Friday, June 21, 2013

Finish Line

Hello!

At a party to celebrate Stephanie's family visiting in May and
our engagement!


It has been months since we last wrote about our work here.  This is not because we had nothing to write about, quite the contrary in fact!  We were just too busy to make a decent post.  The following will attempt to fill in the gaps but we look forward to catching up soon in person or by phone when we are back stateside.

Speaking of which, tomorrow we wake at 5am to run the Dili marathon then immediately board a plane heading home.  Thank you to all of you who have supported us and kept us in your thoughts during this journey!

Community Health Project

Now, back to the project followed by several other stories.  As you have probably long forgotten by now our main project while in Timor was to reformat, improve, and expand Bairo Pite’s mobile clinic program.  What follows is a summary of the work we have been engaged in that I wrote for a different purpose:

Community visit in Osolia, a remote community in the interior
of Timor Leste.

“The Bairo Pite Hospital Community Health Program has undergone significant change over the past 6 months.  For many years it operated as a pure mobile clinic, visiting 11 sites spread throughout Dili and Bobonaro Districts on a weekly or bi-weekly basis with a team consisting of a driver, Timorese nurse (who provides consultations), Timorese volunteer (to register patients and hand out medications), a foreign doctor or medical student, and a Timorese volunteer translator.  Patient volume depended on site and season but averaged 10-30 people.  Very ill individuals would be brought back to Bairo Pite for more definitive management.  In three communities Bairo Pite employed Tuberculosis monitors to facilitate detection and treatment compliance concerning this disease.  While the mobile clinics were held in high regard by participating communities it was felt the program could be improved upon.

The new program was instigated in order to re-focus the visits in a more prevention-oriented direction and to empower communities to take charge of their own wellbeing.  The first major change was to create a program coordinator position.  The prior mobile clinics were managed by a number of clinic staff with other responsibilities while the new position is dedicated entirely to the community health program.   

Each site visit now commences with community education on topics such as hygiene, nutrition, diarrhea/dehydration, tuberculosis, malaria and more.  Education is delivered by three program staff each teaching a separate small group and is designed in this manner to maximize community participation.  With the focus now on prevention the team now visits communities only once per month instead of weekly but will send an emergency vehicle when the need arises.  After education, consults are carried out as normal with the one change being that visiting medical student are no longer allowed to conduct consults on their own and may only assist the Timorese clinical nurse or visiting doctors.

Several changes have evolved from the intent to build a stronger partnership between Bairo Pite and participating communities.  Key contacts were identified early on and include village leaders, teachers, as well as other community members.  Coordinating with these individuals has been invaluable in organizing one of the more exciting aspects of the new program, identification and training of community health workers and lay midwives at each site.  The curriculum is currently being finalized and communities have been guided through how to choose individuals for training.  The CHWs and midwives will provide community education, deal with minor health issues, help identify and triage ill patients (for example malnutrition and TB), conduct home deliveries (midwives), and coordinate with both Bairo Pite and local government health facilities to meet the needs of their respective communities.  This aspect of the program is in the initial stages of implementation but holds great promise for the improvement of community wellbeing.

Lastly, in the overall evaluation of sites visited several communities were determined to have quite good access to health services.  The goal of the Bairo Pite Hospital community health program is to serve those communities most remote, most in need, and most willing to engage in a productive partnership.  Thus, so far, one site has been discontinued and one new site in the Bobonaro District has been opened.  The current total of communities visited by the program stands again at 11 but will likely drop to 9 or 10 in the coming months.”

In addition to the above work we also traveled to and evaluated two remote communities in the interior of the country for potential collaboration.  These sites were indeed remote; one being over 8 hours from Dili much over atrocious roads that at times become impassable due to heavy rains causing flooding.  These communities were also facing many health challenges.  For example, in one site in a population of 1,300 they lost 9 children to diarrhea/dehydration in 2012 and 11 women to child-birth complications over the two year span of 2011-2012.  We determined that the most useful contribution we could make being so far away was to empower the communities and assist in the prevention of disease by assisting the communities to vote on community health workers and lay midwives who we would then train. 

We returned to both sites and helped facilitate the selection process (for choosing the midwife students only women were allowed to vote but men kept trying to butt in – we had to eventually tell the men to sit down and shut it or they would have to leave!)  The first two lay midwives have almost completed their intensive 3-month training course at Bairo Pite (one week left as I write this!) where they will have participated in close to 300 deliveries by the end of their training. 

Voting for the community health worker trainees in Osolia.

Training CHWs in Osolia with good old chalk and chalkboard!

Adese with Professor Marcelo the community
leader who petitioned for assistance
to improve the health of his people.

For the training of the community health workers we developed a curriculum based off the book “Where There Is No Doctor,” work by Partners In Health, and other sources.  I traveled to one of the sites with a Timorese colleague, Adese, to conduct a 4 day training for two health workers in late May.  The road had become impassable due to heavy rains causing small land slides to deposit boulders in the road and we thus had to hike in the final 6km with our gear.  And of course it rained:)  Future trainings are being planned as additional communities select individuals for training.

While sad to depart we leave the program in good hands as our dear friend and colleague Lourenco (previously misspelled as Lorenzo) has been selected as the new coordinator of the program – we are very proud and excited for him!

Professor Marcelo and his wife in their home
with a breakfast they got up at 2am to spend
2 hours preparing so we could eat at 4am and
start walking out at 5am in order to catch the bus
in the distant town.  Thank you.
           

Yoga!

Stephanie’s yoga truly blossomed in Timor.  She taught a total of 42 classes, creating a new theme each week complete with quotes and moves to reflect the topic.  Her classes were extremely well attended and a few times people had to be turned away!  I was able to attend as well on an almost weekly basis and know it helped keep me centered and rejuvenated my stores of empathy.

Perhaps even more exciting, a goal since coming to Timor, was Stephanie teaching yoga to Bairo Pite Clinic staff!  She taught 5 classes with 3-6 students per time and after each class the students emerged refreshed and glowing.  Stephanie was grateful to share the power of yoga and see how it affected their lives – many students espoused the desire to continue practicing in the future as it made them breathe easier and feel better.

Stephanie teaching yoga at the clinic!

Community

Timor has astounding natural beauty but the true riches as we came to see lie in its people.  The warmth and kindness we experienced from our Timorese friends and colleagues was unlike anything either of us had previously encountered.

Stephanie leading a yoga session at the home of a good friend
from the clinic.  Yolanda's (our friend) kids got a hold of the
yoga magazine stephanie had brought for Yolanda and started
flipping through imitating the poses as best they could.  Stephanie
eventually joined in to provide some guidance:)


My "host mom" during my week in Osolia making a Tais.


Close up view.  I later purchased a completed tais from her and she
gave me a different one at no charge for  helping the community.



Walk with kids

We took numerous walks and hikes all around our community.  One of our favorite destinations was an old semi-abandoned road leading up into the mountains.  We hiked it so many times that the local children came to know us well and would accompany us on our adventures.  On our final hike we attracted a group that numbered 20-30 strong and at several points they all burst into song in unison.  It was moving and beautiful experience.  They joy of children and their ability to be fully present in each moment is remarkable and something we are working on incorporating more into our own lives.

Walking up the hill, hand in hand with singing children.  They seem to like Stephanie more:)

Mana Lou

During our final week we finally made a long awaited trip up into the mountains surrounding Dili to meet Sister Lourdes, aka Mana Lou.  Called a modern day Mother Teresa for her work in Timor she strives to improve the lives of those with less.  From healthcare (she was an original and continues to be an avid supporter of Bairo Pite), to farming, to business she works to empower her fellow country-women and men.  All are welcome to join her cause and her popularity among the common people for a time engendered fear amongst the ruling elite that she had politicial aim.  She told them this was ludicrous and since that time has formed working relationships with the president and prime minister.  When the Ministry of Health (MOH) wanted to shut Bairo Pite Clinic in 2007 she met with both the president and prime minister, explained her side, and in the end the an agreement was made where the MOH would provide the clinic with a $15,000 per month operating budget that continues to this day!

Us with Mana Lou in her flower garden, one of many small businesses she has started.
We expected to see Mana Lou briefly and thank her but were pleasantly surprised to find Lourenco (a former student of hers) had told her about our work at Bairo Pite and Mana Lou took over an hour on two occasions during our stay to talk with us, ask us about our lives, and explain her work.  An inspiring woman indeed, we hope to support her cause in the future.

Goodbye

The day before we left we received certificates of appreciation as well as hand-woven “tais,” traditional weavings of great cultural significance. Saying goodbye was difficult but this reflected to us just how important our new friendships had become.  The question everyone posed to us was, "when will you return?"  We do not yet know what the next few years will bring but we most definitely plan to return.  Our experience in Timor has been pivotal for us professionally but just as importantly, if not more importantly, it has helped create the foundation of our partnership together.



Receiving Tais with our friend Lourenco.  



















Sunday, May 5, 2013

Timor Fun

Hi folks.  We, that being Stephanie and I, realized we have been sending out mostly intense medical/project oriented blogs.  This is a big part of our time here to be sure but there have been countless magical moments that don’t fit into that category.  This blog (and perhaps a few more soon to come) will try to fill that gap.  We hope you enjoy:)

Relaxing with friends at Bairo Pite Clinic.

Children!

Hanging out in Dili.  Umbrella not for rain.

There are lots of children around in Timor and they delight in informing us of our status as foreigners.  Or maybe it’s just their way of saying hi.  Shouts of “malae” (roughly translated as foreigner) accompany us virtually wherever we go.  Even children small enough to be barely walking seem to have figured out this charming game and squeak out, “malae-malae-malae-malae” with machine-gun rapidity as we pass.

1-2-3 Jump!  Stephanie gets some sick vertical!

We often visit the local park where I like to do pull-ups on the monkey bars and the kids like to attempt them or count for me.  We also chase the kids all over the play structure (their favorite game).  Sometimes things get rough and we have to lay down the law.  “Stop hitting each other in the head or we will go home” usually does the trick. 

Swinging around after a big rain!

up...

...and down, jumping "rope" with a rope made entirely of
rubber bands!

The local neighborhood girls have taken to Stephanie like white on rice and whenever we show up they flock to her.  She has taught them a few basic yoga moves which was a huge hit and quite a sight to see - kids wobbling into kids, smiles all over:)  When sometimes I go alone to the park the first words I hear are usually, “Stephanie, iha nebee?” – “Where is Stephanie?”  Her “fan club” has grown to such proportions that now when we go for neighborhood walks we invariably hear shouts of “Stephanie” (pronounced Stefan-yah) from all directions.  It’s great:)


Running

Stephanie running up a dry riverbed near our home.

Prior to traveling to Timor I read the book “Born to Run” which Stephanie also read soon after our arrival.  We were both inspired.  I consider it one of the most inspiring and life-changing books I have ever read.  It combines an adventure tale with very plausible argument that humans were designed to run – and to do so bare-foot or in very minimal footwear.  At the time of reading I had been suffering a nagging knee pain whenever I ran more than 30 minutes or so.  Switching to minimal footwear has been a slow road but in Timor, after months of building up previously neglected muscles in my feet and lower legs, I have been able to run for over 2 hours straight, up and down mountains, with no pain.  None.  It’s amazing!  To say I am a convert is a massive understatement:)

Stephanie and I go running several times per week currently.  Usually we choose early morning (6-7am range) to beat the heat.  It’s early but we’ve seen more amazing sunrises here than I think I’ve seen in all my life prior!

Running with a group of local kids on the same riverbed -
kids here just love to run!
At present we are training for the Dili ½ and full marathon, which is scheduled for June 22nd – the day we fly out!  We had been planning on doing the event for months and when we found out they had scheduled the race later than ever and on our departure date we were heart-broken.  Examining event and flight times though we realized we could still fit it in, barely.  The plan is to pass the finish line and keep going, have our place already cleaned and stuff packed and go straight for the airport!  Hopefully our legs don’t cramp too bad being stuck on the plane:)

Look at that smile:)

On a morning run looking at the sunrise over the mountains
east of Dili.
Sunrise from a run along the coast - it never gets old I tell you!



Beach Escapes

A conch shell I found and later gave to the local co-op that
ran the huts we stayed in.  The water's clarity was unreal
around Jaco Island.

Twice now we have had the opportunity to escape the scorching, humid confines of Dili for idyllic ocean-side escapes.  Our first adventure took place a couple months back but we never managed to post anything about it.  We traveled to Jaco Island, located on the easternmost tip of Timor.  The beaches are pristine and the snorkeling (or scuba diving if you do it) is phenomenal.  The area is part of what is known as the coral triangle, a zone known to contain arguably the worlds most diverse coral reef system in the world.




Boats on the beach at Atauro island. 


Our second trip was more recent and out to an island called Atauro 3 hours north of Dili by boat.  We hiked, snorkeled, swam, ate, read and recharged our batteries as much as possible before heading back to Dili.









Stephanie by a mangrove tree wearing a traditional sarong skirt.  Such a nice smile:)

A cave we were guided to near Jaco Island (but on the mainland).
This and other similar caves were reportedly used as hideouts
for Timorese resistance fighters during the Indonesian occupation.

Stephanie in the hut we stayed at while
visiting Jaco Island.

Sunrise from a sea cave near Jaco Island.

Lidia

One of the roles Stephanie has taken on at the clinic is assisting in the pediatric malnutrition ward by helping to engage the children in play.  Malnutrition causes children to become listless and apathetic and encouraging play is an important part of their treatment plan.  


Stephanie and Lidia at the park

The main staff member of the ward is a young woman named Lidia.  Essentially a volunteer herself, she is paid a minimal wage (to cover transportation costs), but despite this her dedication and care is superb.  Lidia and Stephanie hit it off from the beginning and when Lidia informed us she is studying English with the hope of earning a scholarship to study abroad and hopefully become a doctor one day Stephanie began to work with her to improve her English.  Their friendship has blossomed and Lidia recently invited us to visit her family at their home and share a meal! 

At Lidia's home with her parents and a feast of traditional
Timorese foods!
Rosalia


Stephanie and Rosalia in the courtyard outside
our apartment.
Our land-lady is a Timorese woman named Rosalia.  However, the word land-lady does not do the relationship justice as she has essentially become a second mother to us both.  From bringing us little treats (fried tempe, bean soup, bananas), to sweeping our little porch, to greeting us with excitement and smile, to offering to teach Stephanie how to cook regional food she has been a true blessing in our lives here.










Super Shopper!

Yesterday, Saturday here in Timor, was our shopping adventure day.  We had a long list of items both for an upcoming overnight community health trip (bedding, pads, mosquito nets etc.) and a future community health worker training (more on both of those in a future project related blog).  We managed to find all our items after roughly 5 hours of searching but then realized, “how the heck are we going to get all this home on our bikes?”  The answer, in part, can be seen below:)

I am not sure whether it was the mosquito nets
strapped to my back or the fact that we generally
stick out like sore thumbs but it felt to me like
there were an awful lot of people staring at us as
we rode home from the store. 

Lorenzo’s Birthday

Lorenzo, for those who may not remember, is the Timorese young man who has been invaluable in helping move our project forward.  We attended a triple birthday (including his) last weekend.  Through Lorenzo we have come to know most of the members of his house and it was exciting to be a part of their special day.  After singing happy birthday in portuguese (birthdays have little meaning in traditional Timorese culture and there is no song for them) we all feasted on fish, rice, local greens, banana juice and pumpkin flan - yum! 




Party time!











Sunday, March 10, 2013

Over the hill and across the river.

In order to better reform the Bairo Pite mobile clinic program we were recommended to accompany Dr. Aida Goncalves (a Timorese doctor trained in the US who runs her own community health program with funding and support from a Japanese NGO called Frontline) on several of her community visits.

Our four wheel drive vehicle before we got a
flat tire.
Dr. Aida (left) and nurse Pinky (a volunteer from the
Philippines); Aida may be petite but she is a firecraker!

And what great experiences they were!

We have now accompanied Aida to two communities and learned a great deal on what it takes to make community based health promotion successful as well as learning about the challenges inherent to such work in Timor.  What follows is a description of a trip with Aida and team from February 15th 2013 with several clinic pictures spliced in from our first trip.

The ride out to the rural community of Sare (pop. Approx 3000) started along the main road heading west out of Dili.  You might think this would be a decent size highway but the truth is there are no highways in Timor.  Nope, none.  Barely wide enough for two cars to fit past each other, pot holes a welcome site compared to the many rough unpaved sections, enough swerving turns to make almost anyone lose their breakfast, well, it all makes for eventful car travel to say the least.  This country has redefined what a “bad road” is for me.  Four-wheel aficionados would think they had died and gone to heaven!


A typical home in the community of Sare. We were told a
roof like this can be fabricated in one day by the community
helping one another and using palm leaves.

The last hour or so we turned off the “main road” and made our way across grassy plains, past flooded rice fields, through forests and finally across a wide river comprised of many rivulets – maybe 500m across – with the deepest water at about 1 foot.  With no rain for a few days I could only imagine what would happen after a good downpour…

Arriving in Sare Aida’s team sprang into action – and it was a sight to see!  (Sabino, our team driver, had of course already done his work safety shepherding us to our destination.)  In each community where Aida works she has trained two community healthcare workers (CHWs) – selected by the community itself - who monitor the health of their neighbors (detecting TB, child malnutrition, severe diarrhea, and other illnesses) and assist during the community visits.  They receive $75 per month in compensation.  The two CHWs along with Aida’s staff member/records keeper/pharmacist set up the tables and equipment while Stephanie, Lorenzo and I distributed donated dolls and clothes to young children and expectant mothers.  The open-air tin-roof building ready to go, the CHWs then held a community education session with all present (mostly women and children this time as it is rice planting season – maybe 75 people in total) about TB: warning signs mostly such as chronic cough, weight loss, night sweats/fevers, and coughing up blood.

A community health worker presenting on diarrhea
and dehydration warning signs.
In each community Aida has also asked the community to select one woman to be trained as a midwife.  Such women receive 3 months of hands on intensive training at Bairo Pite Clinic participating in nearly 300 deliveries and once finished are capable of dealing with breech and twin deliveries, post partum hemorrhage and more.  They are highly respected in their communities and receive $150 per month.  Aida told us the midwife in Sare is one of their champion graduates – she had just delivered a baby in the wee hours of the morning and was ready at clinic to help Aida do pre-natal checks on all the pregnant women several hours later!

Community education session complete it was time to run the consults.  Aida did all the pre-natal checks (roughly 15-20) and saw the adult consult patients (roughly 40).  She had me see all the pediatric patients, 48 in total, ranging in age from 2 months to 16 years.  Most presented with colds or other viral illnesses but several children were truly ill including the adolescent who had been suffering bloody diarrhea for 1 week – not good! - and a small infant with copious amounts of pus leaking from one ear.  Doing consults in this environment is much different from the US.  Mothers, their teeth and gums stained bright red from years of betle nut chewing (a mild stimulant commonly used in Timor) press in close clutching their children.  Privacy?  No way!  Children scream as I try to hear whether the two year old in front of me has any wheezing.  Then the rain starts, intensifying it’s barrage of the tin roof over our heads until I can hardly hear what the patients are saying.  Lorenzo however, can still decipher the complaints and we keep moving.  Stephanie takes on record keeping and note keeping in addition to taking temps to help us move more efficiently.  The rule with Bairo Pite (and with Aida’s clinics) is you stay until all patients are seen.  Aida and Dr. Dan can fly through patients but I am not so speedy yet. 


Lorenzo and I consulting with patients. Stephanie behind
keeping records, handling medicine and snapping photos.
Lighting not ideal...

It seems like the crowd of patients pressing in around us will never end but finally they thin and then suddenly, the last patient!  Quick, quick we pack the car, rain still falling, and then head back down the road.

Dr. Aida checking on the river, at this point too high to
cross. She arranged our accommodations and told us
being unable to cross the river has not happened in 5 years.

Once down at the river I join Aida outside to assess the situation.  Our peaceful river from hours prior has turned into a torrent, sweeping small trees by, waters a muddy grey brown.  Last year a large truck was swept downstream trying to cross in a similar situation (luckily no one died).  Looks like a night out in the community!  Fortunately the Chefe Suko (local community leader) is happy to take us in.


Back in the community we are provided with tea and crackers.  Sitting for some type of hot beverage when hosting guests is, I am coming to see, a very important social event/obligation.  After tea, Stephanie and I decide to take a walk before dark.  The rain has stopped and we go barefoot, the mud squelching through out toes.  Soon curious children start to join us and before long we have invented the “count to three and then start running and screaming down the road game.”  Everyone shrieks with joy and at one point we grow to perhaps 30 strong.  Neighbors come to the edge of the road to see what all the commotion is about.  An experience we will not soon forget:)

Barefoot running with the joyous children! This is an
activity Stephanie and I greatly enjoy. Wherever we go,
the kids love running along side us :)
After a tasty communal dinner of rice, veggies and chicken we settle down on a guest bed under our mosquito net and try to sleep.  At one point in the night I awake at a slight noise.  Soon a small puppy pops out from under our bed – where did he come from?!  Dogs are always underfoot here.

The next day it’s time to try the river again.  Once down on the riverbank we see it is still quite high but fortunately the husband of the local midwife has agreed to use his tractor to test out a safe route and guide us across.  After that it’s the familiar bumpy road 3 hours back to Dili.



Shot of the river from the passenger seat.  The river was
comprised of multiple water channels like this one, some even deeper,
totaling roughly 150-200m across and took us perhaps
10 minutes to fully cross!


Take away lessons from the experience:

- Rivers change fast here!
- Always be prepared to spend the night out.  Pack supplies accordingly! (we did not:)
- The relationship with the community is key. Aida has formed a solid partnership with those communities she is working with and the benefits go both ways.
- Community health workers are vital to the success of rural health programs.
- Laughter and smiles transcend language and culture.




The future of Timor- Leste.  Smiling and hopeful.  The
children make our  long days worth it.





Tuesday, February 5, 2013

Efficiency


If you look in the dictionary you will find the following definitions for efficiency:

1) Accomplishment of or ability to accomplish a job with a minimum expenditure of time and effort.

2) A concept that does not exist in Timor Leste.

Let me explain.  

One of our patients is a woman who has suffered a severe drug reaction after being treated with dapsone for leprosy (a sulfone reaction to be precise).  This hascaused her skin to become inflamed and start peeling off her entire body.  At present her skin – where it has not broken or peeled off leaving raw oozing sites – is a thick, stiff shell.  So stiff in fact that she cannot even close her eyes.  Another potential danger exists with this type of drug reaction.  One’s red blood cells (RBCs) can be destroyed.

And this has happened to our patient over the last 24 hours. 

Her hematocrit (a measure of RBC concentration) dropped from 30 (already low) to 15 virtually overnight.  The number one priority of the day outlined this morning on ward rounds became secure this women 3 units of blood to replenish what she lost (and then start her on prednisone to stop the auto-immune process destroying her RBCs).  No problem right, just get a cross match done and order up the 3 units right?  Not so easy. 

The lab at the clinic either did not understand or did not know how but for whatever reason they did not draw blood to check the patient’s blood type.  Though asked to do so around 930am initially, at 3pm on a recheck we realized the patient was still not receiving blood.  The staff had been unable to find a vein as the woman’s skin was thick and stiff.  But they had neglected to tell anyone about it!  Eventually a foreign doctor who had just joined the clinic team today was able to do a radial artery puncture to obtain the requisite sample.  The patient was determined to have O + blood.

A quick call was put in to the National Hospital Blood bank.  The reply, we are out of O + (and O – blood, which could also be used).  Sorry. 

We then asked the family if anyone was willing to be tested as potential donors.  Perhaps 8 family members were present but no one stepped forward.  I was not quite sure why as my language skills are still in their infancy.  We took a pole among volunteers and found two among us who knew they were O + and were willing to donate.  I am O – (universal donor) and knew I could donate as well.  The three donors to be hopped in the back of the ambulance along with Stephanie as our support person and a Bairo Pite clinic lab technician and sped over to the National hospital.  Though they normally close around 4pm they sympathized with our case and agreed to stay open.

There was only a quick form to fill out, not the extensive questioning like in the states, and then onto the table – I made sure he pulled out a needle from a sterile pack – and then lay back as the red stuff flowed.  I forgot how large the needles are!

When all three of us had donated we sat around to wait for the cross match process (a quick mix of our RBC’s with the patient’s serum to make sure no antibodies from the patient attack our donated cells – a way to ensure the donation will work).  After 10 minutes or so the technician came out and said the patient’s sample had been delivered in the wrong tube and he could not cross match.  We knew we had put her blood in two tubes, one of them correct, and it seemed the Bairo Clinic lab had sent along the wrong tube.  Doh!

It was now nearing 6pm and the clinic staff member along with us called back to our lab.  They had indeed sent along the wrong tube.  We waited another 30 minutes as the correct sample was raced over by motor-bike.  During this time our clinic staff member/translator had to leave. 

Finally the blood was ready.  I peered in the ice-pack chilled box and saw only one unit.  One, we needed three!  With our Tetun-fluent clinic compatriot gone my Tetun was the strongest of the group and believe me – it’s not so hot.  I tried to explain why we needed all three but he didn’t seem to agree.  He said something about a fridge and that we should come back when we needed each additional unit.  I said we planned to give them all successively and he should just hand them over, that it made no sense for us to come back for each unit.  It was a stalemate.  Finally we had the idea to call Dr. Dan who after I handed over the phone fixed things somehow.  He added in the two additional units are we were ready to roll.

So, case settled right?  Remember the definition?  Efficiency: not in Timor.  The trip back to the clinic was uneventful besides lots of traffic.  We handed off the blood to the night nursing team around 6:30pm with detailed instructions and made sure they understood.  I gave them my phone number and told them to call with any questions.

At around 8:30pm I received a call, “umm, the patient’s fever has not gone down with with Tylenol.” 

“Did the fever start after starting the blood?” I replied.

“No, we haven’t given the blood yet.  We are trying to get the fever down.”

“What?!  The patient needs this blood as soon as possible, please start it, I am coming over as soon as I can.”

Arriving at the clinic I saw the ambulance pulling out (apparently a man had been hacked in the arm by a machete and it was too much to deal with at the clinic).  Making my around back to the patient’s isolation room I saw a great number of her family crowded around.  Let there be blood I said in silent prayer.  Making my way inside I saw the patient’s mother fanning her to keep the flies off and there, hanging triumphantly, a unit of whole blood, drip dripping away.

Efficiency.  It does not exist in Timor Leste.  But, usually, somehow, things do happen here.  It just takes a little extra time, prayer, hard work, and luck.  

Sunday, January 27, 2013

Shock


January 22nd 2013 9:50pm Dili, Timor Leste.
Shock

I am in a state of shock.  Much like the child’s side whom I just left 10 minutes prior to beginning to write this.  That is, he was in shock.  Severe hypovolemic shock induced from one and half weeks of profuse diarrhea.  I say was, because when I got there, it was too late.

9:20pm my phone rings in Stephanie and my small Dili apartment, jarring me from a relaxing evening.  I somehow knew…  I wasn’t expecting any calls, it had to be Dr. Dan Murphy – the head physician at the Bairo Pite Clinic where I am working - and it had to be something at the clinic.  Just the night prior he had joined us for dinner and I had told him as we reside about 50 yards from the clinic he should call me if ever an urgent matter arose.

“Just got a call in from the clinic, young boy, dehydrated, I want you to go in and evaluate him: mucous membranes, pulses, sunken eyes, etc. and give me a call,” his voice came through metallic, distorted by the poor telecommunications of Timor-Leste.

I donned my clinic attire, grabbed my tools and headed out the door, promising Stephanie to be back as soon as I could.  The busy streets had quieted and you could almost call it a comfortable temperature.  The clinic gate was open slightly and I walked in, calling good night to the entry guard.  No one was on the small ER but as I turned away the night nurse called to me and I hurried over to the room he mentioned.

The sudden bright lights inside the room cast their fluorescent glow over two nurses, a crowd of people at the door, a woman seated at the end of a bed and small boy, maybe 4-year-old, supine on the bed, an oxygen mask covering half his face.  The steady whir of the O2 machine was the only noise.  The woman, I presumed the mother, looked apprehensive.  The nurse, in broken English gave a quick run down – “ they are from far away, Liquica, the child had over a week of diarrhea, it was long ambulance ride in, kid was shaking when he got here – we gave Tylenol and ceftriaxone.” 

A phone was handed to me before I could examine the kid – it was Dr. Dan.  “So, what is going on?” 

“I am not sure yet, I haven’t had a chance to do anything,” I replied as I started to assess the child.  No evidence of breathing… no radial pulse… no carotid pulse… no heartbeat detected by stethoscope… I relayed each finding to Dr. Dan.

“Look at his pupils,” he instructed me.  “If they don’t react it’s too late, and would indicate irreversible brain damage secondary to cardiopulmonary arrest.”

I shined my high power flashlight directly into the child’s large dark left pupil.

It did not move.

Each year around the world thousands of children die from easily preventable and treatable diarrheal diseases.  I know this.  Tonight though, I looked into the face of just one boy, one person, affected by this tragedy.  His only crime was to be born to a poor family far from medical care.  I will never forget him.  Nor his mother’s hidden sobs of grief.  And I hope one day stories like his will no longer have to be told.

Timor-Leste: The Beginning





Introduction:

We’re alive!  We have now been in Timor-Leste slightly over two weeks and finally have a chance to share some of our new lives.  Things have been busy, challenging, and exciting and the following stories and pictures, will, we hope, give you a sense of this.

Arrival story:

The final leg of our journey to Timor-Leste was a short 1.5-hour plane flight from Bali.  No problem right?  The airport is set right along the ocean and as we approached to land the pilot descended till we were what appeared to me 20-30 feet above the sea, then kept descending – I thought we were going into the ocean!  At what seemed the last possible second land appeared and we touched down within seconds.  Welcome to Timor:)

Timor Leste Coastline a couple of miles
outside of Dili.  The entire country is
very mountainous

Customs was a breeze – nice!  We had arranged to be picked up by the clinic and as we pushed our overloaded cart out of customs and into the mass of sweating dark bodies we searched for a sign with our names on it.  Nothing.  Being over a foot taller than virtually everyone in the airport and very pale we didn’t think it would be too hard to spot us but after 15 minutes of wandering around we had to conclude no one was there for us.  One taxi driver “befriended” us and hung around like a vulture, waiting for us to give in, admit our friends were not coming, and pay him an exorbitant amount because we were malae (foreigners).  I had a phone number for a contact at the clinic but no phone to use said number and there were no pay phones to be found.  In a mix of broken Tetun (the most common local language) and some English I was finally able to convince a kind lady to let me borrow her cell phone.  I was able to reach Aida Goncalves, one of the doctors at the clinic and things were back on track.  Apparently a team had come to find us but had been there too early/not seen us?  Oh well, in the end we figured it out.  Welcome to Timor round two:)

Dili lies just to right of this frame.

Housing:

Prior to coming to Timor we had arranged to live in a house located several miles across town from the clinic.  We planned to get bikes and figured we could ride in each day.  However, we did not realize how much of an obstacle it would be living farther away from the clinic (no taxis run past 7pm so getting home from late shifts would be hard, rainy season makes biking more challenging, etc.).  Thus, we elected to look for something closer.  For the first few days the clinic director Dr. Daniel Murphy (who goes by Dr. Dan) graciously took us in until we found the place below.  Located roughly 50 meters from the clinic we could not have asked for a better location.  We have a small living/bedroom, kitchen and bathroom.  Bonus items = an air conditioner, fridge, and flushing toilet – living the high life!

Hallway leading to our apartment (hidden behind bush on right)



Stephanie in our lovely kitchen with fresh greens and hudis!
(bananas)
Sink zone!


Shower and toilet.  Nothing like a luke warm shower after a day of sweating your brains out!  Such a battle to stay hydrated here.  One night some small red ants started coming out of the shower spigot entry into the wall.  I picked one up.  Then it bit me - OUCH!  I think it was some kind of fire ant as the pain to size ration was not in my favor.


Book shelf, dresser and part of bed.   Just enough room for us both to do yoga in the middle - nice!


Food:

This has been a real highlight!  Partly because the food we have been eating is delicious/nutritious and also because we have yet to suffer from horrible diarrhea and/or vomiting!  There are several supermarkets where we stock up on grocery items (mainly beans/lentils, jam/PB), we bought a 25 kg bag or rice for carbs (people stared at us a lot when I carried it home on my shoulders but then again we tend to get stared/shouted at pretty much all the timeJ), and we almost daily buy fruit, veggies, eggs, bread etc. from a small outdoor market close to our house. 

Our friend the man with one blind eye and his amazing
greens - 25 cents a bunch!
We now have new friends there: the avocado lady who after several visits started giving us 5 avocados per dollar instead of 4 (nice!), the man with one blind eye who gives us a great deal on leafy greens because he doesn’t believe we should be charged more just because we are malae (foreigners), and the adolescent egg boy who I tell smoking is bad each time I see him (Timor has a huge smoking problem, it seems every male out of diapers is lighting up… all the time!).

Breakfast is usually oatmeal with fresh bananas, lunch is at small local restaurant where we get rice/beans/meat or tempeh/several veggies and iced tea all for $1.50!  Dinner though is my favorite where we have been experimenting with our own ideas and eating lots of rice and beans/lentils combined with epic stir fries comprising delicious locally grown greens I have never seen before, purple sweet potato, carrots, tomatoes, onions, garlic and more!  We add in fresh mango, pineapple, and avocado as often as possible.  Yum yum!  We are eating almost entirely vegan most of the time but I feel very healthy/fit and Stephanie feels, “spry as a gazelle.”

Breakfast! Oatmeal and local fruit + nuts!





Typical lunch - $1.50!!!
Typical dinner.  and yes, we eat avocado almost every night!


Clinic:
One of several clinic ambulances.  

Our days alternate between working on a community public health project (detailed further on) and working at the Bairo Pite Clinic (clinic description can be found in the previous blog posting).  The day starts at 8am with teaching ward rounds facilitated by Dr. Dan.  Starting with the maternity ward and progressing through two tuberculosis wards, a larger general adult and pediatric medicine ward, several isolation rooms and finishing with a pediatric/malnutrition ward a small group of volunteer students, visiting health professionals, and Timorese staff learn create plans for the day for each patient with Dr. Dan.  There are roughly 50 inpatient beds and rounds last till 9:30 or 10am.

Bairo Pite Clinic waiting room - normally much more full.  Dr. Dan sees
around 300 outpatients per day!

 
After rounds Dr. Dan begins his clinic (which he does 6 days per week and sees roughly 300 patients per day!  I didn’t think this was possible but after observing him I have seen that many people come for common and benign ailments such as a cold and he can spend very little time with them but he likes to see everyone because out of every 300 patients he will see 10 or so who have a serious illnesses occurring.)


Me and Sarah a med student from Australia in the main office where we students hang out and research about various cases and topics etc.
For the volunteers we spend our post round time completing tasks; for example: dressing wounds, draining abscesses in the small ER, buying chocolate milk/avocado/banana to have the kitchen mix a nutritious smoothie for a patient that cannot chew, researching about cases that the team is unsure of a diagnosis on, taking a patient to the national hospital to convince them she needed dialysis and a great many more.  The variety is endless and it is as hands on as you want to make it – great for self-directed learning!  The clinic shuts down from 12-2pm for a lunch/siesta (even in the rainy season it is still very hot and humid, I am guessing mid 80s to 90s and 75-85% humidity most days).  In the afternoon there is time for more tasks and then we conduct an afternoon student only wards round to make sure no one has decompensated/needs urgent changes in management.  Twice now I have stayed for a night shift split with other medical students to care for more urgent cases.  One was a young boy with tetanus and the other a man who went into hepatic encephalopathy (liver failure leads to build up of ammonia and other waste products in blood and leads to confusion). 

The young boy with tetanus died suddenly after doing well for almost a week.  It hit us all hard.  We had been controlling his spasms with regular diazepam but one night he had a sudden massive spasm and - we believe - underwent laryngospasm (contraction of the vocal cords prohibiting respiration).  He had never received a tetanus vaccine.  Death here has been much more present than it was for me in medical school in the US and it has been a hard adjustment.  It has been just over two weeks since we arrived and I have already pronounced 4 people dead.

Stephanie has been helping with general care of patients (such as applying aloe vera from the actual plant to a women with a severe entire body drug reaction causing over 90% of her skin to dry, crack and slough off in places).  However, most of her time has been devoted to the community health project (as well as working to sort out our lives here i.e. phones, electricity, supplies etc.).

Community Health Project:

Prior to our arrival we thought the community health project we would be assisting with was the development and sustainability of a program training women from rural communities to be skilled birthing attendants.  We are not doing this.  However, the project we are working on has both of us very excited.

Bairo Pite has long had a mobile clinic program that brings a medical student or doctor, interpreter, and nurse, to a rural community outside Dili in order to see patients, address basic problems, and bring any truly sick patients back to the clinic.  At present then, these clinics are purely curative, that is there is no effort made on community education and prevention of illness.  However, after over a decade of dealing with the terrible sequelae of preventable diseases such as rheumatic heart disease, tuberculosis, and even simple diarrhea Dr. Dan hopes to shift the focus of the mobile clinics to use them more as a platform for the prevention of illness in addition to direct patient care.  Ultimately, Dr. Dan hopes to reduce visits to those sites whose needs are already being fairly well met and begin to work with even more rural areas far to the east which at present have almost no access to health care – preventive or curative.  And he wants Stephanie and me to launch this initiative.


Stephanie with our good friend Lorenzo who is working with us on the mobile clinic project.  He spent 7 years in school in the states and thus has been a cultural and linguistic ambassador for us!

There are currently 12 mobile clinic sites, each visited every week or two.  They reside between 30 minutes and 3.5 hours away from the clinic, often along poorly maintained roads.  Our initial task therefore has been to visit all of these sites to assess the overall health of the community (specifically focusing on the areas of child health and nutrition, maternal health, and tuberculosis), remoteness of location, what other organizations (government and NGO) provide services, where community members access care, how long they must travel to do so, and lastly if community health workers reside in the community and if so assess interest on their part and the community in general regarding the formation of a stronger partnership with the Bairo Pite Clinic focused on education and prevention.

Lunch spot - under an animal shelter in a rain storm!
Another lunch spot on mobile clinics - the beach!

Based off our site visits we are creating recommendations for improvement of the mobile clinics and suggesting which sites could be visited less and/or cut all together.  We have already visited 8 of 12 sites and will report in detail on the project in coming entries.  However, right now my bottom is too sore to continue sitting and writing after a total of 6 hours bouncing around in the back of a land-cruiser ambulance traveling to the remote community of Atabae Dam Laran. 

Good bye for now!

Coming soon, “Challenges and Triumphs” of Timor Leste