East Timor Medical Elective - Week 4 (Part 1 / 6)

Week 4 (22/9/14 – 26/9/14)

DR DAN'S 70TH BIRTHDAY

Monday this week was Dr. Dan's 70^th Birthday. The morning ward rounds proceeded as usual, but when we arrived at the Malnutrition Ward, there was a surprise! Luisa and “Livia” (another assistant) started playing a Happy Birthday song from their radio. There were balloons, and large colourful letters saying “HAPPY 70TH BIRTHDAY DR DAN” hung across the wall. A table with the birthday cake and several beers was in the middle of the room, surrounded by much of the BPC staff.

The ward rounds took a pause. I thought that Dr. Dan would cry or be very emotional, given that he's reached a new decade in life, but he smiled and shook hands with everyone who congratulated him, one by one. It was so cute to see the little children smiling and reaching up to shake his hand too.

“Amy” (a volunteer Dr) then presented Dr. Dan her handmade Birthday Card that we all signed. This was then followed by the cutting of the birthday cake and distributing of the beers. The room was small, but at that moment felt cozy, so very “Gemutlichkeit (sp?)/ Gezellig”.

It was a very pleasant start to the day, and I (selfishly) felt lucky to have my medical elective coincide with this occasion, along with the BPC 15^th Anniversary on Friday.

East Timor Medical Elective - Week 3 (Part 6 / 6)

TEMPORARILY GETTING RID OF AUSTRALIAN MINDSET (TOXIC “TALL POPPY SYNDROME”)?

At night after giving Chicken for the first time, I was worried about how I'd be perceived.

My normal Aspie self would see this in a concrete, objective manner as an act of spending money to buy a Chicken and giving it to people who otherwise would have difficulty buying it.

However, my past experiences with NTs (Neurotypicals) was that they had a statistically much higher chance of putting a skew on events, particularly with stronger emotional biases, even to the point of discrediting the person who had “neutral” or “altruistic” intentions to begin with. Ie, I already knew that acts of charity aren't necessarily viewed as good by everyone. 

I pondered, is buying things for other people considered [ patronizing / showing off / egotistical / arrogant / trying to please everyone / insecure and wanting to be liked by “buying friends” / an attempt by a potential “Paedophile” to lure innocent children ]?

I asked another assistant (“Martinho“) whether buying things for East Timorese people was at any times considered patronizing, offensive, or ignited criticism and cynicism from others. He said,

“In East Timor, people appreciate the gift, no matter how much it's worth, even if it's just 5 cents. We won't get angry or think it's patronizing.”

 

That was it, no more, no less.

I was very relieved to hear this, but then confused. How could the response of East Timorese people be so simple/pure and positive? Aren't they predominantly NT as well? How could they be so different in mentality? Are they still “human” for having such a straightforward, “bestial” response?

My mind was racing, trying to think of the underlying “Physiology” behind this mentality. Could it be that East Timorese think like this coz of their poverty, so “beggars can't be choosers”?

I realized that the cumulative negative reactions of NT Australians in the past (towards me, and others) have made me feel like EVERY F***ING-THING I said, did, or achieve, would somehow be offensive, unacceptable or Politically Incorrect to somebody, for some G-d-damn reason that was initially beyond my “simple” AS mind. My constant attempts to update my “social skills” database as a means of facilitating my function within a predominantly NT-environment actually worked against me here. But in reality, it wasn't just the NT-environment that I was attempting to adapt to, but an Australian one. I underestimated the influence of Australian “culture” on the environment.

There are Australians who deny the existence of “Tall Poppy Syndrome”, but my observations in the media, along with my personal experiences, suggest to me that it's alive and well. The person being “cut down” doesn't even have to be rich or intelligent, it seems to be as long as they attempt or do something that other people don't do, that it frequently attracts criticism or derision, even if others had zero intention of doing that task in the first place.

I thanked Martinho for the explanation, but felt really upset, and really nauseated inside.

I wasn't sad at the gratitude of the East Timorese people, but sad that “Australian cynicism/jealousy” and “Tall Poppy Syndrome” had “poisoned” my mindset, even outside of a social environment, and OUTSIDE of Australia. My worries in the Chicken incident were for nothing.

I was unable to purely accept a charitable act for what it was, and in the grueling process of understanding people, paradoxically lost my ability to appreciate goodwill without triggering negativity.

The East Timorese are much poorer than Australians, and have access to far less amenities, medical and non-medical. The children seem so innocent and easily entertained, whilst the youth are disillusioned re: unemployment. Yet in spite of all of this, emotionally and spiritually they seem “purer” and more “elemental”. Despite 3rd-World conditions, in some ways, they are “freer” than Australians. Their “freedom” from cultural cynicism and Political Correctness is exquisitely liberating and luxurious for foreigners who've “walked on egg-shells” for years. What is the price to experience such Mental Clarity in one's country, to regain a part of one's “Inner-Child”? 

 

I'll miss East Timor very, very much when I come back to Australia... : (

East Timor Medical Elective - Week 3 (Part 5 / 6)

BUYING CHICKEN

This week, I asked one of the clinic assistants, “Luisa”, if there was anything I could do to help them or the children on the Malnutrition Ward. One of them told me that the children like eating meat, especially chicken. Unfortunately, their (very meagre) budget only allows for THREE chickens / month, split amongst the SIX children.

I decided to start buying a roast chicken every Saturday for the children as a treat. (This would be completely illegal in Australia, as under the litigious climate, would be seen as a potential health hazard, and as a “conflict of interest” towards to children as a staff/volunteer!!!)

On Saturday, I approached the Rotisserie on the way to BPC, to buy a roast chicken (chopped up) for $5. It was eye-opening to see the presentation of the meats. They were all stored on trays in the glass cabinet at room temperature. There was a risk that it may be spoiled, but I was told that it's actually a popular place. I hypothesized that if the place was popular, then it was unlikely that it'd sell spoiled meats, especially when the prices are expensive by local standards. I asked for the chicken, and the woman chopped it up, placed it in a paper-folded “container”, added a little bag of soy sauce, and placed the container in another plastic bag. Primitive, but workable and memorable.

I slowly walked to the clinic under the hot sun, wondering how they would respond, and if everything would turn out fine. I was too “shy” / anxious to present the chicken to the parents myself, and asked Luisa to distribute it evenly amongst the children. I nervously waited in the office, before preparing to walk home. 

Luisa bumped into me and said, “Ken, the children are eating the chicken, go have a look!”

I followed her into the Malnutrition room, and it looked like a “Kodak moment”: it was quiet apart from the ceiling fans and the chewing noises of the children. The parents were quietly focusing on them eating the chicken with the porridge. No complaints at all.

Inside I felt very “touched” but couldn't figure out why, and had to leave the room after a few seconds, coz I thought I was going to break into tears. They weren't openly worshipping me, but I suspected they were happy.

It seemed way easier to please people in developing countries. $5 was what it took to brighten the day of 6 families. I can see why working in a developing country could be attractive, with the poverty and reduced resources (medical and non-medical). The people seem much more grateful, and are less inclined to take things for granted.

But I had to remind myself, that if I wanted to work in a developing country in the far future, to truly consider how much of this would out of genuine altruism and/or job satisfaction, vs the desire to feed one's Ego and be “worshipped” by the patients etc.

I've decided to continue buying a roast chicken for the remaining Saturdays I'm in East Timor, but leave the Malnutrition Ward ASAP after I have distributed it out. At least that way, there is minimal potential time for me to “gloat” about this deed and “thrive” in their live gratitude.

East Timor Medical Elective - Week 3 (Part 4 / 6)

East Timorese Patients (Observations so far)

It's now clear to me that the East Timorese patients are most amused by the Neurological Exams, by far. When I used the tendon hammer to do knee jerks on a patient, the other patients and relatives were looking on in amazement. Natalya was with me and she said that after I left, some of the patients were hitting their knees with their hands, trying to elicit the jerk (so cute)! A few patients were quite strong for knee flexion, and when I was trying to stop them from pulling their feet towards their bottom, stumbled over to others' laughter. Then there was the grandmother, who when asked to touch her nose, ended up putting her index finger up her nostril (lol), with her children “cracking up”!!!

We got to debride the dead/macerated skin from the Leprosy Pt's feet. It looked quite gross, and I pulled off his toe nails, but he didn't feel pain. I was very worried about causing pain if cutting too deeply, and “jumped” when his foot suddenly shifted for easier viewing by another student. It almost felt as if I was having more pain than him, and he was laughing so much the entire time.

It made me happy that the patients etc took joy in taking part in physical exams. I couldn't tell if it's because of their “Un-Medicalized” state, or coz they take humour in little things, perhaps because they'd otherwise have little to be laughing about (in light of poverty and hardship). In fact I think their threshold for humour is very low by Australian standards, to the point of finding “slapstick” content hilarious. I imagine they'd love the classical Charlie Chaplin movies. Even outside the clinic, I've seen children laugh at me when taking big bites out of an ice-cream cone, or when my head hit a low-lying branch whilst walking. Adult strangers have laughed just coz I was walking fast / running from one place to another in a hurry. It seemed Aspie-ish, in that they perceived these little details with more value, and don't overlook it automatically. But I strongly suspect that this “Humoural Sensitivity” will gradually fade away if they become wealthier, and progressively de-sensitized by the deluge of Western media and culture.

(In fact, maybe I could make a list of things that have amused the East Timorese patients, or amusing responses by them...)

It was touching for me to see a Heart Surgery Pt return from Australia, and donate his remaining Oxycodone to the Clinic's Pharmacy for other patients in severe pain coz he didn't need it anymore. I've never seen such “medication” generosity in Australia, where Oxycodone and Morphine have a reputation for being overprescribed and abused or diverted for money.

Unfortunately, part of the “Medical Innocence” manifests in a lot of patients as being rather “poor” historians (even taking communication barriers into consideration). It's not uncommon for a patient to say one thing, and then say the opposite several sentences later. I thought they were lying, but seemingly according to my Tetum Language Book, it states that East Timorese people will state something as the truth even if they're not sure that's the case – the usage of modifiers such as “perhaps”, “maybe”, “if I recall correctly” is less prevalent than in English. If they've had a certain issue for several years, they often just say “kleur ona” (a long time), without specifying the years. I have to “prod” them to state how many years. And then there are a handful of patients who misunderstand Asthma, thinking that it means shortness of breath (from any cause).

It doesn't help that Tetum has several deficiencies in facilitating history-taking. Despite the inclusion heaps of Portuguese loans for scientific/technical terms, the core Tetum actually misses several grammatical points that would've facilitated history taking. For example, you can't ask “How long have you had this pain for?” Instead, you have guess the units of time, ie “How many days/weeks/months/years have you had this pain for?” There were others but I can't think of it for now.

My observations so far are that they're most accurate when it comes to discussing medical issues that are very recent onset (eg abdominal pain startig last night), with progressively less accuracy for more chronic issues.

The “Medical Innocence” is quite interesting at times, especially the heterogeneity in medical knowledge amongst the East Timorese patients. There was a village girl who had Pneumonia, and I told her mother that she'd be receiving “antibiotika” (antibiotics). She didn't know what antibiotics were. I then said it was a medication that helped eliminate certain “bakteria” (bacteria), but then she didn't know that word either. Then there was another patient who knew what bacteria was, but never heard of a “virus” (virus). I had to get the interpreter to explain to her that a virus was a bit like a bacteria in that it can cause infections, but it's even smaller, and you can't kill it with antibiotics.

East Timor Medical Elective - Week 3 (Part 3 / 6)

“FRACTURE GIRL”

On Wednesday evening, I was about to leave BPC, but then got called into Dr. Dan's office.

I thought he was going to show me a patient with a heart murmur, so was surprised when he showed me a girl with a Greenstick Fracture. I looked at her arm, and she looked up to me with her big eyes. My heart “jolted” when he told me to put a temporary splint in the emergency room, and ride the ambulance with her and her Dad to GVNH's ED for an X-Ray and proper cast. Initially I got annoyed coz I wanted to go home and rest, but it quickly subsided as I felt really sorry for her and wanted to help, plus I was having another Adrenaline rush (which masked my fatigue), so said Yes to him.

A new “quest”. I forgot to take my medication that afternoon so was a bit scatter-minded. I needed to think things through methodically otherwise it'd be hard to get things done properly. 

Step 1, I had to bring them to the Emergency Room. I asked them to follow me to it. I walked a few steps, and they were behind me, stopping as I stopped (as I didn't want them to lose track of me). I felt like the Villager in Age of Empires who had to guide the Sheep back to the Town Centre. She entered the room, and I pushed the main bed away to make space for the chair for her to sit on.

After entering the Emergency Room was Step 2, finding a splint. I've never put on a splint before, but was aware that you needed a long solid object, wrapped in bandages to help immobilize the limb. I immediately visualized the “perfect” long plank of wood classically shown in First Aid Textbooks, and scanned the room up-down, left-right for it, triple-checking. Nope, it wasn't available. I then brainstormed of alternatives – long thin pieces of metal / plastic, cardboard. Nope, not available either. Time was ticking and I felt frustrated. Both the girl and her Dad were staring at me quietly.

I realized that I hadn't checked my bag yet, and as I opened it, realized I could use the cover of my note book as a (mediocre) splint. I ripped out the cover, rolling it into a cylinder and placed it around her arm, forgetting that it was only supposed to be on one side. I told her Dad to hold the cylinder up at her elbow level.

Step 3, find a bandage. This was much easier. There were bandages on the shelf, but I couldn't find the perfect textbook one, but didn't want to waste more time being indecisive, so took a guess and opened up the closest package to me, which was a thick, puffy one. I wrapped it around the cylinder, but couldn't let ago otherwise the bandage will go loose again.

Step 4, I needed string to secure it. Tetum time, I said “Hau presiza...” (I need...) whilst nodding at the bandage, but temporarily forgot the word for “tying”, in which case he said “kesi” (typing), and I said Yes! Then I had to obtain the word “string” in Tetum from my memory. I remembered “talin” being a unit of items being held by a string, and said it, and he understood.

He scanned, and then took out one that was hanging out of a folder. He brought it over, holding the bandage firm whilst I tied a few knots around it.

Step 5, find an ambulance driver to take us to GVNH. We walked out, and I couldn't see one. Dr. Dan was outside and I told him, in which case he asked another person to contact the driver to pick us up. He said that the driver will arrive in a few minutes, but those 5 minutes felt much longer. I looked at the “splint” I made, and felt rather embarrassed but proud of this “improvization”.

The ambulance driver arrived but I wasn't allowed to sit in the back with them. On the way to GVNH, I was constantly worried about her, wondering if the bumps on the road may have caused further trauma.

We arrived at GVNH, and I entered the ED. The first time I entered this place, it looked very “drab”, and even “greyer” by Australian standards. Step 6 was registration. The “Boss Level”. From my previous experience with the Cuban Radiologist, thought that I had to behave in a very meek manner without showing any signs of aggression or anger, as the Drs here have the potential to avoid helping patients with virtually ***NO*** medico-legal penalties compared to Australia. The extremely frightening reminder of this risk, was a furious-looking mother and her crying daughter of similar age to the “fracture girl”, screaming in Tetum to the Triage man. I suspected that they've been waiting for a while and haven't been seen by a Dr, despite the presence of empty beds, and Drs chatting at the counter. “Don't let them push your buttons, hide your feelings, censor yourself, don't get angry, don't get angry, don't get angry”, I repeated in my mind. 

I walked up to the Triage man, and in my most “formal” accent, slowly greeted him in English and introduced the girl's medical issue. He took further details from her Dad and pointed us to the main ED counter. The furious-looking mother immediately became even more outraged, which disturbingly confirmed my hypothesis. 

Step 7, the actual “Boss Battle”, or advocating for the Patient. The girl and her Dad followed me, as I walked slowly towards the ED counter. The Drs stopped chatting as they looked in our direction. I greeted them with the same accent again, and described her needs. I tried to add “weight” to my sentences by beginning them with “Dr. Dan Murphy”(needs / thinks / wants etc), hoping they'd be obliging to help secondary to my name-dropping.

As soon as I mentioned “X-Ray”, one of the Drs immediately said “The X-Ray machine is broken. She will need to come tomorrow to have the X-Ray done.”, followed by another Dr saying “Does she only need an X-Ray?”, seemingly ignoring my mentioning of the need for a cast.

I paused. The clincher: my answer to this question would determine if they would help us or kick us out. Say the wrong thing and I'd lose the level and prolong the girl's suffering. The answer was obviously “No”, but in the past (when un-medicated) I had a higher risk of saying the wrong answer, or forgetting to say important things at high points of stress. Surely the Drs knew that she needed a cast? It almost felt as if they didn't want to help in the evening, whether out of laziness or fatigue.

I worried that they'd give more excuses even if I said “No”, so formulated a sentence in my mind and quickly analyzed its truthfulness and influencing potential, coming up with:

“Dr. Dan Murphy needs her to have a cast put on her arm to stabilize her fracture, even if she doesn't receive an X-Ray today. It is important to have a cast, to prevent the greenstick fracture from potentially getting any worse.”

If the Drs disagreed, then it'd make them look really bad, even if they couldn't get sued. I wasn't aware of a way to argue out of delaying putting on a cast for a greenstick fracture in a haemodynamically stable patient. 

Thank Heavens the "Rivers Parted", and the Drs “agreed” to help us. They told us to go to another room, where a Dr started undoing my “splint”, and began preparing a cast. Unfortunately I wasn't able to watch the entire process, as the ambulance driver called me out to drop me off at home. On the way back, I was relieved but even more exhausted after that ordeal. 

Mission accomplished for the cast. What a diversion, I felt so “battered” by the time he dropped me home. I think this task was the one that so far (by end of Week 3) demanded the most of my improvization/flexibility and communication skills. I thought that advocating was a simple task, but in retrospect realized you needed to demonstrate the medical knowledge to justify your demands and facilitate delivery of treatment. G-d help the non-critical patients who come on their own without a Dr or medical student to escort them, especially when the public here are much less “medically literate”. 

Whilst I personally found their “Medical Innocence” endearing last week, I now understand how this can work against them in a potentially very dangerous sense. I'll never forget this episode...

East Timor Medical Elective - Week 3 (Part 2 / 6)

EAST TIMORESE PEOPLE AND FORGIVENESS

I couldn't understand why the East Timorese people forgive so easily. Especially with regards to the Indonesian massacre of the East Timorese in 1991 and 1999 (apparently up to ~1/4 of the population died), why they have still have little problem with Indonesian culture or Indonesian people. It's a complete contrast to a significant portion of Chinese and Koreans who hate Japan coz of WW2, and the Australian Aboriginals who still complain about injustice even though they've already received an official apology, and copious social welfare (unlike the East Timorese who receive virtually NONE) and academic scholarships despite the statistical majority not making the most of what they've been given.

I got told that it's because East Timorese people need to look forward and not dwell on the past. Their economy is also still largely independent on Indonesian products, so it's important to have amicable relationships to avoid an embargo that would destroy their economy even further. But I wondered how much of their external humility is due to their poverty. If East Timor was in an economically superior position, could they then be less forgiving and get away with it? Do they genuinely forgive Indonesians (eg as a Catholic notion, eg “turning the right cheek”), or is this a strategic move to not “rock the boat” any further lest they suffer from a hypothetical Indonesian embargo?

An Aspie (before I came to East Timor) told me that she never burns bridges with other people, “you never know when you need them”. Maybe East Timor is in a similar situation.

Nevertheless I find their attitude very inspiring, and it helps to put into perspective the significance of some of my previous problems, of which I've now moved on from.

MINI-CLINICAL NOTES

- I saw a patient whose respiratory symptoms were milder than before. I thought that it couldn't be TB, if he wasn't diagnosed with it after the first time (that was more severe), but I was proven wrong. He was still given a provisional diagnosis.

- There was a dyspnoeic patient who had suspected TB. He didn't officially have Asthma, and never used “Ventolin” (salbutamol) before. He had digital clubbing for a long time. I was puzzled as to what condition he had. Maria came to listen to me present the patient, and soon commenced him on nebulized salbutamol + budesonide. 

I felt dumb; it was obvious but it just didn't occur to me at the time. Just because a patient has never been diagnosed with the condition, doesn't mean they can't have it. You might as well give the treatment a try.

East Timor Medical Elective - Week 3 (Part 1 / 6)

Week 3 (15/9/14 – 19/9/14)

BEGGING & POVERTY IN EAST TIMOR

I've been surprised at the seemingly lack of begging so far (in spite of the rampant poverty), but finally encountered my first case on Monday this week.

I was walking home from BPC and bought a Magnum ice-cream. After finishing it, I held the wrapper in my hand, intending to discard it once I went back to the Motel. Along the way, a boy snatched the wrapper from me, put it in a pre-dug hole, then held his hand out for what I believed to be money. I didn't like the fact that he was “littering”, and that I wanted to discard the wrapper myself, so I ignored him.

I felt a bit guilty afterwards. According to the Lonely Planet Phrasebook for East Timor, begging is considered unacceptable here, but then again he did help me, albeit without my request. I asked an East Timorese person for what they would've done (ie the “correct” response), and she said that she wouldn't have given him money either coz she didn't ask for him to get rid of it.

Still, the sequence of events stuck in my mind. I had spare money available, but there were also principles that may need to be followed. If I simply give money just for the sake of supporting someone, will this perpetuate the cycle of poverty? Would giving money to him be a mini representation of the dependency of East Timor on foreign aid? Am I over-analyzing this? I think what saddened me at the time was that he was “begging”, when in Australia he would've been at school, with the parent/guardian receiving a certain amount of welfare. Maybe that's why in Australia, there seems to be an undercurrent of “Anti-Intellectualism” in schools and even (especially public ones) public discourse, because you can still be financially well-off (or at least not starve to death) even if you do badly at school or drop out early, ie the incentives of academic achievement have been significantly reduced. Public schooling is technically free in East Timor, but the poverty in many families pressures children to drop out of school early to assist with their parents in housework and income-generating activities.

I feel that a lot of Australians are very fortunate (if not “spoiled”) and take many things for granted (including public health care), because they've had so many things “too good, for too long”. But with the predicted economic crash in the coming years, their collective values may change...

Re: Poverty in East Timor, I got really disheartened after speaking to a Timorese Dr. about corruption. She claims that the oil money (which makes up ~90% of the GDP) is nearly all gone due to corruption, and that the newspaper reports / research papers about remaining oil reserves are largely inaccurate. It's so sad that a country that had the money to improve itself (at least in public infrastructure like Brunei) was unable to do so “on-time”. When the oil money is 100% gone, I suspect the country will be screwed totally and remain a 3rd-World Banana Republic, unless some extremely generous organizations will help foot the bill in the country's development.

How much more impact will all the NGOs have if this country becomes a complete “basket-case”, when the government runs out of funding? Different countries (especially America and Australia) are trying to help East Timor, but disturbingly in a sense it also lightly mimics the turf wars of the colonial era, with European powers all trying to have a slice of their pie in a new land...

This reminded me of when I ate out with the other foreigners. Never in my life, have I felt so guilty/uncomfortable in the 3 times I ate at a “Western-style” restaurant coz of the exorbitant price of the meals ($US 8+) relative to the average East Timorese income (<$US 10/day). I was at a bar, eating pasta, while the East Timorese waiters were serving us, knowing inside that these luxuries were for the most part beyond their reach, and only for viewing.

The NGO involvement just looks fragmented at the moment. I think there needs to be cooperation with the local government to help integrate their collective efforts, and prioritize local expenditure, especially towards developing local infrastructure. Sadly, my impression from browsing the official government notices in the newspaper is that they (government) have their priorities in questionable places. Apparently hundreds of thousands of dollars was spent on renovating government buildings, when it could've been spent on improving sanitation (eg septic tanks), increasing access to potable water in villages (or Dili itself), or purchasing medications and vaccines which are in short supply in public hospitals. It disgusted me. So while East Timor is now an independent country, later on it may be the case that it'll be totally dependent on other countries for its sustenance...

It worries me that given the gravity of East Timor's situation, that the economy is insufficiently diversified. The majority of food products etc are Indonesian. There's East Timorese coffee, but the relative yields are quite low due to inefficient agricultural practices, and very hilly terrain. I'm not aware of many Secondary Industries in East Timor.

There are tons of tiny shops selling the same every-day products, everywhere. I feel there's not enough diversity at the community level. Then again, most people don't have the capital to set up a more complicated business to begin with, especially when they don't have regular internet access. And customers don't have the money to buy more complex items and services. A lot of the tiny shops, and also taxi drivers don't have enough small change, which makes financial transactions difficult, a bit of a Catch-22.

For example, there's a lady living with her sister and her 2 children, with a cart selling food and drinks, with her shack behind it. I take pity on her, and buy 2 bottles of water from her for the day, paying $1.50. It was depressing to see that she didn't even have enough change for a $5 note, so I was nice and paid her in exact small change.