It was an uneventful (thankfully!) flight from POM to Brisbane, and then I grabbed my bag, went through customs, checked my bag in again for a domestic flight to Sydney, took the train to the domestic terminal, and had just enough time to buy a bottle of water before boarding the plane to Sydney. Then in Sydney it was another transfer from the domestic to international terminals before it was time to go through customs again (this time for departing Australia). This layover was a little longer, which gave me time to peruse the duty-free in Australia (I bought crocodile and kangaroo jerky to replace the confiscated beer) before hopping on a nine hour flight from Sydney to Honolulu, most of which I slept through (thankfully).

I was awake for the last two or three hours, which gave me time to start reading a book I bought at the Sydney airport called A Doctor’s War, by Rowley Richards, a former Australian Regimental Medical Officer who was captured in Malaysia during the Second World War; the book is from his diaries of his time spent in the POW camp. I’m not done with it yet, but so far, it’s an amazing book, right up there with A Surgeon In Combat by an American Army battalion surgeon in Europe during this same period. Many of the things Dr. Richards writes about I have experienced myself as a young, future medical officer in the Army in a time of war. One thing that really rang true to me is his descriptions about his excitement about seeing combat, which in the wisdom of his older years (after having been a POW) he scoffs at as youthful ignorance. I will admit, I have experienced the same anticipation about deployment, which I am sure will happen, it is just a matter of when and where. I know it is youthful ignorance, and I know that my preconceptions about what the life of a doctor is like in a combat zone are probably 90% false, but those feelings are still there, and I am sure that someday, like Dr. Richards, I will look back and wonder why I looked forward (if that is the right term) to being deployed. Still, what I have read so far is very powerful, and I’m very impressed with what Dr. Richards went through and how he managed to continue working as a RMO during his time as a POW. And all of that was in the tropics, so he was dealing with things like malaria and dengue fever and tropical ulcers, most of the time without any medications (the Japanese confiscated their medicines); he wrote about applying good hygiene and preventive measures in a time when such ideas weren’t popular at all. He’s now a preventive and occupational medicine physician (well, he’s now semi-retired, but he was a preventive/occupational medicine physician), so there’s another reason for me to look up to him. I hope if I’m ever in conditions half as bad as he faced that I can show the same initiative and integrity that he writes about.

But anyway, back to the never-ending day. I ended up landing in Honolulu around 9am, still on Wed. Feb. 11—in other words, I landed before I left PNG, which made me laugh. I had to calculate time zones to determine if I should take my anti-malarials or not (I did, including my first dose of my terminal prophylaxis on primaquine), and then wasted time on the internet in the Honolulu airport (I would have rather been at the beach, but we don’t always get what we want) until it was time to board for the last leg of today’s flying, a five-hour flight from Honolulu to Los Angeles, where I will be for a few days for the American College of Preventive Medicine conference. I’m still on that flight as I’m writing this, to be posted later.

Overall, it’s an exhausting 30 hours of travel time (not counting my flights from Kikori to POM “yesterday”)—all of which spans 11 hours on the clock (10am in PNG to 9pm in LA). I’m just hoping that my sleep won’t be so disrupted that I’ll miss out on important parts of the conference.

The day has actually gone fairly smoothly.  I headed over to the “airport” (this must be another Pidgin word, which roughly translates to “wooden shed at the side of the airstrip”) at 9 to confirm my ticket and get a boarding pass, and was told to return with my luggage at noon for my 1:45 flight.  So I finished packing, settled business with the hospital, cleaned the house, said my good-byes, and headed down the the airstrip at noon.  As luck would have it, the plane was early–we took off at 12:30!  “Security screening” consisted of, well, nothing.  I didn’t even have to show my boarding pass, as there were only two passengers, and the station’s one agent definitely remembered issuing a boarding pass to one of the white doctors.

Our flight took us into Western Province (I forget the name of the village, but it starts with an S), then back to Kerema (the capital of Gulf Province) and back to Port Moresby, landing around 3:45.  God must keep sending me people to watch over in my travels, because this flight also had a passenger who was very helpful, and even offered to drive me to the Guesthouse.  I declined, as I still had to go to the international terminal to confirm tomorrow’s flight, but I was touched that she thought to offer.

Everything went smoothly at the Air Niugini desk, so I headed over to the Red Dot taxi stand to request a taxi, and there was no one there.  Fortunately, being watched over in my travels continued, and one of the security guards at the airport saw me standing there, asked what I needed, and went to the Red Dot stand back in the domestic terminal to get a taxi for me.  Then it was short drive to Mapang, where I got to meet Ruth and Grace, the students on my itinerary 6 weeks later.  They’ve been reading my blog, which was nice to hear, and had many questions and enjoyed hearing my stories.  I’m glad I was able to help them even with that slight bit.

Unfortunately, not all continued to be so smooth.  One of my emails was regarding a change to my flights tomorrow, asking that I call Orbitz.  It’s not easy (or cheap) to call the States from here, and I ran through an entire 20K phone card before even being connected to a live person.  Seeing my struggle, the host of the guesthouse let me use the landline, so I was able to get in touch with someone and get everything straightened out.  Now I just need a lot of prayers that I will make all my connections and actually arrive in LA at 9pm on Wednesday.

I got an update from Kapuna on the sick mystery patient (the one who
was sick and we didn’t know why).  Dr. Archer attempted to do a lymph
node biopsy, but every node she checked was full of pus.  He has also
developed very thick skin that feels wooden, as well as necrotic
ulcers.  The new working diagnosis is pyoderma gangrenosum.

Anyway, back to my day.  After our adventure into this infected,
necrotic foot, I went back to the house and proceeded to pack,
separating things into “goes back to America” and “stays in PNG”.  I
wasn’t planning on running today on account of having washed my
running clothes (to be donated to the hospital) as well as my shoes
(so I’m not completely disgusting on my flight back to the States),
but it cooled down right at six, and I couldn’t resist one last run
in PNG.  The weather cooperated; it didn’t start raining until after
we got back to our houses.

In the evening, I decided to sit in on Sarah, the hospital matron,
giving a talk about HIV counseling to the nurses and CHWs.  Most of
it was about basic counseling techniques, such as confidentiality and
building trust, and she didn’t really get into how they actually
counsel for HIV testing yet, which was too bad.  I was interested in
seeing how they do it here, compared to home, but I guess I won’t get
that opportunity.

I’m excited to begin my journey back tomorrow.  I’m a bit weary about
my Airlines PNG flight back to Port Moresby; I’m hoping it’s on-time
without any problems, so I can get checked in for my flight Wednesday
morning and get to the guesthouse with enough time to go souvenir
shopping.  Failing that, I’m just hoping that I get to Port Moresby
with enough time for me to get on my flight Wednesday.  I really
don’t want to deal with having to find alternative transportation
back to America.

Today Dr. Manar and I set out to Babaguna, a
village not far downstream from Kikori where
Robbie Petterson, a Bible translator from New
Zealand, had been running an adult literacy
workshop for the past week.  He had twelve
students in this workshop, and the main point had
been to write stories in both their native
language and English, with set assignments for
each day (write a short story about life in the
village, write a longer one about something that
has happened in your life, write a poem,
etc).  They also worked on a picture dictionary
in English and their language, as well as
translated some of the health education posters
that seem to be everywhere.  The picture
dictionary and the stories will eventually be
compiled into a book, with the printing costs
covered by Australian-New Zealand aid (ANZAid?  I
don’t remember the name) and distributed to the
schools in the area that speaks that language,
and will be available for sale (for about 2K,
which about 70 cents) to parents, so they can use
these to help teach their kids to read.

So today was the graduation ceremony for the
workshop, and everything seemed to be running on
standard PNG punctuality (in other words, no
punctuality at all) and nobody seemed sure of
when anything was happening.  As Manar and I
thought that we were leaving around 8 (the dingy
came to pick us up at 10:30), I had a fairly
early breakfast, so I was getting pretty
hungry.  They did feed us green (young) coconuts
to tide us over until the big meal, which didn’t happen until 2:30.

And it was quite a feast.  They had prepared a
number of traditional PNG foods, such as turtle
meat wrapped in sago (good), shellfish wrapped in
sago (not so good), greens with boiled bananas
and fish (fairly standard­pretty good), some sort
of red fruit, which was more of a pulp (not so
good), fried clams (my mother’s boiled clams are
better), some other things I wasn’t brave enough
to try, and bananas and cake (“cake” meaning more
of a pound-cake type texture, not birthday cake)
for dessert.  In all, it was quite the
experience, and I was rather full at the end.

The graduation ceremony came after that, which
was fairly straightforward­Robbie explained the
workshop and its goals, and then distributed
certificates and said something about what each
of the men had done well with his writing (good
spelling, neat handwriting, a good story,
etc).  Then we loaded the dingy back up and
headed back to Kikori, just in time for the power
to come back on (one of my favorite times in the day).

As I’m getting closer to going home, I find
myself looking forward to it more and more.  It
has been quite the experience in PNG, but I think
I’m ready to resume my normal life, with
electricity and internet and roads and an oven
that works and a washer and dryer and grocery
stores…  I guess I never realized how spoiled I
was until I didn’t have those things.

Ward rounds started fairly well.  We started in recovery ward, as
always.  Leprosy Man, or The Guy With Two Toes, is healing up
nicely.  He’ll probably be ready for amputation of his remaining toe
on Tuesday, but I probably won’t be there for it, as my flight leaves
early Tuesday afternoon.  The baby with the abscess has also resolved
and was discharged today.

And that’s when the people I have seen before came back.

There was a man at Kapuna who had been there with his family for so
long that he essentially became a patient advocate for all the other
patients.  Well, I saw him today, as he brought his daughter in for a
recheck.  She had been seen at Kapuna for an eye injury, but came to
Kikori (I believe the family actually lives here) to begin secondary
school (high school; starts in the 9th grade).  Her eye was still
bothering her, and after trying to look at the board and do her work
for a day, she couldn’t handle the pain, so she came in.  We got to
play ophthalmologists again, but there wasn’t much we could do
without a slit lamp.  We put in some flouresceine drops, which showed
either a corneal abrasion or an ulcer (the difference is how deep it
is, which you need a slit lamp for), so we just gave her some
chloramphenicol (antibiotic) eye ointment and some eye patches and
told her to come back on Monday.

Then we continued rounds.  There wasn’t much exciting going on.  The
tiny little baby in general ward–the three-month-old who weighs
about 2 kg–is still around and still tiny.  The mother wants to go
back to her village, but we dissuaded her from that for the time
being.  That was what caused the baby to be so malnurished in the
first place–she would go off to the work camps (the places where
they make sago or go fishing), and left the baby with her mother (the
baby’s grandmother) who fed the baby reconstituted milk powder out of
a bottle.  Not good.

After a lazy afternoon, I woke up on my veranda a bit disoriented (I
didn’t really know where I was at first) and with a few new mosquito
bites (I hadn’t planned on falling asleep, so I didn’t put any
repellant on) around five and remembered that I had wanted to go to
the store and the market.  Well, there was nothing I needed at the
market (I wanted greens and fruit, and nobody was selling either), so
I stopped by the store and got a few things I need for the next few
days, as well as ice cream.  While I was heading back, I ran into the
man who I talked to while waiting for our plane to leave from Port
Moresby almost six weeks ago.  As the plane had been quite a bit late
leaving, we had talked for awhile.  I had wondered if I would run
into him here, as Kikori isn’t that big of a place.  Well, we talked
for a bit about how my stay has been and the kinds of things I had
seen.  It was nice, to be able to talk to the same person as I was
starting my trip and now that I’m almost ready to end it.  It feels
like quite a bit has happened since then.  He asked if I was looking
forward to going back.  I told him I was looking forward to having
electricity whenever I wanted it.  He seemed to think that was pretty
funny (his wife and children live in Australia, so he does grasp the
concept of not needing gasoline-powered generators).

So now I have one more weekend in PNG to look forward to.  Hopefully
my Saturday this week will be better than last (when I was sick in my
house the entire day).  Sunday Manar and I are supposed to head out
to a nearby village with Robbie (a Bible translator from New
Zealand), so that should give me the opportunity to see one more new
thing before I head home.

The day started with TB rounds, which again went fairly
quickly.  Part of that was because of our decision to split up the
patients and see them individually instead of seeing all of them as a
group, as we typically do during rounds.  Since TB patients are
fairly simple, in terms of decision making (”Keep taking medicine and
stay until your two months are over”), there isn’t much need to see
them as a group.  The only big decision was on a patient I had seen,
with a diagnosis of Pott’s disease (TB of the spine), whom we started
on streptomycin last week, which was already six weeks into his two
months.  He reported some improvement with the streptomycin, but
still wasn’t able to move his legs, so we decided to keep him around
so he’ll get a full month of the new medicine, in hopes that it
really will help him.  Other than that, everything was simple, and so
we had another long break before clinic in the afternoon.

TB clinic is an interesting beast.  Most of the patients probably do
have TB lymph nodes, but before we can make that diagnosis (no lymph
node biopsies here), we have to try them on some other antibiotics
first.  So they get a week of amoxicillin, then come back to be
checked.  Then a week of erythromycin.  Sometimes that gets
accelerated a bit, if they have other symptoms or risk factors, such
as having a cough, or losing weight, or having a family member with
TB.  For kids, there’s a TB score that we use, and if they score
above a 7, you assume TB unless another disease is more likely.  So,
my first two patients got their week of amoxicillin and told to
return in two weeks for a recheck.  My third patient was sent over
because the person who had seen him in outpatient thought he might
have TB spine.  After getting a history, which is never easy in
PNG–a combination of not speaking the right language and the patient
saying what they think the right answer is–I found out that he “did
heavy work” (construction-type work) at a company site for years.  No
fevers, no night sweats, no weight loss, no cough, no enlarged lymph
nodes, just back pain in a man over fifty with a lifetime of manual
labor.  So I diagnosed arthritis and sent him off with some
anti-inflammatories.

We were actually pretty busy in TB clinic, which was a combination of
a family of a TB patient in the ward now (a seven-year-old girl with
eight siblings) decided to all show up in clinic to be checked
despite the nurse having told them to come to the ward in the morning
for that purpose, and a multitude of people who were either not
scheduled, or were scheduled for next week.  The ones who weren’t
scheduled or were scheduled from later who live fairly close were
sent away, and the ones who came from far away were seen.  It’s not
the most equal treatment system in the world, but it’s really the
only way to do it in an area with no good roads and unpredictable
transportation options.  In all, it was about four when we left,
which was far too long to be baking in the clinic house, and the
breeze was a welcome change as I sat out on my veranda and finished
my last book.  Then that breeze turned into a storm right when I was
getting ready to run, so there was no evening run for Manar and I
today.  Hopefully tomorrow the weather will cooperate with out exercise plans.

When rounds were over, we had three hours to sit around and relax
before reporting to the clinic in the afternoon.  Fortunately, we had
electricity for those three hours, which meant the fan was running in
the house and it wasn’t too hot.  Unfortunately, the power went off
just as soon as I arrived in clinic, so we cooked in the oven of a
clinic house for the afternoon.

I decided to see patients on my own in clinic, in part because
sitting around listening to someone speak to patients in a language I
can barely understand isn’t much fun, and in part because there were
a lot of patients to see.  Alofa, the CHW who was providing the
nursing staff for the clinic today, was picking and choosing patients
for me based on their abilities to speak English, which I
appreciated.  The first one was an elementary school inspector, so
she had very good English.  Unfortunately, she also had a long list
of complaints, making her more like an American patient than a PNG
patient.  She had a hysterectomy in September, so now she has
menopause symptoms, including hot flashes and headaches.  She also
has chest pain, and a sore throat, and abdominal pain, and pelvic
pain, and chronic hypertension.  She kept listing off these problems,
and finally I had to tell her that I can only address one problem at
a time.  I took her blood pressure, and that was normal, so that was
easy–I told her to keep taking her regular blood pressure
medicines.  Well, then she said that sometimes she feels funny and
light-headed when she takes them, which is also easy–I told her to
take them at night instead.  So we kept going through one problem at
a time until we both felt like everything was addressed and dealt
with.  In all, she left with instructions on how to take her blood
pressure medicine and birth control pills (the PNG version of
estrogen-replacement therapy), medicines for heart burn (the chest
pain and abdominal pain and sore throat), and stool softeners with
diet instructions (the abdominal pain and pelvic pain), as well as
instructions to return in four weeks for recheck.  I’ll be gone then,
so she’ll be someone else’s problem.

The other patients I saw were much more of your typical PNG-type
patient–one recheck for a wrist injury, and one medical clearance
form to apply for the police department.

Then it was back to the house to sit on the veranda trying to catch
the briefest of breezes (there wasn’t much) while I continued to burn
through my reading material.  Just when I thought I’d run out (I am
down to the last fifty pages of the last book I brought), Manar
brought over some fairly recent periodicals–a Time magazine covering
the inauguration and a Guardian (publication from Australia or New
Zealand or some other not-America place) from within the month.  I’m
looking forward to going through those and seeing what has been going
on since I’ve been cut off from the news.  Of course, I’ll be home in
a week, and then it won’t be long before I’m complaining about being
constantly inundated with news about things I don’t care about.  I
guess you can never win.

Our reasons for the vasectomy being iffy were completely
different.  None of us have ever performed one before; I’ve never
even seen one live.  However, Ovoi felt confident in her abilities to
do one, based on having seen it done, and having the surgery book
open to the vasectomy chapter.  We were going to do it, but then we
couldn’t find the right instruments.  Someday, someone else will have
to be Ovoi’s guinea pig.

The skin graft went fairly well.  I was feeling pretty confident
going into this one, since I did a month of skin grafting while doing
a rotation in the burn unit.  Skin grafts in American and PNG are
different, though, mostly because at home we have fancy equipment for
preparing the skin of the donor site, removing the skin, and
preparing the shaved skin for grafting.  Here, we “prepared” the skin
of the donor site by having me pull it taught, and Ovoi removed it
using an instrument (I don’t know its name) with a razor blade
attached, and we prepared it by taking the tip of a scalpel and
dotting it with skin.  We wrapped it up pretty tightly and told the
mother to make sure she doesn’t walk on it (its a 14-year-old girl,
and the graft was on the top of her foot) for a couple of
days.  Hopefully it’ll take.

As far as the fracture reduction, well, we had three guys holding
traction while Manar did the anesthesia, Ovoi did the plastering, and
I held the fracture in place.  Hopefully it worked.

Since we couldn’t do the vasectomy, we were getting ready to go home
when we heard that the brother of one of the CHWs was chopping a tree
when the sap, which was white and watery, squirted out into his eye,
burning his eye, so we grabbed stuff to do some emergency
ophthalmology, including anesthetic eye drops, flouresceine (to see
if the cornea was damaged) and antibiotic eye ointment.  And we read
the chapter on eyes in the surgery book (good thing Ovoi had it out
in preparation for the vasectomy).  I’m assuming the sap was alkali,
which is the worst possible thing for eyes.  Well, we gave him the
anesthetic drops, then the flouresceine, and the entire eye lit up,
which is bad–means there’s a lot of cornea damage.  So the only
thing we could do at that point was put in the ointment, cover his
eye, put his name in the book to the see the ophthalmologist in March
or April, and be thankful that his other eye was spared.

After our morning in theatre (I still enjoy writing that), I headed
back home to do some cleaning.  I’ve had this infestation of little
green bugs at night (like on X-Files, only these don’t eat flesh when
the power goes out).  I’m able to kill them pretty effectively with
the bug killer I have in the house, but then my floor is littered
with millions of little green bug carcasses, which is kinda
gross.  So I borrowed a broom and swept them away.  Hopefully they
don’t come back tonight, because they’re really getting on my
nerves.  After that, I “enjoyed” a very hot afternoon, without much
of a breeze, so not even sitting on the veranda was much
relief.  It’s cooled down somewhat since then, so hopefully it won’t
be too hot for sleep tonight.  I can use a good night’s sleep.

After a somewhat rocky start this morning, I headed over to ward
rounds a bit late (I apparently didn’t miss anything), and was only
there for a few minutes before Sarah, the hospital matron, found us
and told us that a whale had washed up to shore down at the coast,
and the villagers were requesting a doctor.  We really weren’t clear
why they would need a doctor for such a problem, but I was keen to
get out of Kikori and see more of the Gulf, so I quickly
volunteered.  I gathered up everything I would need and then…
nothing.  Went back to the wards, finished rounds, and headed up to
my house around 12:30.  As soon as I got home, one of the CHWs asked
if I was ready and said the dingy would be by to pick us up in a few
minutes.  So I quickly grabbed lunch (a cucumber and a peanut butter
sandwich I made earlier) and headed down.

The coast is about three hours away by dingy, and most of the trip
was fairly smooth sailing (so to speak).  At one point, we had to
stop to refuel, and a sudden downpour hit us then.  As we weren’t
moving, we were able to grab one of the tarps and hide under it.  The
rain had passed us by by the time we were underway again.

We got to the village with the whale (the whale wasn’t actually in
the village, just where they go to fish), and they directed us to the
whale, and sure enough, there was a dead, beached whale.  They
estimate it’s been dead for about two weeks, and based on the smell,
I’m inclined to agree with them.  If anyone ever asks you what the
most offense smell in the world is, decaying whale flesh has to be
near the top of that list.  Well, we didn’t do much except confirm
that there was a whale (check) and take pictures (check).  We brought
along a police sergeant with an M-16, because there was word that
there were crocodiles lurking around, but we didn’t see them, so
nobody got to shoot anything.  Then we headed back to the
village.  The reason they wanted a doctor is that they were concerned
about eating fish and crabs that were feeding on this dead and
decaying whale.  As I didn’t see any signs of toxic bacteria around
(no floating fish or dead birds or anything), I declared that as long
as they boil their crabs long enough and make sure their fish is
properly cooked (wise precautions in any case), they should be
okay.  And that was that.  I have done my public health duty of the day.

They broke out the food on the way back–biscuits (cookies) and
biscuits (hard-tack) (I don’t know how they distinguish the two when
talking, honestly), tinned corned beef, and lemon pop (like Sprite or
7-Up).  Well, now I know if I ever find myself in a cold battlefield
(or a dry desert–let’s be honest, that’s what we Americans are using
for battlefields these days) with nothing but the hard-tack from my
MRE and a tin of meat (which would probably be Spam, as it would be
American), I could bring myself to eat it.  And as I probably won’t
be in a dingy with ten other people, bouncing on the waves, it would
probably be easier to do.  It was a day for new experiences all around.

So, I know I didn’t write anything yesterday, but this is still going
to be a short entry today, as nothing exciting has happened over the
weekend.  I did plan on going in to check on the patients with Dr.
Manar yesterday (she was on call for the weekend), but I woke up
feeling sick, and was sick for pretty much the entire day.  The
furthest I got from my house all day was the veranda, and as that’s
attached to the house, I don’t think that counts.  I was feeling much
better today (I’m attributing the 24 hour sickness to the tinned
chicken I added to the soup I made Friday, so I threw out the rest of
that), and went about my usual Sunday activities–the forty-five
minute walk in the sun to church, followed by a stop by the market
and store on the way back–without any problems.  Then we had the
unexpected gift of a few extra hours of electricity during the
afternoon, making the house cool enough to actually sit in (usually I
spend my afternoons on the veranda, where there’s a breeze).  And I
got to have my computer plugged in and charging during that time, so
that’s a plus.

And that has pretty much been my weekend.  I know, it’s a terribly
exciting life here in PNG.