En Voyage

Brisbane Day 2: A Zoo in Pictures

2009-07-04T09:13:00.000-04:00

This morning we had reservations for "Brekkie with the Characters" at the Australia Zoo, the one of the late Steve Irwin. After waking up at the time we meant to be leaving, we made good time north to the Zoo itself. In the dash, we managed to forget that this is winter here, and thus we might want our jackets. Live and learn, I supposed.

Breakfast was a good time, though, despite the shivering (and the stares of the locals who thought we were nuts for walking about in the "freezing" weather). We made friends with Squirt the whale, Floyd the pink elephant, Khan the tiger and BW the croc. Games were played, breakfast was eaten, and no one froze to death. Afterwards, we stopped into one of the gift shops for jackets and found a couple that were not going to cost us too much money.

Afterwards, we fed the farmyard animals (goats and sheep) before watching Terri, Bindi and Robert Irwin feed decidedly more dangerous animals. The whole croc show was facinating. They had several varieties of birds flying around the Crocoseam for the first half, some of which must have been flying at 40-50 mph. Then the real show started as they brought in one of the crocodiles and introduced us. The handlers were so enthusiastic, it seems Steve's legacy will live on for quite a while yet.

Next up were the Koalas. They taught us about them and then walked around, holding one and let everyone pet them. This zoo is the most hands-on approach to zoos I have ever seen. Nearly every animal could be touched, many included in the price of admission. Those that aren't included tend to be the ones a bit more dangerous, like the tigers. That said, you can pay for a walk with them or a photo shoot. (Since this also includes the necessary insurance for such encounters, I can understand it. And had Miriam not been with us, we would have been sorely tempted to pay the money they were asking for to walk with a tiger or a cheetah.)

Speaking of hands-on, next up was "Roo Heaven". We went through some double-doored gates and then into an open enclosure. Inside, kangaroos and walabies roamed about. You could purchase "Roo food" for $1 AUD and feed them. They were quite friendly creatures. The enclosure also had some fenced areas that were "No humans" zones, so the animals could get away if they needed time and space. But most seemed very friendly (though not all of them were hungry).

Miriam got a pony ride on the way back to one of the more exciting zoo-activities I've done: feeding the elephants. Twice a day, the queue interested people up, free of charge, in specific locations. They bring the elephants up to the edge of their pen, put a mat where we should stand, hand us a bit of fruit and... The elephants just taking it right from us. Miriam was a little worried about those long noses, but she did want to keep going back to feed them until they ran out of food. The morning lines were huge, so we skipped it at the time. The afternoon ones, however, we could just go from the front to the back. We probably fed them 6-8 times at least, among the three elephants there.

Then it was off to see the red pandas, the tigers, and more koalas and kangaroos. Then, on the way out, we find a small playground, tucked in a corner. Two khaki-clothed kids are running around it, from some guys in blue security uniforms. Yes, it was Bindi and Robert Irwin, relaxing after a day of shows. It was refreshing to see that they get some time to be just kids. Miriam played a bit with them and they posed for us with her for a picture. All in all, a very good day and far more engaging than I thought a day at the zoo was going to be.

Brisbane Day 1

2009-07-03T09:07:00.000-04:00

All the baskets cleared Australian customs without a hurdle. My two specimens I'm carrying for pathology did not, however; they're on a shelf at the Brisbane airport awaiting my return. It's all right - now I don't have to worry about Miriam thinking the jars are toys.

Picked up an Australian cell phone, which has a ridiculous number of minutes because of this curious "cap" system for prepaid cell phones, so Matt is using it for Twitter messages. I don't know what international SMS rates are, but if anyone wants to try sending one I'll happily provide the info.
If we wait 6 months, we can unlock it from the Vodaphone network for $25 AUD and then we'll be able to use it wherever the dual-band phones will still work (primarily Australia and Europe, it seems).

We spent today on the Sunshine Coast (after dragging ourselves out of bed and getting a slow start) at the Buderim Ginger Factory, which is a cute little ginger-themed park.
We didn't go to the Bee Exhibit or tour the factory itself, but we did ride on "Overboard", which is an awful lot like "It's a Small World" with a gingerbread man as the protagonist, and we took the little train tour, that talked about the history and the buildings of the ginger industry in Queensland.

And we had ice cream, which made Miriam happy. She's eating a cone with mango on top and ginger-pomegranate on the bottom scoop there. It's going to be a few days before I can think about ginger rationally again.

She also likes carousels.

We're Leavin' on a jet plane

2009-07-01T17:39:00.000-04:00

Packed and ready to go - Miriam is eating cereal and the last of the pineapple out of plastic bowls, the trash is emptied. The house is more or less devoid of our stuff.
Today's trip is from Mount Hagen to Port Moresby, and then Port Moresby to Brisbane. We'll have a few hours in Moresby before facing Australian customs with our woven baskets (sprayed with bug spray, frozen for at least 24 hours, and banged on the table to remove bugs) and miscellaneous other New Guinean souvenirs. And then we'll be spending the next four nights in Scarborough, just north of Brisbane. We have a busy few days booked there.

I meant to write something about leaving yesterday, but I was so exhausted by packing all day that it never got done. Perhaps it will still come, eventually. It's been bittersweet the last few days.

A different world: On call

2009-06-29T17:36:00.000-04:00

We're out of oral flucloxacillin again - apparently it was a brief and glorious week of in-stock. We're also out of cloxacillin and dicloxacillin. A month ago, I don't think I even knew such drugs existed, let alone that you could sort of interchange them. I know because I got called at 7:30 PM with this information. "Are they already on Cipro? Bactrim? Oh, this is Surgery ward? Call Dr. Taiye." Jim told me not to take calls from D ward - that's Taiye's job, he's the resident. It felt good, mostly because if you're already on Cipro, chloramphenicol, and Bactrim, then I don't know what else to substitute for flucloxacillin.

The ER nurse called me - baby with vomiting and diarrhea. I gave him orders for IV, admission, and antibiotics. Came up later on to see a woman with massive ascites from hepatorenal syndrome who'd just delivered a baby and had a hemoglobin of 6. Nursing was concerned because she was short of breath, oh and, Doctor? She refused to have any IV fluids. Called Becky on that one, got Erin. She approved of my plan A, which did not involve a paracentesis at 9pm. Got hit with two more gastroenteritis babies and then a man who fainted after his wife's delivery (blood pressure 85/45, pulse 50, carried into ER). I will note that the nurse told me to head on out, he could handle fainting. They handle a lot of things here that in the States would require a physician. It's quite nice. I only get called when they need my specialized skills. It took less getting used to than I would have thought; I know a lot of nurses back home who probably don't need me to tell them what to do 95% of the time, and I don't mind saying it.

Miriam requires Audio Adrenaline on the iPod now to go to sleep. My little rock and roll baby. She's been quite a handful at bedtimes these days, up and down a lot. I think the different environment really gets to her.

Back over to B ward to see the lady with hepatorenal syndrome twice more last night - low blood pressures, worsening pain. Wishing that there were a nephrologist or a GI doc or an ICU or something that I could punt to. Finally, I called the lab guy in from home at 4 in the morning to give a unit of blood. And they haven't called me back yet to tell me she died, so I guess it was the right thing to do.

Last Call: Halfway done

2009-06-29T06:44:00.000-04:00

Three days on "A" ward - pediatrics. Came in this morning and someone cleaned house over the weekend; at one point last week we had at least ten floor beds occupied - this morning started with five. And my first patient was this smiling cutie - Anita.
Anita has primary pulmonary tuberculosis and is finally well enough to go from the inpatient ward to the TB house. This is backwards - folks with TB start in the hospital and when they're no longer desperately ill, they go to the TB house until they're done with the daily medications, since the PNG requirement is directly observed therapy for at least the first month to 2 months. She's feeling great and full of beans, and tolerating her streptomycin regimen quite well. It's just a little too far for her to come to the hospital to get her medicine every day.
Anita's mother tried to have a conversation with me in tok pisin, and I sort of stumbled through it. We managed the basics, like 'where are you from' and 'I'm a doctor for moms and babies in America'. It was fun, and she was such a nice woman. I printed a copy of this picture out for her and brought it to the TB ward, and she hugged me.

Like most days here, it went sort of uphill and downhill from there. There were less kids on the floor, but it was still 11 before we finished rounding on the ward, and then one of Susan's little ones decided to try to die. Successfully, unfortunately, despite suction and CPR and 2 rounds of adrenaline. He'd been working on it all morning, with sats in the 50-75% range and some kind of illness we couldn't beat - platelet counts of 1 and 2, white counts not much higher. Maybe TB. Maybe something else entirely. We'll never know.
We took lunch after that; it was close enough to noon that nobody minded. Came back and saw patients from 1 to 5:30 PM.

I sent my first five or six patients to Xray for chest films; one of them was a man with no cough but shortness of breath for the last few months. He also had back pain. He'd been treated with prednisone and amoxicillin (they spell it amoxycillin here) and salbutamol, but hadn't really improved, and I didn't think the air on his right side was moving very well at all, so I wasn't really surprised when he came back with a big right-sided lobar consolidation. Off we went to ultrasound, with Steph's assistance, and produced some very nice images of a loculated pleural effusion that looked a whole lot like it might be TB.
At home, this is when I might have called the pulmonologist. Here, we sent him over to the ER and got out the thoracocentesis kit, and I pulled off 180 mL's of straw-colored pulmonary fluid with a big syringe. Then he got dizzy, so we stopped. Follow up Xray looked good, and lab confirmed a probable TB effusion, so he'll be starting TB medications tomorrow.

While we were in the ER, one of Becky's patients apparently rapidly metabolized his Valium. We use ketamine and valium for our conscious sedation procedures (I&D, minor surgery, D&C, that sort of thing) - it's a fast-acting dissociative anesthetic (related to PCP) that doesn't suppress respirations. The downside is that when it wears off, it induces hallucinations. Vivid hallucinations. Most of the time, this can be avoided by co-administering a benzodiazepine such as Valium with it - our usual practice is to always co-administer these in adults. Apparently, this particular patient didn't get enough Valium, because he was lying on his ER table with five men holding him down - one on each limb - thrashing and screaming in the midst of some kind of religious ecstasy. "JESUS! JEEEEEESUS!" He nearly thrashed himself and his handlers off the table, almost kicked out a window, and then calmed down a bit after a few more milligrams of Valium IV (two men on the arm, Becky with the needle ready). After that, there was no more thrashing, just the preaching. "Do YOU! Have a Heavenly Passport?!" Finally, one of the security guards answered one of his questions: "Do you know JESUS?!" "Yes." "That's the right answer, praise JEEEESUS!" And he settled down.
Mental note: Never skimp on the Valium.

Little Jesicka, to the left, is my other unfortunate chest X-ray patient from the day, and her story isn't nearly as entertaining. She's eight months old and has been treated several times for recurrent shortness of breath and coughing up blood. I couldn't tell if anyone had ever done any X-rays on her before; it seems almost inconceivable that they had because of what our X-ray showed. And there isn't always a machine available - even in Mount Hagen - and the notes are generally sparse. One note mentioned her features (which I kindly referred to as 'slightly dysmorphic'; they wrote 'mongoloid?') - the wide set eyes, slightly low ears, turned-down mouth and large tongue. She doesn't quite look like a Down Syndrome baby. But nobody, anywhere, mentioned her abdominal exam.
My note is sketchy; just-the-facts. 100% on room air, respiratory rate 60-70 breaths/minute, liver margin palpable at 1 cm below costal margin; very large spleen. It doesn't adequately portray my request for Susan-the-pediatrician to "please come check this baby out" or her frowning face as she palpated the firm mass on little Jesicka's left side. Feels rounded. Start with a chest X-ray.

Chest X-ray - here, a babygram; we use all the film we take - gave us more questions than answers. Why is her heart round and why is the border so hazy? Why is her stomach displaced? What are those curious shadows over her spleen and left side? Why is her right hemidiaphragm elevated? And are those little round things in her lungs vessels, or something far more sinister? Something is desperately wrong with this child's physiology. Susan nodded at me. Everyone had to look at "the strangest baby X-ray ever". Nobody knew what it meant, but everyone agreed: it was time for an ultrasound.
I didn't have the heart to charge 12 more kina for something that I was sure was going to be bad news. Furthermore, they were longwe patients who I was going to have to refer back to Mount Hagen for management, so I just called it a followup ultrasound on the chest X-ray and went for it without billing.
I laid the probe on her belly and scanned what I expected to find: liver, right kidney, bowel gas, and then awholebunchoffluid where no fluid should be. I tried to make sense of it, but couldn't; big cystic things full of fluid and debris without reference point, and Susan wasn't in her room. So I asked Scott to come in - showed him the X-ray, told him the story, and he frowned.
A few minutes later, ultrasound probe in hand, he was staring at the screen with the same solemn expression. That's not a spleen. Did you find a left kidney? I shook my head. I think this is it. We found her spleen, tucked up under her ribs, but half or more of her belly was occupied by what, under his guidance, revealed itself to be a multicystic structure with solid components. Maybe a nephroblastoma? I don't know. I thought they were solid. Neither did Jim, or Susan, but we all agreed on one thing: that has to come out. And then I had to explain it to Jesicka's mother, who thought maybe her little one just had pneumonia before we laid hands on her. I told her that sometimes this is cancer, and that I needed her to see a surgeon in Mount Hagen, that Dr. Jim thought there was someone there who would do the surgery. She nodded. "Jesus." It was an invocation. We prayed - for strength, for guidance, for the right surgeon's hands to be guided to the right place. Wednesday is surgery clinic day in Mount Hagen, so I wrote my referral note and gave it to her, told her to be there early in the morning. And I pray that someone there will look at it and understand.

Wilms' Tumor, or nephroblastoma, is the most common abdominal tumor in early childhood. A little research indicates to me that there is, in fact, a cystic variant (multilocular cystic nephroma) which looks on CT scan sort of what I imagine this kidney would look like, if there were a CT scanner in range. In the US, with nephrectomy and radiation therapy and chemotherapy, it has an 85-90% survival rate in Stage IV disease (assuming those really are lung metastases). I don't know here; I'll have to look at the Cancer Treatment in PNG book tomorrow. It's associated with several genetic syndromes, none of which quite exactly match Jesicka's abnormalities.
It frustrates me that I won't know the outcome; but I'm going to choose to believe that God does great and wonderful things, and that someday Jesicka will be just another PNG woman who only happens to have one kidney. What else can you do?

I will call to mind the deeds of the Lord;
   I will remember your wonders of old.
¹²I will meditate on all your work,
   and muse on your mighty deeds.
¹³Your way, O God, is holy.
   What god is so great as our God?
¹⁴You are the God who works wonders;
   you have displayed your might among the peoples.
¹⁵With your strong arm you redeemed your people,
   the descendants of Jacob and Joseph.
Psalm 77:11-15

Village Church Visiting

2009-06-28T19:08:00.002-04:00

Over at my study blog, I have some comments on our recent trip to a village church - cross-posting here.

This Sunday, we went to the village of Banin (we think that's the spelling) for worship. Pricilla, one of the clerks and translators for the hospital had invited Nykki and us out for worship. It was a sort (5-10 minute) drive down the highway to the village, only past a couple large potholes. The village was a collection of small houses, similar in construction to the church in the picture. (Roofs are either tin or thatched, but the walls were all a weaved siding.) We were greeted by the pastor and several others when we arrived, about 10-15 minutes early for the service.

Church began with the ringing of the "bell": an old, empty tank of the sort one might store pressurized gases. The service was led by Pricilla, who led us through some worship songs. A pair of other women in the church played guitar. Actually, most of the congregation was female, perhaps a half-dozen men, plus a few young boys being the only men present. (And they apparently asked if I wanted to preach.)

The church had posters and signs all along the walls. Some were from the Church of the Nazarene denomination, some were sign ups and schedules for who was doing what during worship, and others were home-made signs.

The music was vaguely familiar. There were more Tok Pisin songs here than at the church just off station, though there were a number of English songs as well. The songs also seemed to blend a number of familiar tunes into one song. One such song went from the chorus of "Power in the Blood of Jesus" to the chorus of the "Battle Hymn of the Republic" (with a few words changed). (It's also possible that I'm forgetting how some of the old hymns go.)

They had a time when they would share memorized scripture verses. One member would get up, give the citation. The congregation would repeat it. Then they would give the verse a line a time, the congregation repeating each line after them.(I'm not sure if this is particular to here, but I know I've not seen adults memorizing Scripture for a while when it wasn't part of a class.)

Other than those few things, it reminded me a lot of US worship. It seemed, perhaps, more communal, but a lot of that may also be that the whole village seemed to show up for worship, barring a few of the younger kids.Churches here are very local, each village having one of its own. And usually only one, as decisions tend to be group led. Thus, the village decides to join the church all at once. (See the baptism with 16+ people being baptized.)

The culture is very tribe-based, so there has been some dividing done on denominational lines. Most of the churches I've seen around here as we drove from one place to another were Nazarene. A few others exist: there's a Catholic mission up the hill next to us and a Lutheran church down one of the roads. But that said, most of this "tribe" around here seem to be Nazarene. Some of the literature around here seems to comment about how this may help continue tribal divisions, rather than try to bring the tribes more together.

I will say that everyone seems to be overly welcoming of guests into their church or tribe. If someone is an invited guest, a lot of the suspicion and mistrust seem to vanish. I've seen this when we go to church services and to the singsing the day before. Since Jonathan (our wasman, "watchman" or "guide") was with us and was part of one of the tribes in the singsing, we were welcome with open arms. I'm not sure how they would have greeted us had we just shown up. I know that Mt Hagen seemed particularly less welcoming, though that may be city verses village/town dynamics.

Anyway, before the service started, one of the women (I think Pricilla's aunt, but family relationships get blurred in villages, as everyone a certain age is a mama or papa) gave Nykki and Miriam each a meriblos, one of the traditional dresses. (Traditional at least since contact with Western cultures.) And as we were leaving, they gave us all the fruit off the altar (enough to fill to the brim a reusable shopping bag). The other missionaries tell me they do this every time one of them visit one of the small village churches. In all, a very rewarding experience.

Picture Post: The Sing-Sing

2009-06-27T08:19:00.000-04:00

Steph got the car today so we could go out and see some of the actual sing-sing. We packed up, loaded up the Tracker with Steph and Jonathan, Matt and Miriam and I, and set out down the road toward the river to see the goings-on. It was much busier today than it had been on Wednesday; truckloads of people being toted up and down a one-lane partially-gravelled road that apparently used to be the Highlands Highway. It was quite an adventure in itself, rocking precariously on the side of the road as another vehicle scraped by literally inches away sometimes, but one we weathered well. And the views were incredible.

At the place where we'd seen the dance rehearsal before, there were only a few scattered vendors and some folks sitting around, but two women were dressed except for their paint. They had beautiful headdresses, shell necklaces, and tree-kangaroo pelts on their chests. Jonathan had been given the charge of our printed out sing sing rehearsal pictures, and he distributed them to people so they could take them home. Then we rattled on down the road - and down and down and down.

Jonathan proved to be an excellent tour guide, directing us to the sights that were worth seeing - a structure built of bamboo and vegetables (which the locals were happy to pose on) that I suspect was for the actual exchange of cows later on, but nobody seemed quite clear on why they'd built the thing. I do know that it was something else to see a man in ceremonial garb and a flower-encrusted hat posing with fruit in classical style.
There were a number of beautiful floral decorations tied to the trees around this spot; the natural loveliness of the land is something its inhabitants know how to take advantage of. Decorating with fresh flowers takes on a whole new meaning.

Everywhere we got out of the Tracker people crowded around. We spent the first five minutes at any location shaking hands and exchanging greetings, letting women pinch Miriam's cheeks and rub her legs (someone always picked her up, and bless her adventurous spirit she was willing to be carried by total strangers), introducing ourselves and nodding that yes, we were going to take some pictures. I've been hugged and squeezed and shown around by more women whose names I don't even know today than, I think, ever before. It's a very friendly culture - and the fact that we came and wanted to know what was going on was a source of some evident pride. We stayed at a few little stops, enjoying the scenery.

Eventually, when one lane was more like three-quarters of a lane, we came to a field where the cows were grazing, just next to the primary school and basketball court (there's one in every village, I think). There was a stream where some of the folks were bathing (no pictures), and a swarm of pikinini who brought us a cassowary-feather hat to try on and posed for pictures. They seemed very interested in everything we were doing, and wanted to show off the cows. Miriam wasn't so certain about the cows, but she did get on fairly well with the children.

We turned around, then, and headed back up toward the general area where the sing-sing participants were gathering. Along the way, we encountered a lotu just getting out, so we climbed down a steep incline toward the river and watched the baptism. The pastor was very glad to have our attendance, even if Miriam did steal a tomato from the garden, and told us to come by later after the women had finished parceling out the meal, so we could have some of it. We thanked him graciously and continued on.
According to Jonathan, most of the Christians don't take part in the dressing up and dancing for a sing-sing. He doesn't find there's any biblical prohibition regarding it - they just don't. And in this little village it was fairly tranquil, with women preparing food and no bird-of-paradise feathers to be found.

We came back up to the little village where we'd watched the painting on Wednesday and encountered the girls from up the road, now with face paint - and several other folks all garbed up - and then we hiked a few hundred yards up the road to where all the shouting was taking place. There was a big circle of dancers all shaking their as-gras (I don't make these words up) and shouting something which Jonathan told us meant "We're going to get the cows" in tok ples. Their dance was something like a big group shuffle with plenty of hip shaking, which does exciting things to the as-gras, which is a giant tuft of leaves strapped on behind. It's a chaos of color and sound. Very exciting.

One man asked us to e-mail him a picture of himself - he was a student - so I got some good poses from him with his axe. Once upon a time, the axes were stone, but the waitskins came and brought steel with them, and now the axes are bought at stores. His headdress is an excellent example of decorating with pigeon breasts and bird-of-paradise feathers; there's a kina shell at his neck, and you can see pig's tusks on his necklace.
The loincloth in front also has meaning: each region has a different kind of coloring. We saw some women in long white fringey ones, as well as the Western Highlands black and white stripes. The Hagen folks had a different look as well.

We drove up to Jonathan's house, then, and stopped along the way at the village - the pastor had our food in plastic bags and wrapped in banana leaves to keep it warm - to pick up lunch. There was chicken and pork, cooking bananas (which are fairly bland and not at all sweet), and plenty of kaokao, all still warm from the stone-and-earthen ovens. Each of the four of us had our own individual plastic grocery bag of food, all jumbled together, and they provided four cans of soda as well. We ate with our fingers, out of the plastic bags, and were glad for the wet-wipes to clean up with first. Miriam mostly ate chicken and the cooking bananas, while the rest of us enjoyed our kaokao and meat. The leftovers went to Jonathan to save. He also had a tree-kangaroo in a cage, and got it out for us to see after we ate.

Refreshed, we headed to one of the meeting-up places. An old man greeted us, stalking up and down the pathway and yelling something I couldn't quite make out. There was a group of women in everyday clothing with as-gras and face paint and decorated headdresses dancing and chanting, and when one of them noticed my camera there was a flurry of lining up and turning. The dance got more interesting as everyone tried to make sure that my camera could see them. They stayed mostly in a circle. And then, beyond them, there was a group of men. When I got over there they were mostly just standing around, but the camera does seem to bring out the best in people, so everyone wanted to make sure they were seen in the picture.

And then someone broke out the Coke. There's something about watching a bunch of half-naked men in traditional garb and feather headdresses all swigging Coca-Cola that gave us the giggles. I can't blame them for wanting a drink - today was hot, bright and sunny without a drop of rain or hint of clouds; a lot of people were carrying umbrellas to protect against the tropical sunshine and I got a little dizzy from the heat and the dehydration once or twice myself. So we watched them drink their Coke, and then someone in one row started shaking his hips so the shells clattered together, and someone else stamped his feet, and the next thing we knew they were dancing and chanting once again, following a corkscrew pattern through the crowds (when a bunch of men come stomping at you, you move) like so many well-armed honeybees.

They danced, and the women danced, and there was a lot of singing and shouting that, after a while, starts to reach down into some primal place inside and make you want to dance and chant too, but we were heading back to the Tracker, since Miriam was getting pretty tired by this point - and then along the way we came across the adorable little guy on the right. He can't be more than two or three at the most, but he was holding on to a broad-leafed plant as if he owned the place, all dressed up in traditional garb, with his little pot belly hanging over his loincloth and paint and all. The man watching over him and the kids who were with him were just thrilled that we wanted to take his picture, but from his expression I'm not certain he liked the idea much. He stood for us anyway, though.

We were about to leave again and had actually gotten back to the Tracker, when there was a great deal of shouting coming from down the road, so we stopped and waited - and a whole group of folks from earlier came charging up the road, dancing and shouting, followed by the marching men with whistles who'd been putting on paint on Wednesday. There was nothing for it but to sit back and watch the scenery, since they were turning into the little clearing where we'd parked. Steph moved the Tracker out of their dance floor, and two groups of dancing men circulated for a while - long enough for the men and women we'd just seen to come down and join them in one big dancing, shouting, singing, noisy sequence. There was as-gras waving and feet stamping and feathers bobbing, and the crowds were shouting along. According to Jonathan, it was more of the same: "We're going to get the cows."

At one point, I found myself directly in the line of march, as the groups formed up and moved out back to the main road, so I scrambled up a little hillock with some sure-footed children and watched the excitement pass by with one eye glued to my camera. Everyone was very intent on their dancing and shouting - and there's something quite intimidating about a line of dancers with spears and axes coming straight at you. I wasn't quite sure if they'd move if I didn't, so I got out of the way.

We'd gotten the Tracker a hundred feet down the road, in the wake of the crowd following the dancers, when there was more shouting and singing, so we pulled over and I climbed out with my camera. An old man met me at the back door, and shook my hand, and asked if I was going to take pictures. I'm glad for my rudimentary tok pisin because it lets me understand old men - and so I told him that yes, I was going to take pictures, and he told me there was a line of dancers coming. I noticed. And when I got around to the front, it was Brother Robert and the dancing men from Wednesday coming down the road all painted and decorated, so we got to see them again. You'l notice their loincloths are a different print than some of the others - apparently, that's the Hagen cloth.

Once they'd passed (by now there was a string of five separate dancing groups, each with its own accompanying crowd, all shouting something different and heading down to (we presume) the place of the cow exchange, the road was finally clear. With Miriam dozing in the Tracker and the rest of us exhausted from sun and heat and the primal excitement of the whole thing, we headed back home to nap.

Coda: On Call

2009-06-27T06:10:00.000-04:00

Came in Thursday night to see a patient encephalopathic from liver disease, no longer responding. He was breathing and his vitals were stable. "He just won't wake up." I scanned him - some ascites, some nodular densities on the intestines, giant liver - declined to do a paracentesis (nowhere to put the needle), offered the family an NG tube dose of lactulose. I don't need a lab to tell me when someone is hyperammonemic. We talked for a while about hepatic encephalopathy, and with my limited skills I tried to explain that he was sleeping - not suffering - and that if we did nothing, he would eventually sleep until he died. He fought the NG. At 5 in the morning the ward called to ask if the family could take him home. Better now than paying for a car for a dead man. I gave the OK.

Our smallest NICU baby died yesterday morning. My exchange transfusion did nothing but hold her bilirubin at 30; I came in and looked at her, barely breathing, with an occasional gasp. All 775 grams of preterm infant, with nothing left to give. A fighter. I called her mother in and talked it over with her - do you want me to keep trying to breathe for her? She's just too small. And her mother shook her head. We knew, starting out, that this was an uphill battle, and she's an intelligent woman who understands that we've done everything we can. So I put in a stat call home to print out a picture of her for her mother, who sat and stared at it, and thanked me while I prayed for her baby to die without pain. Dear darling Baby of Dorin.

Spent my lunch hour on Friday researching oral methotrexate for choriocarcionoma and how to dose it, since our methotrexate tablets are in-date, while the newest methotrexate injectable we have is over 2 years out of date. Got some suggestions off the Internet. Wished I could just call up my friendly neighborhood gyn-onc doctor and ask him. Wished we had the right medication to begin with. There's leucovorin in the chemo fridge, at least - thanks to some anonymous donor who sent us their medicine after there was no longer need.

Got called up from home at the end of lunch time for another baby, "6 months, born at home", who was in respiratory arrest on arrival to the nursery. No spontaneous respiratory effort after being bagged the whole time it took me to go up to the nursery. He was very young - no creases to his feet, no descent of testicles, skin fragile and delicate. I estimated 28 weeks or so. I tried pushing epinephrine - after a quick recalculation of dose, we had only 1:1000 instead of 1:10,000 - and did compressions and used my Neonatal Resuscitation skills and accomplished nothing, in the end. Another baby too small and too late to come. Who knows if we could have done anything to begin with?

Came home to an email from someone I deeply respect, reminding me not to make technology my god: you well know that even WITH all our technology, we sometimes lose them [...] God's in charge and we may never know the why's... sometimes it's enough just to know he's there.....sometimes it's not....

And she's right. But it still hurts, here, knowing that maybe there's something more we could have done, somewhere else. I feel sometimes like the expression on the nursing students' faces when I tell them to stop a code - as if, somehow, they think I have the magic medication to save lives! and have been withholding it. And I wish I did.

On Call: Ups and downs

2009-06-25T06:55:00.000-04:00

Switched call with Susan - she took yesterday and I took today - so that I could go to the sing-sing practice yesterday. She got a car accident and didn't get home until 9 pm. So far I've been rocked gently from highs to lows.

The very smallest baby in the NICU - 775 grams the last weighing - has a bilirubin of nearly 30. We tried a bili light, but it's not a very good bili light, and the numbers climbed again today, so we decided to go for an exchange transfusion. (For the non-medically inclined, this means I draw off 10 mL of baby's blood and then put in 10 mL of donor blood; repeat until we've exchanged the estimated volume of blood in baby's body - hopefully replacing the bad blood with good.) It would have been much easier if the umbilical line hadn't stopped working this afternoon, so I did my best to do an exchange transfusion through a peripheral IV in the lower leg - the only IV we could start. Baby's not really stable enough to attempt a cutdown. We exchanged about 10% of the target volume before I could no longer draw blood off the IVsite, and then we gave up. There was really nothing else to do. So now we wait, and we check it again in the morning. Things don't look good for her.

This morning I did a D&C for an incomplete abortion, and hopefully I got everything out. There's always a crowd of nursing students around me so I try to teach them what I'm doing. They seem to be listening. With Susan's help (we spent a lot of time together today) I set a broken arm and casted it. Very exciting.

There's a little boy named Junior on A ward who fell into the fish pond today; he was breathing when they pulled him out, but nobody knows how long he was in there. He's pulling with every breath, lying quietly with eyes closed, and 89% on room air. We don't have a ventilator. I did a chest X-ray and he was already developing a little pneumonia. What he needs is a ventilator and blood gases and big gun medications. What he's getting is 1L by nasal cannula, a CBC, and chloramphenicol with flucloxacillin - and I prayed over him with the woman who brought him in, and told her to call his mother and have her come stay with her son. I'm very worried about him.

ER asked me to see a patient with acute abdominal pain; I laid hands on her and called backup Bill. "I think she has appendicitis." He came up and examined her as well, and nodded. We had Surgery in the room and getting her ready for the OR when the WBC came back at 26,000 (more than twice normal). Jim whistled. "That's a lot." It was quite satisfying to feel like I knew what I was doing - even if my first reflex was to send her to CT scan.
He just called: her appendix was gangrenous but not ruptured. "Perfect timing." What a relief.

I was about to leave when I got a call from A ward. "Baby arrested." And he had; a little asthmatic 6-month-old who'd been wheezing and gasping in the ER, was on theophylline and salbutamol nebulized treatments and steroids, who we'd considered giving magnesium to if he didn't improve soon, had just gotten to the ward when he stopped breathing. By the time I got there there was nothing to be done: pulseless and apneic, with his mother softly wailing over him. So I prayed with them, and she thanked me. I almost wish she hadn't; it just underscored how completely helpless we are here sometimes, without all our machines and our technology.

A generation goes, and a generation comes,
   but the earth remains for ever.
⁵The sun rises and the sun goes down,
   and hurries to the place where it rises.
⁶The wind blows to the south,
   and goes round to the north;
round and round goes the wind,
   and on its circuits the wind returns.
Ecclesiastes 1:4-6

Walked home from the ER tonight and saw a beautiful sunset. Had dinner, took a deep breath, and then went back in to see a patient who might or might not be in labor. She's having "small pains", second baby, previous C-section. She doesn't know why she had the section and she doesn't know why her baby died. It was all done in Hagen, though, so I asked her where she was from. Longwe - not from Jiwaka - and the OB ward has full beds. We talked. I told her she could pay extra money (longwe is 75 kina instead of 55 for a week of bed space, plus 185 kina instead of 110 for a C-section - for a total of about $60 for Jiwaka or $95 for longwe - imagine that as your hospital bill) and sleep on the floor, but that the best thing to do was for her to go to Mount Hagen to get her care. She took this quite well, and ultimately I gave her a shot of salbutamol and told her to go to Hagen if her pains recurred.
Driving back down to the house, the strangeness of the situation struck me. It's like telling a patient "You're not from this county, so we're going to charge you 50% more and also, since this isn't emergent, I think you should go back home, maybe in the morning." And (a) I just gave tocolytics to a patient at term in early labor and (b) I told her to go home and go somewhere else to get her surgery done, because we were full. I'm sure there's some kind of law in the States about doing that, but here it means that we don't have more patients than we can take care of with our limited resources.

There's another 10 hours left of call. I'm afraid of what more it may bring.

Picture Post: Sing-Sing Rehearsals

2009-06-24T03:22:00.001-04:00

Left the hospital after rounds this morning. I have to admit: it felt good to leave during a workday for once. It's intense here, with outpatient clinic every day, the never-ending stream of sick patients. The hospital is running over capacity on Medicine, Pediatrics, and OB - the floor beds are out, and we're low on those, so some people just bring their own mats to sleep on the floor with. I've admitted one or two children every single clinic here: vomiting and diarrhea or pneumonia or both, mainly. So I stepped around the mats and the beds and I admired all the babies and I found a bili light (it's tied to the top of the warmer) for the littlest baby and I got rounds done.
And then we loaded up the Tracker with me and Matt and Becky and Miriam and Lena's husband Jonathan and some other man - Anton - who came along too, and we headed out down the road - and up and down and up and down.

The occasion for this particular sing-sing appears to be the exchange of many cows from one tribe to another. Today, they were putting on makeup and rehearsing for the big exchange of cows and pigs on Saturday, so we got some behind-the-scenes shots of the preparations, as well as being included in the circle dancing.

At our first stop, they told us they "weren't ready yet" so Becky asked if they minded if we watched them prepare. They didn't mind. Miriam hopped out of the Tracker and into the arms of a local woman she'd never met before. She's such an ambassador - nobody can resist her smile. And we thought we were going to have problems keeping an eye on her...
So we trekked off through the kaokao fields and past crops of peanuts and corn to a few little houses where men wearing fancy headdresses were getting their faces painted. Miriam made friends with the local children, and was much admired by the elder women as well. Light-skinned children are popular here, it seems. She tolerated being touched and having her arms and legs rubbed without any complaint.

After a while, we were told that antap there was a whole group of people who were dressed, painted, and ready to practice some singsing dancing, so we headed up the road a way, and we heard them before we saw them. They were marching in a circle, accompanied by whistles, and chanting. According to the translation given to Becky by our guides, the chanting meant "Look at me!" They danced around for a while, and then our picture-taking got their attention.

Brother Robert, the bigman of the group - and, if I understood correctly, the one who'll be receiving the cows on Saturday, stopped to talk with us about the singsing and to ask if we wanted to come back on Saturday (and if we did, could we bring some of the pictures?) After some questioning about the whole process, he and his retinue admitted that "once upon a time" a very long time ago, the singsing might have had something to do with spirits - but he was quick to tell us that since "the government" and the missionaries came to the Highlands, that now it was simply for celebration and cultural reasons. I suspect that our being missionaries may have had something to do with his not wanting to discuss the history of the event, but I'm not certain.

We watched them dance and shout for a while, and a great spectacle it was indeed! The boy in the picture above was the only child in the entourage, but some of the children nearby had painted designs on their faces as well. They shared a marble with Miriam, and left paint-marks on her arm. She had a lovely time. There was also one woman with paint and headdress, dancing at the end of the line. She had on the same garb as the men, only she was wearing a shirt and knee-length shorts underneath it. We didn't have a chance to ask whether she had a particular role.

The dancers graciously agreed to pose for pictures with us, and then insisted that they had another dance that they wanted to show us before we went. So they brought Becky into the middle of a circle, and linked elbows around her, and then jumped up and down, moving counterclockwise, and shouted. There was a lot of shouting.

After they shouted at Becky for a while, then they wanted Matt and I to stand in the circle. They gave me the spear that the man on the left was holding to hold - I'm still not sure why - but they seemed to appreciate our participation. There was a whole lot of handshaking and a long speech by Brother Robert about how exciting and "cultural" the actual cow-exchanging on Saturday would be, and how he would be very pleased if we came. There would be plenty of food for us and more dancing. And if we wanted to come back tomorrow, we would be welcome as well for more practicing, because they're celebrating all week long. He seemed very happy that we were there.

Miriam caused some amusement among the kids when, after the circle dance, she took one of the bamboo rods that the dancers had discarded and did her own dance with it. There was much amusement, and we took our leave. Becky's on call Friday so she can't go Saturday, but she promised to tok save to the other missionaries about Saturday's cow-exchanging ceremony, and if we can find someone to take us we'll head back up there.

Matt has video of the dancing; once we have some Internet stability we'll post it so as to make the above bits about shouting quite clear.

Another Technical Day

2009-06-23T01:54:00.002-04:00

Spent today in the Tech Center, a couple of rooms filled with the servers and spare parts from the station. The server room is usually slightly warm and stuffy (the A/C is out, but ambient temp in the room is likely about 80, maybe mid 80s). The room attached to it with a number of spare parts (as well as the Big Ultrasound Machine) manages to stay cooler than more or less anywhere else on station. I'm just not sure how.

Today, I gained access to the station firewall/gateway/packet shaper. Mostly, so that I can show Scott how to reset usernames/passwords as needed. However, I also get to look around and see if I can find a better way help filter traffic. I think I might have already done so, but I'm not 100% sure yet. We'll see if the changes I made help. (They seem to be, but I can't tell if that's just because I'm the only one on the web right now or because I moved http(s) traffic to have its own (sizable) chunk of bandwidth.)

Tomorrow, we go to a singsing, or at least a practice day for it. (I think. Lena says she -thinks- the man in charge of this whole thing is going to be there for a practice tomorrow. The actual singsing is Saturday.)

What is a singsing? It's a traditional feast/dance/party/thing where one village gives gift(s) to another. The culture here has a -lot- of gift giving built into it. Basically, whenever you have extra, you give it away. (And it's understood that the people you give it too will give you something if you need it and they can.)

God's Country

2009-06-22T07:11:00.000-04:00

You visit the earth and water it,

you greatly enrich it;

the river of God is full of water;

you provide the people with grain,

for so you have prepared it.

You water its furrows abundantly,

settling its ridges,

softening it with showers,

and blessing its growth.

You crown the year with your bounty;

your wagon tracks overflow with richness.

The pastures of the wilderness overflow,

the hills gird themselves with joy,

the meadows clothe themselves with flocks,

the valleys deck themselves with grain,

they shout and sing together for joy.

Psalms 65:9-13

The picture at the top is taken from the mountain where the baptism took place. Our station is a tiny little white spot down in the valley. I can't even describe the incredible beauty of the Waghi valley - like God left a thumbprint on the earth, that can't help but burst forth with fruit. And such fruit! The land around here is rich with pineapple and banana and oranges; we get lemons from the tree down the road - pick them or they rot on the ground from such quantity - there are coconuts and beans and coffee and tea and sweet potatoes and onions...

We walked down to the market on Saturday after getting back from the baptism - outside the station by ourselves. It seems such a small and trivial thing, but it was meaningful to us. We went and bought pineapple and toilet paper and raspberry jam, looked at the kaokao (sweet potatoes) and the unidentifiable greens, bemoaned the lack of carrots and peppers, stumbled into the buoi-and-cigarettes section and back out, and walked home past the folks selling peanuts and grilled meats along the path, sipping Coke Zero and feeling very proud that we didn't need someone to walk with us.

It's dry season right now, or as we've heard it dubbed, "Less wet season". It rains almost every day - sometimes, just a gentle drizzle. Most of the time it's a pounding storm. Last night, the VSAT went out for hours - and just as Matt was getting called about it, the power went out too. We get some great rains, with mud rivers in the road and waterfalls of water into the rain cistern (if it rains, I don't feel guilty about taking a shower). The other day, we caught a rainbow across the sky. I got a few pictures before it faded, and incidentally discovered that the circular polarizer filter on my camera lens is capable of polarizing the rainbow right out of existence. It was an entertaining little physics lesson, really.

I'm finding it difficult to believe that next Thursday (the 2nd) we'll be getting back on an airplane and heading to Australia for a few days' R&R - and then back to the US. It seems like we just got here. I'm finally starting to feel like I'm something more than a burden on the rest of the station medical staff. Sister Sylvia today complimented my tok pisin and said she was very impressed at how much I've learned. I can manage basic rounds in the OB ward on my own, I did a C-section today with only a nursing student and a new scrub nurse for assistants (and she didn't bleed all over the place), and I can handle basic things in the OPD. I'm keeping Priscilla-the-translator though.

The 25-week baby is still breathing; I started feeds (sugar water) down the NG tube this morning. She weighs 800 grams and cries when I unwrap her for examinations. I keep praying, although I know the end is hardly likely to be good. Scott says he had a baby like this once who lived for three weeks, until every bit of reserve was used up. I keep praying. What other medicine do I have?
We've been out of betamethasone for a while, so I've been using dexamethasone instead. Today I was told we're out of injectable dexamethasone too, so we're using orals instead. I don't know what the data says on effectiveness, but I guess I'm thinking oral has to be better than nothing at all. My diagnostic criteria for giving steroids here are simple: patient-reported contractions and an ultrasound age of 34 weeks or less. The cervical check is a nice addendum if I get it. A different world. We give Cytotec here and check fetal heart tones every 30 minutes. There's no such thing as continuous monitoring, NST's, or internal monitors. If I want to know about contractions I get a nursing student to sit by the bedside with a piece of paper and a stopwatch, recording palpation, duration, and time of onset of contractions.
A new baby got delivered today to a mother whose HIV test on admission came back positive - she was essentially delivering when we got the news; not the best time for a C-section then. "All the medicines were started." At least we have plenty of HAART medications around here, and there's a standard protocol for what to give to babies.

Only saw a few patients in the clinic today: recheck for high blood pressure, kid with chronic cough and room air sats of 85% (pneumonia), and the girl with no periods. Her TSH is normal: 1.7. Her blood sugar is normal.
I put her back on the ultrasound machine. I still couldn't find a uterus. Scott couldn't find a uterus, although he found something that might be a very small one. What she needs is a list of endocrine tests with long names involving words like "stimulation", maybe a CT scan, a genetic study to see if she's really a male or what. We talked it over, Scott and Jim and I, whether we set her up with Surgery for an exploratory laparotomy where we cut her open and see what's inside (suppose she's a genetic male with androgen insensitivity; she might have undescended testicles which could become cancerous later) or put her to sleep to do a vaginal exam (is there a cervix?) or tell her to go to a private endocrine clinic in Port Moresby, where they can send lab work to Australia. She'd need to raise 1000 kina for testing, plus 600 for a CT scan, plus airfare from Mount Hagen to Port Moresby (and remember, only one airline flies from Hagen to Moresby, so imagine the prices), just to find out if she's really a girl.
And suppose she's not? That kind of revelation would be difficult at best for a well-adjusted Western woman living in a culture inundated with sexual liberalism. For a New Guinean girl in a culture of carefully defined gender identities and roles, I'm not certain it could be truly comprehended. We gave her the option of going; Scott told her that if she wanted to spend the money he'd arrange the referrals. What we didn't do was explain the complex genetic concerns of androgen insensitivity and genotype/phenotype mismatch. And for now, I wrote for three months of oral contraceptives, under the idea that if we give her a progesterone withdrawal bleed at least it's evidence that there's a uterus in there somewhere.
Scott did a very nice job of explaining to her our general concerns: that sometimes the bokis pikinini doesn't grow correctly, and sometimes not at all. That the body sometimes makes marasin called hormones that don't always work right. That we weren't sure if she would ever have periods or be able to have children. That there were some very expensive and complicated tests that could be done in Moresby, should she desire. That we would try and treat her here as best we could. And that once, we were perfect creatures created without flaws, but that no longer was that true - that our bodies were imperfect and didn't always work the way they should. Some people have high blood pressure. Diabetes. You have something wrong with your bokis pikanini. It's not something you did wrong. It's just the way your body is. We're not perfect.
I wonder what will happen to her.

Sunday morning

2009-06-20T18:08:00.000-04:00

He left that place and entered their synagogue; ¹⁰a man was there with a withered hand, and they asked him, ‘Is it lawful to cure on the sabbath?’ so that they might accuse him. ¹¹He said to them, ‘Suppose one of you has only one sheep and it falls into a pit on the sabbath; will you not lay hold of it and lift it out? ¹²How much more valuable is a human being than a sheep! So it is lawful to do good on the sabbath.’ ¹³Then he said to the man, ‘Stretch out your hand.’ He stretched it out, and it was restored, as sound as the other.
Matthew 12:9-13

Told Carol I would be her C-section backup Saturday, in case she needed one. Reserved the right to go and do Interesting Things, and so arrangements were made to go to the baptism that Angel covered in the last post. I'd more or less forgotten about the whole thing until the phone rang at 5 AM.
Primigravida with prolonged rupture, pushing for 3 or 4 hours now, no progress, stuck at +2 station and the decision's been made to go to section. I called Jim. He said you'd be willing. Of course I am, and at 6:15 we're cruising up to the hospital in the Tracker, changing and scrubbing.
It's a little bit different here, when I look up at my assistant and realize she's not an obstetrician and I can't hand the section over to her at the first sign of an obstacle. It makes me take a deep breath and try just a little bit harder. Makes it real. And everything went just fine, even the bit where I was up to my elbow in the incision levering the baby out. It came eventually, just like they always tell me it will.

I'm learning a lot here - and more than just medicine.

Going up to the Mountaintop

2009-06-20T09:58:00.002-04:00

Today, we went to the mountaintop village of Konduk (/KOHN dook/) for a baptism there. We were told it'd be about an hour's walk up the mountain, but we had enough people going that we took one of the Landrovers instead. I'm glad we did, as the road started as a very uneven stone road and then we turned off it onto a dirt road. You can see one of the wooden bridges to the right. Some of the group decided to walk over the bridges rather than ride. I'm not entirely sure I blame them for that, as it was an interesting ride.

When we got there, they were doing a worship service before the actual baptisms. They had several people being baptized today, I believe I heard the number 16, but I'll admit I didn't get a full count. (And some were rededications, and just gave testimony, but more on that later.) It seems one of the elders in the church had recently died of leukemia and that death moved a number of his family to come to the church. The service was in the middle, though its order seemed similar to the Sunday services I've been to here (and elsewhere, to some extent, though I found similarities in worship services in Shinto shrines). They were singing English worship songs, some of which I knew or were similar enough to ones I knew. The spoken parts were a mixture of Tok Pisin and tok ples, that is one of the local languages. In the image, those in white tops and black pants or skirts were the baptisees. The congregation sat in two sides, the left side had most (all but one or two) of the men and a few women, the right was nearly all female. I'm not sure if it's a conscious decision to sit as such, the missionaries do not follow this tradition if it is one.

There was a sermon that I could almost follow in Tok Pisin in places, and then it would switch, I assume to the tok ples and I would be lost for a moment. It was on Matthew 4 and fighting agianst the temptations of Satan, even after baptism. When the sermon finished, we walked further up the hill, past where they were preparing the traditional Papuan feast in a mumu, an oven dug into the dirt, filled with hot rocks and then the food (pork) being cooked and covered with earth, straw and leaves. (See right.)

Up the hill, and past some of the town gardens was where they had dammed up a part of a stream (or it might have been a drainage ditch, or a wadi that only filled when it rained) as the baptismal font. They had thrown flower petals into the water. (This seems to be a tradition here with major events. The missionaries throw flowers for those leaving for extended periods or when they're leaving at the end of their terms. I suspect the missionaries adopted it from the locals, not vice-versa.) The area around the font was hilly and uneven (and muddy, as even in the dry season that the country is in now, it rains nearly daily). Yet, despite the lack of good views, it seems most of the village and likely several from nearby (such as ourselves) had turned out for the baptism. Thus, it was a bit crowded and the footing unstable in places, but everyone seemed helpful in getting through the bad parts and helping us to get a good view.

There was a second sermon here, this time from a woman preacher, which I found striking as almost all the rest of the church leadership I have witnessed here has been male. She preached mostly in tok ples, so I could follow very little of it, save for a few Pisin words that had made their way into it. During her scripture reading, someone read the the Scripture in Tok Pisin first, then she gave it in tok ples, a verse at a time.

What followed were the baptisms. One at a time, they came forward and gave a testimony. Some were rededicating their lives to the church, and thus didn't get immersed, but the others did go in and were immersed in what I can only assume was a cold mountain stream.

A bit of a side note: They are very unaware of the American culture behind a good bit of their clothing. A large amount of the clothing in Papua New Guinea is second hand from Australia and other Western nations. As you can see on the right, one of the elders doing the baptism has a South Park tie, and I will admit while I am fairly liberal in my faith, I am not certain I would wear that tie to a baptism in the US. Simiarly, there was a young man wearing a t-shirt for MTV's Jackass, with the title for the series prominently displayed on the front of the shirt. I doubt that the people here know the culture that these things represent. There was the knowledge that this is the sort of even that one wears a tie to, and I suspect there are not a large number of ties available. (And I doubt that South Park is well known here.)

As Miriam was getting a bit tired, we left about halfway through the immersions. On the way back to the car we did see them taking the pork out of the oven and getting ready for the feast. The natives here feast often, as food is usually abundant.

One other note, we did see the grave of the village and church elder who had died. He wanted to be buried near the church (it's the brown building in the background). This is the traditional grave for those who can afford it here. (Or those who are important enough that their families feel they should spend the money on such grave sites.) Inside the small house is the coffin, above ground, surrounded by flowers. I have seen other such graves along the roads here, both the stone and dirt roads up the mountain and the main road back into Mt Hagen. This is the traditional way to bury Big Men, that is civic leaders. (I need to ask how long the graves stay like this, as I have not seen more than one or two in a village.)

In all, a very interesting day.

x-posted to Lainim long Hailans

A different world: the NICU

2009-06-19T09:30:00.001-04:00

This is our emergency and procedure room. You're seeing the entirety of it right there: four beds, one semi-private space for pelvic exams (although I've tried; you can't actually do a pelvic in it unless you're Houdini), and a nurses' counter. For all minor procedures like I&D's and joint taps and lumbar punctures, you go to the ER, since that's the best space in the hospital to work. I used it on call night to do an LP on a new baby, who was born fine and then tried to stop breathing on the Health Center folks, so they sent him to us. He's been all right ever since then, although trying to get anything done around here is an adventure in creative thinking. Eventually, I scooped the baby up in his blanket and carried him down to the ER, commandeered a table without asking, told the nurse I was doing an LP and could she get me supplies now please, shanghaied a security guard into holding him for me, swabbed and tapped and bandaged and thanked everyone, then carried him back and deposited him in the warmer with his warmer-mate, who's doing quite well. Since then, he's done just fine.

The other new baby night before last didn't do so well: born at home at about 6 months' gestational age and brought in at 1075 gm, he was just too small to survive. Our threshold here, if you're wondering, is 1kg and 28 weeks - no baby smaller or younger has made it home yet, and the kilo kids don't have a great rate. As I've said before, we don't have any surfactant, or ventilators, or anything more than one neonatal bag-valve-mask arrangement, some antibiotics and theophylline, and a selection of IV fluids. He came in at 6 PM and at 2 AM I was bagging him with the nurses and listening to his heartbeat slow and dwindle, feeling sick and helpless. There were agonal respirations every now and then, great gasping breaths involving his whole body, but after a while he stopped doing that, and then I put my stethoscope on his chest and heard nothing, and I shook my head at the nurse. "Stop."

And then I turned around and they needed me in the delivery room for a breech fetal demise, and I will never be able to forget the look of the grey thing that was delivered there, shaped like a baby, but also like the very essence of death, skin stretched over bones still soft and deformable, face expressionless and bland, flesh peeling back from the skull. It - he - looked as if he had come directly from the crypt. I didn't know what to do - nobody seemed to, really - so we cut the cord and wrapped it up like a baby, and when I left the room the nurses were explaining to the poor mother that her baby had been dead a long time, and that she could see it if she wanted.

So I didn't sleep well, after getting home at 2:30 AM, and I don't know that anyone could have, but there is no postcall day off in the Real World.and so I was back in at 8 doing rounds. And I stopped in on the patient with the placenta previa - we admitted her for bedrest and monitoring, but she wouldn't stay, she went home and came back the next day - my call day - after making some arrangements at home or doing whatever it was that was more important than maybe bleeding to death or having her baby die. Nobody had much hope that baby was going to live in any case: not at 25 weeks, not here, but we started steroids and IV fluids and got her family to come and donate blood so there would be blood in the bank for her, and ordered a type and cross (everyone is Rh-positive here) of two units.

Saw her in the morning, CBC got done at least, but nobody knew where it was. She said she was still bleeding. I gathered an army of student nurses around me and gave an impromptu lecture on placenta previa and vasa previa and why it was absolutely vitally important that they monitor her bleeding closely. Everyone was impressed with my drawing of a uterus, and they all looked very serious while I talked. Around 3 or so the nurses came and found me. "She's bleeding a lot." 2 pads an hour for 2 hours, then 1 pad in 2 hours. And I finally found her morning CBC: 6.7, down from 11 the day before. And I went to get someone who knew more than I did.

They did her C-section around 6 last night, with mom still bleeding a lot and blood bank seeming to not understand what "stat" means on a type and cross, delivered a baby that we still haven't weighed, because every time she comes off of oxygen she tries to die - estimated around 700-750 grams. One knee is bent all oddly because of the oligohydramnios. I didn't feed her, but we gave her IV fluids after Susan put an umbilical line in, and she's on all the medicines we have for tiny babies. And when I left this afternoon she still was pink and struggling, but I imagine that my "very early baby row" in the nursery will only have two babies when I get back on Monday. And I wish it weren't so.

It hasn't all been dying babies - it just seems like it sometimes. I'm more than a little emotionally exhausted by B ward all the time, but I find I still love what I do. And I finished my Friday with a C-section with Steph that went stunningly well, and I feel good about that.

Today I did a morning conference about TB which went quite well, and I learned a lot in the preparing of, and then I rounded on everyone and went to OPD for the day. Saw several very interesting cases:

This very nice 17-year-old girl has never had a period. She came with a primary complaint of generalized malaise which has forced her to miss enough school this year that she wants to repeat the 12th grade (apparently, this is common because there's no help to catch up). The primary amenorrhea was a "by the way" mention by her mother, who thought it odd that her eldest daughter was behind the youngers. And then the plot thickens: I go to do a basic examination and note the complete lack of secondary sexual characteristics - no breasts, no pubic hair. She can't tolerate much of a pelvic - only enough for me to determine that there's no imperforate hymen - so we went to ultrasound and I pulled Becky in and we could not find a uterus. We have a very limited set of available labs here: I got a sodium (147) and a potassium (5.2) and a blood pressure (120/80) and a CBC (normal). I've ordered the only hypothalamic-pituitary axis lab I can - a TSH - and I'll find out Monday if it shows up abnormal. I can't do any of the sex hormone studies or genetics that are recommended to rule out CAH or 17-hydroxylase deficiency. I could possibly do a bone age if that would be very helpful, but it would be expensive, and I've already charged this girl a lot of money. I'm going to re-scan for a uterus on Monday when the TSH comes back, I think - and look at the kidneys and try to see adrenals. We'll see where it goes.

This little guy came in on Wednesday with a horrible conjunctivitis and respiratory bug - his eye was swollen and glued shut with pus, so that I could barely peel it open to see the inflamed conjunctiva. Exam showed a preauricular node, but unilateral conjunctivitis that oozed pus constantly, so he got gatifloxacin eye drops and oral antibiotics and a "CSI" - a "skip the line and come see me" card for today. Eye is doing much better, decreased discharge, but his mother noticed a "white spot" on his eye - showing here to the right.

It looks like a bacterial keratitis - apparently more common in the tropics, according to the book I had - so he got an additional dose of Tobradex (with fear and trembling, but the book said to add steroids after 2 days of antibiotics) and a referral pass to go straight to Hagen to the eye doctor, today. I hope I find out the end of the story.

And number three in the series is the girl who fell and hit her knee a year ago, but whose knee effusion has never quite gone down. I got a CBC, and a sed rate (both of which weren't done last I tried to get them) and an X-ray and went to tap her knee. I got nothing on the tap, but the X-ray gave the diagnosis. She'll be back on Monday for admission to have her chronic osteomyelitis debrided - and that big sequestrum behind her knee drained and scraped.

I don't have a picture of the woman who got hit in the breast a week ago and has since developed a suppurating abscess of the entire upper breast (I winced) or of the man with the gangrenous pinky who came in with it wrapped in leaves, but it was a fabulous day for pus. The stuff is literally everywhere. I'm amazed at the number and severity of infections that we see every day - things that are beyond rare in the States. And I'm still learning what gets admitted and debrided versus not.

Never a dull moment...

2009-06-16T04:59:00.001-04:00

This morning Baby of Rose had developed seizures overnight. Nursing tells me we have phenobarb somewhere, but when I opened the drawers of medicines I could only find phenytoin. Also, they use paraldehyde here which I'm not familiar with, like so many other medicines. Started her on phenytoin because we had it, and Becky had already started antibiotics. Contemplated lumbar puncture but treatment would be the same regardless, since I don't trust a pretermer not to be septic. We can't measure phenytoin levels around here, so I went low and will see how she does. So far so good.
Got called for a retained placenta after lunch, came up and by the time I got there (it's a 5-10 minute walk) Sister was standing at the bedside. "I got it out. I solved my own problem. But she's bleeding." So I gloved up and gowned up (after I'd already leaned against the bed and gotten blood down my leg) and dug out a piece of placenta with my fingers while waiting for a ring forceps, and she stopped bleeding before I had to ask for a banjo curette. She has a small tear. "That's what students are for." So I scrubbed out and got on with doing other things, which mostly meant trying to escape and go home to change my skirt, since the sensation of wet blood slapping my bare thigh was really quite icky.

I am, apparently, "a good sonographer" as such things go around here. Picked up the book on ER and critical care ultrasound that was in the doctors' office to help sharpen my skills. I get called to look at uteruses with people a lot, and I no longer feel badly about asking others to help. I can identify normal and abnormal liver architecture, gallstones (found one!), normal kidneys, free fluid in the abdomen, a normal spleen, and I've done a few subxiphoid windows of the heart as well.
Today, I got handed a book. "Here, it's a threatened AB, you see this one." And off we went to take a look. 16w fetus, 1.3x4.25cm subchorionic hemorrhage, the whole placenta looking a little ratty. I wrote a long list of instructions: no lifting heavy things. No sex. No walking or standing a lot. Come back in 4 weeks. And we prayed with her, because what else can you do?
Stayed to watch Scott sono a patient with a complete previa, possible vasa previa, 2cm of amniotic fluid. Bleeding "big clots". 25 weeks. Our minimum survival threshold here is about 28 weeks and a kilogram - and what do you do? Bed rest, fluids, and prayer. I know what would happen at home - I can almost hear the voice of MFM ordering me to "cut her as soon as she bleeds more". Cord dopplers. Fetal growth assessments. NICU consults. All the things we don't have.
It was a good day for sonography: saw a woman with a 12x15cm abdominopelvic cystic mass. She looks 20 weeks pregnant. She's also from Hagen, so back she went for her surgical consult; Jim has his hands full just with Jiwaka. We're suspecting an ovarian cystadenoma.

Women here carry their babies in big bilum, which are basically mesh bags. It's sort of surreal to see these well-padded bulky bags being toted around everywhere and knowing that there are new babies in them, but there's usually a few layers of blanket under and around the child. That's the other thing: it's winter here. It's like 70 out most of the day, and people are walking around wearing coats. I'm sweating. They keep their babies well wrapped, even if they are in bags carried across the forehead. Seen to the right is one such bilum baby in her blankets and the bag around her. She's getting ready to go home, five days after a C-section, since that's the usual time we keep women. Vaginal deliveries go home the next day.

Home by 5 today; tomorrow is a call day and then no more for a week. I'll appreciate that - and the free weekend coming up. Need to ask about the sing-sing that might be going on this week, and see if I can get a half-day to go to it. I would like to go to a sing-sing very much. I'd like to get off station this weekend too, see some more of the Highlands, so may ask around for places to go walking. It's only three days away - but seems like forever.

I keep meaning to talk about tok pisin in a less scholarly way. It's such a curious language - and it is a language, for certain - but it has many roots in Aussie slang, so for a nupela speaker it's fraught with unintentionally funny words. I spend a lot of time trying to manage to say pispis without giggling, and the word for 'broken' is bagarap, pronounced 'bugger up'. This leads to things like Scru bilong yu, em i bagarap, which means 'your joint is broken/injured' but takes a great deal of practice to not feel a little awkward saying to a little old lady. I can't read the sign on the lawn quite yet, but I can get by with basic questions in the exam room: Yu gat skin hat [fever]? Traut [vomiting]? Pekpek wara [diarrhea]? Blut [bleeding]? Kus [cough]? Yu gat pen? Long wea? [Pain? Where?]. As long as the answers aren't too complicated, I can mostly understand them, too. Today, a man was asking my translator a long complicated question. She turned to me to explain, but didn't have to. "Yes, she can breastfeed now that she's stopped the antibiotics." It was a great moment. About the time I head home - which is in 2 and a half weeks already - I figure I'll have the hang of the basic tongue. Then I'll have to come home and remember English again.

We're out of chloramphenicol (CMP) tablets - which is our staple antibiotic for typhoid, osteomyelitis, pneumonia, some cases of meningitis, postpartum endometritis, and sepsis. I'm using Cipro or Omnicef instead, since we have plenty of those for now. CMP isn't even manufactured orally in the US because of its aplastic anemia side effects; here it's used for everything. At least we have IV still for surgical prophylaxis. We're also out of IV fluids, as previously noted, but they picked up some in town and out of the donation boxes so we're surviving. Today, I made D10-1/4 NS by mixing D10W with hypertonic saline (75 mL 3% saline to 1L D10W) and we gave that to my babies.

There's a N/S (nil stock) list on the whiteboard by the wards. As of Sunday, it had the following: CMP caps, All IV fluids, ephedrine injection, nystatin suspension, clear plaster, Keflex 250 mg tabs, Augmentin tabs, digoxin pediatric suspension, avelox 400mg, CMP suspension, flucloxacillin caps, dicloxacillin caps, morphine 20 mg/ml suspension, Intracath-20 (20-gauge IV catheters), some kind of inhaled solution I can't identify (looks like 'nunab'), Reglan injection, gentamicin 80mg/mL, flucloxacillin injection, pethidine 50 and 100mg IM injectables, Phenergan injection, azactam injection, and Decadron.
This isn't a world I'm used to living in. It's very strange, to be told "we don't have Reglan". We also don't have oral salbutamol (albuterol), except for the bottles Erin hid back; there are only a few inhalers and nobody uses them right around here. We don't, apparently, have clindamycin except as an outpatient medication and last time I tried to order Dilantin I wound up raiding the donated medications until I found a bottle of 100mg caps, since all we had was 30/5 suspension. And I don't think we have any Solumedrol because nobody knows what I'm talking about when I write for it.

Miriam has the Tupperware out to catch bugs with, now that I've shown her how to do it. It's very cute. We're headed out for an early-evening walk to deliver the Tracker to Carol for her call, now.

Technical Difficulties

2009-06-15T07:28:00.002-04:00

So, this afternoon was an IT afternoon. Found the AV software that had been lost and installed it (and the remote management software) onto the server. (Also copied the files from the CD there should the CDs go walking again.) And then started the old AV software uninstalling. When that came up and said it was going to take 120 minutes we decided to go look at the cabling for one of the houses that has been without internet for over a year or so.

We get to the house and go around back where the cable comes out of the ground. Let's see if you can tell me what's wrong (or at least what might be the problem) from a couple pictures:

And let's get you a close up:

Having seen this, I hacked off the ends of both RJ-45 plugs. I tried simply splicing the cables together, but that didn't work. So I recrimped both ends exactly as they were before, as that had worked sometime in the past. (Even though the cable from the ground had only the orange and green pairs in its plug. The blue was just loose and the brown I think might be used for their phone connection.) Once we made sure that the connection was good with the coupler back in place, we wrapped the whole thing in eletrical tape to give it some sort of protection.

Oh, and taped it up to the underside of the house in hopes that will keep it out of the dirt. And mud. And water.

(There was a spiget not 2 feet away and the gutter above this area had rusted through.)

A different world: The C-section that wasn't

2009-06-15T05:08:00.000-04:00

Pretty evening tonight after a beautifully sunny day - with the rain and the clouds and the part-sun still out. A few more stories from call, and today. I slept from about 1:30 am until almost time for devotions at 7:30 this morning, and a welcome sleep it was. That's our guest house on the right of the picture, with the porch that has clotheslines strung under it for the rainy season. It's raining; a fine misty drizzle, and the evening sun is behind me - over the mountains.

Dinner was fresh-grilled pineapple and pork and brown rice and baby carrots in margarine and brown sugar. And the rest of the pineapple was eaten fresh. Miriam and I picked lemons off the tree (and the ground around it, which is where ripe lemons are found) and we made lemonade. Had the feeling that maybe I was being reminded of the delicate wonder of creation. It's been an up-and-down few days.

Last night after a quiet afternoon I got a call around dinnertime - "I've got two ladies here, I need you to see them." So I loaded up the Tracker and headed up to the hospital. Patient is a G3P2 with 2 previous c-sections, complains of contractions every 4-5 minutes. I scan her for dates - 38+3 by LMP and 37+3 by my ultrasound, pretty good dating for around here. She's not really contracting while I'm in there, and it's after hours. I call Susan. We talk about it for a bit. We decide to do the C-section...and then she calls back. "You know..."
I want to do this with you, but it's not really cost-effective to bring in the on call staff for a non-emergent c-section...is she really in labor? And the answer is "not really", honestly. Her contractions are spacing out, she doesn't look all that uncomfortable. And so we put the patient on subcutaneous salbutamol (that's albuterol, for the US folks) because there's no such thing as terbutaline here, and they're all the same thing really, and I wrote orders for it to be given every 6 hours and to prep her for a morning c-section, and I went home.
This morning was devotions, and at the end of the devotions was tok save, and Jim stood up. "We only have a handful of flasks of IV fluid left. Please only give IV fluids to people who truly need them. Nurses, do not hang another flask without a doctor's order." And I cornered him. "You want.." Yeah, how long can you hold the section? Two days? "No contractions yet. I'll keep her on the tocolytics." And he nodded. If she goes into real labor, we'll deal with it.
And then there was the matter of the tubal ligation consent. Under most circumstances, the third c-section on a patient is considered an indication for tubal ligation, and patients are counseled that without extenuating circumstances (dead babies, new husband, etc) they'll be asked to sign a consent for tubal at the time of consent for c-section number three. However. There's a law in PNG that states that unless it is a life-threatening emergency, both the woman and her husband must sign the tubal ligation consent. Patient's husband absconded in her third month and hasn't been seen nor heard from since. And, if he did come back, she wasn't sure she wanted him back. "He's not a very good husband. I just married him because it was better than being single." But the law exists, and he could come back and sue the hospital for performing a tubal without his consent.

Sister Sylvia brought me a bilum that is pink and green. Plenty big for all my stuff. A gift, she insisted. And she cornered me: "This patient, the C-section. She lives in Hagen. You want we should send her to Hagen for her section, since we don't have IV's?" And three hours and a few phone calls later, off she went to Mount Hagen to get her affairs sorted out at some other hospital, which is quite possibly the best thing that happened regarding this whole bizarre affair.

Today I also learned how to use the vacuum affair here, which is an old-fashioned glass bottle vacuum pump attached to a metal cup with a chain on it. Most impressive. I also got a new stethoscope, since the one I had borrowed didn't have a diaphragm on it, rendering it a tricky bit of business to use at all. Unfortunately, I also got to use my new stethoscope to confirm time of death on one of our NICU babies. She's not in the picture post; she was one of a new set of 33-ish week twins, birth weight 1200 gm, the smaller twin. She wasn't looking so hot this morning and then I got called emergently out of outpatient clinic to come code the baby. We did compressions and bagged for a few minutes, but it was pretty much futile - what are we going to do for life support if we did get her back? So I did what I have come to see as my most important code duty: I prayed for the baby and the mother and the family. There doesn't seem to be much more that I can do in the face of death around here, and that's hard.
She doesn't have a name - just "Baby of Lucy, twin two". That's the way of newborns around here.

Last night, stitching up a chop-chop in the ER (wife one got the better of wife two with a bush knife), I was busy closing two-layered wounds and irrigating with iodine when I noticed a little commotion behind me - a car pulling around the circle drive with flashers on, security taking the gurney out and bringing it back in, a whole lot of people crowding into my already crowded ER thick with friends and in-laws and interested security men and police from Banz. I looked over my shoulder at the ER nurse (only one!) pressing a stethoscope to a man's chest, amid a rapidfire hum of Tok Pisin. "Arrest?" She nodded. I need your help. I stripped off my resterilized latex gloves and took powder-covered hands to assume the correct listening position. Nothing. His skin was waxen cold, lips pale. Not moving. Not breathing. Heart not beating. She checked his pulse (why do they check at the temple?) and shook her head. "I think he's dead." I concurred, but we spent some time looking busy, examining him. Getting out the flashlight to look at pupils. When someone brings a dead man to the emergency room, you don't just shake your head and leave.
There was surprisingly little wailing. The whole family bowed heads to pray, and they thanked me. Shook my hand. Bundled up their dead father/brother/cousin/uncle and took him back where they came from. And I got out another pair of gloves and went back to stitching, three feet away. Sometimes, it's just surreal.

Got out of the ER last night around 1 AM after all this suturing and coding and business, and went to get into the Tracker. As you can see to the right, this truck is nothing like my two-door Honda coupe; the step to get into the driver's side (on the right) is somewhere the height of my knee. It's also a diesel, which apparently means that I have to wait for the coil light to go out before cranking the beast (news to me). Anyway, I got in and turned the key like always and the engine went wurrwurrwuh. Repeatedly. Security hiked over. "Won't turn over." He asked me to try a few things. Wurrwurrwuh. Hm. There was a lot of discussing and then a large man walked over. "This is a police captain at Banz; can he try to push-start it?" I handed over the keys, and the police captain got in, and about six big men got in front and they pushed it backwards for about ten feet and wurrwurrROWR! went the engine, and it started chugging along once again.

It started fine this afternoon for Jeff, I don't know what happened. I was sure the alternator was gone. But I'm glad there were a bunch of ~~guys~~ people there who knew what to do with a diesel at 1 in the morning, or I would have been walking home with Security. It's only about an eighth of a mile, but after dark all the female doctors take the Tracker so as to be safe.

Appears that the creature in last night's post was in fact a cicada. It was still there this morning, but disappeared during the downpour this afternoon. Pretty bug, in a creepy sort of way.

A couple of images, for the medical folks

2009-06-15T05:07:00.000-04:00

	Severe osteomyelitis in a young child. This little guy has been to Hagen and had his periosteum stripped, as well as having been on antibiotics for the better part of a year. Not much else we can do. There are holes in his bone, and bone grafts tend not to do well around here because of patient compliance.
	This is a you-tell-me, because I don't know: a purpuric skin rash in a Sri Lankan man, age about 30, no significant medical history. He was seen in Mount Hagen and they got labs: cholesterol normal, WBC about 8K with a normal diff, Hgb 13, platelets 225, sed rate 45. He was placed on high-dose prednisone and the rash resolved. He's been off steroids for about a month now and has noticed over the last week the rash recurring. It's on both feet and legs, his buttocks, and his flank. I sent him for labs, and on his return I also noticed a large bruise where his blood draw was done. Lab results here were similar except for a sed rate of 68. It's not ITP; he's not septic; the rest of his exam is normal - no lymphadenopathy, no dyspnea, no abdominal pain, urine normal. I told him to go to Port Moresby, home of the only CT scanner in PNG, and maybe on to Australia to find a dermatologist or rheumatologist and get a biopsy and maybe platelet function studies. I think he has something autoimmune.
	And for all the med students out there: This is what temporal wasting looks like. This gentleman has some kind of liver disease - I just rounded on him this weekend for one day, so I don't know the whole story - but I took 3L of ascitic fluid off his abdomen with a 14-gauge angiocath and some IV tubing. It was very exciting.

Entomology help!

2009-06-14T08:25:00.000-04:00

This guy was hanging around on our screen all evening, and I'm desperately curious to know what kind of bug he is. It's about two inches long of body and an additional two inches of wing beyond that; counting the wing length it's the width of my palm.
When it flies, it makes a loud buzzing noise that scares Miriam. Is it some kind of cicada?

Picture Post: A walk to the river..

2009-06-14T07:12:00.003-04:00

We went for dinner and a walk at Mike and Diane's yesterday afternoon, after the rain stopped. Diane suggested we head down towards the river and see where the kids go tubing. Sounded like fun, so we packed up the Cups and off we went.

Up on the hill, to the right of the cross, is a Catholic mission; supposedly it's not a bad trek. These are the Western Highlands of PNG - some of the most fertile soil in the world. That's contributed to the worldview here that drives we Westerners crazy: as Matt talks about in Lainem Long Hailans, the PNG folks wait until they're out of something before looking for more; they don't order anything in advance or get a spare part when replacing one. This leads to extensive out-of-stock lists in pharmacy of all our commonly-used meds, at least once a month.

We walked down past the remains of the dam that ought to have diverted the river to provide the hydroelectric power for the station. You'll notice in the picture on the right that something vital is missing: namely, the sluice gate is wide open and there's only bare rocks visible in the canal that runs all the way up to the station. It's empty. That's because they had a hundred-year flood that completely wiped out the other half of the dam, the bit that pushed the river over toward the sluice. It changed the course of the river, too, so now the tribesmen are upset because their land is being undermined by the greedy river. Mike has a lot of work in front of him to rebuild the retaining walls and the dam itself - and the hydro itself is in need of repair as well. There's never any lack of construction work on this busy station, once he's done with the new hospital buildings.

We went past some of the folks' houses on the outskirts of the station and exchanged "Apinun" with everyone. This very strong little girl was happy to pose for a picture, and the men watching over her thanked me for taking it. There don't seem to be any superstitions surrounding photography, but I'm besieged by requests to see the pictures afterward. Miriam, of course, made friends quite quickly.

Down by the river is a little church (technically still on station property) and out by the church is their basketball court. You can see the stones laid out to form lines. During big meetings, they pitch tents on the court - but the rest of the time it's a place to play. Basketball seems very big here.

Just past the basketball court and over the improvised stile in the razorwire-topped fence was the river. We stripped Miriam down so she could play like the native kids, but I'm not showing any naked baby pictures on the Internet. The river is about mid-calf to almost knee-deep and has a pretty swift current, considering this is the dry season. She didn't want to go in very far, and pretty soon wanted her shoes back on because of the stones on the riverbed. There wasn't much sand, and I thought the water was pretty cold. So she sat on a rock and threw stones and watched the local kids play.

These are a few of the local boys having a tube ride. They all three got on the tube up by the dam and rode down quite a ways. One of them fell off, but there was no waiting! So he ran back up to the nearer put-in point. I'm told the missionary kids do the same thing, only with their clothes on. It's typical to wear baggy pants or a skirt over one's swimwear when one goes swimming as an adult woman - I think the water's far too cold to make swimming much fun, no matter what.

The view across the river is quite amazing, really; even though it was a cloudy day and had rained most of the time the mountains were stunning. This land is truly a blessed place, with greenery everywhere. They have a type of liklik grass that grows in front of the church that is tiny and green and - get this - never needs to be mowed. What a wonderful depth to creation! Nobody bred for the stuff, but it grew here.

On the way back - you'll notice we put the bare minimum on our wet little girl - she encountered a gate she simply had to close. What the gate did or why it was there nobody seemed certain, but Miriam dragged it shut.

Coming back up the hill toward the compound proper we met some folks carrying burdens in the traditional way - in a bilong with the strap tied across the forehead. You'll notice that everyone carries his or her share - in the woman's bag are a full load of vegetables, so imagine the weight. The little child next to her has a full bag as well, though I don't know what's in it. They came up from the houses in among the banana trees.

We had chicken and rice and oranges and cabbage-Ramen salad for dinner, and it was lovely. Walked home in the dark and tried to take some pictures of stars, but I'm not very good yet so this is all I have to show for it:

Saturday Rest

2009-06-12T18:33:00.002-04:00

They sent me home around 4:30 yesterday, since call was so long. I got a few hours of sleep after coming home before being woken by a call from B ward. "We have a patient here, footling breech, 6 cm." Well, drat. And that was the end of the night for me - from 3:30-6:30 I was doing 2 C-sections. First one Jim did with me assisting; second one I did. He says I don't need a section backup; he was quite comfortable with my skills. "Call me anytime if you have trouble." Felt good.

What didn't feel good was the rest of the long, long day in clinic. Quite exhausted. But I did see a couple of interesting cases - and they sent me home at 4 or so, to get a nap before dinner. I've got a cold which cropped up in the middle of the night, likely secondary to flying 10 days ago and seeing snot-nosed kids, so you'll have to forgive this not being much of a post.

For those who were asking: The answer to the medical teaser post is TB :) She has miliary TB on chest X-ray and a T8 compression fracture likely secondary to Pott's disease.

Today at 10 will be the tour of the new hospital and then we may go up to a little town and look around. I was going to stay home and sleep, but not so much, it appears.

Addendum to the Day

2009-06-12T06:00:00.002-04:00

We have sticker charts for Miriam and potty training. Today, we started a new one and also had a number of new stickers. She went in the potty and wanted a sticker. I asked "Do you want a Tinkerbell sticker, a Star Wars sticker, or a Surfer sticker?", as those were what we had.

And you know which my daughter picked?

"I wanna Star Wars sticker."

She's already on the path to geekdom.

Sick Day

2009-06-11T19:08:00.002-04:00

Have managed to catch some sort of intestinal bug. Likely I didn't wash something as much as I should have or it was the fried dough ball I split with Scott in the market, as Miriam and Nykki seem to be fine. (In fact, Miriam has already voluntarily gone to the bathroom on her own today. *crosses fingers*) Now for some tea to try to calm my stomach some.

On Call: Code Blue

2009-06-11T10:32:00.003-04:00

Headed up to the ER at around 6:45 or 7, after dinner and before Miricups went to bed. She had a patient there, vaginal bleeding, possible miscarriage. Got the ultrasound out and took a look - nothing but debris in the uterus - and by her scalebook she'd had a 7w ultrasound 6 weeks ago that showed no fetal heart tones. Cervical check was closed and bloody; she wanted to go home and come back for a D&C in the morning.
Dear Dr. Stiver: Thank you for taking me in on the molar pregnancy D&C. We just did one here and Becky was glad I knew something about what to expect. There was a startling amount of tissue, just like you told me there would be. You will be interested to know that we can only monitor her HCG status here by doing serial dilutions of urine pregnancy tests.

And then after that there was an infected foot to review and then there was the three month old with the fever of 39.7 (103.4 F) to get a lumbar puncture on (with an 18ga standard needle), admit to ward A, bed floor-I (peds is full; they're lining them up on the floor in the middle of the room) with some of our precious Rocephin for his cloudy blood-tinged CSF, and then I got a call from C-ward about this woman with abdominal pain. So I headed over there and I called Becky-my-backup and I put my hands on her belly and we ultrasounded her ginormous liver and there was nothing else abnormal about her exam. Belly was soft, very tender, bowel sounds faint but present, visible peristalsis on ultrasound. We wrote for IV antibiotics and IM morphine and some labs to be done in the morning and weren't sure what else to do.
And then I got calls every 30 minutes, it seemed, about this woman. "Dr. Nicole, we made a mistake and gave this woman 5mg of IV morphine. Her pain is better, respirations are 24." Call me if they go down to less than 10. "Dr. Nicole, her pain is back, it's been an hour since we gave her the morphine IV by accident. She's doing okay." All right, you could maybe try some IM now. I think I told the same nurse four times that it would be ok to give the patient pain medicine, and maybe that should have been my clue, but there is this curious quality to talking with nurses here: we both speak English, except we don't. And I was busy with learning how to reduce a dislocated shoulder and I went home at 10:15 or so, and then the phone wouldn't stop ringing. "Her pain." It's still alright to give the IM morphine you haven't given yet. "She hasn't eaten, she's shivering, can we feed her?" Put some D50 in her IV fluids (we don't have any D5 currently, so it's 1 liter NS plus 1 amp D50 to make D5NS, good as we have). And my thoughts were somewhat less than charitable at the point I got the call "She's having vaginal bleeding." Is it her period? "I'll go check." Five minutes later, phone ringing again. "She hasn't had a period for 8 months before now." Well, I know she's not pregnant. Ten minutes after that: "It's just a spot of bleeding really. But she looks very pale, and blood pressures all day were 60-70's-" (first I'd heard that) "- so we got a CBC, stat. Hemoglobin 11.2, WBC 8, platelets 14." And I called Becky, who suggested maybe I should get back in the Tracker (please imagine me driving a gigantic 4WD diesel truck thingy) and drive back up and see what was going on. The whole thing was just weird. And - reluctantly, because nobody on call likes getting out of the bed they've just gotten into at last - and with a whole lot of bad-natured grumbling - I got my skirt back on and started to head for the door. Ring! Nurse 1: "She's sort of almost coding now." I'm coming! "OK." Ring! Nurse 2: "How fast should I hang the IV fluids." I'm coming, just wait.

And I got there and she really was sort of almost coding; they were bag-ventilating her, and she was sort of maybe responding to my questions, and her extremities were the cool-pale of a code. And the ultrasound didn't look any different than before, and she still winced a little when I pushed on her belly, and then she stopped wincing and stopped responding and stopped breathing and then she stopped.
They have a code cart here, and I'll freely admit that I coded her blindly - no EKG's, no IV pumps, my only fluids were D5NS. She had a heartbeat, but no pulse, so we did compressions and ran D5 wide open in case her sugar was low and I found some Narcan that was only 8 years out of date and pushed it, and some epinephrine that was only 5 years out of date, and some atropine similarly. And sometimes she had a pulse and sometimes she didn't, but she didn't breathe on her own, and eventually after a few rounds of code drugs and some on-the-fly teaching about how deep to do compressions (I felt one rib crack, oops) and how to adequately bag-ventilate an adult (pointy end of the mask over the nose, oxygen tubing attached to the bag or mask) and how to check for a pulse properly (carotids or femorals, not brachial, and that's your own pulse you're feeling) I looked at the medicines I had available to me: dopamine, epinephrine, ephedrine, atropine, all the things that go in a code cart, and some of them might even be in date - and I thought about how codes were run where I came from, and about hanging dopamine or something like that, and about how there wasn't an ICU or a ventilator, and I told them to continue compressions and I called Becky.

Becky told me I'd probably done more than anyone else on station would have, and that it was all right to stop. So I went back, and in my absence the thready thud-thud of her heartbeat had at some point ceased. I had them hold compressions. I listened. They listened. I didn't argue with the nursing student who wanted to try one more round because he thought he felt a pulse - I remember that kind of desperation - but after that, I told him he was feeling his own. Don't check at the brachial artery.
Her family was quietly dignified about their grief; I wrote a code note and they sobbed but did not wail. One of the other patients - apparently a relative; remember, this all took place in a ward of beds only a few feet apart - came over to cry with them. And I prayed, and I took my bag, and walked out into the night feeling painfully inadequate.

I don't know what happened; I think if I knew then it might make things a little better. I have my suspicions - overwhelming sepsis (platelets 40 this morning, 14 now, but you can't always rely on the lab accuracy), fulminant hepatitis, some kind of non-visualized abdominal process - but I'm going to have to put this one on the list of things to know at the end of things. And that's hard for me, so very hard. And part of me wonders - if I'd had a CT scan, all the labs I wanted, if at 7:45 I could have gone looking for that elusive something - would it have made a difference? I want to believe it wouldn't have, so very badly, but I can't make myself know that.

And I feel so guilty for thinking badly of the nurses; I can't help but wonder if they had been trying to tell me something, and I was too tired or arrogant or not-listening to hear it. I find that the hardest piece in all of this to let go of, somehow. If I had listened differently, instead of with my frustration at repeating the same things over and over, would it have changed things? Probably not, not if she was septic. Not if her liver was failing. We don't have anything more than we did for things like that, here. But I'm finding it hard to forgive myself for it, right now, which is why I'm up, writing, at 1 AM - and not sleeping like I probably should.

Lord, let me listen with an open heart, and hear what is really being said.

A Good Day

2009-06-11T06:24:00.002-04:00

I'm constantly amazed at what my child will do sometimes that makes me happy. One wouldn't think going the whole day with 'only' 2 accidents (and those being BMs rather than just urinating). Still, it means that it was a 2 pair of underwear day for her (the accidents were while she was refusing to put pants on) rather than a 5-6 pair day. And she's starting to recognize that she needs to go, which is even better. Now if only she would stay in bed at bedtime.

The weather seems to have fallen into a routine and only rarely varies it, other than the amount of rain. The mornings are cool, but not cold, and damp. The day starts cloudy, but by 8 or so the sun has found its way out of the clouds. Then, around 4 or so, the clouds start to return, usually with some rain. The rain stops for the evening, but there seems to always be a bit more rain over night. Temperatures never change much, starting in the mid-low 60s in the mornings and maybe touching mid to upper 70s by mid afternoon. Particularly sunny days might glance at 80.

Life here is starting to fall into almost a routine. I work one day and watch Miriam and study some the next. Lunch around noon, dinner somewhere between 6 and 7, depending on when I can get started on it and how long things take at higher altitudes to cook. (Noodles and rice seem to take just a minute or two longer than I'm used to.) Baking is always an adventure. Today, I was guessing as to the size of a "square of chocolate", as the chocolate we do have came in 1 cm squares. The brownies were a bit lacking in chocolate, but still gooey and good. (Almost caramel-y.)

Nykki's on call tonight, off at the hospital and I hope it's taking a long time just because she's getting a feeling for something, and not because it's complicated or life threatening. Though there isn't much I can do but pray.

Picture Post: NICU

2009-06-10T22:41:00.003-04:00

This morning spent very little time in OPD - had plenty patients to round on (and send home) - including a few who'd been in false labor! Just wrapped up with that and got called to drain a paralabial abscess, then help with a D&C. Last night's call night was rough for Jessica and Susan - two D&C's and a fetal demise delivery - so when I came in everyone was getting blood and CBC's were being checked left and right.

Took some pictures today of our babies - this is the NICU crew right now. To your left you'll see the WHOLE NICU in one picture. That's it - three warmers and some IV tubing. We have four babies today - yesterday we had five, but I sent one home.

And to the right you'll see our babies:
The one on the pink blanket is Baby Rosemary, who's the little 1200-gram baby that I keep expecting to be missing one morning. So far she's hanging on and doing all right.

The one in the yellow is Baby Genits, who I drained an IV site abscess on yesterday. She should get to go home soon.

And the two in the crib are Baby Wendy-2 (Baby Wendy-1 is out with Mom already) and Baby I-can't-remember-right-now, who are our feeder-growers. They're both doing really well and will transition to just breastmilk soon.

A medical teaser!

2009-06-10T22:25:00.003-04:00

30-ish woman comes into clinic yesterday with complaints of chronic back pain. She's been sent on referral from an outside health clinic, where she's been haunting them for months with her mid-back pain and swelling.

She states she has occasional fevers and chills, but no weight loss. Denies cough. Pain is excruciating. On my exam I see an average-height slender woman of typical PNG'ian build. She stands and sits with shoulders hunched forward in an "old-lady" type of posture. Lungs are diffusely pretty clear, limited mainly by the congenital inability of patients around here to understand take a deep breath. Back has a notable kyphosis (that's a forward curvature, for the non-medical folks) and consequent arching of the ribs - the "swelling" described by my medical triage personnel is actually just her ribs winging out from her kyphosis.

I send her for X-rays, and today she brought them back to me. They're on the left - chest and thoracic spine. Click for larger images. What does she have?

Meanwhile, back at the ranch

2009-06-10T18:49:00.005-04:00

While Nykki was dealing with all the fallout from the station docs all leaving to see the ambassador (she's in yellow in the middle), I got to go to the meeting. (After figuring out that the work I wanted to get done on cabling in one of the buildings was going to be stymied by all the long-term station people being at that same meeting.)

Ambassador Rowe toured the station and then had a small town-hall-ish meeting. In the meeting, she went over what the embassy is doing with PNG (and the Solomon Islands and Bantu, as they're all the same ambassador position). She also appologized for not getting out to the station until now, but everytime they tried to plan something, some 'excitement' in Mt Hagen would nix the trick. (Things like burning down the court house. It's weird hearing about these things in Hagen when it's been quiet here in Kudjip.)

She also went over how to join the Foreign Service. Apparently, there's an online test. After you take that, assuming you pass, you go to one of several sites around the US and do an oral exam. (Individual interview, group interview, and some more written testing.) Then a security/health exam. And then you're on a roster. When you're up, you get a list of postions which you rank. (Entry level rank in tiers "high", "medium" and "low", mid and upper level rank numerically, similar to ranking residencies.) It sounded interesting, though I'm not ready to up and join. Not sure what Nykki would do. (Though she said that they had people from fresh-out-of-undergrad to their 50s and 60s starting in her class. Maybe as a "retirement"...)

(I really have to start limiting what I find interesting. I think I'm supposed to have picked a career by now. :D)

A time to mourn...

2009-06-10T07:13:00.002-04:00

For everything there is a season, and a time for every matter under heaven:

²a time to be born, and a time to die;
a time to plant, and a time to pluck up what is planted;
³a time to kill, and a time to heal;
a time to break down, and a time to build up;
⁴a time to weep, and a time to laugh;
a time to mourn, and a time to dance;
⁵a time to throw away stones, and a time to gather stones together;
a time to embrace, and a time to refrain from embracing;
⁶a time to seek, and a time to lose;
a time to keep, and a time to throw away;
⁷a time to tear, and a time to sew;
a time to keep silence, and a time to speak;
⁸a time to love, and a time to hate;
a time for war, and a time for peace.
Ecclesiastes 3:1-8

Steve found me this morning. "I scoped your patient." The sweet little old 60-something lady, black stools, last patient yesterday. I could hear something Bad in his voice. How'd it go? "Gastric adenoCA, inoperable." He exhaled. "Soft diet, liquids, comfort measures." They'll probably go home from C ward, then. No reason to die in the hospital here: the PMV won't take a dead body and it's 125 kina to rent a vehicle to transport one home. As if dying weren't injury enough.

In the three hours I was seeing patients while my OB labored, writing scripts for plenty of PPI's (coffee seems to be a staple everywhere I go, with its attendant friend gastritis), tentatively ruling out pyloric stenosis (nobody knows if they'd recognize it on ultrasound or not) and seeing five-year-old boys who might have hepatitis, the power went out twice. Today, that was our curse - the pouring rain and gusting wind brought instability at the other end of the power train, and since the hydroelectric power for the station hasn't worked since (a) something broke in the plant and (b) the river went elsewhere during a flood, we're on city power from a long way off.

Most of those times were brief - not more than a minute or two - but this hospital doesn't have battery-backup failsafe power outlets and generators to keep the mechanisms working. When the power is out, we have nothing. No X-ray, no lab, and no oxygen concentrators in the wards. I'm not entirely certain what happens in surgery; I know I keep a flashlight in my bag any more, just in case. (An addition to my Medical Missions list: A Mini Maglite (the AA battery kind) with the LED adapter kit). And suddenly there was a knock on my door and there's a man standing there in a nursing uniform, and behind him are two girls in nursing student uniforms, and they say "We need you on A ward. Emergency."
And they ran, so I ran, and left my patients waiting. And I said "What is it?" And they told me "Baby having trouble breathing," and all of the permanent missionaries had jumped ship from clinic to go meet the American ambassador over at the new hospital, so there were only three of us volunteers running clinic, and one of them was already in the A ward pale-faced and managing the code on a baby boy.

His name is Michael. Admitted for rule-out meningitis with a tap that looked clean, chest X-ray suggestive of heart failure, on oxygen and the things that we can do here, and then the power went out and the oxygen went off, and then he just stopped. And it wasn't just trouble breathing; it was trouble living he was having.
We don't have an ICU. Or ventilators. We could maybe have found some epinephrine, it's on the code cart, and it might even be less than two years out of date, but there's only so much you can do here, and we did what we could. I pushed the nurse out of the way, I'm sorry to say, and got some actual chest compressions that actually gave the child a brachial pulse going, and they bagged and we compressed, 15:2 like the sign said, because continuous two-rescuer CPR isn't on the teaching sheet, and all the time I knew it was hopeless.
Maybe six months old, this little one, limp and lifeless, not breathing, chest silent. No pulse. Not even the sound of a heartbeat - and Jessica gave me her stethoscope, which is better than the good-enough one we found for me to use, to listen. And we tried, but there wasn't anything else we could do for him, not here. So we stopped, and we took the tape off his face, and Jessica prayed - I don't think I could have kept my voice steady; it was a good prayer. And then I helped his father wrap him in a blanket while his mother wailed and beat on the bed, and then we walked them outside.
It's been a rainy day; no different. A soft grey drizzle and we stood underneath the eaves with a bundle of dead baby covered in blankets to keep him from the cold, and his mother wailed and sobbed and I cried and Susan-the-pediatrician came and helped us with the administrative stuff, but it still amounts to having to buy a ride back home for him. And it's not fair. Not fair that babies have to die and that we can't save them.

We stayed outside for a while, away from the family, under the eaves still, Jessica and I - probably mirrors of each other, red-nosed and spike-lashed and sniffling - and we did what we do in these cases. There wasn't anything else to do. I was trying to think of drugs to give him. Maybe epi. But what are you going to do then? And I talked about the little baby with recurrent GBS meningitis and a brain like Swiss cheese in the PICU back home, and we wondered out loud whether maybe it was better like this. It's so rarely the heart in kids, anyway. If you oxygenate them and they don't come back... I know. Unless it's WPW or something. Maybe he had something like that. I'll, um...just get the peds cardiologist on that now. Put in a pacer. We laughed. It's the guilty sort of laughter that comes with knowing that you are alive and someone else is not, but all the same it's what keeps us going sometimes. A time to weep, and a time to laugh.

They told me it would happen, that babies die here, people die who wouldn't in our world of technology. And now it's real. And it's a jagged little gouge in my heart with a sweet baby face that I never saw smile. And you always wonder - why?

Requiescat in pace, Michael.

I love B ward (subtitled: ups and downs today)

2009-06-10T04:07:00.002-04:00

Today was brilliantly sunny until about noon, then the horrible rain rolled in - as seen to the left. This meant that power came and went like the wind, as did the functionality of the lab and X-ray machines.

The nurses do the vaginal deliveries on B ward. They call us - whoever's on B ward - for C-sections or problems or pretermers or things like that, and so it behooves one to check every now and then and see if anyone's in labor or not. And they do things very differently here.

Today was an up and down kind of day; morning went swimmingly well and I did several abdominal ultrasounds without feeling like I needed to call for help. Came back from lunch and got mobbed by nurses from B ward. They had a woman in labor, G2, previous C-section for transverse lie, "oblique lie" and they wanted me to come see whether she'd stalled out. Now here's the creepy bit about working here, for those of you out there who do OB: Patients with one previous C-section are allowed to labor, and sometimes they even get pitocin. Fetal heart tones are ascultated hourly, and the women are otherwise unmonitored. That idea took some getting used to. So I walk into the room - their L&D rooms are three cubicles with curtains - and grab a sterile glove ("What size, doctor?" "Whatever you have.") - today I'm in 7 1/2's, last time it was size 8. She has meconium-stained amniotic fluid and a left-sided cervical lip and I'm certain the baby is ROP to ROT, no caput, no molding. And I look around at the room and the nurses and I tell them she's OP, get her up and let her labor some more, let me know.
Three hours later, after everything else that happened today happened, she's been pushing for 50 minutes and they want me to come back and check. "Her contractions have stopped." I'm not entirely certain if this is true, but I successfully avoid starting pitocin by encouraging them to give her a primigravida's worth of pushing time.

And an hour after that I'm skipping out on the last half-dozen clinic patients to go see how much bleeding is "a lot" around here. And I might have muttered Carlton Lyons' name under my breath while staring at a delivery table covered in at least a liter of the red stuff, and I'm taking report from the midwife: vacuum extraction with episiotomy, shoulder dystocia, postpartum hemorrhage. But I didn't panic. We got some pitocin running and an IV started, I closed the episiotomy and the left paramedian extension and I put her perineum back together pretty. (The nursing students watched me, curious, amazed that I used a single continuous suture to close the extension and another continuous suture for the episiotomy; apparently they sew with interrupteds here). It wasn't the best needle, on 3-0 Vicryl, but it worked, and she stopped bleeding after I pulled a gigantic clot out of her posterior fornix. And as I was writing up my note, the power went out for the fifth time that day.

And that was the good half of the day. We're headed up to Becky's for game night, so I'll post this - and save the bit that had me standing in the rain sobbing for later.

Apinun!

2009-06-09T21:27:00.000-04:00

Afternoon dragged on and on and on, although I was so busy I was surprised when we got out at nearly 6 PM. Had to send a few folks away, because early in the afternoon the water pump to the hospital cut out completely, meaning that there was no X-ray (no water to develop films). Also, nothing to wash speculums with, so glad I had plenty. I had a bottle of hand sanitizer in my room, at least, although with the number of pelvic exams I did for PID today who knows if that was adequate.
Learned how to use the ultrasound to find tubo-ovarian abscesses and evaluate kidneys. Went looking for ectopic pregnancies and didn't find any. Got asked to help out on an ultrasound or two, very reassuring. Today was, apparently, pelvic pain day - and so we did plenty of ultrasounds.

Last patient of the day was a charming old lady who'd had three days of black tarry stools. She had a hemoglobin of 11, but hadn't eaten in three days and had a pulse of 110 and a blood pressure of 90/60. And it just so happens that Steve the visiting surgeon does lots of colonoscopies, so he's going to scope her tomorrow. We're having a great time, and he's a lot of fun to talk to.

My travel pack for medical missions now includes the following: Harriet Lane, Sanford Guide, Tarascon pharmacopeia, the Travel and Tropical Medicine pocket books I have (after reading the section on Pigbel I feel much better informed), and the cute little finger-pulseox sensors that Erin has (portable and very nice). Also, a stethoscope.

Tomorrow I move to B ward - OB. We'll see how they do things there, and whether my MFM/NICU experience will serve me well or ill.

Lunch hour

2009-06-09T13:00:00.000-04:00

Every day, around noontime, we all stop working and go home for lunch for an hour. Our patients will wait for us. It is simply the way things are done. This morning was a socks morning, cool and dreary, but it has developed into a brilliantly sunny day - warm, almost hot - and so beautiful.

I am treating acute severe asthma with Decadron, IV theophylline, and PRN Xopenex. That's all I've got, around here. Although I'm considering breaking into the OB ward's stock of magnesium if needed, and I think I saw some Advair in the pharmacy while I was getting fentanyl lollies for a cancer patient.

Jessica came to me today to confirm some abnormal findings on funduscopic examination. I successfully identified a liver abscess on ultrasound. It is a better day, even if there are 23432545 patients yet to be seen after lunch.

Comparing Oranges to Oranges

2009-06-09T07:43:00.003-04:00

The oranges here are green. Don't believe me? Here:

The one on the left is an "orange". The one on the right a tangerine. Now, to be fair, they are indeed orange on the inside. (And taste like oranges/tangerines.)

In other news, I went to the local market today. I'll just copy/paste from my "study" blog below:

Went to the local market in town today. We say "market" but it's a bit different than Hagen's. There is a trade store there, with a smattering of goods, all behind fences in the building, topped with razorwire. One section had individual items (cans of coke, cooking oil, flour, etc.) the other side had more wholesale type items (cases of coke). Bought a can of coke to break a K50 note (think stopping at the quick-e-mart to break a $20 bill).

The market was across the "street" (loose term for a gravel path slightly wider than the upiquitous trucks). Market consisted of people (mostly women and older men) sitting under umbrellas with their fruits and vegetables for sale. Some had cardboard signs with prices, other you have to ask. Some produce (like the kaukau, the local sweet potato) are sold by the small pile, others sold individually. Almost all of it looks of decent quality, though the bananas they had you'd want to eat quickly as they were already yellow-brown.

Scott, who went with me the first time, said that it's mostly safe for station people. A lot of the people on station who sell their produce (and buy it) come down there and will look out for the white-skins (which are assumed to belong to the station). Sort of "our tribe", if you will, versus the local townsfolk. (I'm not sure how much bigger the town actually is. The station has a number of houses, but there is a school outside the walls and a church. Several small shops along the market way, but I can't see much else through the dense vegetation around the market and roads.) He also said that today's selection was down, as there are usually more bananas, pineapples (we bought the only 4 available) and the like. Though if we ever run out of kaukau, I know where to get more.

There are also street vendors selling food which We Are Not Supposed To Eat. Scott and I split some sort of deep fried dough thing, though it was cold. There were also on the way back "lamb flaps" or something like that. Basically they're lamb ribs that are grilled fresh for you. I was full (and not quite that adventurous) or we would have stopped for some.

I've had better days.

2009-06-08T04:10:00.004-04:00

Daytime today started dreary and wet, then by lunchtime was sunny and beautiful. This evening, leaving clinic at 5:30 PM, the air was cool and breezy, scented with campfires. I am glad I brought my Advair.

It was a long day today, starting with tok pisin lotu at 0730. I sang along with songs whose words I did not completely understand, although one of them was a translation of "Just a Closer Walk with Thee", which I sort of pieced together. And then I listened very hard as the chaplain read the passage where Jesus calms the wind and the waves:

And when he got into the boat, his disciples followed him. ²⁴A gale arose on the lake, so great that the boat was being swamped by the waves; but he was asleep. ²⁵And they went and woke him up, saying, ‘Lord, save us! We are perishing!’ ²⁶And he said to them, ‘Why are you afraid, you of little faith?’ Then he got up and rebuked the winds and the sea; and there was a dead calm. ²⁷They were amazed, saying, ‘What sort of man is this, that even the winds and the sea obey him?’
Matthew 8:23-27

There was a meditation following the devotional - about how Christ is always with us, and how He doesn't promise us a smooth ride - just a safe landing. And there was probably a lot more to it, but it was all in tok pisin and my skills are woefully inadequate for that sort of philosophical discussion. I'm more on the level of discussing children's activities: You gat wanem sameting? Ya, snake! But there was something soothing about the rhythm of the words, about the repetitive voice, about the bits I could understand. Win go down. Wara go down. It was a good prelude to a day that was tumultuous at best.

I'm accustomed to being pretty good at what I do; I've had excellent training and plenty of experience. But I feel like an intern, here. I'm slow - I was inordinately proud this morning that it only took me three nurses and two and a half hours to see fifteen patients, most of whom I'd seen before and didn't need any new changes - I'm sub-confident - checking in with the others on things that normally I would never need to staff - I'm hesitant. All of that will change, once I'm comfortable with what I'm doing. It will also help as I learn more Tok Pisin, I think. Sometimes, entertainingly enough, it's like a game of Telephone. I speak English. My nursing student speaks Tok Pisin. The patient's watchman speaks Tok Ples. The patient answers in Tok Ples. The watchman repeats it in Tok Pisin. The nursing student tells me in hesitant English. And out of all this I'm supposed to get a history. Top it off with the Melanesian concept of time - if you ask a PNGian if they've had a headache, they'll tell you yes, even if the last headache was years ago - and it's a nightmare mishmash of questions I would never ask at home.

Today, mingled among the interesting patients, were four women with menstrual complaints. One had a history of 2-week-long periods, according to the intake nurse; when I asked her, she said she'd only had one, and it was over now. One told me she bled for 3 weeks every month, with big clots. One told me she'd always had irregular periods, and that was all right, but they hurt a lot, now that she'd been treated for her chronic PID. And one was a patient billed as "a girl" in her chart who was perhaps sixteen, hadn't menstruated in five or six months, and had glomerulonephritis which we finally decided was steroid-resistant, which meant I got to decide how to taper her steroids. Not one of them had a hemoglobin less than 9 or any abnormal findings at all. Furthermore, I'm not certain any of them actually had period problems in the first place, but I did offer a short course of oral contraceptives (we have them!) which was accepted by one of the three women I considered it in.

I've done a lot of pelvic ultrasounds today. I can now successfully identify a non-pregnant uterus and do a transabdominal measurement of the endometrial stripe, and maybe even visualize the ovaries, with a little luck. Once Scott found the kidneys for me, I could visualize them as well, but the finding is still a bit tricky. They think it's funny. "Um...that's outside the uterus. I'm not so hot on it." But I can do an AFI, an estimated fetal weight, and I figured out where the color-flow and pulse-wave dopplers are on the ultrasound, so I looked at outflow tracts today. I don't think I can do cord dopplers, but only from lack of having someone to show me exactly how.

Saw my patient with the gouty knee from this weekend, first-off. He greeted me with big smiles and a big handshake. He's feeling much better after two days of colchicine. I started him on allopurinol for when he's done with his week of acute therapy. And it wasn't a septic knee, which is so reassuring to know.

There's lots of heart failure in the Highlands - rheumatic fever, malaria, typhoid, high-salt diet, idiopathic, cor pulmonale, etc. I saw some today. I managed some today - ACE inhibitors, diuretics, sometimes beta-blockade, and aminophylline. I'd never used aminophylline in patients with heart failure before I came here - but I know at least one at home that I would try it on now. A brief literature search suggests it has positive effects and decreases the frequency of Cheyne-Stokes breathing in heart failure patients. It's also used here for apnea of prematurity in newborns, since we don't have caffeine drips, ventilators, or any of the other trappings of NICU docs in the States. I tweaked some meds. That much I was comfortable with, with checking X-rays and looking at fluid in fissures and eliciting symptoms (although, slip means both"sleep" and "lie down" in Tok Pisin, so sometimes it's hard to pin things down).

Wasn't so comfortable with the woman who walked in with "a mouth sore". What she really had was a giant fungating mass on the right side of her palate, extending way back to the pharynx. And on the left side of her tongue, she had leukoplakia - firm white scaling of the skin that is in no way normal. And I looked at it and my mind said "she has cancer". And I didn't know, I'd never seen anything like it before, so I went and got Scott. And by the time I was done describing my findings, he was nodding. "She smoke?" Used to. "Buai?" Blank stare. "She chew betel nut?" Oh! Teeth and gums stained with it. He nods. "That's the killer combination."
He came with me anyway, and looked into her mouth, and clucked his tongue. Two different oral squamous cell carcinomas, extensive. ENT referral - to Mount Hagen hospital, the nearest specialist clinic. And he spoke rapid-fire pidgin, explaining to her that she must go, this Friday, to Hagen and see the ENT - and that it still might be too late. And then he did what the missionaries here do so well. Yu save Jesus? I followed enough of the flow of the conversation - the urging that she put her affairs right, the discussion that her life was more than earthly existence. And the prayer, so unlike my own clumsy words - for healing and understanding, calling in the promise of salvation, heartfelt and eloquent in a language that is not built for eloquence.
I hope she goes to Hagen, and gets treatment, and does well. I may never know. And I hope one day I can speak with that much open and unapologetic faith.

Ran from room to room most of the day, trying to spread my questions out so nobody realized I was staffing almost every patient. Saw maybe half of what anyone else did, I think. Learned a few things about treatment costs. A doctor's outpatient visit here costs between 8 and 10 kina ($3-$4). A CBC costs 4 kina, but a TSH costs 20. An X-ray costs 6, an ultrasound 12. Everything is "go buy this, then get it done."

Several chronically perforated eardrums, one with a hole I could thread a pencil through, red and draining. Dug through Pharmacy 2, then came back and wrote for eardrops after verifying I had them. I had to staff that one, to find out that I could go look in the pharmacy. And I had to ask the nurse working there to show me where the eardrops were. But I made it through.

There's a woman on the ward who came in almost three weeks ago with fever and altered mental status. Successfully treated for typhoid, she's now much less confused and wants to go home. I glance through her chart, and notice a nursing note from several days back: "patient with pressure ulcer, chart out for MD to review, seems infected." So I peek. And I call Jim the surgeon over. You can't send her home like this. And I know I can't, not after looking at a 4x6 inch wide purulent mess that is her sacrum, the fevers that are mounting, the smell that emanates from her. It's not body odor, it's the stink of infection. You can't miss it. Steve the visiting surgeon comes over, as do all the nursing students. "This is why you turn patients." Everyone stares. We'll put her on the schedule for today. Any other 'oh, by the way' folks?
No, sir.

Overwhelmed. Exhausted. And tomorrow may not be any easier. I am comforted only by the knowledge that I am helping, even if only a little bit. Wednesday I move to B ward - OB. I am strangely terrified by this idea. We'll see how it goes.

Cooking in the Highlands 101.

2009-06-07T06:52:00.002-04:00

This is a cake. The bit we did right was to bake it in a bundt pan. Now on to the bits we did wrong.

Everyone who has ever made baked goods at 5,500 feet (roughly our elevation) is probably laughing by now. Everyone who isn't is wondering what the big deal is.

Epicurious.com has a great little article on the science of why our cake turned out two inches high and crunchy, but the short version is that things rise very fast and fall very hard. Next time, we'll try adding an egg or increasing the liquid and decreasing the baking soda. Also, baking with a cake tube or in a bundt pan is advised, as is - at this height - greasing the pan, lining the pan with parchment paper, greasing the parchment paper, and flouring the greased parchment paper, in order to facilitate cake removal. We used a broad-bladed plastic knife, and most of the cake got detached eventually.

The icing is a homemade buttercream icing, substituting fresh-squeezed orange juice for milk and vanilla. It's positively scrumptious. It's also take 2 of making icing. Take one ended with me saying to Angel: "Corn flour? I didn't know that you used corn flour in icing..." Apparently, both the yellow bag of corn starch (corn flour here) and the yellow bag of icing sugar were open, filled with fine white powder, and he didn't read the label clearly. Thankfully, it wasn't actually on the cake at the time.

So far, mostly, we've been eating quite well on the large quantities of meat we brought home from Hagen. Not having access to staples (should have bought more onions!) and the market being outside the gates (bring a guide!) has forced some creative solutions involving milk, cheese, and sour cream instead of yogurt, but we've managed a passable falafel, spaghetti and meatballs, and all manner of regular home dishes. Baking is the real adventure.

Unfortunately, the microwave smokes when you turn it on, and that didn't seem very safe, so we're limited to the gas stove. Have learned all over again about thawing things in warm water baths. We have a pasta pot and I found a pressure cooker today but don't know where the little doohickey that goes on top might be. There was a steamer disc, so we had green beans today as well. We've got fresh-sliced pineapple, bananas ripened on the top of the fridge (buy them green or they go bad within days), fresh oranges and nectarines, sugar fruits (sweet, with lots of seeds like pomegranates), and some kind of lumpy ovoid fruit I don't remember the name of and am therefore not sure about eating. Also: peanuts, still on their stems. If anyone knows how to roast them we're all ears!

2009-06-07T05:25:00.002-04:00

English Lotu (worship) was today. It was not so different from what I'm used to, but at the same time... I miss Rob's sermons. We didn't have a speaker, but we did have a video of someone through Focus on the Family. My dislike of that particular group aside (or at least of some of their positions), the video wasn't bad. There was some injecting of Christian thought into the practices of the ancient Israelites and their religion, but not so much that it skewed the message he was trying to convey. (I don't remember the name of the speaker, or I'd look him up.)

Tonight and last night we hear the noises from a local church, I can only assume. Loud music is coming and it's Christian worship songs. American ones. Very strange. Especially when the power dies and it suddenly stops, save for what I think is the congregation singing. (It's hard to make out and it's off-station, so we don't go.)

Speaking of... There's a fence around the station. Guarding the missionary homes, the hospital, and other buildings here. Uniformed security can be found along the road nearly constantly. In Mt Hagen, all the businesses have 6-8' fences with barbed (if not razor) wire on top. Even the churches lock themselves away behind these barriers.

On one side, the culture here is so tribal oriented that crimes are only really crimes if they are done against a member of your own tribe or clan. Thus, stealing from a "rival" clan, or just someone passing by isn't bad, or at least isn't as bad. There has been some instilling of Western values, but not everyone takes them. It's the same reason every business has gates and guards at the doors.

And yet, were not the words of Christ:

“You have heard that it was said, ‘An eye for an eye and a tooth for a tooth.’ But I say to you, Do not resist an evildoer. But if anyone strikes you on the right cheek, turn the other also; and if anyone wants to sue you and take your coat, give your cloak as well; and if anyone forces you to go one mile, go also the second mile. Give to everyone who begs from you, and do not refuse anyone who wants to borrow from you.

Matthew 5:38-42

I just think fencing your church in sends the wrong signal. And yet, if the fence is what keeps it there, so that you can come back tomorrow and the whole church hasn't walked off...

Though, I suppose I'm still here, inside the fence.

Lazy Sunday...

2009-06-06T18:45:00.002-04:00

8:15 was circle time, saying goodbye to a volunteer I didn't know. Hung back and felt the love anyway. Most of the folks went down to Emmanuel church for the Tok Pisin service. We weren't ready to take Miriam to that as well as the afternoon English service, not yet, but I felt guilty not going. After all, what is Sunday for around here except going to church?

Talked to Becky yesterday. She still hadn't fed the little preterm baby; still looked too sick. You did everything right, full-court press on her. But I don't think she's going to make it. She agreed with me, baby looks 30 weeks max. We don't have surfactant, we don't have any NICU. All we have are IV fluids, crystapen, and gentamicin. And NG feedings if we get that far. Not so much to go on.

Got some pictures and video yesterday of Gideon working. The mouth harp is really amazing to hear him play (link to video). He uses coconut shells in a fire, charred to embers, to burn these fabulously complex pictures into bamboo. Miriam was very interested. I'm fascinated. The sheer amount of dedication it takes...

Post Call

2009-06-05T20:01:00.003-04:00

It could have been a lot worse. Yesterday was a national holiday, so the OPD was closed. Any number of people had been told to come back to the clinic, and they all had the option of paying 30 kina ($11) to come through the ER instead of coming back at another date and paying the much cheaper OPD clinic fee. Fortunately, nobody who came was that ambitious. I got called only a few times - spoiled, they tell me - since I stayed in my own bed from 23:30 on.
I called my backup a lot last night - practically every patient I saw I wanted someone else's input on. Most of the conversations were "hi, Steph? I feel like an intern." At which time she would comfort me and explain to me the use of medications I'd never heard of. It was quite an adventure.

I took a bunch of fluid off of a gouty knee (all by myself!), read chest X-rays, admitted several people to the hospital. Sent several people home from the ER. Happened to be in there while the nurse (nurses here do a lot, from suturing to writing meds according to "the green book" - the standard manual of treatments issued by the government - so they only call me in when people are really quite sick, or they're stumped) was suturing up a kid's head. His watchman was looking on and then suddenly just crumpled to the floor - silently, like a falling tree. There was a truly remarkable "clang" as his head hit the base of the ER lamp, and we all scurried to his side. Save nem bilong yu? He did. And after a few minutes sitting down he was all right again. And I couldn't help thinking: he'd be sent for some kind of evaluation in the US, if that had happened in our ER. But here, fifteen minutes later, Yu stap arit? And off he went.

"I need you to see this baby." I have to drive up after dark; women can't walk alone on the station. I find the nursery - three warmers with two infants each - and unwrap the little package of infant. 7 months gestational age, born at home in the morning, not feeding well. Weight is 1225 grams. The umbilical cord is tied with a string. Baby is breathing well, startles, good reflexes. Looks about 30 weeks or so, though I don't have a chart in front of me. The blue book - the pediatric standard manual - has already instructed that IV antibiotics be started, crys-pen and gentamicin, about what we use at home, so it's just up to me to order fluids and approve the baby's admission. I write an order: keep in warmer. I can't imagine them taking her out, but the nursery is clearly at capacity. Tomorrow, they'll place an NG tube and start feeds. I explain carefully to the baby's mother what the risks are, simply: very small, infections are common, and I tell her that what she needs to do is pray for her daughter. And I pray. I'm careful to keep my requests reasonable - aware of the results-oriented Melanesian culture - but I don't know what else to do here, with no NICU.

B ward comes looking for me in the ER - they have a laceration after a vaginal delivery that needs fixing; the students only sewed up the external portion. They've allocated their maximum lidocaine, so now it's my turn to close the deep portion. I do a quick check - three centimeters long at least, left paramedian sidewall. Bleeding. And patient won't tolerate more than a little exam, so it's sedation time: ketamine and valium, one and one. Nursing starts an IV. I push the drugs. Two minutes later, she's staring off into space absently and I'm opening the deep laceration tray, with sidewall retractors and weighted specula and Jackson retractors and ring forceps and an army of tools. 0-Vicryl, per request (I can use that or chromic, she tells me), and a student to glove and hold my retractors, and the process is easy. I tell Steph I'm all right and will call if I need her, and I'm surprisingly proud that I don't. Nursing watches, and makes approving noises. I think I have a friend.
I stopped to see her today. She's doing well, feels good. No more bleeding. She thanked me.

Middle of the night, I get called for a distended abdomen on a child. I come into the ward and find a tense, hypertympanic, silent abdomen that's clearly painful. Review of the chart shows a dehydrated child with gastroenteritis on hospital day 5 of IV rehydration. I call my backup. "Steph?" I'm in desperate need of a CT scanner right now. Probably hypokalemic ileus, she reassures me. Make sure he has potassium in his IV and drop an NG. It's a discussion with the parents, who don't like the way their child coughs and gags during NG placement, about how this is important. And when the doctor says, they agree at last.
I'm by his bedside drawing out fluid with a 5cc syringe. No wall suction here. I have to keep readjusting the tube as the child retches it out, pushing it back in until I get return of breastmilk and the belching sound of gastric air. Finally, I re-tape the thing and it stays put. I say a silent prayer of gratitude for the hundreds of nurses who've started IV's and showed me how to tape tubes so they don't slide, and try the belly again. Miracle. I hear bowel sounds and the distension is already less tense; the child stops crying as I rub his belly. His father leans over him. Em i pullim win? I lay his hand on the baby's chest. Em i pullim win. He relaxes as he feels the movement of quiet breathing. And we say a prayer for the baby, and both parents thank me.

Had dinner last night with one of the missionary families; Friday is unofficial pizza night and we had lots of it, along with stove-popped popcorn and Kool-aid. Miriam made friends with four-year-old Olivia, who was quite tolerant of her presence, and showed off all her books and her tent. Very restful, except for the bit when I had to leave and go see a patient.

Today has been a day for rest and recovery; Gideon, who makes art by burning designs onto bamboo, came to show off his work. We bought a few pieces, and a letter opener for Miriam that had her name specially burned into it. He also played the mouth-harp for us. It was supposed to rain, but so far only a few sprinkles - nothing like the downpour that was yesterday.
We have been promised that Diane's housemeri will let her know, she thinks there is a sing-sing next weekend and if so we will go to it. There will be native gear and dancing and music. I am thinking that I should brush up my tok pisin by then, or I will be sorry.

Another Day, Another Destiney

2009-06-04T06:33:00.002-04:00

So the day wasn't that dramatic. Did laundry again to cover the things that needed bleached. Most of them dried on the line. Cloth diapers are amazingly absorbent, which I'm thankful for on one level, but it means that they take forever to dry. (All day, in the sun, and they're still clammy when I take them down around 5.)

Today's major accomplishments were fixing Quickbooks for the Maintenance office, discovering that the license for the AV software they have here expired in April (And hasn't updated since May). They're looking into options on the AV front. Internet seems to be going faster now, but at the cost of all network-visible devices having to log in once a day. (And each log in works for only one machine at a time, kicking off whatever device was using it before.) The mail server is -not- currently exempted, which is problematic, at best.

It's strange, mostly because I don't quite have free reign to do what needs done. I have internal mail working at this point, but need play with the station firewall if I want external to come -back- to the server. Also, the machine would need an exemption of some sort for mail to work consistently, or someone will have to log into it everytime they want mail to go out (and possibly come in). Will have to consider dumping their mail server for other options, but to do that would need DNS keys.

Need to see if they want the wireless router I found in the Tech Center (read: 2 adjoined closets with -all- the spare parts for anything that plugs into a power outlet. Oh, and the server and phone system. And what I -think- is an air conditioner that is not currently turned on). I'm not sure how far the wireless would reach from the one I found. Maybe I should turn it on tomorrow and start prowling with my iPhone.

Other than that... I get tired early here. Like, around 9. I think I'm stopped waking up at 5 am, though only to wake up at 6.

First Day of Work

2009-06-04T03:31:00.004-04:00

I'll try to post what I wrote yesterday evening while Angel was using the computer, a bit later. Today's thoughts are for today, though.

My camera attracts attention here: people stop and ask me if I'll take their picture. And they all know that shortly thereafter they can look at the back and see themselves. My tok pisin is just good enough to ask them before I snap, mi laik kisim piksur? The answer is always yes.

Miriam makes friends like nobody's business; she charms everyone she meets and hardly seems to know a stranger. Potty-training is going slowly, but everyone who watches her is very understanding. I think the chronic dehydration of the tropical clime is helpful as well; she goes less often.

Today Erin saw 8 patients on rounds while I saw 3, with her help. Then she asked me if I wanted to see outpatients on my own, with a translator. I said yes, with some trepidation. But I'm here to help, not stand around like a medical student and watch. So I took an empty room and discovered we didn't have any translators available. There really aren't any formal ones anyway, so while they went to looking for some off-duty nursing students who wanted to earn merit points, I went down the line of waiting patients. "English?" And saw the folks who spoke my tongue. There were enough of them, including the man who complained of a finger infection. "Better," he told me. I peeled off the dried cotton balls and looked at a necrotic mess. To the ER, set up for debridement, X-ray of the finger, chloramphenicol and Bactrim by mouth. Come back next week, we'll X-ray it again. He spent the whole day, almost, here at the clinic; I saw him at 8 and debrided him at 12, once the ER had a spare bed. And sent him home at 12:30 with a bandaged finger and a handful of pills I hoped the dispensary would have. Nothing like at home; he would have had wound cultures, daily dressing changes, IV antibiotics, isolation and thousands of dollars worth of care. Here, it was one nervous family practitioner and a pair of iris scissors, thanking the good Lord that she'd taken the "easy" wound care rotation for a few weeks back at home. Probed the depth of the wound, felt bone. Hence the X-ray. Surgery says "come back next week" and we'll watch.
Osteomyelitis - bone infections - are common here; they're treated with long courses of outpatient oral antibiotics and sometimes surgery. Sometimes we stick needles into the muscle, apparently, to drain off excess pus.

One man showed up at my exam room door with two X-rays in hand. He'd been sent back to get another one, it seems, and then sent to see "an MD" by the health extension officer. I put the film up on the viewbox and went to get Erin, feeling like an intern all over again. It wasn't like the problem itself was hard to find: the entire left lower lobe was solidly whited out. It was the eternal question here: What do I do now? "Ultrasound him!" She hauled him off to the ultrasound room and put the probe on his back - et voila, nothing but fluid and fibrinous stranding. No cancer, just run-of-the-mill TB. Off to the white house to get started on TB treatment. No isolation, no masks, nothing like it.

I feel almost useless here, when it comes to evaluating new complaints - not because of lack of knowledge, but because I am without my crutches - labs, CT scans, a closet full of new and interesting drugs. I give salbutamol tablets to infants because there are no nebulizers and we don't have any aminophylline solution in stock. Those are my meds. I've never used so much oral Decadron in my life. We have Lyrica, oddly enough, and I write for some for the man with chronic pain after being "chopped" nearly to death by raskals four years ago. He tells me that Dr. Jim and God saved his life. We pray about it.

I find the chance to pray with a mother today as well, and it is not nearly as awkward as I feared. She brings her child - an infant in arms, seen yesterday and the day before for possible malaria. She threw up the malaria medicine this morning, and hasn't eaten well all day. Not suckling well either. I am already concerned, and then I focus on the child - pale around the lips, eyes closed, head tilted back over her mother's arm. She is breathing rapidly - I count 66 times a minute - and with the soft whining grunt that accompanies respiratory distress in children; her lungs are ronchorous. I can't get her to respond beyond a little stirring when I peer into her eyes. Her arms and legs are cool when I put on the pocket pulse oximeter, watch the waveform on it register a strong signal: 69% on room air. My heart stops for a moment.
Erin helps me with admission orders: chest X-ray, CBC, malaria smear, oxygen at 1L nasal cannula, no breastfeeding. One of our precious flasks of IV fluids (I didn't know there was such a thing as D4) goes to maintain hydration. I start her on chloramphenicol and malaria medications and review the little guide to caring for pneumonia in children in PNG to see if I've done the right things. I think I have. And then I look at the mother: Mi likim pray. Em i alright? She nods and smiles, and I find the words to ask for the things this child needs that I cannot provide: strong lungs, strong body. Healing. And they walk to the crowded pediatric ward when what I really want is a Peds ICU.

And this is my ministry here, in this place: to pray when it is called on me to do so, to heal when I can, and to give my strength and my mind to the tasks to which they are suited. I am overwhelmed, exhausted, but at the same time exhilarated. And I can do this. I know I can.

Tomorrow, I am on call. Whatever comes into the emergency department bilong mi. And tomorrow is a national holiday, so there is no outpatient clinic. I need Thee every hour.

2009-06-03T07:23:00.002-04:00

I think I've not had this many grown men threaten to kiss me... ever.

I fixed the Internet for the houses of 1/2 to 2/3 of the medical staff and their families today. Bad wireless card in one of the wireless bridge components. I'll admit I was weirded out by the presence of a PC card (remember those? From laptops built 90s? Before everything went USB?) just connected up to a circuit board witha an ethernet jack and some LEDs on inside the boxes. Thankfully, they had spares which had already been scavenged for parts or something, just not those parts. I thinkI could piece together 2 more (at least) of the things and set them up so they have spares.

Their Exchange server also has issues. But that might have been easier than this was, as I started a service and mail started being delivered. Though I'm not 100% sure what the problem actually was on e-mail. Will likely take a look at that tomorrow.

I also managed to get laundry done while Miriam was napping. I have been Busy and Accomplished Things today. It felt good.

Miriam seems to love it here. Making friends with everyone, regardless of what language they speak. It's facinating to watch her total lack of fear approaching people who live such drastically different lives than she does, and who look so different from those she knows at home. I hope she can keep that optimism and openness throughout her life. I hope some of it rubs off on me.

June 3 (AM): Some pictures

2009-06-03T06:01:00.002-04:00

“Welcome to Mount Hagen” – Angel is fascinated by the complexity of the local languages: tok pleis , or village dialects, tok pisin , the trade tongue, and English. We're learning bits of tok pisin as we go, out of necessity; the pikanini don't start learning English until third grade or so.

Children come through and try to hustle us, carry our bags in the market, hang on the shopping cart. We shoo them away repeatedly. They're bright-eyed and clever, well fed, in clean clothing, but still contrive to look pathetic.

On the way in from the airport we pass some straw-topped houses on a hill. It's not easy, taking pictures at 65 MPH over poorly-maintained roads, but I try to manage.

Yesterday, Diane explained to us that part of the road maintenance problem involves the clay soilbase here. Apparently, nobody dug down to the soilbase and leveled before laying road, so the topsoil slips and sinks, leaving an uneven road surface. In some places, it's completely gone.

I wouldn't describe what we do in the vans here as “driving” - it's more sort of a controlled careen, hurtling down the road as a projectile, trying to see and slow and avoid the worst of the potholes. I'm very glad I'm not the one steering this thing.

We arrive around twilight; unpack and eat dinner with Jim and Kathy. There are so many things I want pictures of, but I'm exhausted and I tell myself there will be more time.

There are days off, here, and when the outpatient department is done for the day I get to go home. My first call is Friday. She tells me that I'll be rounding on my assigned ward Saturday morning, and that then I'm free for the rest of the day. I can't go off base unaccompanied but I haven't lacked for company so far. I just need to arrange to borrow someone's vehicle so I can drive up to the hospital in the middle of the night, as I'm not allowed to walk alone after dark.

It's 6 AM and the light is brightening outside. The air is cool and humid, clinging to me, and the steady hum of night insects is being replaced by the chirp and twitter of morning birds. Everyone is up with me, Miriam coloring on the notebook, Angel reading pamphlets on Melanesian culture. It's going to be a good day, I can tell.

June 2: Filling the pantry

2009-06-02T05:57:00.000-04:00

June 2 ^nd :

Today was the get-acquainted day. The airport folks have not seen my wallet, but they will ask around and keep an eye out. We are trying to cancel cards, but cannot dial US 800 numbers on the cell phone we picked up from another missionary for a handful of kina, so I have left 4 AM messages on my mother's home number.

Drove into town this morning for a shopping trip to stock our cabinet for the next month. We looked around, bought pottery at the Christian Bookstore and woven baskets from the street vendors (now residing in the freezer, to kill all the bugs), and spent ridiculous amounts of money to buy groceries – pasta, carrots, corn, green beans – all the staples, as well as replenishing the curry powders and spices that are mandatory for cooking any more in our house. Noted after getting home that most of the pasta we bought was gluten/dairy/egg free vegan pasta made mostly from corn meal. It's very good. Tonight was pork loin medallions and penne with a coconut curry sauce and fresh pineapple.

Kumi came with us – one of the nationals – and helped guide us around to the right places, as well as putting the face of legitimacy on our business, so to speak. Or at least that was my initial understanding. There's a great deal of reverse discrimination in certain aspects of the culture – for example, Diane our American driver made certain to hold on to Kumi's hand when we left or entered a shop to indicate he was with us and therefore did not need to be patted down on exiting. On the other hand, my white skin and fragmented Tok Pisin meant I was a stranger and therefore got the higher prices for bags and baskets. We negotiated – or rather, I walked away and came back and Diane badgered the women and we walked away and came back – until the bag I wanted went from 50 kina to 35. But there's no bargaining. They say that, but what they mean is that you don't counteroffer. It's just a matter of deciding whether you want to pay their final pris .

Mount Hagen is a city like so many other third-world cities I've encountered in the travels I've done: dirty, noisy, full of people – and like it was in Nicaragua, I feel the curious sensation of moving within a bubble that is created by my essential strangeness . My skin is the wrong color, my voice the wrong timbre. I will never blend in here, not if every word I spoke was perfect. It is a curious sensation.

We had to wipe the dust off of the groceries before putting them away. Angel marvelled – he, whose only brush with a culture like this was in taking the wrong road in Mexico – and moved like a man unsure of where his next step would take him. His discomfort and anxiety were obvious, at least to me, and the little things like covering my money with my hand did not come so much as second nature.

We had dinner at the Western hotel, and drove through a gate in the wall to get there. We ate by the pool – burgers and fries and chicken nuggets – a little oasis that was a welcome relief from the press of the streets.

And then the market: hot, crowded, filled with trencher tables covered in fresh produce. Everywhere you looked there were vegetables – some familiar, some not so much so. We bought carrots and peppers and potatoes and onions and sugar fruits and leeks and some peanuts still lingering on their stems, fresh off the peanut plant. And pineapple and bananas as well. Elsewhere, oranges and nectarines and kaokao , the national tuber, which looks like a mutant potato and apparently is some variety of yam. We have it all in bags and bags, rinsing now to wash it all later, since nothing is safe for our delicate GI tracts fresh out of the ground or off the farms. The debate seems only to be whether it's soap and scrubbing or a dilute bleach soak to render it safe.

I had my tour today of the hospital: four wards, some operating theaters, and an outpatient clinic. The ER is a tiny five-bed affair that sees a lot of trauma. Everything is done differently here. We don't have much IV stuff, Erin tells me. Lots of PO antibiotics and casting supplies. Don't order labs like you do in the US. And I get to thinking: When was the last time I needed electrolytes to tell me what was wrong with a patient? It's been a while, although I check them on everyone. And our labs are limited indeed. A CBC, basic electrolytes (nothing to replace them with, IV wise), some liver functions, amylase and lipase. That's about it, and most of the time we can get most of them.

There's no ICU. There's no Q2h accucheck. Erin tells me that when someone codes, they're pretty much going to die. You can do some epi, some code drugs, try to intubate. But it's pretty much futile. Four wards: medicine-OB-pediatrics-surgery. Four concrete-floored rooms with bare-frame beds lining the walls, patients occupying each one almost solidly. No curtains between beds, no pretense at privacy. No air conditioning: the window slats are open to let the breeze through. It is still warm here in the Highlands, and humid. The air clings to me. I stare – rudely, perhaps, although it is my job to stare and to evaluate – and the patients stare back. Mutually evaluating. There are oxygen condensers and IV poles and white bandages. In the OB ward, there are three delivery rooms, side by side, with curtains for privacy. We cannot get to the OR. And I realize that I have left my stethoscope in the United States – so much for being helpful. Tomorrow, I will find out what kind of charting will take place on these people who are being given the best we can offer them under the circumstances.

Erin tours me through the hospital and then waves goodbye. Meet at 8 tomorrow and we'll round. You'll be with me in the morning, and Susan in the afternoon. I am “Doctor Nykki”, which settles comfortably around my shoulders, but it is the only comfortable thing about this place suddenly. One week peds, one week medicine, and two weeks of OB. They're pleased that I can do c-sections and seem ready to let me plunge in without auditions. They do D&C's in the delivery rooms under conscious sedation. There is no suction for such a procedure; it is done by curette. Oh. I am on call for Friday, which appears to be a national holiday, and the clinic will not be open, so it will not be a good day to be on call.

Baptism by fire. I do not know exactly what to pray for, today – for strength, and goodwill, and humility, and brilliance. That I know when to ask for help and what to do about it when I get it. And I wish I had not forgotten my stethoscope.

On the ground in PNG

2009-06-02T03:27:00.001-04:00

>
> Arrived without incident, despite having to get our bags, change
> enough money to purchase visas for the three of us, and make it
> through customs before boarding the plane in Port Moresby. We were
> met by our ride - and it wasn't until about halfway to the hospital
> that I discovered my wallet was missing.
> We'll check in with the airport in Mount Hagen tomorrow when it
> opens; if they don't have it then it's time to cancel credit cards
> and shut down my debit card and pray that that doesn't disable
> Angel's Citibank card as well, or we'll be up a short road when we
> get to Brisbane. Contents: driver's license, insurance cards,
> medical license, $150 total in mixed currencies, Citibank and debit
> cards. I still have my ATM card, at least, and some money, and
> Angel has all of his.
>
> We prayed over it - spontaneous, spur-of-the-moment sort of prayer,
> and the mission folks are coming together to step up to the bat.
> We'll be able to call the credit card company and the banks without
> difficulty - we may pick up a local pre-paid cell phone ourselves.
> And my heart is coiling with anxiety in me, but somehow I seem to
> have held it all together. And the Lord will provide, somehow. It
> will all work out.
>
> A blur of names and faces, melded by fatigue and unfamiliarity. And
> there will be time; it will work out. I will understand eventually.

Something Had to Go Wrong

2009-06-01T05:53:00.000-04:00

Trip from Brisbane to Port Moresby was uneventful. Port Moresby was a
bit... Slow and frustrating, but we made it. Met another doc on the
flight for the mission. The flight to Mt Hagen wasn't too bad, either.

The drive out to the hospital... I'll never complain about US roads
again. Foot deep, two to four wide holes in the road.

And just before we got to the hospital, Nykki realized that she didn't
have her wallet. We -think it got left on the plane. Airline didn't
have it, but we only got the departing one, which is where the plane
was by then. Will be calling the airport here in the morning. If not
there, we'll have to start calling cards and canceling.

And it seems my job is to fix the network on the half of the campus
where the house is. And tomorrow is a trip to town.

Dawn in the Land Down Under

2009-05-31T17:48:00.002-04:00

I've long lost any sense of what time it should be, at least according to when I woke up this morning. It's just after dawn here, and since I slept a good portion of the flight, it almost seems right, save for the 4-5 hours I've been awake during the end of the flight. Still....

Nykki was concerned I'd be feaking out. We weren't checked in for our next flight (or the one after that). Our luggage is -supposed- to be moving to our next flight, save the stroller, which in theory is coming up here to meet us for a plane-side check. So much is out of our hands that normally I would be a bit stressed about it, on a good day.

However the blur of jet lag is making me feel... well, a lot of things right now are no longer in my control, so I'll have to let what happens happen. Hopefully the luggage makes it, but I suspect it will. The stroller isn't a huge loss, as the toddler seems to thrive on airports, running around them with an energy I envy. And the rest? We'll make it happen.

Perhaps I'm mellowing. Or it's the jetlag. Perhaps a bit of both. These last two legs are what remain between us and stopping for a while. And the stop will be more unplugged that we get, even on vacation most of the time. (At least until I can fix the network there. It seems they have problems with it and email. We'll see when we get there, I suspect.)

I'm tired. I'm ready for the travelling to be done, I think. Tired of airports and cramps planes. Not much longer now.

Step 3: Brisbane to Port Moresby

2009-05-31T17:30:00.003-04:00

On the ground in Brisbane after a flight that continued to run smoothly. Miriam slept most of the way, and then watched Playhouse Disney and Dora on the in-flight entertainment system, and did not annoy our row-mate overmuch. She also did not cry. American Airlines checked us through only to here, so they have a lookout for our bags and are planning to take them off the carousel and recheck them. Similarly, our stroller was planeside checked and is hopefully going to be returned to the transfer desk.
This makes me anxious.

I am wearing a skirt now, unfamiliar as it feels, and have read the section on Melanesian culture in my travel guide. The Highlands are spoken of universally as a wild and fierce people, but fascinating. I cannot imagine - I do not know what to expect. I am a little bit afraid.

My Angel is experimenting with Tok Pisin, and seems to have the basic grammatical structure down. It is mainly a matter of vocabulary from here. We read the phrasebook portion of the Lonely Planet guide and toyed with roots of words. And soon we will see how right we are...

Half hour from now we're to check in at the transfer desk once again. Hopefully we'll have boarding passes. Then when we land in Port Moresby, we clear New Guinean customs before boarding the last leg. And then...

fly by post

2009-05-31T13:44:00.001-04:00

in the air somewhere over the ocean. so far an unetentful flight. tot slept 8hrs or 6re, and is watching dora. 2h of flight time left.

Message sent from a passenger onboard a Qantas flight

Limit your reply to 160 characters or message may be truncated.

Step 2: LAX to Brisbane

2009-05-31T01:31:00.000-04:00

Flight from O'Hare was smooth, almost disturbingly so. Only the bit where she poured apple juice all over her car seat was problematic. And the bit where we lost her snack cup. And the bit where she threw her goldfish everywhere. Small bits, really; overall this has been uneventful.

We've an hour to go before departure from LAX for Brisbane, and she hasn't stopped moving yet. We're both hoping this presages a crash lasting most of the overnight flight so we can get some sleep.

So far I've managed not to snap at my Angel for anything, and he hasn't been too grumpy despite irregularly ordering coffee, and we're going to Brisbane and it's so surreal I can hardly stand it. I guess I lack the ability to comprehend anything but the 14 hours facing us now, let alone the rest of the trip.
We've claimed a conversational semicircle of chairs for our things. She is running in circles with infantile mania; explaining to us how to wear our in-flight neck pillows; looking out the window at the planes.

Lord, grant me strength...

I keep reflexively checking my hip for my pager and almost panicking when it's not there. It feels very strange to be away at last. For good, even.

Step one: Get to LAX.

2009-05-30T19:33:00.000-04:00

It's 7 pm home time, 6 Chicago. Miriam is watching the airplanes through the terminal window and getting excited. I don't know how much she understands; she tells me we're going "up inna sky" on the airplane, and she explains quite well that out endpoint is Papua New Guinea, but she's also quite sure that we're going to see Grandma and Auntie Chelly there. I'm not sure how much I understand, really.

It's starting to become real, now that our luggage is checked and we're ready to fly. We'll have to pick it up in Brisbane, the way things stand now, and check in all over again. I only hope everything arrives with us.

Suffer ye the little children...

2009-05-30T00:12:00.000-04:00

I'm sitting on the South Shore line, watching my daughter make friends with a little girl she just met, chattering nonstop. I'm watching, and wondering where this extroverted creature came from. I look at strangers and I'm afraid - so worried about what they'll think, what they'll say - that simple conversation is a daunting task. What if I say the wrong thing? What if they don't like me? What if...
And I begin to understand what it means to be "like a child" - to know no strangers, to be ready to wonder, to approach the world with curiosity and joy. There are no 'what if' moments for Miriam - no worrying about what others will think. She just is - herself - without any artifice.

And what she is is beautiful.

"I tell you the truth, anyone who will not receive the kingdom of God like a little child will never enter it."
- Luke 18:17

On a warm summer evening, On a train bound for somewhere

2009-05-29T21:15:00.000-04:00

And we're off. Taking the train from our sleepy university town to The
Big City. We made the train with perhaps five, ten minutes to spare.

Tonight: a late night train. Tomorrow, a late night flight. And then...

Leaving work was hard. I won't miss the frustrations. But I will miss
the people. Even some of the customers, believe it or not.

For now, I'll follow the track laid before me.

Leaving On a Jet Plane

2009-05-28T08:27:00.005-04:00

I have two days left at work. It's becoming incredibly surreal here, the prospect of 30+ hours of airports and airplanes inching closer. And then... Then the Highlands of Papua New Guinea.

Part of me didn't think we'd actually go. Something would come up, whether it was the swine flu scare closing airports or something more likely, such as licensing not happening. But here we are.

I think I'm fearing the plane ride more than actually going. Eighteen hours in the air. Miri is normally so wonderfully well behaved, but I get stir crazy on trans-Pacific flights, I can't imagine it as a two-year-old. (Though I did do one at four. I don't really remember it, though.) Airports make me edgy. Travel makes me edgy, actually. I just want to -be- there, don't want to deal with all the tedious mucking about in the space, and time, in between. My family's habit of always being pathologically early doesn't help my psyche when it abuts Nykki's more European time frame. Lord grant me patience for this trip, as I suspect I will need it.

I waited patiently for the Lord; he inclined to me and heard my cry.
²He drew me up from the desolate pit, out of the miry bog, and set my feet upon a rock, making my steps secure.
³He put a new song in my mouth, a song of praise to our God. Many will see and fear, and put their trust in the Lord.
⁴Happy are those who make the Lord their trust, who do not turn to the proud, to those who go astray after false gods.
⁵You have multiplied, O Lord my God, your wondrous deeds and your thoughts toward us; none can compare with you. Were I to proclaim and tell of them, they would be more than can be counted.
Do not, O Lord, withhold your mercy from me; let your steadfast love and your faithfulness keep me safe forever.

Psalms 40:1-5,11

Here I am...

2009-05-28T00:13:00.003-04:00

It's late at night - midnight-fifteen or so - between Wednesday night and Thursday morning. I've been staring at the blank "compose" box on Blogger for two weeks or more now, trying to figure out how to write a first post.
I don't think I got it right.

These last two weeks - on call every third night for 24 hours at a shift - have been a whirlwind of trying to prepare for something I don't think I'm prepared for. Packing, purchasing, washing, and reading. We have bibles from World Medical Missions - a translation I like, with my name silk-screened onto the softcover. And I've thumbed it and read the passage that was inscribed on the gifting page, and stared at it. And I'm not ready.

I wasn't ready when we knelt in front of the church, with their hands on us and the little one, and prayed for blessings and strength and understanding. But I felt the power there anyway, and the Holy in the touch, and I thought maybe I could be ready. If I had time to think.
I haven't gotten it - that time - there are so many things I have to do before I go that every moment is packed full of doing and there isn't any time for reflection, and now it is Thursday and we leave on Saturday.

Thirty hours in the air: Chicago to LA to Brisbane to Port Moresby to Mount Hagen. We leave at 1900 local time on Saturday; we arrive at 1600 local time on Monday. Somewhere in the air between LA and Brisbane, Sunday evaporates like so much wind, and we land thirty hours and two days later. The idea of this flight - that is real to me, as real as the concrete understanding that we will be seventeen hours with a two-year-old who possesses very few skills that approach logical reasoning in the air. I am terrified by the travel.

I am not prepared for the arrival, for the journey from June 1st to July 2nd, for what is going to befall us in the Highlands. I have not had time to think about it - about the inevitable changes that will befall me, about the challenges that I will face. About what it means to put aside all of the familiarity and comfort of home and go where I am sent.
I am afraid I may not be a very good light on a hill. I am sometimes unsure that I am any sort of light at all, really, coming as I do from a church where evangelism is an uncomfortable and alien term. I find it awkward - frighteningly so - to use the word God in meaningful conversation, let alone to talk about Jesus or salvation or any of those terms from which the modern world has stripped the holiness. They feel empty, trite, as if I am falling into line with an -ology lacking the theos, the sanctity. And so I don't talk about it - I just do what I do and I pray that there is healing in my words and my hands, and I whisper to the Holy in the dark moments and the bright - but I don't talk about it. They want me to talk. To spread the Word that I feel so incompetent to speak about. To evangelize. And I don't know if I can do that.

I know I'm not prepared. I can't quote Scripture and verse. I haven't read the things I wanted to. I'm skimming and cramming for culture while Matt ponders learning Tok Pisin and political and anthropological depths of something I barely comprehend. But I want to go. I want to find myself immersed once again in another world, to feel the power of infinite complexity that shows in all creation. And I have to believe that it's enough that I am willing. I have to believe that the voice within is the voice of the Holy, and that I am a vessel for a love I cannot contain more than one iota of.

Because, after all,

He has showed you, O man, what is good.
And what does the LORD require of you?
To act justly and to love mercy
And to walk humbly with your God.
- Micah 6:8

The Times, They are A-Changin'

2009-04-28T14:04:00.002-04:00

With less than two weeks until we leave, the reality of this adventure and the move that follows is starting to set in. A week from this Saturday, we board a plane and head probably as far away from Western Civilization(TM) that I've ever been. It's a bit daunting.

The culture shock - that I can probably deal with. Yes, I'll miss the internet, but I've found I deal well enough when unplugged. I'm actually not too worried about the culture differences. The reading I've been doing has put some things at ease, though I do wish it was a bit more recently published. (1985 is when most of these were published, which was 10 years after the country gained independence. It's been nearly 15 years since then, and I know how much the US has changed in that time.)

I'm feeling a bit ungrounded with what I'm going to be doing. There's been talk about me doing tech work there, as they're apparently desperate for on-site technical support. The real questions I have are what decade of technology will I be supporting. (And will all be computers or will it be things like "the ultrasound doesn't work right".) I'm sure I can muddle through that well enough, but a bit of foreknowledge would be nice.

It will be an adventure, certainly. (The flight out there alone with Miriam will be an adventure.)