Ma dernière semaine à Nouméa!

This past month has been such an adventure! So many firsts in so many ways. I remember thinking at the start that my ambition was going to bite me in the butt - I just couldn't see how I'd be able to manage! I don't really feel proud of myself very often, but looking back, I do feel really happy that I challenged myself this way - language, medicine, loneliness and independence. One of the lessons I've learnt is to ask for help. It's very humbling to see the kindness of friends when you're in need. I have so many people to thank for the guidance, help, conversation, insight and laughter over this month.

In my last couple of days in Nouméa we went to watch 'Les Seigneurs' in a beachside pop-up cinema that was literally just around the corner from my place.

N and H

Visited the (kanaky) Tjibaou Cultural Centre, esp renowned for its interesting architecture

Played pétanque for the first time and had a taste of the obligatory matching aniseed liqueur, 'pastis'. It's a wonder how the french version of lawn bowls became so popular amongst young frenchies - i think this is aided by the fact that drinking makes you better at the game, haha. We played in 2 teams where each person bowls 2 'boules' as close to the red ball as possible, and at the end the team who bowled the ball that is the closest to the red ball gets the points for that round. The winning team gets as many points as they have balls that are closer to the red ball than the other team's closest ball.  This pitch is lit up every night - every time we passed it previously there were always ~3 pétanque games happening at the same time. pretty sweet spot considering it's just by the beach! 

Clinical diaries pt 2

In my last week at the hospital I sat in on some interesting cases/consultations. 

1. Delusional parasitosis (aka Ekbom’s syndrome or Mogellons)

At times, I wonder if medicine has failed patients when we start labelling them as crazy. Epileptics were once ‘crazies’ too. Only 3 months ago, this ~40yo lady was ‘normal’. Since she started having the sensation of worms crawling underneath her skin, especially around the time when she has sex, she’s been documenting her discomforts in a diary and sending them nearly daily to the doctor. She’s been through all the normal tests for parasites (blood, stool, skin) and has repeated courses of anti-parasite medication, so if she ever had parasites, they should now be gone. <insert argument with the doctor> Her neighbour advised her to start taking MgCl2 to fix the problem, but it had limited effectiveness on her symptoms and she’s getting diarrhoea. The doctor’s advice was to stop her self-prescription of MgCl2 and see a psychiatrist.

     2.  Miraculous bone marrow biopsy without extra pain relief

My first encounter with a bone marrow biopsy last year led me to believe that it could also be called prescribed torture (we drill into the back of the hip and take out a ~1.5cm piece of bone marrow). The poor patient was trying to refrain from crying out in pain, and despite the ‘green whistle’ analgesic he let out blood-curdling cries that made me persevere and watch the whole procedure because for some warped reason I feel that patients deserved to have us know their pain as a reminder of why we should work our butts off.

Having had only one traumatic experience of just watching a bone marrow biopsy, my heart rate increased significantly when one of my colleagues told the 30yo lymphoma pt that he wasn’t going to be having any patient controlled analgesic (the green whistle). She’d just anesthetise the area locally and that they’d proceed. I was really worried for him and not looking forward to watching. 

Miraculously however she managed to retrieve a perfect piece of bone marrow with the patient telling her that she could push harder if she wanted! The technique is apparently slow and steady, but you have to be forceful to drill into the bone and then to snap the piece from its base. Make sure it is completely dislodged from the base by aspirating the drill piece with a syringe so that when you remove the drill piece, the piece of marrow is in the drill piece and not left behind (what a scary thought that you’d have to repeat the procedure!).

I was seriously so impressed. I wish I will be able to do biopsies like that one day. 

      3. pyoderma gangrenosum on her shins – a systemic presentation of Crohn’s disease (a systematic inflammatory disease that commonly affects sections of the bowel). Painful pus filled 1cm wounds that burst out all over her shins, treated with corticosteroids because it’s an inflammatory reaction. Pretty horrible!

     

     4.  Erythema nodosum – bruise like skin lesions all over the arms and thighs of a scleroderma patient.

     

     5. Subcutaneous metastases that started bursting through skin and from under toe nails in a terminal prostate cancer patient. Varied from small white lesions through the skin of the arch of the foot to red and black bulbous ‘angry’ ones from under toe nails. 

sign on the door of the office for medical staff

2 specialists, 2 specialists to be and me in the medical office. All doctors wear white coats, and a lot of the allied health workers wear white scrubs so it's near impossible to tell who's who! 

nurses' room

Raoul Follereau Leprosy Centre

I must admit, the first thing that really attracted me to NC was the fact that there was a leprosy colony on the island. I had no idea that leprosy still existed – wasn’t it an ancient disease of the Bible that tore apart the faces of crusader kings? Apparently there are 200,000 new cases per year around the world– awful when you think of how it can be cured with antibiotics if it is caught early. It’s one of WHO’s ‘diseases to eradicate’ – I’ve been looking into the definition/process/logistics of disease eradication of late, pretty interesting. After learning that it is quite difficult to catch leprosy if you’re immunocompetent (healthy) and that the very rare flipside is 6 months to 2 years of antibiotics, I thought I’d put on my adventuro-medico hat and see the place before it turns into a museum.

The centre is 30min out of Noumea, and the first thing I saw when I got off the bus was a deer carcass (not unusual road kill victims here). After a good 20min walk down an isolated path that gives you the feeling that they wanted the colony to be very far away from civilisation, I found myself at the edge of a bay. New Caledonia is very physically beautiful, and this bay is no exception. 

I had a long conversation with L, the only patient who is still mentally 'with it'. A lot of the medical problems that the other leprosy patients have are actually to do with their age rather than leprosy (they range from 65-90yo). Many have alzheimer's for example, and aren't really present. 

L is an 82yo who has been living at the centre ever since he contracted leprosy at the age of 30. He told me that both brothers and one of his two sisters also had leprosy, the youngest having caught the disease at 8yo! what a life sentence. Antibiotics to treat leprosy only came into full swing in the 70s. He is the last one of his family to survive leprosy, but he thinks he will be buried in the cemetery behind the colony because there will be no one to take his body up north where he was born. 

He has 'classic leprosy' hands that are stuck in a flexed position, almost making a fist but he can move his thumbs and therefore can write. His right leg is amputated and he can't feel anything with his left leg (since the form he has is more a neuropathy). He has a few open ulcers and his toes are all in different fixed positions. Later I saw him with a fake leg and walking with crutches. He is missing all his front teeth, so when he talks his upper lip flaps. He loves talking so it was a bit funny. His eyes were really watery (they have something wrong with their eyes as well. I think they become very dry so they give him something so that they're always watering). While he has a more neuropathological form, there are 5 main categories that vary between the spectrum of neurological and dermatological presentations. 

he's holding a PEP device to help keep his airways open

This Australia day weekend was also International Leprosy Day, and a trip to the aquarium was organised for them which is nice because they don't get out much. He told me about the different ways they pass the time there, and how that has changed over the years. When I was in the Isle of Pines I met the manager of several of the luxury hotels there and he told me that he installed a vegetable garden about 15 years ago. Unfortunately I don't think it's used very much any more. Now they just kind of sit there on their veranda, they have carers who help them bathe etc and they watch TV. He said he's sick of reading. Before you could talk to the other lepers since there were so many, but they always had the same stories to tell. They used to listen to the radio (started at 5am and ended at 9pm) and he told me about the first time they had a TV at the colony/centre - how extremely excited everyone was and how everyone rushed down to see the black and white pictures flashing inside a box. He told me that he had a wife there too, her name was Irene and she caught leprosy when she was 18. They didn't live together - there was gender and race segregation (Europeans and Melanesians/aka the kanaky) despite all having the same disease.

The site itself has a couple of buildings - one for the 5 remaining leprosy patients and one for the diabetic patients (now that there are very few cases of leprosy, the centre has been turned into a reeducation and treatment clinic for diabetic patients). The old houses that used to cater for the 35 or so leprosy patients are now empty. There's also a chapel - a nun comes to visit on a regular basis. Before there was a cure, nuns used to run the leprosy centre themselves (and some did catch the disease). Brave. 

the chapel

~14 bed diabetes centre

twin room inside the diabetes centre

Ultimately the leprosy patients here are well looked after, though you get the sense that they felt their time was up a long time ago and now are waiting to die. It's more than an eerie feeling. One of the carers asked me if I was afraid of leprosy and I replied in the negative. I think healthcare workers are used to seeing people with many diseases, and this one is as cruel as the next. I definitely hope that treatment becomes more available in the more remote parts of the world, it'd be great to see leprosy finally eradicated.