Pago Pago

Pago Pago is the capital of American Samoa.  With a population of just under 4,000 people, it is the largest village on the island.  The hospital is right on the outskirts of the city.

Here is the view of the city from the ridge above the harbor. (taken 1/4/15).  The port encompasses a deep bay, which was of strategic importance to the US Navy during WWII.

As you drive into the city, the first thing you notice is how clear and blue the water is.

In the afternoons, you will see families playing in the water.  (Of note, you will see multiple EPA signs around the harbor signifying the mercury content of the waters around various shorelines.  It is not recommended to eat any fish that are caught in the harbor due to toxins and heavy metals.  I decided to avoid swimming in the water, as well).

There are multiple public Fales (Fah-lays), the traditional meeting place of the Samoan people.  They also used to be the homes, as well. 

At the far left of the photo below, is the building which houses the Fautasi, the traditional Samoan longboat.  There is a major race every year around the islands, and the team spends months training for the event.

Below is a [blurry] photo I shot of the Pago Pago harbor entrance.

 

There are many boats and ships coming in and out of the port.

Another view of the port.

 

Next to the Government, the largest employer on the island is Starkist tuna, which operates a major factory on the outskirts of the town.  The smell is absolutely horrendous, but the company is a major economic player in AS.

 

Charlie the Tuna.

 

Back in 2009, there was a Tsunami in American Samoa that killed many people.  There are signs all over the island warning you that standing next to the water is unsafe during a Tsunami.  FEMA was sent to the island for cleanup and you can still find people using the FEMA tents as functional buildings in the villages.

 

This is self-explanatory.  Nothing beats cold ice cream on a hot day (and for $1.00!).  To the right of the sign, you see an example of the water stations that are at most mini marts.  For 50 cents, you can fill a gallon jug with cold water.

 

The government guarantees that at one time (on the sticker) the water is free from bacteria and parasites, however the quality of the water is dependent on the business operating the machine.

Taken on January 4, 2015.  Here is a tree full of bats (the flying fox).  They have up to a three foot wingspan and look like pterodactyls.  At night, you can see them swooping in and out from the trees.

Some of the many colorful buses in Pago Pago.

LBJ Tropical Medical Center - American Samoa

Here are some various photos taken around the ground of LBJ Tropical Medical Center:

This first photo is the main sign at the entrance to the main parking lot.  The hospital's main bus stop is situated behind.

The hospital is laid out in wings, with two main hallways joined by cross hallways.  The US and American Samoan flag fly out front.  It is not uncommon to see dogs sleeping on the sign (see my previous post).

 

One of the several open air pavilions at the hospital that acts as a waiting area.  Due to the heat, much of the hospital is open-air. 

Another view of the open-air courtyard. There is a picnic area in the middle, to the immediate left of the camera is the women's axillary snack shop, where you can buy egg sandwiches, tuna sandwiches, and various drinks.  Tuna is a staple here due to the starkist factory in Pago Pago.

There are almost as many chickens running around as there are people.

Here is the drive-up to the Emergency department.  There are usually 4 physicians or NP/PAs working in the ED per shift.  Two trauma bays, around 10 separate bays with curtains.  They do not have any advanced imaging - no MRI, CT, or even ultrasound.  They have XR and use the PACS system that we use at HCMC to view films - though the monitors are standard definition. The ambulance parking is on the right side of the building in the photo (not pictured), and patients are loaded through a side door that is guarded.  Most pediatric procedures are performed by the Peds on call - LP, catheterizations, lines, etc.  The staff in the ER are a friendly bunch, and do a great job with the resources they have available.

(I think this would be an awesome place for HCMC's EM program to rotate - they could really help out with their ultrasound and trauma skills, and the hospital could really use their help)

One of the main hallways of the hospital.  The pipes above are exposed, which adds a neat dynamic to the building. In general, the hospital is very clean and well-maintained. 

 

There is a very affordable cafeteria here with good portion sizes.  You can usually get a good meal for around $4-$5.

 

 As you can see, the placement of the wards and departments are fairly random. I got lost for the first two days any time I needed to go somewhere.  I especially like the fact that the "spare parts" are located next to the morgue. Hmmm....

 

The doorway to the ICU.  I did not take a photo inside for patient privacy reasons.  It is basically two rows of beds facing each other and separated by curtains.  There is one isolation room in the back.  The ICU has a reputation on the island as the place nobody leaves alive.  (I had to admit a kid for DKA to the ICU and had to talk mom out of hysteria because she thought her kid was going to die simply because she was in the ICU)... again, this reputation is a testament to the struggle that the amazing doctors here face on a daily basis.

 

The wards were recently renovated (I think using stimulus money). Here is the pediatric ward.  Very bright and colorful - well, apart from the seasick pooh bear on the wall.  The nurses here are very nice.   

 

In the corner of the outside courtyard (across from the ER) lies the Pediatric Clinic, the place where I spend most of my time when I am not on call or in the Nursery/NICU.  There are two benches outside and generally it is packed with people waiting to be seen.

 

The waiting area of the clinic.  This photo was taken at the end of the day. Usually this place is completely packed with patients waiting to be seen.

 

At the back of the clinic is where bicillin shots, albuterol nebs, and other medications are administered.  The nursing staff in the clinic are super friendly.

 

Here is one of the patient rooms.  It is equipped with pretty much everything you need.  The one downside is that there is not enough ear pieces to go around - so we save them for cleaning and reuse at the end of the day.  We use CPRS for our Electronic health record (same system as the VA), which is adequate to get the job done, but not as complete or easy to use as the EPIC system we use at Hennepin.  There is also a very large written component to the documentation (a fact that I kept forgetting the first few days).

For the animal lovers out there, here is my furry companion.  She sleeps right outside my door at night and is always there to greet me in the morning.  The hospital has "adopted" her, and she is the only dog I have seen around that actually wears a collar. All the other locums and families throw her scraps of meat, so she is fat and happy.

A sweet truck...

There are many unique "island vehicles" on American Samoa.  Here is one of the jacked up pickups...

Another fairly common sight around the island are the pickup trucks with 8-10 people in the back - with several sitting in plastic lawn chairs (unsecured, of course) that are propped up against the tailgate.  As soon as I get a good photo of one, I will post it.

I guess when the speed limit is 20mph, you can get away with a lot.

Sunday December 28, 2014

Today, I was post call after a 24+ hour shift. I was exhausted and slept pretty much all day.  That night, I went to the movies with the Broges and watched the new "Night at the Museum" movie, which happened to be Robin Williams' last film.  While I hadn't seen the other ones, I thought the movie was really funny.

Movies here cost $5.50.  The popcorn is "all you can eat", and large sodas have unlimited refills.  While an awesome deal, I don't think it helps fight the obesity or diabetic epidemic sweeping the island.

Saturday December 27, 2014

Today was my second 24 hour call day.  This time, it was on a weekend, which meant that I would need to round and write notes on all the patients in the wards, Nursery, NICU, PICU.

Tangra was taking care of a very sick kid in the ICU who started out as a fever of unknown origin, which then progressed to decompensation, respiratory failure, upper and lower GI bleed, DIC - presumed to be from a serious infection.  He was intubated after coding.  Tangra had been on the telemedicine site with doctors from the Tripler Army base in Hawaii discussing his case. 

Without going into great detail about his case, there had been several setbacks - including the hospital running out of his sedation medications and the patient waking up.  It was also discovered that the hospital's CT scanner, which was rumored to be "broken", was actually still sitting in a shipment container in the harbor - where it had been for several weeks due to ?the holidays (nobody seemed to really know).  This case is a good example of how much the hospital needs resources - both in trained nursing and physician staff, and equipment.  It is crazy to think that this actually happens on US soil.

Throughout the week, the patient improved on the vent and then was extubated.  His respiratory status was tenuous, but stable.

Anyway, my call that day was again very interesting.  I ended up sitting in the ICU almost all night watching the patient and adjusting medications, monitoring machine settings... something WAY outside of my comfort zone (since we had literally one month of MICU in residency, and most of the actual management of those patient are not done by residents, but by critical care attendings).  I took for granted the excellent nursing staff we have at HCMC - namely that you can trust them to call you when a patient's vitals change, or even trust them to correctly use lines, administer medications, etc.  While I don't blame the nurses here (they are wonderful people, but  way overworked and the acuity of the patient population is ridiculous), it seems that you have to explicitly double and triple check everything that goes on in the ICU.

I was also called away to the ER for admissions and consults.  There was also a couple of C-sections that Dr. Marrone ended up coming in to help on.

Throughout the night, the ICU patient's respiratory status and cardiac status remained stable... until about 6am, when he became tachypneic and started desatting... long story short, he ended up getting reintubated, which made me feel absolutely terrible (though, after talking to Tangra and Dr. Marrone,  I don't think I made any gross errors in his management... I definitely am not cut out to be an intensivist!).  Thankfully, both Dr. Marrone and Dr. Shushunov were in the hospital at the time and took over care of the patient.

All in all, it was an exhausting call, though an amazing learning experience.

Friday December 26, 2014

Went to the hospital for AM rounds with the team, then rounded by myself on my patients. Then it was off to clinic for the day - which was slammed, since the clinic was closed on Christmas.   Finished up at clinic around 4pm.

Christmas Day 2014

 Christmas morning, we all woke up early.  I went out on the back patio and made phone calls to Carlyn and my family from the cell phone (still no access to Skype, but by this time I wasn't really missing it).

Here is a photo of the Broge family in front of their Island Christmas tree.  Pictured from left to right - Matt, Noah, Tangra, Nolan, Linda (Grandma), and Neeli.

 We watched the kids excitedly open their presents....

 I bought the kids a set of Chinese guns that shoot plastic darts - which was awesome. They had a good time shooting each other (and me)... I'm sure their parents were thrilled.

Later that morning, Matt, Tangra, Noah and I decided to go for a swim out beyond the break.  The water was at high tide, so you could swim out beyond the ledge without much difficulty.

It was a bit tricky at first, due to the waves, and there were the occasional cracks in the reef that dropped ?? depth (you couldn't see the bottom).  I was a bit concerned about getting my foot caught in one of these holes while walking out to the break (visions of compound fractures danced in my head as the waves crashed over me), so I treaded slowly.

Once over the break, the reef dropped instantly into the void.  There were huge fish.  The waves were quite large, and we were lifted up and down 15-20 feet like ragdolls.  I attempted to get a video of the waves, but my camera ran out of battery halfway through.  You can still notice the power of the ocean.

 Here is a photo of Matt, Noah and Tangra swimming.  Noah and Tangra had life vests on, which was clearly the smart thing to do.

 Noah acting cool in the water...

It was difficult to conceptualize the depth with the camera (was about 50-75 feet deep).  Here is a photo of Matt swimming about 10 feet below me.

After about 30 minutes, the waves began to get rougher & we noticed the tide was going out.  This was problematic because without the high tide, there is no way to safely get back onto the break.  We swam over to the edge of the wall and literally timed our approach with one of the large waves, which carried us over the wall and crashed us down onto the reef.  I ended up getting my snorkel ripped in half (the bottom was still in my mouth), and I cut my hand and arm on the reef. We managed to get back without any broken bones - it was quite the adventure.  (I can see now why the Samoans have a healthy fear of swimming... I don't think I will swim out past the break again).

Back at the house, we all changed and made preparations for dinner.  The power went out for about 3 hours.  During this time, I decided that I needed to learn how to crack a coconut the "Samoan way".  

Basically, you slam the coconut on top of a sharp, pointed stick.  Eventually you make a big enough hole to rip away the husk so that you can drink the coconut water.

My first attempt was an utter failure... (Matt had a great time poking fun at me. I swore at the time that nobody would ever see these embarrassing photos!)

Eventually, I got the hang of it...

This is me with my mangled coconut. 

 

Which I cracked open and used the coconut scraper to get out the meat. (Much easier than actually cracking the darn thing open)...

Later that evening, once the power came back on, we had dinner and relaxed out on the patio. There was another awesome sunset... truly paradise.