Filling you in on the last week…
On Sunday (Valentine’s Day) Eva and I met the two Australian medical students (Dan and Liam) at Hotel Timor for lunch, dessert buffet, some pool time, and the hope of free wireless internet. As usual things did not go quite as planned- lunch and the all you can eat dessert buffet were amazing, we snuck into the pool area and lazed around for hours no problem…. the internet however was of course a myth (thus the delay in the last posting and no new picture). I have realized how much I take internet access (on laptops and iphones) for granted at home.
I returned to clinic Monday morning after basically recovering from dengue (although my legs were still covered in a rash for a few more days). I spent last week traveling to a few mobile clinics- seeing around 50 patients in 2 hours at one Eva and I went to together which was a 3 hour drive west of Dili (the evaluation at mobile clinic is very brief and really serves as a means of identifying those few patients who are very ill needing to be brought into Dili for further evaluation/treatment as well as to ensure these communities feel their health concerns/needs are supported). I was able to assist in/observe a few deliveries this week which was also exciting. I have been a bit disappointed in the amount of obstetrics Eva and I have been involved in… the midwives at the clinic handle the majority of the deliveries and it always seems our days are filled with other tasks- unable to just hang out in maternity.
The malnutrition program continues to function and has been greatly aided by the addition of a pediatrician from Australia. Her name is Maggie and she will be spending several months here in Dili. She was excited to work with Grace and I on the program and (as I have hoped to see other parts of the care provided by BPC) she has basically taken over coordinating the daily efforts. We continue to have a large inpatient population of tuberculosis (TB) patients which has been quite interesting. The advanced stage TB presents in Timor Leste is basically unheard of in the United States. Eva and I are both learning a great deal about the varied presentations, treatment, and prevention strategies. Aside from malnutrition and TB patients there are several cases of malaria, dengue, pneumonia, pylonephritis, urinary tract infection, pelvic inflammatory disease, leprosy, mastitis, and gastrointestinal worms.
Last Monday Eva and I were invited to dinner at Tracy Morgan’s home by Dan (one of the Australian medical students). Tracy Morgan is an expat living in Timor Leste working for an NGO… she is fairly well known due to the length of time she has been active in the country/Dili community and because she owns a large home where she houses many foreigners traveling through Timor Leste (Dan is currently living there). The dinner party was in honor of one of the Irish girls living with Tracy and Dan as she is leaving the country to return to Ireland. It was a wonderful dinner and I write about it only to give some insight into the diverse group of foreigners we have met who are here in Timor all working on various projects. There was the Irish girl working for the UN, an Australian working for the police force in Dili, an Australian working for the education system, an Australian working for Marie Stopes Clinic (a family planning center), a Japanese girl working for the office of immigration, a Tasmanian pediatrician, two Australian medical students, two American medical students (Eva and I), and Tracy who is a lawyer by trade. Needless to say dinner conversation was interesting as we enjoyed pasta with marinara and feta, egg plant, garlic bread, red wine, and mango crisp with ice cream for dessert (definitely the best we have eaten since our arrival). It has been great to interact with so many individuals from varied backgrounds.
Now… for the highlight of this blog… and possible the entire trip!! Eva and I spent the weekend in Atauro, which is a small island about 30km north of Dili. The island is 140 sq-km, has a population that totals around 8,000, and only two small cities with occasional electricity. Dan, Liam, Eva, and I all decided it was time to get out of Dili for a weekend and explore Atauro. We boarded a ferry on Saturday morning for the two hour ride across the Wetar Strait. Upon arrival we walked to our accommodations for the weekend called Nemas. Run by an Australian named Barry, Nemas, includes 5 thatched huts right on the beach. We were fortunate to stay in the largest hut which actually had sleeping space for around 8 people and open air bathroom facilities in back. The other huts were occupied by a group of 3 Australians, 2 Portuguese, and a group with 1 Australian and 2 Portuguese. We all enjoyed each other’s company as we dined together in the main hut where Barry and his extended Timorese family live.
After arriving on Saturday, eating a bit of lunch, and getting settled in we spent the afternoon enjoying the beach, reading in the hammock, and playing a bit of Frisbee on the beach. Dinner was served again in the main hut and then the majority of the guests at Nemas returned to our hut for some music. Dan is a talented guitar player and singer (Eva joined in on a few songs and experimented with the harmonica which was great). It was really the perfect ending to an excellent day.
On Sunday, after breakfast and a café Timor or two (East Timor is known for its wonderful coffee), most of us guest loaded in Barry’s small boat for some snorkeling. Having never snorkeled before I was a bit apprehensive but let me just say it was amazing!!! The coral reefs around Timor are supposed to be some of the best in the world and I was reminded over and over again by the other guests how fortunate I was to have this be my first look at life in the sea. We spend several hours flipping around the crystal clear water looking at all sorts of sea creatures… just long enough for both Eva and I to burn our backsides. The remainder of Sunday afternoon was spent in the same manner as Saturday afternoon. I finished another wonderful book in our hammock, the title being “What is the What” and recommend it to anybody looking for something to read. The only downside of going to Atauro for the weekend is the only way to return to Dili is by fishing boat on Monday morning (the ferry only goes for the day on Saturday leaving around 3 PM- not enough time to enjoy the island). So at 3:15 AM Monday morning the alarm went off, all of the guest from Nemas enjoyed one more cup of café Timor together, and loaded in the back of a truck at 4 AM to head to Vilo to catch our boat. The fishing boat was better than I anticipated (we had heard horror stories of foreigners scooping buckets of water out of the bottom of boats as waves crashed over the edge wishing they had a life jacket). Our boat was much different than the image I had in my head. The majority of people stretched out on the deck and slept during the 3 hour trip back to Dili. I stayed awake, saw a few dolphins and flying fish in the early morning light, enjoyed the ride/breeze, and watched the sunrise over the water and Timor. It was truly a wonderful/perfect weekend- great atmosphere and great company. Eva and I returned to BPC refreshed for another week.
This week looks to be very similar to those previous. Eva and I plan to head out to several mobile clinics after morning rounds and spend our evenings with the friends we have made here. We went to the US embassy this evening as a birthday party was being held in George Washington’s honor- turned out to be a standard BBQ by the onsite pool. Eva and I enjoyed a cheeseburger, Diet Coke (for me), and a beer (for Eva) while chatting with several military personal who are working with the Mercy Ship (a naval boat with first class facilities that travels to foreign countries providing medical care). Turned out to be an interesting evening… the US embassy grounds are almost embarrassingly extravagant compared to the surroundings (not sure what else I expected). On Thursday we plan to go out to dinner, maybe Thai, as both Liam and one of the Australian doctors we have spent time with will be returning home on Saturday. Friday is Dan’s 31st birthday (Australian medical student not Dr. Dan) … the plan was to celebrate, however Dan became ill after returning from Atauro… so we will have to wait and see how he is feeling by Friday. Regardless it should be a good week.
Eva and I have booked our return tickets to Australia. We will be spending some time in Darwin and Sydney both before heading home on March 13th. Hope this message finds everybody well... and for those in Iowa while it is scary to say… I miss the snow.
(PS- I apologize for any typos/improper grammar as I have not been proof reading)
Wednesday, February 24, 2010
Sunday, February 14, 2010
2/11/2010, A few bumps in the road...
Since the last post my main project has continued to be developing a malnutrition program at Bairo Pite Clinic (BPC) for the children that continue to come into Dr Dan’s office looking emaciated. The hope is to develop a program that can be maintained by the volunteers and clinic staff after we leave here. It sounds like there have been several attempts at this in the past always ending with a similar story- volunteers come, set up a program, leave, and the program falls apart. Candice, the Australian intern, actually helped establish a malnutrition program here on her first trip to BPC over a year ago. I feel a bit uncertain about how to set up a malnutrition program and I also feel a bit uncertain about how to ensure that it will last.
As a general rule here is Timor-Leste, as in most developing countries, infants receive adequate nutrition as long as they are breastfeed and can avoid illness resulting in diarrhea, vomiting, or poor feeding. That being said when children transition from breast milk to whatever food Mom and Dad are eating many run into trouble. Whether it is the frequency of feeds (which need to be more than 3 times a day like the parents), the quality of food/food preparation, the quantity of food, or any number of other factors malnutrition can become a problem quickly. The majority of the children we are admitting with malnutrition also have complaints of diarrhea, vomiting, and in several cases worms.
With the use of several resources, including the WHO malnutrition guidelines, the advice of two Australian pediatricians, the advice of several volunteers, my fellow medical students, and the clinics nutritionist (that’s right there is a clinic nutritionist…. not sure what else she is all responsible for but I question how you can have a nutritionist on staff and have children dying of hypoglycemia… frustrating) I think we have come up with a pretty good system. It is far from perfect; there just isn’t the staff at BPC to monitor the kids and their feedings as closely as should be done. That being said the kids are eating and gaining weight.
One of the volunteers, Grace, a 19 year old who has recently graduated from high school and is hoping to get a scholarship to study medicine outside of Timor-Leste, has been the best of help. She has been our partner in crime. We weight the kids everyday and hand out packets of what looks like powdered milk called F100. The parents just mix the F100 with 100 mL clean water and feed to their kids every 3 hours. The premixed formula is distributed by the WHO and has all the essentials in the appropriate proportions. We have had several children discharged looking a bit plumper which is promising. One of the children passed away during the night. Dr Dan was not informed until I found out when I had one less kid to weigh and asked the other mothers where she was. Again… frustrating and sad. Really… unnecessary. We have several children in the malnutrition ward that would likely be better served at Dili National where they have a well established malnutrition program with the appropriately trained staff but continue to meet resistance when the suggestion is made to transfer these patients. So we just keep suggesting… and hope for the best.
Now for life outside of BPC… at the end of last week I was sick with what I thought was just a sinus infection (of all things). I was congested, had a headache, pressure/pain over my right maxillary sinus, purulent drainage, and a fever. I started a course of antibiotics, which I brought from home, and stayed in bed except to run to clinic to get tested for malaria just to make sure. I was anxious to feel better so I could accompany everybody to Mt Ramelau for our weekend getaway. By Saturday morning, when we were to depart Dili for the three hour drive south into the mountains, I was feeling a bit better so I loaded in to our rented 4 wheel drive with the other med students. The roads were horrible!! I don’t get motion sick but this trip was enough to put both Eva and I over the edge- up and down, winding through the mountains, avoiding pot holes/sections of washed out road, and just about everything else you can imagine.
We arrived in Maubisse mid afternoon and pulled up to the Pousada, a Poutugesse guesthouse, where we were spending the night. The plan was to hang out Saturday afternoon, enjoy the view of the mountains from the Pousada, wake up bright and early Sunday morning, climb Mt Ramelau, and head back to Dili Sunday afternoon. The Pousada was a beautiful guesthouse tucked in the mountains with gardens and great views all around. Unfortunately, I was feeling rather rotten by the time we arrived so spent all day laying in bed. Eva, the Australians, and the New Yorker played Frisbee and foosball. The air was cool, quiet, and clean in the mountains (very different from Dili). We ate dinner at the main house and I again returned to bed hoping to feel well enough to climb in the AM.
Sunday morning Eva, one of the Australians (the other one was feeling ill), the New Yorker, and I headed for Mt Ramelau at 5 AM. We were able to find the trail head with only a few wrong turns and were hiking up the mountain by 7:30 AM. The hike was wonderful, I was feeling better, and it was so nice to be out and get some exercise. The views on the way up were remarkable and thankfully it remained clear the majority of the way. We reached the top around 10:30 AM by which point clouds had rolled in and we weren’t able to see much unfortunately. The top is marked by a 3m high statue of the Virgin Mary- we took in some sustenance (cheese and crackers, oreos, and bananas) in her presence before heading back to our vehicle. Upon returning to the Pousada we ate lunch and again loaded into our 4 wheel drive for the painful drive back to Dili… this time it rained the entire way. Feeling ill once again by the time we got home Eva and I were in bed and asleep by 8 PM.
This week started just as any of the others have… we were up and headed to clinic for rounds at 8AM. Monday turned out to be a pretty typical day. We went to the grocery store in the evening as we were going to have dinner at Dr Dan’s on Tuesday because the New York medical student was leaving on Wednesday. Eva and I went for Monday night dinner at the Indian restaurant across the street and for some reason I wasn’t feeling quite right. I figured maybe I was still recovering from my sinus infection… so showered and headed to bed when we got home. Tuesday morning I wasn’t feeling much better (dizzy, weak) but again got myself together and headed to clinic with Eva for morning rounds. As I put on bug spray that morning for the millions of mosquitoes I thought maybe I was poisoning myself with DEET (turns out I was wrong). While in the maternity ward I started to feel faint so excused myself and took a seat outside. Dr Dan sent me to the lab to again get tested for malaria and this time dengue as well. Surprise… surprise… I have dengue fever.
For those who don’t know dengue fever is a mosquito-borne virus which is relatively common throughout Asia and thus Timor. There is no vaccine available and they only way to avoid it is to avoid mosquito bites- easier said than done here. Symptoms include high fever, headache, body ache, diarrhea, and some get a rash. Check to all of those. There is no specific treatment for dengue- just rest and take Tylenol for the fever. The other key is to have your platelet count checked daily to ensure they are not falling as dengue can become hemorrhagic. So this is what I have been doing all week... (having the true Timorese experience as many have said). I have been laying in bed feeling lousy and weak, taking Tylenol to try and control the fever, Eva has been drawing my blood every morning to have my platelet count checked at the hospital, and the Australian doctors who round with us on Sundays have been doing home visits to check on my every day. For this I am so thankful!! I have been reading some great books during the day when I am awake to keep my mind occupied. I’m starting feel a bit more like myself but being sick in a foreign place really makes me miss home.
I’m not sure what day I will head back to the clinic… hopefully tomorrow if I feel up to it as I am going a bit crazy in our little room. Eva and I are going to try and go to Hotel Timor (the nicest hotel in the country) sometime this weekend as we heard rumor they have free Wi Fi and an all you can eat dessert buffet… I’ll try and post this blog and maybe a picture or two at the time. Hope everybody has a very Happy Valentine’s Day!
As a general rule here is Timor-Leste, as in most developing countries, infants receive adequate nutrition as long as they are breastfeed and can avoid illness resulting in diarrhea, vomiting, or poor feeding. That being said when children transition from breast milk to whatever food Mom and Dad are eating many run into trouble. Whether it is the frequency of feeds (which need to be more than 3 times a day like the parents), the quality of food/food preparation, the quantity of food, or any number of other factors malnutrition can become a problem quickly. The majority of the children we are admitting with malnutrition also have complaints of diarrhea, vomiting, and in several cases worms.
With the use of several resources, including the WHO malnutrition guidelines, the advice of two Australian pediatricians, the advice of several volunteers, my fellow medical students, and the clinics nutritionist (that’s right there is a clinic nutritionist…. not sure what else she is all responsible for but I question how you can have a nutritionist on staff and have children dying of hypoglycemia… frustrating) I think we have come up with a pretty good system. It is far from perfect; there just isn’t the staff at BPC to monitor the kids and their feedings as closely as should be done. That being said the kids are eating and gaining weight.
One of the volunteers, Grace, a 19 year old who has recently graduated from high school and is hoping to get a scholarship to study medicine outside of Timor-Leste, has been the best of help. She has been our partner in crime. We weight the kids everyday and hand out packets of what looks like powdered milk called F100. The parents just mix the F100 with 100 mL clean water and feed to their kids every 3 hours. The premixed formula is distributed by the WHO and has all the essentials in the appropriate proportions. We have had several children discharged looking a bit plumper which is promising. One of the children passed away during the night. Dr Dan was not informed until I found out when I had one less kid to weigh and asked the other mothers where she was. Again… frustrating and sad. Really… unnecessary. We have several children in the malnutrition ward that would likely be better served at Dili National where they have a well established malnutrition program with the appropriately trained staff but continue to meet resistance when the suggestion is made to transfer these patients. So we just keep suggesting… and hope for the best.
Now for life outside of BPC… at the end of last week I was sick with what I thought was just a sinus infection (of all things). I was congested, had a headache, pressure/pain over my right maxillary sinus, purulent drainage, and a fever. I started a course of antibiotics, which I brought from home, and stayed in bed except to run to clinic to get tested for malaria just to make sure. I was anxious to feel better so I could accompany everybody to Mt Ramelau for our weekend getaway. By Saturday morning, when we were to depart Dili for the three hour drive south into the mountains, I was feeling a bit better so I loaded in to our rented 4 wheel drive with the other med students. The roads were horrible!! I don’t get motion sick but this trip was enough to put both Eva and I over the edge- up and down, winding through the mountains, avoiding pot holes/sections of washed out road, and just about everything else you can imagine.
We arrived in Maubisse mid afternoon and pulled up to the Pousada, a Poutugesse guesthouse, where we were spending the night. The plan was to hang out Saturday afternoon, enjoy the view of the mountains from the Pousada, wake up bright and early Sunday morning, climb Mt Ramelau, and head back to Dili Sunday afternoon. The Pousada was a beautiful guesthouse tucked in the mountains with gardens and great views all around. Unfortunately, I was feeling rather rotten by the time we arrived so spent all day laying in bed. Eva, the Australians, and the New Yorker played Frisbee and foosball. The air was cool, quiet, and clean in the mountains (very different from Dili). We ate dinner at the main house and I again returned to bed hoping to feel well enough to climb in the AM.
Sunday morning Eva, one of the Australians (the other one was feeling ill), the New Yorker, and I headed for Mt Ramelau at 5 AM. We were able to find the trail head with only a few wrong turns and were hiking up the mountain by 7:30 AM. The hike was wonderful, I was feeling better, and it was so nice to be out and get some exercise. The views on the way up were remarkable and thankfully it remained clear the majority of the way. We reached the top around 10:30 AM by which point clouds had rolled in and we weren’t able to see much unfortunately. The top is marked by a 3m high statue of the Virgin Mary- we took in some sustenance (cheese and crackers, oreos, and bananas) in her presence before heading back to our vehicle. Upon returning to the Pousada we ate lunch and again loaded into our 4 wheel drive for the painful drive back to Dili… this time it rained the entire way. Feeling ill once again by the time we got home Eva and I were in bed and asleep by 8 PM.
This week started just as any of the others have… we were up and headed to clinic for rounds at 8AM. Monday turned out to be a pretty typical day. We went to the grocery store in the evening as we were going to have dinner at Dr Dan’s on Tuesday because the New York medical student was leaving on Wednesday. Eva and I went for Monday night dinner at the Indian restaurant across the street and for some reason I wasn’t feeling quite right. I figured maybe I was still recovering from my sinus infection… so showered and headed to bed when we got home. Tuesday morning I wasn’t feeling much better (dizzy, weak) but again got myself together and headed to clinic with Eva for morning rounds. As I put on bug spray that morning for the millions of mosquitoes I thought maybe I was poisoning myself with DEET (turns out I was wrong). While in the maternity ward I started to feel faint so excused myself and took a seat outside. Dr Dan sent me to the lab to again get tested for malaria and this time dengue as well. Surprise… surprise… I have dengue fever.
For those who don’t know dengue fever is a mosquito-borne virus which is relatively common throughout Asia and thus Timor. There is no vaccine available and they only way to avoid it is to avoid mosquito bites- easier said than done here. Symptoms include high fever, headache, body ache, diarrhea, and some get a rash. Check to all of those. There is no specific treatment for dengue- just rest and take Tylenol for the fever. The other key is to have your platelet count checked daily to ensure they are not falling as dengue can become hemorrhagic. So this is what I have been doing all week... (having the true Timorese experience as many have said). I have been laying in bed feeling lousy and weak, taking Tylenol to try and control the fever, Eva has been drawing my blood every morning to have my platelet count checked at the hospital, and the Australian doctors who round with us on Sundays have been doing home visits to check on my every day. For this I am so thankful!! I have been reading some great books during the day when I am awake to keep my mind occupied. I’m starting feel a bit more like myself but being sick in a foreign place really makes me miss home.
I’m not sure what day I will head back to the clinic… hopefully tomorrow if I feel up to it as I am going a bit crazy in our little room. Eva and I are going to try and go to Hotel Timor (the nicest hotel in the country) sometime this weekend as we heard rumor they have free Wi Fi and an all you can eat dessert buffet… I’ll try and post this blog and maybe a picture or two at the time. Hope everybody has a very Happy Valentine’s Day!
Friday, February 5, 2010
2/1/2010
So… this blog is late but as you will see by the time you get through it Eva and I have been very busy since leaving the States and I have had little time to reflect/write. I will try to start at the beginning and hit the high points. We arrived in Australia in the morning on January 21st. Eva’s first cousin once removed (a stretch I know… but you must be resourceful) picked us up from the airport and was an excellent host for our short time in Sydney. We spent the day cleaning up after the journey, visiting a wild life reserve (so many fun animals in Australia), and having a family dinner with a few other extended relatives. We had a great time with good company. The following morning we flew to Darwin, Australia where we again spent the night before catching our last flight to Dili, Timor-Leste on Saturday the 23rd. Darwin was quite nice… we had “fish and chips” and Australian beer before retiring to our airport hotel (thank you Shiva and Irene). Our flight left Darwin around 6 AM and we arrived in Dili in about 1.5 hours.
As we approached Timor-Leste from the air it was clear we were about to see some beautiful landscape- blue green ocean and beaches surrounding jungle covered mountains. While the island is still largely underdeveloped I don’t see this lasting too long as tourists will surely arrive in flocks at some point. After clearing customs we were picked up at the airport by 2 members of the clinic staff and a medical student from New York who is also working at the clinic. Eva and I were relieved someone knew we were coming… we returned to the clinic in an ambulance to join in on AM rounds.
Bairo Pite Clinic, where we will be working here in Dili, is like a small compound all run by one physician, Dr. Dan Murphy (Dr Dan to everyone here). There are about 6 wards (maternity, TB, pediatrics, malnutrition, and two for general inpatient), a basic emergency room, a pharmacy, a lab, a kitchen, and a clinic where Dr Dan sees outpatient consultations all day. All of the facilities are very basic but seem to serve their purpose. In total there are around 30-50 inpatient at any given time and about 300 patients are seen each day in the consultation room. That’s right… its crazy!! In general the clinic/hospital seems to do good work. That said, there have been several occasions where patient care has suffered due to insufficient resources and man power. Patients receive care for free, both inpatient and outpatient. Dr Dan informed me that the clinic and hospital function entirely on donations, which is quite impressive. Currently, there are 5 medical students and one intern spending time at the clinic- Eva and I, two Australian medical students, the medical student from New York, and an Australian intern. We work well together and have been spending what little free time we have together.
Dr Dan came to Dili in 1999, just as Timor-Leste gained independence from Indonesia. He has remained in the country ever since, working at his clinic despite several episodes of civil unrest/violence. He has gained the trust and respect of many people here. I myself am very impressed with his dedication to these people. That being said… Dr Dan is an interesting character and functions very much as an independent physician. He feels strongly that in the majority of patient cases he knows what is best with little room for outside opinion. He is very hesitant to refer patients to Dili National (the government hospital in Dili which is staffed primarily by western trained physicians with many more resources) as a result of poor experiences he has had in the past. However, when you have a group of medical students who have trained in western systems we tend to feel a great many of our patients would be better served if referred to Dili National where more resources are available (x-ray machine, CT scanners, ultrasound, operating rooms, many sub-specialists, and larger nursing/support staff). This obviously leads to many debates within our group when it comes time to develop a plan of action for patients. It has been frustrating and I often feel we are not doing our best to take care of these patients. I try and remind myself that I have only been here for a short time while Dr Dan has been working in the community for over 10 years. I am learning how to advocate for patients, gain confidence in my diagnostic abilities, weigh many options when it comes to caring for people, and develop a working relationship with a “boss” I don’t always see eye to eye with.
Despite the daily frustrations at Bairo Pite, it has proved to be a great learning opportunity- the pathology we are seeing in these patients is quite different from home. Our typical day, Monday-Saturday, begins with rounds at 8 AM for the inpatients. We usually get done around 10 AM at which point Dr Dan begins seeing patients in his office. As students we either sit in with him, go to mobile clinic (load up in one of the ambulances with a driver, volunteer, and box of meds to travel to a surrounding community), work on the long list of tasks discussed on rounds, explore/develop possible diagnosis for puzzling inpatients, or staff the ER performing any number of minor surgical procedures. At around 4 PM or whenever all the students are available we round alone. When Dr Dan has finished seeing outpatients we check out with him and discuss any inpatients we are concerned about. Check out tends to turn into a lengthy discussion given differing opinions about treatment plans and we wrap up around 6-7 PM. On Sundays we just round at 9AM and tend to leave around 12-1 PM. Physicians from other NGOs, Dili National, and several of the embassies show up for Sunday rounds which make them a bit more exciting. Some of the more interesting diagnoses are as follows:
- Malaria
- Tuberculosis (many cases with extrapulmonary disease)
- Malnutrition, primarily in toddlers (I somehow got roped into helping develop a malnutrition program and have learned a great deal in the last week or so)
- End stage breast cancer without the benefit of western medicine
- Abscesses, which I have had the pleasure of draining… along with several other minor surgical procedures
- Marfan’s with advanced heart failure (no cardiothoracic surgeon to operate)
Again, as has been a theme in the majority of my developing world experiences, the pathology seen in patients is always more pronounced as care/appropriate treatment is not as readily available.
So… what’s it like here outside of the clinic??? It’s hot here… very hot especially coming from Iowa winter. Luckily Eva and I have a window air conditioner in our room at East Timor Back Packers, one of the only hostels in Dili. The accommodations are very comfortable- we have a room with a queen bed, mini fridge, AC, common showers and toilets, common outdoor sitting area, no hot water, and a kitchen for making our new favorite dinner (tomato, avocado, cucumber, and hot sauce sandwiches). We are within walking distance of the clinic and several restaurants including a 24 hour gas station which is quite convenient. The people of Timor-Leste are very friendly and both of us feel quite safe. There is a large UN presence here with foreign embassies everywhere which is a bit interesting to see. Dili’s population is about 175,000 people but there are no high rise buildings and the infrastructure is very basic. (I see all of this changing if the tourist industry takes off- currently there are only a handful of hotels in the area)
While restaurants in Dili serve a variety of food (Indonesian, Indian, Western, Portuguese) many tend to be quite expensive due to the large UN/NGO presence. We have been able to find a few in the area that are pretty decent. We also purchased some basics at a local grocery store (primarily food imported from Australia and China) and are exploring the local produce markets regularly (bananas, pineapple, mangos, avocado, tomato, cucumber, etc). I’m pretty sure you could find anything you wanted to eat somewhere in Dili the question would just be price… for instance we passed on a $10 box of granola at the grocery store even though I would kill for a bowl of cereal. We would likely be more creative with our dinner options if we weren’t so drained at the end of the day… a quick sandwich is just so easy.
With all of the ups and downs since leaving the States I think the highlight so far was Sunday’s adventure to one of the many beaches near Dili. The landscape of this country is truly beautiful and I will be sure to share pictures when I return home with those interested. After rounds on Sunday all of us medical students decided to head to the beach for an afternoon of R&R. I ran to the beach from our hostel and everybody else biked. It was a bit farther than we anticipated on a hot day but this made the sea side lunch/beverages all the more enjoyable. We spent the afternoon swimming (the water was so warm), reading, laying around, and chatting. In the evening we went to a local restaurant frequented by foreigners and watched the final match of the Australian open while sipping Indonesian beer. Had to gear up for another week. J
I think we may try and take this coming weekend off to climb Mt Ramelau, which is the highest point in Timor-Leste at 2963 m. On a clear day you are supposed to be able to see both the north and south coast of the island from the top. The five of us students (our Australian intern has headed to Bali) will likely all go together. I’ll write more in the near future and again apologize for the delay.
So… this blog is late but as you will see by the time you get through it Eva and I have been very busy since leaving the States and I have had little time to reflect/write. I will try to start at the beginning and hit the high points. We arrived in Australia in the morning on January 21st. Eva’s first cousin once removed (a stretch I know… but you must be resourceful) picked us up from the airport and was an excellent host for our short time in Sydney. We spent the day cleaning up after the journey, visiting a wild life reserve (so many fun animals in Australia), and having a family dinner with a few other extended relatives. We had a great time with good company. The following morning we flew to Darwin, Australia where we again spent the night before catching our last flight to Dili, Timor-Leste on Saturday the 23rd. Darwin was quite nice… we had “fish and chips” and Australian beer before retiring to our airport hotel (thank you Shiva and Irene). Our flight left Darwin around 6 AM and we arrived in Dili in about 1.5 hours.
As we approached Timor-Leste from the air it was clear we were about to see some beautiful landscape- blue green ocean and beaches surrounding jungle covered mountains. While the island is still largely underdeveloped I don’t see this lasting too long as tourists will surely arrive in flocks at some point. After clearing customs we were picked up at the airport by 2 members of the clinic staff and a medical student from New York who is also working at the clinic. Eva and I were relieved someone knew we were coming… we returned to the clinic in an ambulance to join in on AM rounds.
Bairo Pite Clinic, where we will be working here in Dili, is like a small compound all run by one physician, Dr. Dan Murphy (Dr Dan to everyone here). There are about 6 wards (maternity, TB, pediatrics, malnutrition, and two for general inpatient), a basic emergency room, a pharmacy, a lab, a kitchen, and a clinic where Dr Dan sees outpatient consultations all day. All of the facilities are very basic but seem to serve their purpose. In total there are around 30-50 inpatient at any given time and about 300 patients are seen each day in the consultation room. That’s right… its crazy!! In general the clinic/hospital seems to do good work. That said, there have been several occasions where patient care has suffered due to insufficient resources and man power. Patients receive care for free, both inpatient and outpatient. Dr Dan informed me that the clinic and hospital function entirely on donations, which is quite impressive. Currently, there are 5 medical students and one intern spending time at the clinic- Eva and I, two Australian medical students, the medical student from New York, and an Australian intern. We work well together and have been spending what little free time we have together.
Dr Dan came to Dili in 1999, just as Timor-Leste gained independence from Indonesia. He has remained in the country ever since, working at his clinic despite several episodes of civil unrest/violence. He has gained the trust and respect of many people here. I myself am very impressed with his dedication to these people. That being said… Dr Dan is an interesting character and functions very much as an independent physician. He feels strongly that in the majority of patient cases he knows what is best with little room for outside opinion. He is very hesitant to refer patients to Dili National (the government hospital in Dili which is staffed primarily by western trained physicians with many more resources) as a result of poor experiences he has had in the past. However, when you have a group of medical students who have trained in western systems we tend to feel a great many of our patients would be better served if referred to Dili National where more resources are available (x-ray machine, CT scanners, ultrasound, operating rooms, many sub-specialists, and larger nursing/support staff). This obviously leads to many debates within our group when it comes time to develop a plan of action for patients. It has been frustrating and I often feel we are not doing our best to take care of these patients. I try and remind myself that I have only been here for a short time while Dr Dan has been working in the community for over 10 years. I am learning how to advocate for patients, gain confidence in my diagnostic abilities, weigh many options when it comes to caring for people, and develop a working relationship with a “boss” I don’t always see eye to eye with.
Despite the daily frustrations at Bairo Pite, it has proved to be a great learning opportunity- the pathology we are seeing in these patients is quite different from home. Our typical day, Monday-Saturday, begins with rounds at 8 AM for the inpatients. We usually get done around 10 AM at which point Dr Dan begins seeing patients in his office. As students we either sit in with him, go to mobile clinic (load up in one of the ambulances with a driver, volunteer, and box of meds to travel to a surrounding community), work on the long list of tasks discussed on rounds, explore/develop possible diagnosis for puzzling inpatients, or staff the ER performing any number of minor surgical procedures. At around 4 PM or whenever all the students are available we round alone. When Dr Dan has finished seeing outpatients we check out with him and discuss any inpatients we are concerned about. Check out tends to turn into a lengthy discussion given differing opinions about treatment plans and we wrap up around 6-7 PM. On Sundays we just round at 9AM and tend to leave around 12-1 PM. Physicians from other NGOs, Dili National, and several of the embassies show up for Sunday rounds which make them a bit more exciting. Some of the more interesting diagnoses are as follows:
- Malaria
- Tuberculosis (many cases with extrapulmonary disease)
- Malnutrition, primarily in toddlers (I somehow got roped into helping develop a malnutrition program and have learned a great deal in the last week or so)
- End stage breast cancer without the benefit of western medicine
- Abscesses, which I have had the pleasure of draining… along with several other minor surgical procedures
- Marfan’s with advanced heart failure (no cardiothoracic surgeon to operate)
Again, as has been a theme in the majority of my developing world experiences, the pathology seen in patients is always more pronounced as care/appropriate treatment is not as readily available.
So… what’s it like here outside of the clinic??? It’s hot here… very hot especially coming from Iowa winter. Luckily Eva and I have a window air conditioner in our room at East Timor Back Packers, one of the only hostels in Dili. The accommodations are very comfortable- we have a room with a queen bed, mini fridge, AC, common showers and toilets, common outdoor sitting area, no hot water, and a kitchen for making our new favorite dinner (tomato, avocado, cucumber, and hot sauce sandwiches). We are within walking distance of the clinic and several restaurants including a 24 hour gas station which is quite convenient. The people of Timor-Leste are very friendly and both of us feel quite safe. There is a large UN presence here with foreign embassies everywhere which is a bit interesting to see. Dili’s population is about 175,000 people but there are no high rise buildings and the infrastructure is very basic. (I see all of this changing if the tourist industry takes off- currently there are only a handful of hotels in the area)
While restaurants in Dili serve a variety of food (Indonesian, Indian, Western, Portuguese) many tend to be quite expensive due to the large UN/NGO presence. We have been able to find a few in the area that are pretty decent. We also purchased some basics at a local grocery store (primarily food imported from Australia and China) and are exploring the local produce markets regularly (bananas, pineapple, mangos, avocado, tomato, cucumber, etc). I’m pretty sure you could find anything you wanted to eat somewhere in Dili the question would just be price… for instance we passed on a $10 box of granola at the grocery store even though I would kill for a bowl of cereal. We would likely be more creative with our dinner options if we weren’t so drained at the end of the day… a quick sandwich is just so easy.
With all of the ups and downs since leaving the States I think the highlight so far was Sunday’s adventure to one of the many beaches near Dili. The landscape of this country is truly beautiful and I will be sure to share pictures when I return home with those interested. After rounds on Sunday all of us medical students decided to head to the beach for an afternoon of R&R. I ran to the beach from our hostel and everybody else biked. It was a bit farther than we anticipated on a hot day but this made the sea side lunch/beverages all the more enjoyable. We spent the afternoon swimming (the water was so warm), reading, laying around, and chatting. In the evening we went to a local restaurant frequented by foreigners and watched the final match of the Australian open while sipping Indonesian beer. Had to gear up for another week. J
I think we may try and take this coming weekend off to climb Mt Ramelau, which is the highest point in Timor-Leste at 2963 m. On a clear day you are supposed to be able to see both the north and south coast of the island from the top. The five of us students (our Australian intern has headed to Bali) will likely all go together. I’ll write more in the near future and again apologize for the delay.
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