Bairo Pite Clinic only exists because of the generosity of strangers. Almost all of the funding for the clinic – approximately a million Australian dollars per year – comes from private donations from individuals and families who live outside of Timor Leste. Many of these people have visited the clinic, or volunteered in some way, but just as many have never even met a Timorese person and yet give anyway.
It’s humbling, working in such a place, knowing that the money we are spending has come to us from the pockets of willing private donors, rather than oblivious tax payers (though we’d happily accept their money too!). It adds to the sense of responsibility we feel in making sure that our money is being used well, as we really want the spending of it to reflect the spirit in which it was donated.
In recent months we’ve had some great new donated equipment arrive. In each case the equipment was new, and was specifically chosen with our particular needs in mind.
We’ve received a microscopy camera, which allows us to take high quality digital images of what we’re seeing through the lens. The pictures can be used in teaching and training, but also can be sent to specialists overseas for an immediate opinion. In a country with no practising haematologist, it’s a great thing to be able to send images of a possible leukaemia or an unusual anaemia and get a response from a consultant haematologist within hours. Free of charge.
We’ve also received a neonatal pulse oximeter for measuring oxygen levels in our newborns. This is an expensive, highly-specialised instrument that enables us to detect subtle changes in oxygenation that can help reveal congenital heart disease, and perhaps more importantly, early sepsis and respiratory infection. Early detection means early antibiotic treatment, and as I’ve seen in my own experience here, potentially a life saved.
And we’ve received a brand new ultrasound machine. This is a state-of-the-art, portable model that we can use to image almost every part of the body. Performing an ultrasound costs us almost nothing, is non-invasive and harmless to the patient, and is therefore the perfect imaging tool for underdeveloped nations like Timor Leste.
Some of these donations were actually purchases we’ve been able to make with donated money. Last year one of these blog entries generated an enormous response (to the tune of about AUD$32,000). I’ve been holding off my announcement of exactly how that money is being spent, because I’m waiting for some of the building works to be completed (they’re happening now), but I’m very much looking forward to revealing the results. We’ve been able to make that money stretch a very long way. Thank you.
Sometimes the help we get comes in other forms. Through this blog we met a great family who have come to Timor from Western Australia, and they’ve helped us with a lot of practical things at the Clinic. A few weeks ago, when we were clearing a storeroom to make way for building works we’re doing, we had some forklift trouble. It was quite comical: the young operator of the rented forklift navigated it very carefully through a tight passageway at the clinic – a very busy thoroughfare – but when it came down to the fine maneuvering our assistant manager at the clinic (an experienced forklift operator himself) offered to take over. No sooner had he taken his seat at the controls when the engine over-revved dramatically and then conked out with a bang and a big plume of black smoke. Our Timorese assistant manager tried to look innocent, but we’d all seen it, and were laughing heartily at his obvious discomfort (not that he’d actually done anything wrong). The forklift was now stuck, completely obstructing a very busy passageway, mid-morning on a typically busy day.
Thankfully, our friends from WA were on hand and within minutes one of them had the forklift purring nicely, and the work resumed. I don’t know how long we would have been stuck there without him. Thanks Brian.
When we’re not clearing storerooms and fixing forklifts, we occasionally look after sick people. And when you come to somewhere like Timor you brace yourself for the full range of tropical diseases that might present themselves. What we hadn’t expected was an expat girl who came to us for help after honeymooning in the jungles of Central America. She had something living in her leg.
Sure enough, in a hole in near her shin there lived a nasty little flesh-eating maggot.
These are not native to Timor, and she was suitably concerned that this maggot might indeed grow into a fly and introduce a new tropical disease (Timor is not really in need of any new ones). Plus, she didn’t like the feeling of it wriggling around under her skin. With some help from Google and YouTube, we worked out together that this was the larva of a botfly, and that to remove it we needed to first suffocate it with Vasoline under an occlusive dressing, and then try to remove it in one piece.
Ever the eager surgeon, Bethany performed the honours with a pair of tweezers on our back verandah at home, and with a satsifying pop the suffocated larva was removed.
The other interesting creature we encountered recently was a little guy called Strongyloides. Strongyloides stercoralis is a roundworm that lives in the soil, penetrates the skin and finds its way to your small intestine. There it lays its eggs, which hatch into larvae, which are either excreted or burrow back into you again and reproduce further. They can ultimately migrate to other parts of your body, and really make a mess of things.
We had young man admitted to Bairo Pite Clinic with what looked like encephalitis. He was essentially comatose, and didn’t seem to improve with IV antibiotics, antivirals, nor anything else we tried. One of our doctors spotted an unusual, distinctive, migratory rash on the young man’s trunk. I don’t have the actual photo of our Timorese patient but this one is close enough.
This is called cutaneous larva currens, an inflammatory reaction to Strongyloides larvae moving through the skin. With this new information, the man was treated for Strongyloides hyper-infection – the worms must have been wandering around his brain – and then he steadily recovered. I say it again: have you dewormed yourself lately?
Not all the diseases we deal with are so exotic. Common things are common, they say, and we see things like asthma in Timor Leste too. That might not sound very frightening.
A man in his late twenties was brought in to Clinic early in the day, and was seen in our Treatment Room. Several of our doctors assessed him and commenced the usual salbutamol (Ventolin) nebulisers. I happened to walk into the Treatment Room looking for someone, and my eyes met his. And his eyes were scary.
They were wide-open, seemingly getting wider at the end of each one of his gasping breaths. He was sitting upright, his hands clutching the bed down near his thighs, and his arms were braced in rigid tension. He was using them to help him breathe. His whole body trembled with exertion as he fought the battle for each breath against the tightly constricted airways that simply wouldn’t allow the air in nor out. Soon my eyes were almost as wide as his.
I’ve seen a bit of asthma, but it’s been a while since I was the senior doctor in Emergency making the decisions about managing an acute asthma attack. I felt uncertain, and was getting anxious. We had done the basics, and he wasn’t responding. In fact, he seemed to be tiring. I was relieved when one of my colleagues with more recent Emergency experience in Australia came in to join me. I was very happy for him to take the lead. Together we discussed our options. We had given him most of the standard treatments – should we just wait and see if he can fight through it? Usually I’d be looking to transfer a critical patient like this to the National Hospital. Admittedly, their treatment of such a case wouldn’t necessarily be better than ours, but if such a patient dies on your hands it leaves you wondering whether they – the major hospital in the country – might not have been able to do something more.
But we knew this man from a previous asthma episode, and he had refused then to be transferred to the National Hospital under any circumstances. His brother had died there in the recent past, and there was no way he would agree to us sending him. He was our problem.
So, we added a magnesium sulfate infusion. That sometimes helps, as it relaxes your muscles a little, and we needed those tiny muscles that were squeezing his airways to relax their grip. The effect of the magnesium was visible, but not necessarily good. His muscles did relax, but that meant he was less able to fight for each breath with his chest and arms. After some minutes of this, with his respiratory effort dropping, he slumped back on the bed and his eyes rolled back. He stopped responding to us. When you see this happen, you know his carbon dioxide levels are climbing to almost fatal levels. High carbon dioxide levels act almost like a drug of sedation, which is bad news in someone who needs to be awake and fighting.
My colleagues and I looked anxiously at each other. As one of them said at the time, it was hard to tell if he was straining less because his airways were now relaxing, or whether he was just slipping away from us. We talked about the next step. Would we intubate him? We didn’t have the drugs we needed to make that effective. And in any case, once intubated there was nowhere we could send him that was able to adequately care for him. It wasn’t an option. We would have to wait it out.
And so we stood there, running serial nebulisers, and hoping that the various steroids and other medicines we’d given him would begin to take effect and turn things around. It wasn’t looking good. I continued praying silently. There was little else to be done. His family turned their eyes to us with pleading looks. They knew we had done all we could, but their eyes silently begged of us, “isn’t there something else you can do?”
And then, there was the hint of a change. He began to exert a little more energy in his breathing. Imperceptibly at first, but then more obviously, his respiratory effort began to improve. Over the minutes that followed, the heaving of his chest intensified, and soon he lifted his head from the upright bed and began to fix his gaze on his surroundings. Moments later he was murmuring some gasped responses to our questions. He was back. I’ve never seen an asthma case go so close to the brink, and yet even in Australia around 400 people a year die of acute asthma, many of them young adults who never saw it coming. I don’t know how many die in Timor Leste, but this is country where most can’t afford to buy “Ventolin” inhalers, and the type of inhaler we rely on in Australia to control severe asthma (“preventers”) are not available at all.
Meanwhile, on the home front, Bethany has been juggling car repairs, visiting tradesmen (to repair a series of household setbacks), and the usual bevy of sick children. The average young child suffers 6-10 viral illnesses per year. When you have four children, that’s about 30 viral illnesses per year, and with some of those lingering for up to two weeks, that means that most weeks of the year you’ve got at least one sick child. And that’s if you’re in Australia. I think we’ve used up quite a number of those thirty illnesses these past few months, as it seems like we’ve rolled from one into the next, and Bethany and I have often been dragged down with them. Micah has taken it a step further by developing a moderate pneumonia, though thankfully he’s now on the mend.
Somehow, amidst all that, Bethany has managed to kick off an exciting new training programme at the Clinic. Westmead Children’s Hospital (Sydney) runs an outstanding 12-month diploma of paediatrics for GPs and other non-specialists, and they have had the vision to invite doctors from countries such as Timor-Leste to enrol in the same course at around 2% of the price! Bethany has managed to get three of our Timorese doctors enrolled into this world-class diploma, and others in the Clinic are benefitting from the lectures as well.
People who follow along with what we’re up to in Timor sometimes tell us that what we’re doing is “amazing”. Whilst we appreciate their encouragement, I can tell you it doesn’t often feel like that. If we ever run the risk of getting carried away with our own achievements there is plenty to bring us crashing back to earth again.
A couple of months ago I proudly launched my pilot for a new ‘patient-held medical record’ I designed. This little booklet, which I got printed in bulk in India and shipped over, has the potential to transform our primary care service.
We have hopes it will be taken up (in some form or other) right across the nation. As I handed around the first shiny copies of the booklet, there were murmurings of approval, until someone politely pointed out a spelling mistake… in the main title… on the front cover.
I couldn’t believe it. I had asked several people to proofread it and no one had spotted it. Any sense of pride had been immediately replaced by fury and humiliation. Thankfully it’s only a pilot, and we only printed 500. When we eventually print tens of thousands I’ll make sure we get that straightened out!
Learning a foreign language is generally an experience of recurrent humiliation. A week or so ago I was attending an important function at the National Institute of Health, and as I strode purposefully from my car toward the entrance I felt confident. I am getting used to these kind of events, I thought, and I was well dressed, switched on, and ready to put my best foot forward. As I arrived near the entrance, a dignified Timorese man who I later discovered to be the Director of Cooperation smiled at me. I greeted him with an assertive “Botarde”, which means ‘Good afternoon’. It was 9 o’clock in the morning. I realised immediately but it was too late, I’d walked past him. My aura of confidence evaporated in an instant and I once again felt like a scared little boy on his first day at ‘the big school’. Yep, it keeps you humble.
Last week Bethany asked our three-year-old son, Micah, whether he would be ok to ‘look after’ Estela and Annika while she went out to the Clinic. He protested plaintively, “No! I can’t! I’m not a superhero! I can’t fly, and I don’t even have a cape. I’m not super!”
I think that’s how all of us feel, really. A lot is asked of us in this place, and most days we just don’t feel very super at all. Thankfully we’re not here on our own: we have so many others sharing this journey with us. Some of them live and work by our side here in Dili, but many others support us from a distance. We don’t feel like we’re doing this alone at all. And if you’ve read this far, then you must be one of those who has chosen to walk this road with us. Thank you – it means a lot.