Pages from the Philips Seeking God's leading in medical missions

The Campus is Alive

Sorry for the long post. Our internet access is really limited and so I'll put all of last week's post in one big post. There are also some pictures from our time at ACA and in Kolkata that can be found on the bottom of this post.

It’s hard to believe that another week has passed and that we are more than half way through our stay here at Makunda. This has been a challenging week as we have thought much about what medical missions should look like and how to balance the demands of work, ministry and time with family.

Monday of this week was an exciting day because some of the other physicians who work here had come back from their vacation. Dr. Shilini, the OB/GYN doctor returned to a full labor ward and Dr. Harry and Amanda McNaughton (missionary physicians from New Zealand) returned from their trip to Shilong. Dr. Shilini stays in the same house we are staying at and so it is great to have some extra company in the house as well as someone who can communicate with the lady who comes in to help with household chores and meals. We are finally able to communicate with her effectively about things around the house with Dr. Shilini serving as translator. Dr. Shilini also brought along with her a much unexpected treat for us and the kids – strawberries!! Apparently, in Shilong, there is an annual strawberry festival and so she had brought some extra to share with us and it felt wonderful to taste some delicious strawberries again. Dr. Harry and Amanda and their three kids have been here for about four months and are planning on being here until November of this year. They have three wonderful kids, Jillian, Andrew and John who have been great for our kids to have some older kids to play with. Dr. Harry is a neurologist and Dr. Amanda is a pulmonologist. Dr. Harry has tried to work in the hospital and OPD as much as possible while Dr. Amanda spends most of her time homeschooling their children and helps out at the hospital when she gets free time.

With Dr. Harry and Dr. Shilini back along with Dr. Ann and Dr. Rockfuii it seemed like we had so much extra help on Monday! Dr. Harry was the senior physician on call for this week and served as back up to Dr. Rockfuii and I who have taken call every other night this week. Dr. Rockfuii took call on Monday and my first day on call was Tuesday. Tuesday morning also marked the first time we had internet access here and that was quite a frustrating experience to say the least. The man who runs the nearest internet access site lives about two kilometers from here but because it is a government facility, the access to the place is erratic at best. The café is open from 10-4 daily but that time is often the most inconvenient for the hospital staff because we have to be in clinic or in the hospital during that time. The other problem is that even though those are the advertised hours, if you have not made prior contact with him to confirm that he will be there, there is no guarantee that anyone will be there to meet you. The other issue is that this man often takes vacations and thus he was off all of last week except for the hour he came in to let us get on the internet. We did manage to check some of our e-mail and post on the blog but getting to upload anything was maddening because the connection would drop after each picture was uploaded!

During the day on Tuesday we also had a patient who was about thirty and presented with what he thought was a fracture that had occurred apparently eight months ago. He works as a mechanic and while he was walking he suddenly felt his left femur break and because he was poor he just left it alone hoping that it would heal by itself. Finally because the area on his left thigh kept enlarging in size he finally came to the hospital to get an X-Ray. When we examined him he had about a 20 cm mass in his left thigh that was hard as bone. We took an x-ray and it confirmed what we suspected – a very large osteosarcoma of the left femur that had completely destroyed most of the femur and had started to eat away most of his pelvic bones on his left side. We told him about the tumor and that his prognosis was not good at all. There is no one in this area within 300 kilometers that can do a hemipelvectomy and even if it could be done we still don’t know if that would remove the tumor entirely. Besides a man who couldn’t come in for eight months because he couldn’t afford to get care for a fracture probably couldn’t afford the cost of a hemipelvectomy. So at the age of 30, this man will pass away from a tumor that could have been dealt with if he had just presented earlier.

On Tuesday evening we went to greet the McNaughtons at their bungalow on campus. Two of their three kids had already fallen asleep because they had made a 15 hour overnight bus trip the day before and none of them had gotten much sleep on that trip. Getting to talk them was extremely refreshing and it was great to hear their perspective on life here and how they have managed to adjust. They were also able to give some advice on where we needed to go to get some money exchanged since we had run out of Indian rupees and needed to exchange our traveler’s checks. Unlike other parts of India where there seems to be a bank at the corner of every street, the nearest bank where we can get traveler’s checks exchanged is almost two hours away! So the McNaughtons graciously lent us some money to get us through another week before we will finally be able to get a vehicle to take us to the bank so that we can exchange money. I think that is what I find often frustrating about India has been how even the simplest things take a half a day to a day to get done here.

Tuesday evening was also my first night on call and it started out with sadness. We had a four day old baby who was delivered at home and came in extremely apneic and lethargic. The baby looked jaundiced and had a very distended abdomen and barely moved when I examined him. This was the first baby for these new parents and like most of the other people who live in this area, they did not know when to seek proper medical help. Apparently the story was that by around noon of that day the baby had become extremely lethargic and would not feed anymore but they only decided to bring the baby in about eight hours later. I admitted the baby that evening around 8 PM and I was not sure if the baby would make it more than a few hours. We could not get a blood pressure on this baby but the nurses somehow managed to get a peripheral IV line so that we could rehydrate the baby and start the baby on antibiotics. I talked the case over with Dr. Harry and we started the baby on the strongest antibiotics we had (third generation cephalosporins) and I sat at the edge of the bed and prayed for this baby to survive so that his parents would know that God was working in this place and through that they would come to know Christ. But God didn’t answer our prayer this time and by 11 PM the baby had died. I questioned why God had allowed this baby to die but God kept reminding me that I do not know His full plan and that I must trust him. Perhaps it was a lack of faith as I prayed…I don’t know but it was hard to see my first baby that I had taken care of die. The rest of the night was fairly uneventful for me because the nurses weren’t able to get a hold of me on the cell phone that they assign me on the nights I’m on call. The campus phone lines are still not working and thus the only way for the nurses to let us know if a patient is not doing well or if there a serious patient who needs to be admitted overnight is for them to give us a call on the cell phone. However the problem here is that cell phone coverage is erratic at best and most of the times the calls will get cut half way through the phone call. So then the nurses send a driver from the hospital with the vehicle about 1 km to the housing area to bring us the chart and if we think it is serious then we return back to the hospital with the driver. So on Tuesday night because the nurses were unable to get a hold of me, they sent the vehicle straight to Dr. Ann for their consultations.

Wednesday was more of the same routine with patient rounds in the morning, OPD during the day and then some time with the kids and Melissa if I got home early enough. On Wednesday, Andrew, one of Dr. Harry’s children came over with a treat for us – watermelon. I had never truly appreciated how great a watermelon tastes when you feel completely parched after sweating all day. Dr. Harry’s children have been a big blessing to our kids because they come over and read to our kids. Karuna has grown quite fond of Jillian (who is 12) because she reads to her every time they get together. Wednesday also marked the arrival of Dr. Philip and his family from Raxul in Bihar where they had been working at Duncan hospital for the past five weeks. Dr. Philip was our initial contact with EHA and Makunda and he helped us tremendously in arranging the details of this trip to make our journey here possible. We met Dr. Philip two years ago in the US when he was presenting at an endocrinology conference at Harvard. I had met Philip and his family many years ago because Dr. Philip’s dad, Dr. Finny, was the person who led my dad to Christ. Dr. Philip is married to Leeja and they have two children, Vinay,6 ½, and Rohan, 13 months. Dr. Philip and his family have been visiting other EHA hospitals recently to figure out where God is leading them to work next. Dr. Philip finished his specialization in endocrinology before coming here about a year ago. He has a heart for working at a hospital where he can teach and work with junior doctors and thus they have been looking for a larger hospital with a postgraduate training program. It sounds like they will most likely be going to Raxul to work at Duncan Hospital after the great experience they had there. Duncan hospital is the largest of the mission hospitals for EHA and they have a family medicine residency program so that he can continue to focus on teaching while working there. Leeja is also a physician who has finished her training in anesthesiology and they hope that she will be able to work at least part-time to help out at the hospital in Raxul.

Thursday was my second night on call and it was an extremely difficult night for me with three deaths. The first was a 3 month old baby we had admitted in the afternoon who was having significant difficulty breathing. When we felt his hands and feet they were already starting to get cold and pale. We started the baby on the strongest antibiotics we had and we checked a blood sugar and it was over 500. We were not sure but perhaps the baby was in diabetic ketoacidosis and so we sent for urine ketones but when we put a catheter in there was not a single drop of urine for us to do the test. By six PM, that first baby had died. The second baby was a girl who had been sick for several days with respiratory distress and had been treated at a government hospital in a nearby village. She had been at that hospital for four days but was not getting better and so the parents asked to be transferred to Makunda hoping we could do more for this 10 month old. She was initially admitted to the long ward (female) but when I saw her in the evening she looked quite sick and was breathing over 60 times a minute and so I transferred her to the ICU. We tried our best to give her a fighting chance by giving her everything we had available including antibiotics, our oxygen supply which runs at a maximum of 2 L/min, and drugs for heart failure because she had decompensated from the pneumonia. Right after I got home from evening rounds I got the call that she had passed away around 11 PM. The mom was sleeping when the baby passed away and so the relatives requested that we not wake her mom until the morning (the mom had been up for several days watching over her daughter) so that she would have some rest before she found out the horrible news that her daughter had died. Another experience with death. The third one was probably the most difficult for me because I had met this man several days earlier. Two days before in the outpatient department I had met an 82 year old man who was complaining of a cough for 3-4 days. When I examined him then he was quite comfortable and the chest x-ray was not very impressive and so I thought we could start outpatient oral antibiotic therapy for him. He returned two days later very short of breath and tired. We admitted him right away to the ICU that afternoon and started him on IV ceftriaxone. I prayed that this man would make it. As the evening progressed he became more and more short of breath and no matter how much oxygen we gave him and the multiple nebulizer treatments he just was not responding. The nurses finally called me in around 4 AM to see the patient and by the time I got there he was hunched over and gasping for air. I felt totally helpless and tried my best to help him with what resources we had available. There are no ventilators here and so that wasn’t an option. I tried to get a blood pressure on him but it was too low to measure. So I started the patient on dopamine as a last ditch effort to save his blood pressure and hopefully keep him from tiring out further but to no avail. I stood there by him with his wife and son helpless and praying that he would pass away with a minimum of pain. He passed away 30 minutes later but there was nothing I could offer him to decrease his suffering as he died. There is no morphine available here to help relieve the pain and air hunger patients feel near the end stages of their illness. It was tragic to watch this family grieve. His wife wailed with such passion that most of the patients in the ICU woke up. I was at the brink of tears because there was nothing I could say to comfort her because I didn’t know her language. There was nothing I could offer but to stand beside her as she cried. The third and final death of my second night of call.

This experience also reminded me to write about another quirk about this hospital – the lack of narcotic availability. Because opioid abuse is so common in this part of India, the government has put a restriction on which institutions can have access to opioid compounds like morphine or fentanyl for pain relief. In order for a hospital to be able to have access to opioid compounds, they have to apply for a special license from the government. Of course a license from the government requires cutting through multiple layers of bueracuracy and even though they have submitted the application to carry opioid substances in the hospital for pain relief, it is still sitting in the office of some official waiting to be authorized. So for now the most we can offer for even the patients with the most severe pain is tramadaol (Ultram). I guess the one blessing is that it cuts down on patients who are narcotic seekers because there are no narcotics available here. But the lack of access of opioid compounds severely limits the pain relief that we can offer to many of our patients including people with severe burns, postoperative pain, or pancreatitis. Speaking of severe burns, my second night on call also brought with it two adults and a child with burns over about 15% percent of their body from a kerosene flash fire. Even though they came to our hospital we had to turn them away because we didn’t have enough staff overnight to be able to manage their pain adequately and to provide them the fluids necessary for them to survive their burn injuries. We had to ask them to go to another hospital with more facilities which probably meant a 2 hour drive over roads that are controlled by terrorist groups at night.

Friday brought along with it another busy day in the OPD and even though Dr. Philip was back Dr. Ann was away along with Dr. Vijay (who had traveled to Vellore this week to teach at the medical college for a week). I think we ended up working till about six PM to get thorough the patients in the outpatient department on Friday. We had two unfortunate cases of people who had waited long after a fracture had occurred to finally seek medical care. One was man in his twenties who had been injured in a truck accident about two weeks before who came in with an infection of the injuries in his legs. We took an x-ray upon admission and it showed that he had broken his fibula in two places. We admitted him to get IV antibiotics until his infection could cool down. The second was a lady in her fifties who fell at home 22 days prior to coming to the hospital and had broken her leg to the point that her bones had come out through her skin. She didn’t get access to treatment and thus when she came in three weeks later her leg was completely infected, purulent and emitted the worst odor I had smelled in a while. It looks like she will have to be referred to another hospital so that they can do an above the knee amputation since it looks like the limb is unsalvageable.

On Friday night, the McNaughtons invited us for a special treat with dinner over at their house along with Dr. Shilini and Dr. Finny’s family. Harry’s specialty is making bread rolls from scratch and so we enjoyed some freshly baked bread along with fresh lettuce that they had grown in their garden…what a delicious treat. We even got to drink some great tea while we were there. I think what is funny about this place is that even though we are in the midst of several tea gardens in Assam it is almost impossible to find Assamese tea here while we used to find plenty of tea grown in Assam in the US. That evening we all entertained ourselves with charades with their kids and talked about our home countries. Amanda also filled Melissa in on her perspective on homeschooling and especially what challenges have presented themselves as they have taken their schooling “on the road” during their time in India. Did you know that in New Zealand the government gives parents money if they choose to home school them?

Saturday was not a very busy day in the OPD but because we were short-staffed it still took us until about 4:30 to get finished with everything. Thankfully no one died on Saturday night which was a blessing for me because I’m not sure I could have handled another day like the one I had on Thursday. I was called into the hospital twice. Once to admit another baby in respiratory distress who I started immediately on the strongest antibiotics we had available because I did not want a repeat of what had happened the two times before and by the grace of God this baby did survive and was discharged a couple of days later. I also admitted another man who looked like he had evidence of a right sided stroke and so I sent them the next day about four hours away to Silchar to have a CT scan done.

I was pretty tired on Sunday morning after my night on call because I got several phone calls overnight about patients but a bucket of cold water on my head helped to wake me up enough to give the sermon for the campus church that meets weekly. I gave a message about meeting the spiritual needs of our patients when they come in for physical complaints. We used as the sermon text John 4, the story of Jesus talking with the woman of Samaria. It was a great passage to illustrate how Christ sought to take this lady from her physical need for water to her more important need of living water that comes through Christ alone. I came to the conclusion at the end of the sermon that the greatest amount of service to man divorced from sharing the gospel with them is a disservice because we are ignoring the most important need that man has which is his separation from God. After the service we had lunch with Dr. Finny and his family followed by the weekly soccer game at the school playground. This week it was the nursing staff verses the nursing students and the students won 2-0. It seems like there is now a streak of students winning compared to staff…hopefully next week’s match will reverse the trend.

On Sunday, Dr. Shilini, Dr. Harry and Dr. Amanda went to a tea garden nearby here to provide healthcare for the workers there. Dr. Shilini’s response after going to provide medical care for the workers in the tea gardens was that if we thought the patients in our hospital were poor, they now looked downright middle class compared to the workers in the tea gardens. Most of the workers there are given about 150 rupees a week (about 4 dollars a week), one or two kilograms of rice, daal (lentils) and some vegetables. Because of their limited food supply they are often extremely malnourished and because of the working conditions they are often very sick by the time they get to the hospital. Dr. Shilini said there were many moms who were already well into their pregnancy who had never had an antenatal checkup and almost none of them were on iron or folic acid even though almost all of them are anemic. We had just admitted a man from the tea gardens about four days ago who had a hemoglobin of 3 (normal is 12-14 in a man) almost completely from just iron and B12 vitamin deficiency! Dr. Harry and Amanda are trying to also identify patients in the tea gardens with malaria before it becomes severe to the point of causing cerebral malaria. To facilitate this they have learned to look at peripheral smears for malaria and thus are able to make the diagnosis without a serological test which then allows them to care for patients that have almost no money for testing. Sunday evening marked the end of one more week and we are very glad for our time here in learning about medical mission work in India and how we can best prepare ourselves to return. Dr. Rockfuii and I had a teaching session on Sunday evening to help us learn some more about medicine here and we are hoping to have sessions like that every other day to help us learn some of the intricacies and nuances of practicing medicine here.

Thank you for your continued prayers as we have worked here. Please be in prayer for us as we continue to praise God for not letting us or the kids get sick and as we get ready to return back to the US in about two weeks time. Please also pray for us to have a very productive meeting at EHA headquarters in New Delhi on May 12th so that we can better learn how to prepare ourselves for work in India during residency as well as develop a stronger sense of which direction the ministry is moving and what hospital(s) might be a good fit for us long term.

Along with this post, we’ve put up some pictures from our time at ACA and from the time we spent in Kolkata. We'll try to have more pictures up from Makunda when we get a little bit more time on the internet.