no boundary know unto men;                                                                                               For out of His infinite riches in Jesus                                                                                                         He giveth, and giveth, and giveth again.

I want my patients to rage against the dying of the light. My promise to them is that I will do the same. The only way I make this commitment is through my firm belief in a God who cares infinitely more for my patients than I ever can.

“But He said to me, ‘My grace is sufficient for you, for My power is made perfect in weakness.’”  2 Corinthians 12:9a

Last week we celebrated THREE months of living and serving in PNG!  There is a fairly commonly described “honeymoon phase” of the missionary life and we’re probably still in the thick of it. But as it winds down and we settle into the long-haul of our ministry here, I want to look back and remember what the “early days” looked like. And, since most of my perspective is from home these days, this particular “day in the life” post will detail our exciting lives (mostly) within these four walls. But don’t be too disappointed, as a post about a full day’s work at the hospital is on the horizon!

So, to honor this three month anniversary I’ve taken photos of an entire day of our lives. Actually, I lie. You’ll notice that the photos stop just after dinner time. And, well, the only explanation I can give is the honest truth. Ben and I were both exhausted and I forgot to take photos of bath and bedtime. And sure, I could’ve scrapped it all and started fresh the next day being sure to include every waking minute. But I didn’t want these moments to be wasted.  So, there you have it. But honestly, you didn’t miss much. Directly after dinner comes baths and within 30 minutes after baths comes the boys’ bedtime. Picture some rowdy bath-time play…followed by the donning of pajamas which often turns into a wrestling match…followed by some relieved parents as they turn out the lights and say good night to two sweet (and exhausting) children. And…you’re all caught up! And as things go around here, I’m finding my way to bed not long after the kids are settled in for the night. Afterall, our mornings do start early!

I stood in the hallway as I watched his little hands scavenge through his toy bins. I heard the clinking of toys. He was searching. Searching for the perfect car or truck to give to William on C ward. Although I found myself hoping he wouldn’t choose one of his favorites (afterall, did his almost-three-year-old little mind REALLY understand that this was a gift…as in…gone forever). But as soon as that thought entered my mind, I was quickly reminded that this was HIS idea. When I informed Simeon earlier in the morning that today we’d visit the surgery ward and some sick children that Daddy had helped to take care of, I asked him what he thought we could take to those kids to make them happy. I also told him specifically about William, a 6 year-old-boy, who three weeks ago was walking home from school when his feet and the bottom of both legs were run over by a Land Cruiser. Of course, Simeon has a fascination with all trucks, so that led to a lengthy conversation about the specifics of a Land Cruiser. I informed him that its the same type of truck that we have here on the Station and that he’s ridden in many times and he seemed satisfied with that. He asked curiously about William’s injuries and I explained that he had broken the bones in his lower left leg and foot and that he lost his skin on both feet as well.  (Simeon is quite used to medical talk, given that he’s the child of two physicians and the grandson of one too and he is ALWAYS curious and asking about scratches or marks on someone’s body and wondering if they need some cream to make it feel better.) So, as I shared matter-of-factly about William, he listened intently. I asked him if he’d like to take a gift to William. I tried to explain (in several different ways) that whatever he gave to William would be William’s toy forever. He’d take it home to his house when he left the hospital.  Simeon didn’t seem bothered by this at all and actually seemed eager to share something with “his friend.” He had two ideas—a lollipop (thanks to the recent box we got from Ohio) and a truck. It was at this point I realized we were about to have our first lesson in gift-giving. The lollipop was an easy one and he was frequently happy to share his food treats with friends and family. The truck, on the other hand, might get a little dicey. Simeon has a fiercely strong love (bordering on obsession) with any wheeled vehicle and when he suggested he’d like to give a car or a truck I worried that it might be harder than he thought. I just decided I’d let him lead the way and as he emerged from his bedroom with a (previously favorite) blue HotWheels truck I explained again that this was going to be a GIFT and William would get to keep it.  He smiled and nodded and I knew at that moment that he got it.  I was proud as proud could be and couldn’t wait to see the look on his face when he got to experience the true joy of giving that sweet little sacrificial gift.  I loaded the dum-dum’s, blue truck and the two boys into the stroller to make our 1/4 mile journey to the hospital.

Ben met us in the breezeway outside of C ward. I was behind him with the stroller when Simeon hollered back and excitedly waved me into the ward, “Come on Mama!”  William was in the far back corner of the ward. We made our way past the two rows of beds filled with sick, but smiling patients and their families. Simeon and Matthias were (of course) the
main event as we strolled through the center aisle. With very little prompting, Simeon gave his sweet little wave and said “apinun” (the afternoon greeting here). The Papua New Guinean people love to shake hands and both boys obliged. We finally reached William’s bed where he was joined by his mother and younger sibling. He is one of five children. Simeon stood sweetly at the side of his bed and gladly shook his hand. William was quiet, but did seem interested in this little white boy who had come to visit him. His mother was delighted and grinned from ear to ear. I handed Simeon the prized blue truck and he knew JUST what to do with it. Without a moment’s hesitation he put that truck in William’s little hand and then glanced back at me and smiled.  He reminded me about the lollipops and I encouraged him to give one to William which he did with somewhat serious determination. After we sang a song with William we decided we had enough suckers for the rest of the children on the ward and Simeon very willingly handed one to each outstretched hand. Its easy to think that Simeon couldn’t possibly know the joy he shared with those children, but then I remember that Simeon himself can easily be overwhelmed with joy at the sight of a lollipop! He was doing EXACTLY what I’d hoped he could do. He was giving to them some of the things that he loved very most in life. And he reveled in every minute of it.

As we were getting ready to leave the ward we decided to sing one last song with the patients. Its one of the pidgin songs that Simeon has been singing for months now—Jisas Laikim Olgeta. Its a simple song with a simple message of Jesus’ love for all of us. There’s nothing profound about it, but as we stood around the beds of these sick men, women and children, their smiles and joy were a testament to God’s love for us. We went to give gifts and spread cheer, but in the end we were given an even greater gift of fellowship with some very precious people. 

For those expecting the usual excellent writing on this blog please be advised that this edition is written by the “other” doctor. Just consider me a much less talented guest blogger.

I’m usually not one for writing. Writing requires too much thought and too much time. I’m not sure which is more difficult for me, taking the time to think or just sitting down to write. Neither comes naturally to me. That being said, I wanted to share some of my experiences these first few weeks at Kudjip Nazarene Hospital.

It seems a bit surreal to be back where I grew up, with many familiar faces but also with many things that are so different.  Stepping into my role as the junior surgeon at Kudjip has been an exciting new challenge for me.  It is also a very humbling one. Daily I’m reminded of how much I don’t know and how much I have to learn.  Many things I thought I knew I’m having to re-learn in a Papua New Guinea appropriate manner.  How to diagnose and treat a surgical problem here in PNG is in some ways quite different from what I’ve been used to. For example, a lady in her mid-thirties came in with right upper abdominal pain. She had been having this pain for almost a week and it wasn’t getting any better. Her white blood cell count was elevated and she had a mass on the right side that could be felt on exam. In the USA she’d probably have gotten an ultrasound read by a radiologist and most likely a CAT scan. In her age group the most likely  diagnosis in the USA would be gallbladder disease. The lady had had an ultrasound done by Dr. Erin (one of the family docs here) and she had gotten a second opinion from Dr. Bill. They weren’t sure what it was but thought it might be a liver abscess.  So I saw her, did another ultrasound to see what they were talking about, and saw what looked like an abscess or a mass at the lower border of her liver (although it didn’t look quite right) and promptly called in my senior partner…Dad.  With her concerning exam, elevated WBC and fever we decided to do what any self respecting surgeon would do, get a CAT scan and consults from infectious disease and interventional radiology.  Just kidding! Here the old surgical maxim of “when in doubt cut it out” is sometimes true, not trite.  The next day we took her to surgery for exploration and found a perforated retro-cecal appendix that had formed an abscess walled off by the liver edge, gallbladder, duodenum, transverse colon and omentum.

I am finding out very quickly that common pathology looks quite different when it presents late.  I’m learning that my ultrasound skills need some work and that the lack of diagnostic tools is achallenge, but a challenge that is not without intellectual reward.  I’ve also found that operating here has already given me a breadth and scope that makes being a surgeon so much fun.

Just for fun I’ll list a selection from the plethora of pathology I saw during my first two weeks. Two patients with thoracic stab wounds, one of which needed to go to the OT (operating theatre, yes we prefer the British naming and spelling over here.  It’s quite a step up in class compared to the operating room.) to control bleeding from an intercostal artery.We also saw two colon cancers, five appendectomies of varying sorts (three perforated, one gangrenous and one acute), two sequestrectomies for osteomyelitis (bone infection), trans-anal excision of a rectal tumor, two submandibular gland masses, three pediatric neck abscesses, two modified radical mastectomies, one facial stab wound that came in pumping blood from the temporal artery, a couple of cesarean sections, several hysterectomies, a re-implantation of a ureter with a bladder flap for a uretero-vaginal fistula, two hand incision and drainage procedures, a few upper endoscopies, several rigid sigmoidoscopies, a machete chop-chop to the scalp with an underlying fracture, a machete chop to the upper extremity with a humeral fracture, a C3-C4 cervical spine subluxation, several inguinal hernias, a hydrocele, several lymph node biopsies for suspected lymphoma…and I think I might even be missing a few!  As one can see, if you are looking for variety in your surgical practice, Papua New Guinea is the place to be.

In closing I’ll share one more story. As is often the case in medicine, “you just can’t make this stuff up.”  A couple weeks ago on a Saturday, I was called to the ER to evaluate a stab wound.
Two boys had been “playing” with knives and that play had turned into a fight. The patient, an eight year old boy, had been stabbed in the back by his cousin when he had tried to steal his cousin’s knife. He had a decent sized hemothorax (blood in the chest cavity) and as I began telling him that he would need a tube in his chest to drain the blood I asked him his name. My first stab wound patient in practice was an eight year old boy named….. wait for it…. Zoro 🙂 Yep, I laughed out loud.

Fortunately for him, he did well and did not need major surgery. He has since gone home and I’m looking forward to seeing him in follow-up clinic next week. I’ve already instructed him that there is to be no sword play, at least not until he sees me for his follow up visit!

I am incredibly grateful to the Lord for bringing our family to Kudjip.  It is quickly becoming home for all of us.  Please continue to keep us in your prayers as we live, learn and serve in this new/old incredible place.