Assumptions

          We all make assumptions based on our knowledge, life experiences and cultural context. Some times those assumptions are correct, but many times our assumptions are wrong because we don’t know the whole story. I am guilty of making assumptions the same as anyone else, but one patient this month made me re-evaluate the assumptions I make. 

         On a Tuesday night, I was called in to see a middle-aged man who had been stabbed twice in the abdomen. The only history I obtained was that he was stabbed by his brother. It is quite common for family disputes over land or pigs to end in one party attacking their own family member with a machete. If my patient is a women, I tend to assume she is an innocent victim of gender-based violence which is rampant in PNG. However, if the injured patient is a man, I usually assume he was in some way partially responsible for the fight which resulted in his injury: perhaps he was intoxicated or aggravating the other party or living a less than desirable lifestyle that placed him in harm’s way. Either way, once they become my patient, I treat them according to the best practices (that we can provide) in trauma care. The person could be a criminal or a saint, but once they enter my operating theater they are a bleeding trauma patient who needs to be treated.   In this case, we spent 3 hours in the operating room repairing injuries to the liver, spleen, gallbladder and two holes in the stomach. It was a very labor-intensive case as we tried to stop the bleeding and repair all those injuries. Praise the Lord, our patient did well after surgery. As I headed home, I wondered if he would be able to understand the gift of God in sparing his life. "Maybe he will reform his ways and become a good man," I thought.  

          The next morning, I was astounded when Auntie Margaret, our OT supervisor and veteran scrub nurse gave me a big hug and thanked me for saving her brother’s life! She explained that patient D is a very close friend from her home village, akin to a brother. He is a prominent leader in the local church and had just completed building a new Sunday school room when his brother, out of jealousy, attacked and stabbed him. I was further amazed when patient D told me (on post-op day 1) that he had already forgiven his brother and would not accept any compensation (a cultural practice in which the guilty party pays restitution for the injuries inflicted and medical expenses incurred). Instead, D was praying for his brother to come to church and reconnect with God.  All my previous assumptions were blown away. Here was a God-fearing man who was gravely wounded by a close relative for doing something good and honorable, and he continues to seek a righteous attitude toward his attacker. What a perfect example of Apostle Peter’s exhortation in 1 Peter 3: 9,14-17: “Do not repay evil with evil or insult with insult. On the contrary, repay evil with blessing, because to this you were called so that you may inherit a blessing…. But even if you should suffer for what is right, you are blessed. 'Do not fear their threats; do not be frightened.' But in your hearts revere Christ as Lord. Always be prepared to give an answer to everyone who asks you to give the reason for the hope that you have. But do this with gentleness and respect, keeping a clear conscience, so that those who speak maliciously against your good behavior in Christ may be ashamed of their slander. For it is better, if it is God’s will, to suffer for doing good than for doing evil.” Lord, thank you for toppling my assumptions and thank you for the amazing testimony of this God-fearing man. Amen. 

Margaret and I

Lifeline

Saturday afternoon I received the call: “man stabbed in the upper arm with an arterial injury”. On the way to the hospital my mind ran through the possible scenarios. One look at the injured man confirmed my fears. He had an injury to his right brachial artery, the single vessel that feeds his dominant arm and hand. If it had been a smaller blood vessel, one with an alternative path to maintain blood flow to the hand, I would have simply tied off the injured segment. But this singular artery required a careful vascular repair in order to maintain the life giving flow of blood to his hand.  Two and a half hours later, I removed the final clamp and watched the vein graft, bridging the gap between the two ends of the injured artery, swell with pulsating blood. Relieved, I felt his radial pulse and watched his fingers turn pink again. 

Earlier this month, I attended a retreat for physicians serving internationally, such as myself, in the World Medical Mission post-resident program. We talked about many of the struggles we face working in hospitals that are short on supplies, short of manpower, but never short of patients needing help. The focus of our devotions was “Keeping Our Center”. When everything becomes chaotic and I feel like I’m spinning in circles, how do I find my center again? In essence, what is my lifeline? I realized that I often center my life around my identity as a surgeon, my identity as a missionary, or my identity as daughter/sister/friend. Although those are important parts of who I am as a person, and they can buoy me up emotionally for a little while, in the end, those identities are not the source of life that sustains me. My true center, my true lifeline is my identity as a child of God. In a wonderfully mysterious way, the shedding of Jesus’ blood washed me clean and provided a bridge so that I can connect with God and receive his life-giving spirit straight from the source. If I cut off that lifeline, I, like my patient’s hand without blood flow, am at risk of suffocating and dying spiritually. There is no alternative route. Praise God that when I am able to to spiritually reconnect to my lifeline, just like my patient on Saturday, I feel a new pulse and see signs of life returning
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Unresectable

              Cancer stinks. No matter what form or what stage, there is nothing nice about it. We see plenty of cancer here in the highlands of Papua New Guinea: oral cancer from chewing betel nut, rampant cervical cancer, childhood leukemias, lymphomas, breast cancer, colon cancer, pancreatic cancer, and the list goes on. There are many people who we can help, but unfortunately, many of our patients come too late. Sometimes we can identify metastatic disease during the medical work-up, but due to our limited diagnostic capabilities, we often don’t discover it until surgery. The past few weeks have been a discouraging litany of such cases. Our current series started with an elderly woman who presented with an incarcerated umbilical hernia and bowel obstruction. We fixed the hernia through a small incision, but her obstruction did not improve. On re-exploration, she had metastatic pancreatic cancer that involved several loops of intestine.  

              Later in the week, we attempted resection of a large kidney cancer (Wilm’s tumor) in a 10-year-old boy. Unfortunately, the tumor involved the major blood vessels and after a three-hour struggle, we had to abort the surgery. With limited chemotherapy and no radiation therapy options, we were very discouraged that we could not surgically remove his disease. 

The next case was an exploration for a right upper quadrant abdominal mass of suspected gallbladder origin. Instead, we found colon cancer that had widely metastasized throughout the abdomen. 

             This week, I performed a pelvic exploration for complex ovarian cysts and uterine mass, only to find ovarian cancer coating all the pelvic organs including the rectum. 

Most recently, I was consulted on an elderly woman with history of gastric ulcer disease who presented with symptoms of a perforated ulcer. At surgery, we discovered gastric cancer that had perforated through the mesentery of the transverse colon. 

              Even more discouraging than finding unremovable cancer is the conversation with the family and the patient once they wake up from anesthesia. There is no easy way to break the news that the patient has a terminal illness. Palliative care is all but nonexistent here. Fortunately, we know that death is not the end. We can point patients to the hope found in Jesus and help them prepare for eternity. 

Teamwork

  

Recently, we hosted a volleyball tournament between the missionaries of Kudjip and Mission Aviation Fellowship (MAF). We had a great afternoon of volleyball followed by our monthly joint worship service. One of the MAF pilots took the opportunity to speak about unity among believers, in short: teamwork. How frequently the devil tries to drive wedges between team members based on pride, emotions, and difference in abilities or ideology. But the speaker reminded us that we are all members of the same body, and as long as we are connected to the head, Christ, we can all function together to fulfill his purposes.  I am so blessed to work with a great team of physicians, nurses and ancillary staff here at Kudjip Hospital. Without each person’s unique talents, knowledge and experience we would not be able to continue God’s work here as effectively as we do. I especially appreciate our surgical team. Each person is gladly willing to step in for a teammate who is sick or has urgent family needs. As Solomon stated: “Two are better than one, because they have a good return for their labor: If either of them falls down, one can help the other up.” (Ecclesiastes 4:9-10) Thank you, Lord, that we can help and encourage one another. Thank you for teammates who support me when I am weak. As an African proverb says: “If you want to go fast, go alone; if you want to go far, go together.” 

Emergency!

           Every medical sub-specialty has certain life-threatening emergencies that doctors are trained to respond to.  Surgery is no different. Among the many urgent surgical cases we perform, there are a handful that are true life and death emergencies. Recently, I made a list for our surgical registrar (trainee) of the surgical emergencies we see and treat here at Kudjip. We have treated each and every one of them in the last two weeks, starting with one day when we saw 5 emergencies.

          Going into that operative Tuesday, our schedule held 4 elective cases. Little did we know what was about to come. Early in the morning, Dr. Ben was called for a patient with tension pneumothorax –a collapsed lung with increased pressure in the chest that compresses the heart. He quickly placed a chest tube to decompress the chest and allow the collapsed lung to re-inflate. 

          Next, during rounds, we were consulted on two emergency surgical patients. The first patient had a closed head injury from a rubgy match and was starting to show signs of right-sided paralysis. He was immediately taken to the operating theater for a craniotomy (drilling holes in the skull to release blood that was putting pressure on the brain). The second patient was a young man with tuberculosis who developed a pericardial effusion with signs of tamponade (fluid surrounding and compressing the heart). Dr. Ben performed an emergent pericardial drainage procedure on him.  Finally, we were able to start our scheduled cases—removing lumps, draining pus, and excising cancer—typical surgery day cases. Between our regularly scheduled cases, we also drained a dental abscess that had grown so large it was extending below the patient’s jaw to her neck. This type of abscess, called Ludwig’s angina, can lead to life-threatening blockage of the airway. At the end of the operative day, our fifth emergency patient arrived in the ER with a ruptured spleen after blunt trauma. That is when I sat down with our surgical registrar and made the list of the major surgical emergencies we treat. We had seen 5 of the 8 in less than 12 hours! 

             Over the course of the past week, we completed the list with several c-sections for fetal distress, a ruptured ectopic and a patient with an ischemic arm.  That man presented with a crush injury to the arm. The muscle swelling and bleeding around his fracture site cut off the circulation to his hand (compartment syndrome), so Dr. Ben performed a fasciotomy to release the swelling in his arm. 

          It has been a crazy two weeks of surgery, but praise God for his provision through it all. Please pray for all our patients as they heal from surgery and for our surgical team to get some rest after two crazy weeks of emergency surgery. 

Birds of Paradise

Trekking to the coffee grove

         Papua New Guinea has long been a favorite destination for serious birders. This group of islands holds myriad species, including 42 different types of Bird of Paradise, which can only be found in this region of the world. Dr. Bill and Marsha McCoy, two of our long-term missionaries at Kudjip, are terrific birders and they have shared their enthusiasm (and binoculars) with many people over the years. Soon, the McCoys will retire and return to the States, but before they do, they are rising up a new generation of birders: showing us their special birding sites, introducing us to local guides, and imparting birding tips that they have gathered over the years. 

Ragianna silhouette

Ragianna close-up
Credit: Australian Geographic

         Recently, Bill took a group of us on a sunrise expedition to a village less than 20 minutes from Kudjip. After arriving at his local friend's house, we trekked a short distance into a coffee grove that is shadowed by tall pine trees. High in the trees, silhouetted against the early morning light, we saw nearly a dozen Ragianna Bird of Paradise dancing, displaying their ornate feathers, and calling to their mates. It was amazing to see so many so close together. 

Erin spotting the Superb
Bird of Paradise

Superb close-up
Credit: San Diego Zoo

 If that wasn't enough, we later found a Superb Bird of Paradise flashing his characteristic neck feathers high in a tree. Although we weren’t close enough to see the stunning blue plumage characteristic of his mating dance, we were all enthralled by this small but showy bird. No one was happier than Erin, who has heard the call of the Superb many times in her 10 years in PNG, but never actually saw one until this trip. 

Bill mentoring Matt

Bill definitely ignited a new enthusiasm for birding in this group of younger missionaries. Hopefully we can carry on his legacy for many more years to come. 

Never Say Never

         For the past two weeks, we have been running a neurosurgery/spine unit on surgical ward. Often patients with brain or spine injuries have a poor prognosis in our resource-limited setting, but a few of our current patients are proving us wrong. It started when a young man, David, broke his neck in a tree-felling accident two weeks ago. When he first arrived to the hospital 10 hours after his accident, he was quadriplegic—unable to move all four extremities. We put him in cervical traction—Frankenstein-esque bolts in his head with weights hanging off the bed—to stretch out his spine. Praise God, it worked! Within the first 24 hours he gained back sensation to his arms and legs. In the past year, I have seen one other cervical traction patient who succumbed to pneumonia in the first 72 hours, so we were very vigilant when David started showing signs of respiratory compromise. Lying in bed all day with a paralyzed diaphragm, he was unable to cough or clear his lungs— something you and I take for granted. By God’s grace, he pulled through. The next day, we were overjoyed when he wiggled his toes. Again something we take for granted, but for him it was a sign that the spinal cord damage was not permanent and he has a good chance of regaining motor function. This week, he was able to lift his hands enough to hold his own breathing exercise bottle. It is absolutely amazing to see how God is restoring the lame before our eyes. 

       In the past week we have also treated a man with a depressed skull fracture from a chop to the head. Dr. Ben removed a large bone fragment from his brain and replaced the missing bone with a metal plate. Anton still has paralysis of the right arm and weakness of the right leg, but he is slowly regaining the ability to walk again. 

Henrisa using her right arm!

         A few days later, a 5 year-old girl was brought in with an abscess near her spine and hemiplegia (paralysis of one side of the body). For the first several days, I was discouraged when she showed little improvement after surgical drainage and medications; but recently, Henrisa has started moving her right arm and leg again! God is truly answering prayers. 

           In all these cases, I have seen God’s amazing provision—miraculously providing what we need when we need it. Two days before Anton came, Ben discovered that skull plate (our only one) in another orthopedic set and made a comment to the nurses, so they were ready when he needed it. While searching for a cervical collar in the Emergency Room the night David arrived, I noticed a pediatric collar in the cupboard, and would you believe it was the PERFECT size for our 5 year-old patient the next week. The only pediatric collar we have... perfect fit. I don’t think it’s a coincidence. 

Please join me in lifting these patients up in prayer as they continue on the long road to full recovery. I am confident that God will provide all that they need.