Sunday, December 28, 2014

Photos around the Hospital and the island

Sorry about the delay - it has been very busy here (will update formally soon).  Thought I would update with some photographs from the hospital, the hospital accommodations, and various pictures around the island.  More to come!

Photo 1: The hospital accommodations,
Photo 2: The Main Entrance to LBJ Tropical Medical Center
Photo 3: The view from the main highway into Pago Pago (Capital of American Samoa)
Photo 4: Sunset view from the Broge's backyard

Tuesday, December 23, 2014

Saturday December 20, 2014

Today was a "free day".  Tangra was on call and had to stay at the hospital.  Matt and the Broge kids came at 8:45 to drop Tangra off at the hospital.  Matt took us, along with Dr. Cosman and his two sons, over to the other side of the island for a hike.  All the land in American Samoa is privately owned by various families, and there is no Real Estate.

We decided to hike to a place called "Massacre Bay", a remote bay that was the site of a French Massacre in the 1780's. The history is very controversial, but basically the story goes that a French ship stopped off in the bay to get provisions.  Apparently some of the French accosted the polynesian women, who were naked, and it angered the villagers, who attacked the French and killed 12 of them.  According to the French account, the villagers then ate some of them - a detail that the Samoans deny.

To get there, we had to drive across this guy's land and park at the top of a mountain.  The owner directed us to the trail, which went into the jungle and down the ridge for about 3 hours. The bay is very secluded and is owned by an ex-army man named Tony.  He lives by himself and is rebuilding the site of his ancestor's village in the hope of bringing in tourists to the site of the massacre.  He told us the story and took us to a monument that was built on the site of the massacre by a French priest in 1882.  We spent about 2 hours on the shore there, and I got some incredible photos.  The water was very blue - much clearer than anything on St. Maarten -  and warm.  There were also tons of fish everywhere.  I got very sunburned.

The hike back was almost entirely uphill at a steep incline and quite strenuous.  Neeli got tired and had to be carried, but overall the kids did very well.  It was unbelievably hot and humid.

We got back to the hospital only to find out that one of the kids we admitted was now in the ICU with septic shock, coughing up blood and bleeding everywhere.  I was going to go spend the night at the Broge's house tonight and go to Church with them in the AM, but basically when that kid coded and went to the ICU, all the peds team came in to work (was only supposed to be Tangra today).  I ended up going into the ICU and helping out for about an hour. 

1 - a large hermit crab (these are crawling all over the mountainside)
2 - The view from the ridgeline
3 - Matt and Neeli
4 - Nolan
5 - The beach at Massacre Bay
6 - another view of the beach at Massacre bay
7 - The monument to the French sailors who died, erected in the 1800's by a French priest
8 - Tony and his dogs show us around the bay
9-11 - more views from the hike

Friday December 19, 2014

Today was a fairly light day, as this was the day of the yearly LBJ Christmas Gala, a giant party put on by the hospital for all their employees.  The party takes place in the governor's auditorium.  The doctors donated over $2000 for this party (I think the budget was well over $15k).

That morning we had another CME - this time it was the hospital passing out CME certificates for the year so that everyone could claim their credit.  They had breakfast for us - scrambled eggs, ham, a pear, and very strong coffee.  It was pretty good. 

We met up on the wards for rounding.  Very informal presentations (though very thorough) - very refreshing compared with the formal rounding we go through in residency.  I then spent the morning and early afternoon "shadowing" Tangra in clinic because my license is still not approved due to some political issues.

That night, went to the party.  It was a Disney Frozen theme, which was hilarious - although the decorations were amazing.  It felt like a literal ice castle.  There was a huge buffet with Samoan food and all you can drink beer, wine, sodas, water, etc.   They had a talent show from the different departments - mostly ancillary services - Lab, housekeeping, medical records.  Two of the janitors did a hilarious rendition of "Let it Go", that I recorded.  I tried a couple of new beers from Samoa that were actually very good.  My favoirite was one called "Vailima Natural", which was made with breadfruit. 

There were over 200 people at the party.  All the men wear the traditional Samoan Lava Lava, a kind of polynesian kilt.  The women wear flowered Samoan dresses.  There were a few people, including one of the hospital's fa'afafines, who were dressed up as Frozen princesses. 

Dr. Maronne and I ran into the CMO of the hospital at the party and got assurances that I would get my license.  He approved me to work. Gotta love small town politics.

All in all, it was a fun time.  We left around 11pm.  I rode home with the Broges and Dr. Marrone, they dropped me off at the apartment.

Thursday December 18, 2014

Today, Dr. Marrone was on call and wanted me to be on call with him.  I still did not have my license, though they were working through the channels to find the right people to sign the paper to allow me to legally work. Apparently the CMO needed to sign me off, but he was out getting a haircut and was not around.  I went to the nursery again and also the ICU.  The hospital approved funding to pay for a flight to hawaii for the baby, once he was safe to fly.  LBJ approves off island referral for Baby Mel.  Lots of drama and politics here.

There was another code - a lady who was found unresponsive.  Again, did CPR for some minutes and the lady died. 

Ate lunch at the cafeteria with the Broges.  Noah and Nolan were there, along with Neeli and Tangra.  Tangra has her own patients and works in the clinic.  Had some lamb chow mein and water for $4.  Lots of food.

That evening,  I walked down to the bottom of the hill.  There is a small supermarket owned by an asian man who speaks very little English.  I bought laundry detergent - a tiny boxy of Gain - for $4.25, dish soap, sponges, and a $5 calling card to call home from the apartment phone because I still was not able to use the internet.  I found out that day from one of the PAs who works in the ER that the hospital did not pay the wifi bill and the account was suspended. 

I walked back home and tried to use the calling card.  The menu asked me to punch in the pin number, which I did, and there was just silence.  I tried again, no luck.  I called the help line and got a very annoyed lady who told me that the number was wrong and that I needed to call a different number.  Which I did and got a very annoyed lady who told me to call another number... which I did and the number was disconnected.  Very frustrating and the card is non-refundable.

On the way back from the hospital, Dr. Marrone was notified by the janitor of a "party" up at the nursing headquarters that had some food.  We went up and there was a christmas celebration with the nursing managers - all old ladies in their 60's.  They had tons of food and made each of us three huge to-go boxes (To-Go boxes are a big thing here).  There were several traditional Samoan dishes that I was able to try - including Taro and breadfruit, both are local fruits that taste like potatoes.  There was also a dish made with coconut cream and wrapped in bannana leaves that was absolutely amazing... but extremely rich.  One of the boxes contained nothing but meat - chicken, pork, and a local turkey specialty of "turkey tail", basically the cooked fat pad from the butt of the turkey... which tastes a lot better than it sounds.   There were also several fruits.  Needless to say, I was stocked for several days.

I was called in at 2am with Dr. Marrone for a emergency cesarian section for a cord prolapse.  The mom had gestational diabetes and the baby was very big (over 9lbs).  Most babies are born LGA (large for gestational age) here.  Baby did OK and only needed mild stimulation.  

Went home and fell asleep - only to be woken up again at 6am for an admission.  Went to the ED and admitted a baby for pneumonia.  Did not go back to sleep.

Monday, December 22, 2014

Wednesday December 17, 2014

I woke up, had some Kix cereal and some instant coffee for breakfast (breakfast of champions).  They had CME that morning - a lecture on proctology from Dr. Cosman.

Met with Dr. Marrone in the nursery to go over how to round on the babies and use the electronic health record.  After rounding on all the babies in the NICU and the nursery, we also helped out Sergei, one of the russian pediatricians (also a critical care physician back in the US and hilarious sense of humor) who is helping on a high-profile child case that made the local papers - NU'UULI FAMILY PRAYS FOR THE GIFT OF LIFE THIS CHRISTMAS SEASON.   Very sad case.

During lunch, I went back to my apartment and made a sandwich.  I was able to connect to the wireless - but it did not connect to the internet.  I tried many different things, but all I got was a message saying the router needed to be restarted.  I called down to the hospital to ask if they knew anything about it (the welcome packed from the hospital told me to call that number for help with the wifi), but they did not know anything about there being internet in the apartments.  They suggested that I call bluesky internet and work it out with them.  

You might be wondering why I'm so concerned with internet - the 17th was my wife's birthday, and I had yet been able to contact her.

That afternoon, I was in the nursery again with Dr. Marrone until 6pm.  Very tedious, but he is really cool to work with.  He is a US trained pediatrician from California.  He graduated from residency in the 90's, and has been in American Samoa for over 13 years.  He is single, has a very interesting sense of humor, and loves to play poker.  He can speak some Samoan language, and has been teaching me various phrases. 

There was a "Code blue" cardiac arrest.  A man with a history of stroke went into cardiac arrest.  There are no heart or stroke specialists on the island, so you are basically screwed if you have a MI or stroke. The code lasted about 20 minutes, and the patient died. 

Later that evening, I was invited to watch a breech delivery by Dr. Kareem, a young OB doctor right out of residency.  He is from Indiana and is working at LBJ to pay off his loans.  The baby was born slightly floppy and had to be resuscitated briefly. Dr. Marrone helped me, but this was technically my first newborn resuscitation thanks to the fact that we no longer do NICU at HCMC with our residency program. 

I went to the cafeteria that night for food, and then went to sleep.

Tuesday December 16, 2014

My first day at the hospital, I basically went around to the various offices and had my "orientation".  I had a big piece of paper that had to be signed by all the various people in the hospital - pharmacy, medical records, etc.  I had my photo taken and an ID badge made.

It was Tuesday that I found out that I did not actually have my Samoan license approved - which was also news to the Pediatric team.  Apparently, the new Governor of Samoa decided that he wanted to create a new board and changed the process of licensure without telling anyone.  Dr. Marrone (head of pediatrics.. more about him later... said this was a political stunt because there is a distrust/dislike of American-trained physicians on the island).

For lunch, I went with Matt down to a local cafe called "DDW" (Don't Drink the Water).  It was located about a half mille from the hospital in Pago Pago, right next to the water.  I had teriayki chicken (again), which was delicious.  A huge (and I mean HUGE) plate of food with two chicken breasts for $8.  I was stuffed.

I spent the rest of the afternoon in clinic with Dr. Marrone, also going around the hospital.  I then went with Matt to KS Mart for some groceries.  The hospital had given me $50 for groceries, which paid for cereal, shelf-milk (regular milk is $4 for a half gallon), ramen noodles, bread, ham and cheese, pasta and pasta sauce, and a gallon of water.  The gallon can be refilled around the island for 50 cents.

 I also spent a good portion of the day going around and figuring out what the password was to the wireless network up at the locum apartments.  I was told be three seperate people that the password was ***, but it never worked.

That night, I went to a local burger joint with the Broges and Dr. Marrone.  It was run by a guy named Tapp, who is a local singer and chef.  He imports all his beef from New Zealand.  I had the pineapple teriayki burger (Teriayki is a theme here), which was delicious - almost as good as the Kobe burger at Rockit Bar and Grill in Chicago (my current favorite burger).

Tapp came out and sat with us and had us try some new soup that he had made.  He then brought out ice cream and homemade peach cobbler made by his wife, who is [apparently] a famous chef from some 5-star culinary school in the US.  It was delicious.

Monday night (Dec 15 2014)

Sorry it has been so long -- I will update you on what has been happening (pictures will be added later once I figure out how to get them uploaded)

I took off from Honolulu on Hawaiian airlines.  The plane was a Boeing 767, and was packed completely full - mostly Samoan passengers on their way back home for the holidays.  There are only two flights per week - Monday and Friday, and Hawaiian airlines is the only carrier that flies direct to Pago Pago.  There are other flights that come from Western Samoa (the independent nation approx 30 mins flight from American Samoa).

On the plane, I sat next to a Samoan lady who was probably late 30's, early 40's and pregnant.  She lives in Hawaii, but she and her husband are both from American Samoa - she also has like 6 or 7 other children.  She was flying home for the holidays because she found out her baby was breech, and there is a traditional ceremony/massage that her mother performs in her village that supposedly helps flip the baby into the right position - not really sure what it is, but it did not sound like the ECV (external cephalic version) that we and the OBGYN doctors do back home for similar situations.

The plane ride was fairly smooth.  I had a window seat and was able to see an amazing sunset out the window.  I tried taking a picture of it, but my phone wouldn't focus correctly.  The seats were comfortable - bigger than usual, probably because American Samoa is technically the world's most obese nation (more fat people per capita than any other territory or country).  Had a dinner on the plan of teriayki chicken, salad, hawaiian dinner rolls, and a piece of chocolate with coffee beans (Kona, I think) in them.  It was very good for airplane food.  The entertainment consisted of music (mostly hawaiian music) and a Christian football movie that played over the main TV screens.  I was actually very surprised, but come to find out that AS is very Christian and they always play family/Christian movies on that route.

We landed in Pago Pago, the captial city of American Samoa around 9:30pm.  We flew through some clouds and the ride was very bumpy without any visibility until we literally bounced on the runway and came to halt.  The plane stopped outside the terminal, which basically is a metal and concrete building from the 1960's.  We exited the plane from the rear exit, and went down some stairs directly onto the runway.  Security and immigration were lining the route to the terminal, however they would randomly hug certain passengers that happened to be in their family.  It was very informal.

We were herded through to a big open room with several lines for immigration.  It was a VERY hot room with minimal ventilation.  No air conditioning, just a couple of old rickety ceiling fans.  There were probably 250 people in line, and everyone was dripping with sweat.  There were probably 5 non-Samoan people on the flight.  Come to find out, one of the white men and his two boys were also here for medical work (though I didn't find out until later).  The dad is named Dr. Cosman, and is a colorectal surgeon from San Diego.  His older son, Raphael, is a 22 year old Computer Science major from Stanford, and his little brother is 12 year old Elon.  Anyway, Raphael had a ukelele and was playing random songs while in line, so at least we had music.

I got through immigration without difficulty, though there were several forms I had to fill out.  American Samoa is an independent territory of the United States, though is only loosely American.  They have their own independent government, and I still needed my passport to enter.  I now have an AS stamp in my passport :).  Once through immigration, there was a very crude luggage conveyor belt that looked like a giant, rusty grocery store checkout belt.  I found my luggage and left the terminal.

Outside, there were literally hundreds of people (it is a big deal when the flights come in).  Matt and Tangra were there, with their daughter, Neeli.  They gave me the traditional Samoan beaded necklace made from one of the local nuts (the traditional way to greet new arrivals etc).  They were driving an old ford explorer - that harkened back to the days of St. Maarten. (awesome car)

Cars are ridiculously expensive there (probably double what you would pay in the US), and electricity/AC/hot water is probably double what you'd pay in the US, as well.  Gas is about $3.50/gallon, so very reasonable for an island.  

The roads are very well maintained, but the houses and stores are very run down.  Most of the islanders live in tiny homes, usually one large room with all family members sleeping on mats in the floor.  Many homes are in the style of the "Fale Samoa", which are basically concrete versions of the huts they used to live in 50 years ago.

The island is very Christain.  Each village has one or two churches, and the pastors are viewed as very important members of the community.  Most of the Churches are either some form of evangelical (pentecostal, baptist, etc), or Roman Catholic.  The mormon church is also very active on the island.  Probably half of the people working at the hospital are LDS.  Many of the churches also operate as bingo halls, which is a huge money-maker for the churches (and seems a little unethical to get people hooked on gambling).  Many of the island's poor waste their money playing bingo.  

Some intersting tidbits about the island culture - swimming in swimsuits or bikinis is not allowed.  All females swim in shorts and tee shirts, if they swim at all.  Most locals do not swim - many do not know how.  They have a cultural fear of the water, probably from years of both tsunamis and also attacks from the sea.  There are almost no houses next to the water, and most of the homes have their doors and windows facing away from the sea - probably to allow people to exit up the mountainside in the case of an emergency.

Each village has a chief, and there is a council of chiefs that meets to discuss important matters.  There is also a governor and a senate.  The territory also has a non-voting representative in the US congress that helps to represent their interests in Washington DC.  The chiefs are selected by the families, most are educated or wealthy, and there is a lot of corruption.  The largest employer on the island is the government, and most of the budget comes from US Federal funding that is then distributed around the island.  All residents are classified as "US nationals", not US citizens, but they are all covered by medicaid and can get this when they travel to the US.

The largest private employer is Sunkist Tuna, which owns and operates a large cannery in Pago Pago.  It employs a few thousand workers, and pays about $5/hour, which is one of the better paying jobs on the island.  The cannery processes thousands of tons of fish per year, and the stench is horrendous when they are actively boiling/cooking the fish. 

Tattoos are a huge part of Samoan culture.  Many of the men go through elaborate ceremonies where they have literally their entire upper body tattooed manually using a mallot and various ink blades.  It is very painful, and it often takes 2-3 weeks for people to recover.  There might be the possibility of seeing a ceremony while I am here.

There is also an interesting group of people in Samoan culture - a "third gender" called "fa'afafine".  Despite the conservative culture, they are openly embraced and celebrated, and not particularly looked down upon.  The fa'afafine are men who are raised "in the way of the woman", and there are usually a few in each village.  They dress and act like women from a young age.   Many of the cheerleaders at the local football games are fa'afafine. These people will date straight men in the community, and those who date them are not considered to be homosexual.  There is also a female version of the fa'afafine, but less common.

Anyway, it was great to get the chance to meet up again with the Broges.  Their daughter is adorable, very outspoken.  I did not meet Noah and Nolan that night because both boys were home with Matt's mother, who is also currently living in American Samoa.

I was taken to the locum apartments on the hospital grounds.  They are located just up the hill behind the hospital.  My apartment is a ground floor - 2b - actually the "handicapped apartment".  It consists of a living room with a table, three chairs, two couches, a small TV with cable, kitchen with stove and refrigerator, a bedroom with a closet, and bathroom.  The bedroom and living room have AC (similar to the ones we had in St. Maarten).  There are also two dogs that hang around my apartment (and multiple other + chickens which populate the hospital grounds).  The accommodations are far more luxurious than I was expecting, and are very comfortable.

The hospital itself is very old.  Built in the 1960's under the LBJ administration.  Basically there was an old reader's digest story in the 1960's that was written by someone from Minnesota that sparked an outrage against the conditions on the island (read the story here: Samoa: America's Shame in the South Pacific). This prompted LBJ to travel to the island and build a hospital - now LBJ Tropical Medical Center.  It reminds me of a slightly larger, airconditioned version of the hospital I volunteered at in Migori, Kenya.  There are two main hallways, with open-air causeways connecting them.  They have an emergency room, Operating room, OBGYN delivery suite, a small nursery, a medical ward, pediatric ward, also clinics for surgery, pediatrics, dentistry, and surgery.  They have an Xray machine and a CT scanner.  The CT scanner is currently broken. 

There is basically no primary care to speak of.  The clinics are reserved for people who are sick, and they do not do immunizations there at the clinic - this is done a the department of health.  The government pays for healthcare with medicaid - basically the US government gives AS a lump sum to use for the year.  The AS government charges $10 for a clinic visit, with an additional $10 for ALL additional labs, imaging etc combined - so maximum cost per person for a clinic visit is $20.  An overnight stay in the hospital costs $50.  This does a pretty good job of keeping people away from the hospital who do not need to be there.  I think that they should institute this in the US, because it would keep people out of the ER.

The hospital is staffed by a mix of US and foreign trained physicians - many from the pacific islands of Fiji, Solomon islands, Tonga, etc.   Most of the doctors only come for 2-3 years at a time, and then leave.  There are very few Samoan doctors.

There are virtually no specialists.  If someone needs specialist care (cancer, severe illness, etc), they have to get to Hawaii.  Because of EMTALA (US law which forbids "patient dumping" from one hospital to the next), the hospital cannot transfer a patient unless they find a hospital which is willing to accept the patient, usually on charity.  This very rarely happens - even charity hospitals like St. Jude very rarely accept even kids with cancer because of the expense of transport and the lack of funding.  Usually what happens is the hospital meets and agrees to pay for a passenger ticket aboard Hawaiian airlines.  The patient then flies to Hawaii and "chooses" the hospital of their choice, and then walks into the ER.  There have been several patients who have died en route to Hawaii on the airlines.  It is pretty sad.

Tuesday, December 16, 2014

Quick Update.  Landed last night in Pago Pago around 9:30pm.  I am currently working on getting situated.  Will write back as soon as I can.

Monday, December 15, 2014

Takeoff for American Samoa

Made it to the airport only to find a line out the door for the TSA checkpoint. Thankfully, the Hawaiian Airlines customer service told me of a second line that was opening up in a neighboring building.

I walked for about 10 mins and found a line with no people. Took me about 3 mins to go through. I called and spoke to Carlyn (whom I miss very much - but who also doesn't share my newfound affinity for social media).

Now it is another 6 hour flight to American Samoa. Aloha!

Walk to Waikiki

Checked out from Ala Moana at noon. Dropped off my luggage at the front desk and walked 20 minutes down to Waikiki.  I swear this has to be one of the most picturesque beaches I've ever been to.  Lots of tourists, a few locals. Stopped and grabbed a Kona Longboard beer on draft and sat down to watch the tide come in... texted Carlyn and told her we were definitely moving [back] to an island one day.

I have to remind myself that this is just a layover and that I need to leave for the airport in an hour.

Aloha from Honolulu

Finally arrived in Hawaii last night around 11:30pm Hawaiian time. The flight into the island was fairly bumpy, but the pilot gave us warning of this prior to takeoff.

I spent the night at the Ala Moana hotel, which is about 15 min from the airport. The rooms are very basic, but clean. Had an extremely overpriced breakfast buffet at the hotel's Plantation cafe consisting of coffee, fresh fruits, eggs, bacon, and waffles with coconut syrup. $17.50. I figured the buffet would allow me to stock up on calories until my flight this afternoon.

My first though about Hawaii is that it is absolutely beautiful. It is in the mid 70's and sunny. I have my hotel window open and the view, while not oceanfront, is amazing  (see picture).

At the moment, I am finishing up some overdue charting from last week before I leave for Samoa (and less reliable internet).  I was sick last week with that horrible cough that has been going around, and then worked 27+ hours in clinic and the hospital on Friday  (thank you guest call!).

This being said, I can't complain. I am, after all, in paradise...

Sunday, December 14, 2014

Landed in Hawaii!

Alaskan Airlines

Currently about halfway from Minneapolis to Seattle, the first leg of the journey.

I'm flying Alaskan Airlines - another first. Their service has been top notch.  The plane comes equipped with wifi and electric outlets at every seat.

Grabbed me a gin and tonic... which was going to be "on the house" for trading seats with a dad in the exit row so he could sit next to his two year old daughter. 

Anyway, will write back again later. There is a lady sitting in the row in front of me who opened a mason jar of salmon... so now the plane smells like a fishery.


Welcome to my first blog post!

For those of you who may have stumbled across this by accident, my name is Justin, a third year resident in Family Medicine at Hennepin County Medical Center in Minneapolis, Minnesota. I have chosen to do a month-long elective in Pediatrics at the Lyndon B. Johnson Tropical Medical Center in Pago Pago, American Samoa.

And for those of you whom I know, welcome! I hope you find my random musings and postings [at least] amusing, if not informative.

Especially for my fellow residents, I hope that my experience helps to inspire you to pursue your interests and to think outside the box when designing your electives during your G3 year.

As this is my first attempt at blogging, forgive me if I ramble a bit.  It is my goal to post something daily (wifi pending of course). Please feel free to comment, subscribe, and share with your friends and family.

Thanks! ~Justin

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