Naresh in India

Naresh: Papua New Guinea Picture Stories

Some pictures from the PNG trip in July

My favorite picture from the trip. These boys on the beach in Wewak simply lit up once they saw themselves in a digital camera - quite possibly for the first time

The airstrip in Ambunti, the only "town" in the middle sepik river valley. We halted at Ambunti while arranging a canoe and logistics for the upriver trip to the villages. The medic training was held in Ambunti for a week.

Signs of civilization after a six hour canoe ride. Villages were few and far between. One day we rode about four hours up the april river to get to a village and only barely got back around dark.. scary

The river was stunningly beautiful... much more rainforest and wilderness than the Amazon.

A typical welcome arch at a village designed for us. These were often accompanied by welcome songs, welcome dances and welcome speeches. Except when they weren't. There was also an odd correlation between villages that gave us welcomes and villages where we left tired from seeing every sick person around ;-)

Helena and a medic (Mary) helping a kid. A medical student, a local medic/interpreter and an premed would team up to help patients out, one-by-one, all with Kelly Murphy's guidance and supervision of course

A traditional welcome. These men in Siot village were hiding behind a large tarp and broke out in song and dance in their grass skirts much to our wonder and delight. We were truly touched.

Only in PNG ! Aggressive cockatoo climbs table to steal french fry from singaporean damsel in distress.

Naresh: A Medical Safari in the Sepik River Valley - PNG issue 1

Papua New Guinea: The Last Frontier?
A Two Week Medical Safari in the Sepik

The Papua New Guinea (PNG) Sculpture Garden in Stanford (near Roble) portrays a vibrant yet scary culture, especially by night. The images that stand out are distinctive: an impassive child in the mouth of a crocodile; A snake / kookaburra bursting forth from the mouth of a woman. My pre-departure conversations in India explained PNG as an island near Australia, comprised of many cultures discovered as recently as fifty years ago, beset by headhunters, pests and saltwater crocodiles.

However, modern day PNG presented scarier obstacles than totems of crocodiles devouring children. My two week medical safari only afforded me a snapshot of the cultures and problems of the Sepik River valley. Children covered with fungal infections, hordes of killer mosquitoes and crowds of rascals openly discussing us were only a few. PNG was unlike anywhere else in the world that I had traveled or worked in, including countries like India, Indonesia or Senegal. We traveled by canoe, managed medical problems including a 5 yr old suffering from acute cerebral malaria / meningitis and were afforded welcomes including tribal dances by the men and songs by the women...

Dr. Murphy, Medicine Man:

Kelly Murphy and Peter Lu (or Keli and Pita) have been leading the Stanford PNG Medical Project since 1996 where they venture into the East Sepik rainforest with Stanford medical students and undergraduates to provide medical care as well as train the local medics to take care of their patients. (Google Stanford PNG Medical Project for more information and articles in several magazine)

We traveled from village to village and setup medical camps for sick people in each place we stopped at. I will carry a few stories with me for a long while.

B was a young woman, possibly in her mid-twenties, who had boated in from the village of Saronapi in the dry season to our base camp in Siot. She had heard that a medical team was coming and hoped for a cure. When Kelly, Gideon (a UCLA MS2) and I went to see her, she could barely get down from her hut. Supported by three people, she slowly made it over to a place where she could lie down so we could examine her. It took her about fifteen minutes to cover the ten meters. Her right wrist was enlarged and her feet showed some edema.

Almost as soon as I put my stethoscope to her heart I could hear the characteristic high pitched diastolic murmur over the apex. The Mitral Stenosis murmur was so loud that I missed the regurgitation murmur Kelly heard in the background. A patchy twice-translated (vernacular – pidgin – English) history revealed what was most probably a post-partum infection followed by infectious endocarditis or rheumatic heart disease. Calcification and insufficiency of the mitral valve is a problem routinely corrected in India and neighboring Indonesia. Here it was a death sentence.

In the United States, B would have most probably not have had her fourth child in her early twenties leading to uterine prolapse (reported). She most likely would not have contracted the post-partum infection that might not have set in and damaged her heart valves. If it was Rheumatic, she might have taken the penicillin prophylaxis until she was eighteen.

We could do nothing now. We had no furosemide nor digoxin, drugs that would have helped her pass another day or two. We wrote down what we thought was her diagnosis and the drugs she needed on a piece of paper, and told her that possibly a medic at the Hauna hospital (two days by boat) or Mapoti (one day by boat) might be able to help. We also took down her information in case we could send her the meds from the USA.

The next day we saw an elderly woman with chronic TB and liver failure. She was completely wasted up to her diaphragm and then her abdomen was grossly distended with fluid from her liver failure. You could see and count her ribs on one side, and the distended abdominal veins (caput medusae) were all that was visible in the abdomen. Kelly didn’t give her too long to live in that condition, but asked her to come to our base camp if possible so we could drain a couple of liters of fluid to give her some comfort in her last days

I was shopping in the village for small shields two days later when I heard the wailing at the waterfront. A villager immediately told me that “she had died�. Thinking that the woman with TB must have died from the strain of travel enroute to her paracentesis, I rushed to the waterfront.

The wailing had a haunting musical quality to it. The village gathered there along with me as I saw all the women from the village carrying on a lament as the relatives of the deceased rolled down the muddy bank in distress and lay over the body wrapped in tarpaulin. Upon enquiring I realized that it was B. She had left the village in search of medicines at the outpost in Mapoti. While she was there she went into respiratory distress and arrest and was treated with two antibiotic injections. She didn’t survive the night.

I wonder if she would have had a few more days to live if she hadn’t made it all the way to see us and then go to the outpost in hope of help. We ran into her four children, all somewhat in grief, but also too young to comprehend exactly what had happened. One might say B was too young herself, in her mid-twenties.

D was too young to die as well. Only four, his mother brought him in (above) unconscious and running a fever of 105 F which had apparently been going on for a few days now. The boy was clinically dehydrated from diarrhea and was responsive only to painful stimulation. The medics tried to start an IV line under Kelly’s supervision, but veins in the hands were collapsed. Kelly found the femoral and we started him on dextrose.

Unfortuately for the kid, neither the medics nor us had any medicines in IV form. So we tried both oral and rectal administrations of Tylenol and Motrin, children’s doses to bring the fever down. With the fever not coming down, a decision was taken to move him out of the clinic into the balcony, and Joshua, an engineer with the team, setup the generator and the one fan that we had to blow over him.

Kelvin, an undergraduate and I started taking turns wetting the child down while the other students conducted clinic for the other sick patients in the village. Kelly was supervising the others though he was constantly preoccupied with thoughts about this kid and kept checking in. The fever slowly would down to 101F with aggressive wetting and wiping only to climb up minutes after we stopped wetting him down.

The medics went ahead and treated the kid with Artemesin for malaria and Chloramphenicol for anything else, both strong drugs with strong toxicities. Chloramphenicol especially has been discontinued for use across the developing world for its toxicities – particularly irreversible aplastic anemia in children. We had started the kid earlier on an oral dose of Azithromycin suspension as well. In between, D began having seizures lasting 1-2 minutes, which are not unexpected in kids when their brains are being roasted by fevers of 105.

Our diligence was successful in slowly bringing down the fever to 99 F by about 5pm, but D continued to seize at least once an hour even when afebrile. We began suspecting either cerebral malaria or meningitis – both with pretty bad prognosis given the conditions we were in. Kelly was willing to try one dose of dexamethasone to reduce any meningeal inflammation and irritation. Too much and it would depress his immune response, definitely not what we wanted.

Anticipating the mosquito attack around 5.30pm, we made ready a place in our hut by borrowing Helena’s mosquito net, setting up a tube light, the fan and the generator along with an ambu bag, toilet paper, thermometer, purell and other medical supplies. D was shifted to our hut just before the mosquitoes arrived.

From there on, it was a long night. The entire team took turns wetting D down and making sure that his temperature hovered around 98 F. He slowly began returning to consciousness and by 1am was alert and irritated. He rocked back and forth, obviously in pain and screaming and grasping anything in his reach and kicking over the bucket of water and whatever was available.

It was much easier to take care of him while he was unconscious. The medics wanted to give him some promethazine to calm him down, but Kelly vetoed the idea, since it would reduce D’s seizure threshold. D was continuing to seize even while awake, and we were all afraid for any brain damage post recovery. The ambu bag was used to stimulate his breathing after his seizures stopped and he was coming back each time, but it was a continuous challenge.

We gave him a half dose of lorazepam instead to sedate D a little, but it didn’t seem to have much effect for a while. Just as D calmed down, the medics gave him his second dose of chloramphenicol which woke him right up. Eventually, bit by bit, he fought back and we were able to start him on oral Tylenol, which was controlling the fever from then on. Around 4am, he began taking some oral rehydration solution, and by 6am, he was eating navy crackers and bland beef biscuits.

The locals had formed a crowd around D from 1pm the afternoon before and had waited below our hut until 1am during the night and had seen the kid unconscious and near death. They came back at 6 in the morning to see D smiling in his mothers arms and voraciously eating his crackers. I don’t think there has been a more dramatic testament to modern medicine in that village. Dr. Murphy, medicine man had won a battle. We had to move on that morning, so we left D in the care of the able medics, and went to the next village.

Patients with leprosy seemed to selectively migrate towards me, the Indian face in the crowd, and I got pretty good at spotting it and wrapping up their wounds and giving them the leprosy talk – protect your feet and you’ll keep them, etc.

We saw young kids with scabies, a baby with a large burn on the scalp that was secondarily infected, an unnecessary number of scalp and skin abscesses, a distal complete fracture of the radius and the ulna leaving the hand disconnected from the forearm, and an irreducible inguinal hernia the size of a softball in a guy in his mid-twenties. I also got extremely good at identifying different types of fungal infections based on their patterns – tinea versicolor, tinea imbracata (picture above) and ringworm were the most common, though we did see other varieties.

Almost every child in the villages had an enlarged spleen from chronic malaria, and I think I must have palpated more spleens in those two weeks than I probably will for the rest of my life in the United States.

Medically, Kelly got tougher on us as the days went by and expected us to present as we would back at Stanford, in the correct format and sequence. We began to formulate assessments and plans for the most common conditions that we would see over and over – children with fevers and chronic pains of all sorts.

All in all, the trip was a medically rewarding experience – I was able to leave with the comfort that even as I learned, I actually participated in helping people get better, especially children. However, the trip was an eye-opener beyond just medical care, which I’ll save for the next installment..,,

Naresh: Relearning Trauma in India

Last night my PI showed me a picture of an MVA and asked me if it was real or staged. The victim was riding a two wheeler without a helmet and was in a head down-feet up position underneath a truck with what appeared to be open wounds and large amounts of blood on his thigh and face.

My reaction was instinctive. Having driven around quite a few similar accidents to get to school, I told him i thought that not only was the picture real, but that accidents as gory as this were commonplace. But his question made me rethink my standards. If that picture seemed unbelieveable to someone used to dealing with trauma on a day to day basis, why did it appear ordinary to me, or to my friends whom I showed it to?

I've been relearning India this summer. The first is merely recognizing that while our trauma rates and intensities are higher than back home, the care, both pre-hospital and hospital based is inadequate. Part of this I'd ascribe to an attitude that i'm complicit with when in India - what are we going to do, its too complicated, he's dead anyway.. etc.

I remember calmly following traffic filing past an accident a few years ago when a motorist (again, on a motorcycle without a helmet) lay on the tar, blood gushing onto the street from the back of his head, eyes wide open and fixed at the sky.

Second, I'm learning that the trauma that we see in India is both more numerous and more intense/varied than the varieties back home. I was always under the impression that the speeds in the West were so deadly that if you crashed, you were pretty much dead - however, in India you were more likely to crash, but the speeds were low enough to just injure, not kill.

The reverse is true. We drive in such a clean, isolated environment protected by airbags and large bodied cars and child seats etc., that the worst trauma seen in hospitals back home comes more often from gunshot wounds to the face and the like rather than road traffic accidents. The guy who drives his motorcycle here has to contend with lack of a helmet (self-imposed), direct impact with vehicles and animals of all stripes and a lack of traffic rules (more like traffic guidelines, a la Pirates).

In addition to the devastating injuries sustained, the lack of application of western standards for a trauma work up is killing more people. One part to this equation is the care received in ambulances and hospitals. The aforementioned attitude, lack of training and supplies leads to dismal attempts at support and treatment.

We saw five head injuries at the trauma center in the General Hospital this morning. Of the five, only one was in a cervical spine collar (two sizes too large for him), presumably since he complained of some neurologic symptoms. The other four were being prepped for surgery (heads shaven, disinfected) just in case. The CT scanner was 100 yards away. The trauma ICU ward was being cleaned out during the day so it was not in use. The whole setup was a receipe for disaster. Yet if the head trauma patients dont make it past the night, the blame is laid on the seriousness of the injuries.

In some cases it is frustrating to note that the prehospital care is better than that available in hospitals. Stanford Emergency Medicine International, through my PI, Dr. Mahadevan, has been running an advanced prehospital course for Apollo Hospitals, India's premier (private) healthcare center in Hyderabad and Chennai. The facilities here are comparable to those at Stanford, 64 slice Helical CT, 24 hr MRI on demand, consultant radiologists, orthopods, cardiothoracic surgeons available 24/7/365 etc.

The Apollo hospital techs whom we train are competent to manage airways and intubate patients if necessary in ambulances. However, a few of them are promptly extubated as soon as they reach a private hospital in the name of protocol since there is no one confident to manage the airway there. It is almost a shame to say that some patients would be better off going for a long ride in the ambulance than being dropped off at a small private hospital.

All said and done though, its exciting to be in India at a time when Emergency medicine has still not taken off as a specialty, but people are recognizing its importance. It is very much like what I imagine the situation must have been in the US in the 1960s, with surgeons, anesthetists and physicians passing the ball on a patient's emergent care between each other in a way that didn't always produce good results for the patient. However awareness is developing and people are on the move ... more on Indian EM in a bit ...

Naresh: mmm.. Mangoes !

So.. the Mango tree in my house which was planted when I was in middle school by our now very old Gardener has given its first set of fruit ! And its delicious.. almost as good as the expensive varieties crowding the stores now... i'm in Mango heaven :-)

Its actually the one advantage of coming to India in the summer. The weather is about 95 deg and humid, and the hospital i'm working in for my project is about 110 deg and humid inside (no air con)..Actually walked through the labor ward today with my friend (a recent graduate), and the women were writhing in labor on these metal beds in a long row with a hole in the middle and a bucket underneath to catch the "products of conception" beyond the child.. quite sad.. but then again there were like 15 doctors and an ultrasound machine and people taking care of them in that gunk and filth, so it wasnt a totally bad picture after all..

Home is fun, but all my friends are working in the booming software industry, so very little time to hang out.. a few of them have recently left for Atlanta, Boston, Paris, etc. and the numbers in India of my batchmates are going south very quickly.

Trav scholars work began today, but i'll be able to post more once i'm going full swing later this week

cheers everyone !

~Naresh