Shock

January 22^nd 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