For the want of $5, a $50,000+ bill

A young mother-to-be, at about 6 months pregnant, developed a urinary tract infection. Common enough and quite easy to treat. Coming from a local family with little means, she couldn't afford the $5 for the antibiotic. Until this summer, the Medicaid she had would have covered this routine prescription and she may have gotten her treatment. Because the local government has not paid it's bills to the pharmacies of the CNMI*- over a $1,000,000 owed- that is no longer the case. Instead, the infection spread and caused her to go into labor 3 months early. Rushed to the hospital, the obstetrics team could not stop the delivery. The small, fragile boy was born weighing under 2 pounds and after barely surviving the first few days, it was clear he would need around the clock critical care. At 3 weeks of age, he has made only small improvements and needed to be transported by our medical team across the ocean for specialized care. At a minimum, his bill for the transfer and care at the other hospital will be $50,000. That is besides the critical care hospital bill for the last 3 weeks, and the months of care he will still need in the future.

 We work at the only hospital in the CNMI, on the largest of the 12 islands, three of which have a significant population. In a probationary period by Medicaid, there is a real chance of losing the main stream of funding that keeps this hospital afloat. The governor is currently in the process of being impeached for charges of corruption. If only we could be optimistic that the future is brighter and the local officials would take the healthcare of their community seriously by appropriately allocating funds and finding long-term solutions. Either way, we returned back to Saipan to serve this generous, proud, smiling island people as long as we can.

On a lighter note, we after returning from our Asia travels, we now live closer to the more rugged Pacific (east) coast of the island. Here's some pictures from adventures out here.

*Commonwealth of the Northern Mariana Islands

Complicated Cases? Next island please.

 I've been reluctant to share too many details about the children I'm caring for. Not for lack of interest because we definitely see some perplexing, complicated and even amusing cases. It's mostly to protect their families' privacy. This case from last month will be an exception:

 "Dina" (not real name) needed to be medically evacuated for specialty care that we can't offer in Saipan- we have no neurosurgeons, no MRI machine nor a pediatric neurologist. In fact, we have no pediatric specialists- which actually makes my work that much more enriching and exciting: I get to dig deep in my knowledge base and peruse the literature myself in a range of fields that in the mainland I'd refer out- immunology, cardiology, kidney diseases and by far the most prevalent: infectious disease.

 This 8yr old was having a progressive illness leading her to go from an adorable, active chatterbox to paralyzed from the neck down over a couple months. We needed to get her to the closest major referral center. As of now, that is Manila, Philippines. To get there is a 45min flight to Guam, then a little under 4h flight to the capital of Philippines. Given the complications, a doctor, nurse and respiratory therapist were to travel with her. As my first air transport that involved moving this young girl between SIX places- I thought it worthwhile to document:

#1: ambulance from the Commonwealth Health Corp. Center, the main hospital of the Commonwealth of the Northern Mariana Islands to the helipad in the south of the island:

#2: Onto the helicopter, continuously "bagging" (manually inflating the breathing bag) as we fly the 1hour, four islands south to Guam.

First island is Tinian, 2nd most populated in CNMI. This is where the South Pacific WWII campaign had its strategic location. At one point, North Field was THE largest and busiest landing strip in the world with war planes taking off or landing every minute. It is also where the plane that had the first atomic bomb launched from.

Second island is "Goat Island" an uninhabited island- except for goats.

Third island is Rota, the smallest of the populated CNMI, known as the 'friendly island' where the reaches of WWII did not touch and so much of the original tropical beauty remains. Nadeah and I will get to see for ourselves next week when we visit for the first time. That small isthmus connects the large part of the island and that 2-tier outcropping known as "wedding cake"

Fourth island is Guam, by far the most visited and commercial of the islands in this chain. The north half of the island is essentially the U.S. military, with its own shops, restaurants and economy- not benefiting the locals who survive off tourism. The massive hotels seen here on the edge of the gorgeous lagoon are the hub of that tourism.

#3: Ambulance from helicopter to the United airplane to Manila (not pictured)
#4: Make shift ICU in the economy section of the plane. The outer 2 seats in 3 rows were folded forward and the stretcher was hoisted over them. We sat in the aisle seat of those 3 rows, working through a curtain. It was half to protect the girl for gawkers eyes and half to protect passengers from the disheartening image of a girl with a breathing tube.

#5: Going through customs, immigration in Manila and getting her on the ambulance to the hospital
#6: Arriving at the hospital around 11pm and giving report to the doctors who will take over her care in the ICU. Also not pictured.

 The one update we've gotten from the hospital in Manila is that her condition does not seem reversible at this point, a sad outcome. Unclear if there was anything more we could've done, will have to read the medical reports when she returns to Saipan..

 Hope you learned a little more about what my work entails and the neighboring islands now and historically.

Feasting at Food Festivals

One of the more exciting things about traveling to new places (especially for Nadeah) is trying out different foods. Being on the cusp of Asia, we are immersed in a wide variety of amazing foods. On a small island, we weren't sure there'd be a variety of food options. Thankfully we can easily find the ingredients to make foods ranging from Wahoo fish tacos (actually wahoo just caught here in the photo) to Kim Chi to Sushi to Pad Thai. More surprising was finding all we need to make our first ever home made lasagna.

 Street food and festivals with food booths (think state fair) are big here. Thursday night market takes over one street in the city center a few blocks long with our favorites being chicken on a stick, coconut drinks, noodles of all types and boba drinks. This time of year has a few major annual festivals, including the Flame Tree Festival and the Taste of Marianas as well as Charter Day at the only college in Northern Mariana Islands. Native Chamorro, Carolinians and visitors from other Micronesian islands performed all three 3 nights of the free festival.

a big Fan of the sea

Scuba diving in Saipan has some awesome sights. This photo seems enhanced or fake and besides editing some blurry areas- it is totally this vibrant and colorful. This is at 'the Grotto' a series of underwater caves and tunnels at the gorgeous north end of the island. The surrounding colorful foliage are known as sea fans. Think japanese hand-held fans.

 

In addition to this massive sea fan, in the distance you see large schools of fish- one above me, another below.

 The glow of light coming through into the cave gives this one an eerie sci-fi feel to me. Some moments down there feel a lot more like outerspace than being on the surface.

Strange fusion of tri-athletes and WWII relics

You learn quickly on Saipan that you are surrounded by a high per-capita of athletes. Not just regular athletes, tri-athletes as in triathlons. This past month alone there were 2 international triathlons, the Xterra and the Tagaman. In between actual competitions, the athletes are always up for training sessions wherever they can squeeze one in. Swimming in the always calm western lagoon- protected by the reef a mile out- is a good place. In other parts of the world you'd measure how far you swam by a buoy. But that wouldn't be as interesting..

 Saipan is 3hr flight from Japan, who controlled the island and much of the region until shortly after Pearl Harbor and the U.S. waged its Pacific campaign against Japan. Battle of Saipan was a major one that saw 10s of thousands of lives lost on both sides. Relics of the war are found all over the island. Unexploded shells from planes and grenades are still found on a regular basis..

 Across the street from the courthouse in Susupe, visible from the beach, are 2 Japanese tanks in the shallow lagoon, sunk about 1/2 way with their barrels pointing at the island. Even though they are rusted out, sitting in a picture perfect lagoon, there's still something innate in you that says "run away!" when you look down a barrel of a tank. As I swam toward the tank the first time, I felt a bit courageous and foolish- like a OWS protester running directly at a police barricade. Not so to the residents of Saipan.

 Like scheduling a yoga class, there is a MWF 12pm "Around the tanks" 1.3km swim. There's even a home made promotional video to get a glimpse of all this action. Dont mind the 80s synth beats, they dont get too many live shows around here.

 http://www.youtube.com/watch?v=ypA5NHnTfEU

SCUBA diving into the fish tornado.

 In January, rather than head straight home from Zimbabwe- Nadeah and I traveled across a few areas of Africa. One of our favorite stops was 10 days on the island of Zanzibar off the coast of Tanzania in the Indian Ocean. Known as one of the Spice Islands it is a major scuba diving destination. Knowing Saipan is also a haven of scuba diving, I took advantage of our traveling time and got my 'Open Water' certification. Though it was trade wind season in Zanzibar, making the boat rocky in the wild waves, down below the surface it was spectacular.

 On my first dive in Saipan, with the oddly named Axe Murderer Tours, I got to see the fabled fish ball- which would be better called a 'fish tornado' as this school of over 300 fish swam in a tubular shape that was about 15 feet high. Mesmerized by it as I approached, my partner took the lead and swam into it as I slowly followed. It eventually closed around us and besides sand far below and sunlight on the waves above- we were surrounded by these fish. An awesome experience to be in the "eye" of the fish tornado.

UPDATED (April 4th)-
Thanks to my new friend on Saipan, divemaster 'MikeRonesia' I have attached here a photo of someone in the 'Fish Tornado' at LauLau beach to give you a glimpse. enjoy

From arid winter to lush summer

When fellow UCSF pediatric resident Chris Carpenter (who writes a great blog, Backpacks and Stethoscopes, chronicling his adventures) told me about his gig in Saipan last year, I was halfway into my year in Zimbabwe working for "Doctors without Borders" (Medecins Sans Frontieres). It sounded as far away on this world from where I was as could be. In fact it was just about 1/3 of the world away- 8 time zones ahead.

 My work in Bulawayo, Zimbabwe was in a dry, land locked region of a country handicapped under the rule of a paranoid tyrant, Robert Mugabe. Living in a communal home, making very little as a volunteer, I was part of a large MSF team that I absolutely admired and will remember for the rest of my life.

Saipan, on the other hand is a lush tropical island the size of San Francisco (~45 sq miles) that falls under the lesser known U.S. commonwealth. There would be a small team of laid back docs at the island's only hospital. There, both Nadeah and I could work and get a U.S. type salary- much needed to put a dent in each of our looming 6 digit loans. So we made the leap and here we are.

Tune in soon for the story of my first scuba dive the week I arrived and my experience in a fish tornado..