Elisabeth Hesse’s Blog

1-30-09: Why I’m not going into intensive care

I’ve already written my bit about why I’m not going into obstetrics,
so now I’ll hit another speciality and explain why I won’t be doing that.

The day started well enough–bright and sun-shiny (if that’s a word),
with nothing planned after rounds.  Then we started rounds, and
things went downhill from there.

Recovery ward went fairly smoothly.  The only thing that was decided
there was that one of the broken arm patients, who had his arm in a
splint and elevated to reduce the swelling, was ready for a cast, so
we decided we’d do that after we finished with rounds, thinking that
with the paucity of patients I wrote about yesterday, we would be
done soon.  Then we headed over to the OB ward, and there went our
great plan of having a quick day of rounds.  The premature baby
wasn’t looking that great at first glance, and when we looked a
little closer, we realized that he was gasping for air, and had a
pulse around 70.  That would be fine if this were an adult, but for a
tiny premature baby, it’s a pretty ominous sign.  Dr. Manar ran the
baby over to one of the exam rooms while the nurse ran to find oxygen
and Dr. Ovoi ran to find a ventilator bag with a neonatal mask, and I
tried to get the mother to stand up and walk toward the room where we
took the baby.  Before we could get the oxygen set up, the baby
stopped breathing, so Manar and I found ourselves doing baby CPR and
watching very closely.  It’s a little scary, doing chest compressions
on a baby that weighs less than 1.5 kg.  You can see all of the ribs,
and feel the sternum give way under your fingers, and everything
feels very fragile.  We finally got the baby to the point where we
felt like he was breathing on his own (albeit with the oxygen over
his face), and his pulse was back over 100.  I checked his pupils,
and they were slow to dilate, but they did.  We got another IV
started and hooked it up to the oxygen better (they have these tiny
little nasal cannulas), and the mother was still sitting out in the
hall, looking either depressed or bored, I couldn’t decide
which.  There was only one nurse in OB, and the two doctors and I
couldn’t keep hovering over the baby, so we decided to get him over
to the general ward, where there is better staff, and an outlet where
they can keep the oxygen plugged in after the electricity turns
off.  Unfortunately, the baby stopped breathing again on the way to
the general ward, and despite another round of resuscitation, we
couldn’t bring him back.  In all, we spent an hour to an hour and a
half trying to save that baby, and  we pronounced him dead at
11:10am.  I don’t know where the mother was when we finally said it was over.

After that, we still had to finish rounds (and see two more patients
with casts, both of whom were scheduled to get them off
today.  Neither had good-looking x-rays, so they have to wear their
casts for another two weeks), and it was around 1:30 by the time we
got home.  Since we didn’t get to cast the patient from recovery ward
after rounds, we went back into the operating theatre at 3 to do
that.  My job was to line the bones up while the strong men we found
(a nurse and two CHWs) held traction.  That was kinda fun, but when
I’m not sure the bones stayed where I put them when I had to let go
so we could put the plaster on.  I didn’t really want to become part
of the cast.

All things considered, with the day we had today, I’m glad that I
don’t have any assigned duties on the weekends.  I can use the day off.

1-29-09: Cleaning house

No, I didn’t clean my house. I’m saving that for the weekend. I’m referring to what seems to be a mass exodus of patients from the hospital.Today was TB day, which means we started with TB ward rounds. It was incredibly stormy all night last night (a lot of rain, wind, thunder, and lightning–the whole package) as well as hot and humid, so I didn’t sleep all that well. When I finally decided to get out of bed, it was still raining pretty hard, and after my breakfast of french toast (I felt like spoiling myself, I guess) I had a hard time convincing myself that I really should go to ward rounds. Well, I finally did decide to go, and despite using my umbrella, was fairly well soaked by the time I arrived. I also almost slipped and cracked my head open while walking between wards of the hospital, as the wooden floorboards were very slick. I was fifteen minutes late, but still beat both of the doctors by a good ten or fifteen minutes. I guess I wasn’t the only one who wanted to stay in today.Ward rounds went very quickly, because of the aforementioned mass of exodus of patients. It usually isn’t this way for the TB ward, though, which has a fairly static population–once patients come, they stay for two months, no matter what. Apparently, quite a few patients hit their two month mark since last week. When we walked through the other wards after rounds, we found them strangely empty as well. Either everyone was outside (why, in that rain, I don’t know), or the hospital suddenly got empty. I’m hoping for the latter. It means that not only are our patients getting better, but rounds tomorrow will be quick as well.The time between rounds and TB clinic (in the white oven of a clinic house) was spent doing a whole lot of nothing, which was actually pretty nice. Then it was TB clinic, during which time we told half of our eight patients that they need to go home, get two months worth of supplies (food, clothes, bedding) and come back to the hospital to begin their treatment. Two of those were from the next village over, so they’re supposed to come tomorrow, but the other two were from rather far away, so it’s debatable when they’ll come back, if at all. Then we walked through the wards again, checked on our preemie baby (who is now premature, tiny, and jaundiced) told the mother that she needs to try breast feeding again and, as it was sunny by this afternoon, needs to go outside and sit in the sun with the baby (that took awhile to explain–it took a few tries to get her to understand that she needed to go outside, and once she did, another few to get her to move from the shade to the sun). Hopefully she figures it out soon. Yet another reason why eighteen-year-olds, in any country, shouldn’t have kids.Manar and I decided to hit up the market and store after we were done at the hospital, so I restocked my fruits and vegetables and treated myself to ice cream again, and then relaxed again before our evening run on the “road”, which is more torn up than usual, on account of the storms from last night and this morning. It’s fellowship tonight, so I guess I should probably get home to shower and get cleaned up before then.

1-28-09: Just another day

I was trying to think of something for the title when I realized that there was hardly anything remarkable that happened today. Maybe now that I’ve been in PNG for four weeks, everything will be routine for the remaining two. Right.Since today was Wednesday, we began the day with ward rounds, which took less time than usual, as Drs. Ovoi and Manar decided to split up at the beginning, with Ovoi taking the recovery ward and Manar heading to OB. I stuck with Ovoi (I’d much rather see recovering patients than OB), and the first thing that greeted us was another broken arm, which I think makes four broken arms and a broken leg since I arrived in Kikori a week and a half ago. That’s a lot of plastering limbs, and Ovoi and Manar agreed it was more than usual. But onto some updates about some of the patients: Former Leprosy Patient is continuing to improve, but it’s still looking like we’ll take his remaining little toe once his wound from his last amputation heals. Giant Cyst Guy (from my first day here) came back to have his stitches removed, and we discovered that the cystic fluid is staring to reaccumulate, so we drained that, but did tell him that this going to be an ongoing problem unless he gets it fixed (under real anesthesia) in Port Moresby. We also have a preemie baby in OB who weighed in at 1.5 kg at birth and is still with us, although the mother doesn’t really seem to know what to do. Right now, we’re giving him formula through a nasogastric tube (tube from the nose to the stomach). And The Patient Formally Known As Coma Guy was discharged today. He’s still a little weird (borderline catatonic, I’d say), but his mother says that’s normal for him, so off he went.I also got an update from Kapuna about some of my previous patients. The one who was really sick in TB ward is slowly getting better, eating more and sitting up more. Bleeding Guy is continuing to improve. There’s no swelling in his arm and he’s beginning to use his hand, although he’s still very anemic despite two blood transfusions, and still having high temperatures despite antibiotics and malaria treatment. He’s on TB treatment now. We also had a little kid (not sure if I wrote about this or not) who I thought might have HIV, but it turns out that he doesn’t, so that’s very good news.We ended ward rounds today by plastering one of our fractured arms (before they can be put in a cast, we form a splint until the swelling goes down), and then headed off for lunch before clinic. I felt ambitious and decided to do laundry, and then made my way down to the white little oven of a clinic house to see the four patients who bothered to show up (we were scheduled for ten; three of those came, and one walk in). All of them also wanted their names put on the list to see the ophthalmologist coming in March or April, even though I think most of the people on the list are simply getting old and having vision problems related to getting old.And, of course, since I did laundry today, we got a flash downpour shortly after we returned from clinic, so I made a frantic rush outside to gather my laundry, then rigged a clothesline (out of a mosquito net) in one of my spare bedrooms as an indoor clothes line. They won’t dry as fast, but at least they won’t get soaked while they’re inside.The rain had let up by 6, so Manar and I, as well as Robbie, a Bible translator here for a few days, decided to go on our usual run at 6. And of course, as soon as we started, the rain resumed. We got rather soaked, but considering that we usually end up soaked by the end of a run, it wasn’t that big of a deal.Tomorrow is TB day. Hopefully that means treating it and not catching it.

1-27-09: Walking casts and non-walking patients

Don’t worry; today was a much better day. There will be much fewer complaints about sweaty patients and water pumps :)The day started with a bit on unease, as I thought I’d be spending the morning in antenatal clinic (pre-natal checks), and OB is not, by any means, my strong suit. Fortunately, that didn’t happen. Before heading over to clinic, we checked up on a few patients, including the baby we did the I&D on yesterday (doing fine) and a woman who had a cast for a broken tibia (leg bone) put on six weeks ago. We got some x-rays to see how it was healing, and discovered that it didn’t quite line up before being casted, so she’ll never have a completely strong leg. We checked the book on fracture treatment, and depending on the type of fracture and how they’re doing clinically, a cast should be on for 9-12 weeks. Well, clinically, she wasn’t better, either, as she kept complaining of pain, but we determined that based on the type of fracture, she should have had her large cast for 4 weeks and a walking cast for another 8 or so. So we took off the old cast (which is an ordeal–no fancy saws here!) and tried to figure out the best place to put on her new cast (meaning location of the patient, not the cast–we figured the broken leg would be a good place to put the cast). We ended up taking her to the operating theatre and gave her a nice, fancy walking cast–at least as nice and fancy as we could do with plaster. It’s a bit thinner than we would have liked, because it needs to be light enough for her lift, but we gave it a good rounded bottom and made it so the knee can bend, like the book said. Then, after all this work, we asked her to put weight on it, and she started sobbing in pain–not from the fracture site, but from her arthritic knees. So after all of that, I don’t know if she’ll be walking, anyway.While we were working, we received word that a chloroquine overdose was on its way, so as soon as we washed the plaster off of our hands, we checked our toxicology books to find antidotes for chloroquine. There aren’t any; the treatment is to make them vomit it up, assuming they’ve taken it recently enough. We headed to the outpatient ward in search of our patient, only to discover that nobody had any idea what we were talking about. The only new patient was a known epileptic who had had a seizure.It was almost 1 by the time we finished there, so I decided to reward myself for a morning well done by getting ice cream from the store. The tide was up, and it was raining a bit, which made the walk a bit treacherous. I discovered that the bridge, made from flattened metal barrels, is quite slick when wet. Don’t worry, I didn’t fall, just kinda slid around in my flip-flops a bit. But I got my cheap ice cream, so I guess it was worth it :)The only thing we had scheduled for the afternoon was a staff meeting, most of which didn’t apply to me. The biggest issue that came up was how to do women and child health clinics. As it is now, kids are seen for vaccines on Mondays, antenatals are seen on Tuesdays, and family planning (birth control/depo shots/tubal ligations) are seen on Wednesdays. That means if a woman comes for her depo shot on Wednesday, with her 6-month-old in hand, they’re told to come back on Monday for the baby to get vaccinated. Not exactly the best system when you have people coming from quite a distance away. So Dr. Manar brought up the possibility of making all three days open to anybody in those groups, but the staff wasn’t convinced. It sounded like to me from their arguments that they could do it, but they’re afraid that if word got out that anybody could be seen on any day, they would be flooded. They don’t realize that it would actually even out their workload–they often get swamped on Tuesdays with all the antenatals, but have hardly anyone on Wednesdays for family planning. Plus, changing the system would create a better-rounded patient care system, where mother and child can be cared for in the same visit, but they’re unconvinced, so it’s doubtful any change will take place. It’s not the first time I’ve seen this here, where they seem to have their minds made up about what will work best, so we just gave up the argument and moved on.It cooled down quite a bit by later in the afternoon (it’s been raining on and off all day), so it was pretty comfortable when Manar and I braved the “road” for our evening run. “Pretty comfortable” is a relative term, of course–I’m still dripping in sweat.It’s going to be a long day tomorrow–ward rounds in the morning and clinic in the afternoon. Hopefully I can handle it without flying 

1-26-09: A long and tiring day

Today wasn’t looking all that great from the beginning. It was hotter than usual last night, and I had a hard time falling sleep, leaving me still feeling tired and groggy this morning even before rounds began. And then rounds took forever! Four new patients were admitted last night, so we had to see them in great detail, in addition to all of our previous patients. The Patient Previously Known As Coma Guy is still awake, but not really making much sense or doing much–most of the time, he just sits there and stares into space, but he does respond when spoken to. Former Leprosy Guy (otherwise known as The Guy With Two Right Toes) is actually doing better. The wound where his middle toe used to be is beginning to heal, so we decided we’re going to continue his leprosy treatments and wait for his skin to heal a bit more, then we’re going to take off that remaining little toe. And our patient with the broken arm that had been reduced twice got his second set of post-reductive x-rays, which shows that, once again, we didn’t reduce the fracture. It’s now been two weeks since the injury, so there’s really not much point in trying again, so we’re leaving the cast on and telling him that hopefully the bones will grow together, but he’ll probably always have a bump in his arm.And then there were the new ones. One, which took a great deal of time, was a man with a giant bump on the back of his head that, according to the family, just appeared there in December and hasn’t changed since. His problem, actually, wasn’t really the lump on his head, but the abdominal pains, fatigue, confusion, and loss of appetite. He was a heavy smoker until about four months ago, which back home would mean lung cancer until proven otherwise, so I suggested that we do a chest x-ray. Well, one had been done a few weeks ago, and looked fairly normal, according to Dr. Ovoi (I didn’t actually see it). So, probably not lung cancer. Maybe it’s TB. I don’t know.There was a little baby that we had been following for an abscess on his back, waiting for it to get to the point where it can be incised and drained. It reached that point. We couldn’t do it during rounds, obviously (I&Ds are never all that easy on kids, especially when the abscess is as large as it was), so we told the mother we’d do it in the operating theatre in the afternoon, which meant we had to arrange for there to be power in the afternoon (there’s usually not). We finished rounds at 1:30, after five hours of seeing patients (and none of those were emergencies), and then it was home for an hour and a half before returning to do that I&D, during which we pretty much felt like we were torturing the patient, because the ketamine and diazepam we gave, despite making him rather stoned, didn’t do much for the pain, so he was crying the whole time. We did get a bunch of pus out, though, so I guess it was a success.Overall, I think I have a love-hate relationship with PNG. I definitely enjoy the people, I feel like I’m learning quite a lot, and I’m certainly enjoying the tropical weather compared to the winter back at home, but I’m tired of not sleeping well and not being able to communicate with my patients very well and always smelling like sweat and the wards (my clothes seem to really absorb the smell after being around sick and sweaty patients for five hours). I also miss my ever-present internet connection and my link to the real world. I know people would argue that it means things are simpler here, but I don’t know how “simple” I would say it is, when the doctors have to rely on whatever pocket books they have handy, and consults to specialists in Port Moresby via emails that may take days to send and receive.I guess I’m just frustrated today by the heat and lack of sleep and the pain in my feet from standing for so long in flip-flops (not exactly the most plush of footwear). I thought ice cream would make me feel better, but I’m out of time to go down to the store and get some (the store closes at 6, and it’s already 5:45). Alas. Oh, well. There’s always tomorrow. 

1-25-09: Ice cream!

Yes, there is ice cream in PNG. It made me happy.Today, being Sunday, was church, which is a bit more of an ordeal here than it was a Kapuna. The church is probably the mid-point of the loop that Dr. Manar and I run most evenings, which doesn’t really seem that far or hot when running at dusk–just about a fifteen minute jog on the world’s worst road. Well, running at dusk is completely different than walking at 9am. I saturated myself with sunscreen, wore my sunglasses, and used my umbrella as portable shade, and I could still practically feel my skin burning as we walked. Not to mention, we were walking rather slow, to prevent being completely drenched in sweat by the time, which didn’t really work–we were both (Dr. Manar and I) fairly soaked by the time we arrived around 9:40.Church was an interesting experience, in that it was in both English and Pidgin–Larry, the pastor, would say something in English, then say the same thing in Pidgin. I would say that that’s helping add to my Pidgin vocabulary, but to be honest, I was so tired from the sun and heat that I didn’t pay much attention to the Pidgin. So for the meantime, my Pidgin still consists of a few medical terms and the appropriate greetings at various times of the day (that’s pretty easy: Morning, Afternoon, and Night).On the way back from church, we swung by the market, where Dr. Manar loaded me up with fresh PNG fruits, and then the store, where I had heard they were selling ice cream. They were, for K1.50 (about 53 cents), which I definitely couldn’t complain about. It wasn’t quite the same as Cold Stone or Baskin-Robbins, but it was ice cream, and it was cold. Well, not cold for long–I had to eat quickly, as the heat at noon in PNG can melt ice cream pretty efficiently.After church and shopping, there wasn’t much to do during the day, so I was back out in the veranda, lounging and going through my reading material at an alarming rate. Then for dinner, I cooked myself chicken breast using the grill section of the range (as the oven part doesn’t work), which didn’t turn out too bad–although my mother’s baked chicken is better :)Tomorrow, it’s back to the wards. Hopefully there won’t be any mysterious unconscious patients who miraculously wake up this time.

1-23-09: The long road to Kopi

The day started out fairly routine.  As has been the case all week, I had a hard time dragging myself out of bed, but I did manage to show up at the wards around 8:30 for rounds.  Recovery ward rounds went fairly well, although we did have to talk to Leprosy Guy (otherwise known as Guy With Two Right Toes) about restarting leprosy treatment and the possibility of amputating the remaining small toe (I decided it probably wasn’t a pinky toe after all).  All of this prompted Dr. Manar and I to pull out the Oxford Guide to Tropical Medicine (a pocket reference that Dr. Manar has) to look up leprosy, because neither of us have seen it, and we both (or at least, I) pretty much dozed through the lecture about it, figuring that we never will see it.  After reading that brief chapter, I still feel just as clueless.

No big problems awaited us in the OB/GYN ward, either, until we were leaving that ward en route to the General ward, when we got pulled aside by a few new patients.  One was a girl who had been cutting grass with a knife (they call them knifes, I call them machetes) on Tuesday and managed to get her shin between the blade and the grass.  Since the tibia (shin bone) is fairly superficial, there’s a good chance she nicked the bone, which opens her up to osteomyelitis (infection in the bone).  So we sent her to x-ray, and now that I think about it, haven’t seen her since.  The other was a bit more complicated, and we still don’t know what the deal is.  I’ll call him Coma Guy.  He came in unconscious with a very full bladder (called a neurogenic bladder) and posturing, which is a sign of something bad in the brain.  When I checked his pupillary responses, his eyes were somewhat dilated and very slow to respond to light, another sign that something is bad in the brain.  We’re pretty sure that his brainstem is intact, because he wasn’t drolling (indicates he is able to swallow and has a gag reflex) and he had intact oculocephalic reflexes, known as Doll’s Eyes, because when you turn the head, the eyes move the opposite way, just like a doll.  So, his brain is bad, but he’s not brain dead.  Best case scenario is that he gets better; worst is that he goes into a persistent vegetative state (Terry Schiavo, anyone?).

So while we were doing this full neurologic/potential trauma examination (nobody was able to give us a clear history of what was going on), I was running a differential diagnosis.  The first thing that came to mind was drugs, but this doesn’t fit any toxidrome (toxic syndrome) I know of.  Then we were thinking head trauma, but he wasn’t bleeding anywhere, and his head felt intact.  His malaria test was negative, so that rules out cerebral malaria.  Cerebral typhoid is still in the picture.  We have him on medications for everything in hopes that something will work.  As of this evening, he’s still the same.

After finishing ward rounds around 1:30, Dr. Manar invited me up to her house for lunch (thus saving me from yet another peanut butter sandwich), and then it was an afternoon on the veranda with my mattress and my book until we got word that a car from Oil Search at Kopi had arrived to take us up (I’m still not exactly sure why, but whatever).  During the hour long drive along the road (and I decided “road” is a Pidgin word that in English roughly translates to “completely undriveable dirt and rock path”.  For anyone else raised on a farm, think of the worst canal road you have ever been on, then add a few million rocks of various sizes, hairpin turns, steep grades, and people walking along, and that’s the road between Kikori and Kopi), I talked with Vicki, the nurse who visited the other day, some more about the HIV/AIDS campaign in PNG and what exactly she did.  A lot of her work involves going from village to village getting statistics, which doesn’t seem like that bad of a gig to me.  I think that would be a good way to spend a year, to go throughout the country—or even through a province—getting HIV statistics and checking up on the education and counseling.  That being said, I don’t know if that’s in my future at all.  I still have another few months of medical school, then four years of residency, then my four years of obligation to the Army (which may or may not expand to an entire career) before I can start contemplating year-long stints doing (civilian) preventive medicine in foreign countries.  But I still think it would be fun.

There wasn’t much for us to see or do in Kopi except eat dinner (with fresh vegetables flown in from the Highlands every day!) and then pile back into the Toyota for the ride back to Kikori (now add “in the dark” to the road conditions previously described).  Then we checked on Coma Guy again before calling it a night.  Tomorrow, it’s back in the operating theatre (remember, British English here) to re-reduce the fracture from Tuesday, as our post-reductive x-rays have shown that we didn’t really reduce it at all.  Hopefully we’ll get it on the second try, and we won’t need a “third time’s a charm.”  That’s something to pray for tonight.

1-22-09: Seeing God in unexpected places

It’s not that I don’t see God’s hand in many places, in many different ways, but sometimes it appears where it’s not expected. I’ll get to that in a bit.The started pretty well. For some reason, I’ve been rather reluctant to get out of bed the last few days (it must be the later start here compared to Kapuna), and today was no exception. Knowing that I had to be down for rounds at 8 (it was actually 8:30, but that’s beside the point), I finally got out of bed a little after 7 and began my day.TB rounds actually went fairly quickly. We started around 8:30, and were done by 10, so I was rather impressed. Even Drs. Ovoi and Manar seemed surprised by how quickly we finished. Everyone was doing well and improving on treatment, which meant there wasn’t much to do during rounds, which is always a good thing. After that, we sat with the hospital matron and Vicky, a nurse from Oil Search (I’m not exactly sure what Oil Search is; I think it’s a large corporation here in the Gulf) about HIV/AIDS education, counseling, and testing. She was very helpful in answering my questions about how HIV/AIDS is taught and perceived in PNG, which appears to be several decades behind the US in these things. The state of Washington (I can’t speak for any other state, since I didn’t grow up there) has mandatory HIV/AIDS education every year from the 5th grade until graduation, with the attempts of keeping it age-appropriate for each grade. It has only been in the last two years that PNG has added such a program to their school curriculum, and since I haven’t seen how they teach it in schools, I don’t know effective it is. So, anyway, most of the adult population is completely clueless about what HIV is, how it’s transmitted, and how it’s treated. Part of the problem, as was explained to me, is the language barrier–it’s hard to have someone trained in HIV/AIDS education and counseling in each of the 800+ native languages of PNG.Anyway, after a leisurely lunch of a peanut butter sandwich and more laundry by hand, it was back down to the white clinic house (or oven, as I think of it) for TB clinic. Most of the patients in TB clinic are those with a possible diagnosis of TB glands, so they had shown up in outpatient with enlarged lymph nodes, and were sent to Thursday clinic. Before giving a diagnosis of TB glands in most cases, you have to rule out other infections, so most patients were given a course of antibiotics and told to return to clinic in two weeks for recheck.Then we had the rest of the afternoon off (from about 3:30 onward). I dragged a mattress (really thin foam mattress–think summer camp-style mattress), of which my house seems to be the official storage place in Kikori, to my veranda so I’d have a comfortable place to lounge as I read and somewhat half-dozed off. Around 6 it cooled down enough to go running with Dr. Manar, which resulted in even more blisters on my feet. I should probably give myself a break, but I doubt I will. Then it was back to the house for dinner before heading over to fellowship.And that’s where my ’seeing God in unexpected places’ came up. Not that fellowship is an unusual place to see God, but that’s not what I’m talking about. They showed a video of some American Christian speaker (I don’t know who; nobody I had heard before), who talked about salvation from the cross. He ended the speech with a picture from the Hubble telescope of the Whirlpool galaxy, over 30 million light years away, and what the Hubble had seen was the image of a cross in the center of that galaxy, which I think is a fairly unexpected place to find one. It was a little awing (I don’t know if that’s a word…) to me, the thought that God put that image of a cross in that galaxy more than 30 million years before He created man to need salvation in the first place. That just goes to show that He always has a plan for us, even when it’s hard for us to see.I’m listening to the rain right now and dreading the thought of having to walk back to the house in this torrential downpour, but I guess I have little choice. I have my umbrella, but judging from the sound of the rain, it’s not going to do much good. At least it’s not a cold rain.

1-21-09: Another long, hot day

I guess I shouldn’t complain about the hours too much. The othernight, I was telling stories about some of my third-year clerkshipexperiences with Dr. Manar–the fourteen to sixteen hour days, themean residents, the endless scut work, the mean residents–and Iguess I have it pretty nice here. She, however, couldn’t believethat I was working those kinds of hours, and asked if we don’t havesome sort of work hours restriction in the States, which made melaugh–these are the conditions after the work hour restrictions havebeen put in place. It used to be worse.But that is neither here nor there. The started at about 8:30 withward rounds. Unlike at Kapuna, where one ward is rounded on at atime in a schedule that has each ward visited roughly every other day(except TB ward, once a week), here all the wards are rounded on onMondays, Wednesdays, and Fridays, at once (except TB ward, onceagain–that’s once a week on Thursdays, so I’ll talk about thattomorrow). So we started in the Recovery ward (mostly injurypatients, as well as our two surgeries from yesterday). Our GiantCyst Man is doing well, although he still has some pain. Weexplained to him (since he was pretty delirious on ketamineyesterday) that we didn’t get the entire cyst wall out, so it willprobably fill up again, and he’ll have to go to Port Moresby to haveit completely removed under general anesthesia. We also saw aleprosy patient (former leprosy patient? I wasn’t quite sure) with achronic ulcer on his foot that required the amputation of the middleof the three toes he had left. So now he has two, and the smaller ofthose (it might have been his former pinkie toe) isn’t doing so well,either. So he might soon have one toe.Next was the General ward, which is split into pediatrics and adults,and I got to feel proud of myself for my medical knowledge onceagain. We had two four month olds (unrelated, not twins) who bothhad a heart murmur, so I asked both of the mothers, in my brokenPidgin (which is funny, because Pidgin is broken English), “His skinwet with sus-sus?”, which translates to “Does he sweat when hefeeds?” One said no, the other had giant sweat stains on her shirtto confirm that, yes, he does sweat when feeding. After asking thisthe second time, both Drs. Ovoi and Manar asked why I was asking, andI said, rather confused, “Because that’s one of the classic signs ofa VSD.” (Ventricular septal defect; a hole between the ventricles ofthe heart. It’s a fairly common congenital defect, and most close bythree years old). Neither of them had been taught that! I thoughtit was common knowledge, with how much they drilled it into us duringmy pediatrics rotation (”If a child comes in for their four monthcheckup and the mother complains that he sweats while breastfeeding,what’s your differential diagnosis, in ten seconds. Go!”) So I gotto feel like I was teaching something, which made me feel a bitbetter about the fact that I did little else during rounds.We finished rounds around 12:30, and then it was home for a quicklunch (peanut butter sandwich) and some laundry (which is done byhand–ugh) to hang to dry before heading over to clinic for theafternoon at around 1:30. I actually got there at about 1:45, and Iwas still the first one there. We finally started around 2:30, andabout five minutes later, we were all so hot and tired that we wereglad that only five patients (out of the ten scheduled) showedup. The most interesting patient at clinic was a 13-year-old girlwith a persistent lump on her neck for years, without changing andwithout any other symptoms. We thought it might be a thyroglossalduct cyst, but we tried to aspirate, and it was solid. If it wereeither TB or lymphoma, we’d expect some changes (either growing orotherwise changing) and some constitutional symptoms (weight loss,fever, sweating), but she didn’t have those. We have no idea what itcould be. If she had this in the States, she would have had a biopsydone on it years ago, and then surgically removed.After relaxing on the veranda for the rest of the afternoon, I wenton a run on the “road” (I use that term as loosely as several othersaround here). I’ve been on unmaintained paths that were smoother andin better condition, but it provides a good exercise, if you ignorethe blisters that are beginning to form on my feet from running onuneven terrain in my hiking sandals. Such is life. Then it wasdinner and conversation with John Loscombe, an Australian missionarywho is here for the night before heading to Kapuna tomorrow. He alsobought me some more food and supplies for my house, so I am foreverin his debt.Anyway, it’s getting late, and the power is going to turn off soon,and I don’t want to be caught out in the dark after the lights goout, so I should go. Tomorrow is TB wards and TB clinic, andhopefully both of those go well.

1-20-09: Beginning with a bang

Tuesdays at Kikori means surgical cases (or, as they say here,theater cases. Actually, since they speak British English, it’sprobably ‘theatre’ cases), and those don’t start until 9, so I got tosleep in, which was nice. My new house is actually quitecomfortable, although I think my shower is out to get me: since thewater tank is on the roof of the house, it reaches near-boilingtemperatures as it sits there during the day, so when I took myshower last night, I got pretty well scalded. I think I’ll starttaking showers in the morning again.When we arrived down at the hospital, we found a small gatheringoutside the outpatient ward, and discovered a patient waiting (that’susually what a gathering indicates). A man was fighting with hisson, and his son pushed him off the veranda (balcony or deck would bea good translation), about 2 meters off the ground, and he hit hishead on the way down. He had a rather impressive-looking lacerationon the top of his head. Dr. Ovoi (that’s her first name; everyone isreferred to by first names here. I’m Dr. Elisabeth) looked at me andsaid, “Do you want to suture?” Well, I’m not a huge fan of suturing,but I can do it reasonably well (as well as fourth-year medicalstudents can be expected, I guess), so I said sure. They didn’t havethe kind of suture I would have liked to use, and they use reusable(after sterilization, of course) needles, which aren’t the sharpest,so those 15 stitches took quite awhile, and as the beds don’t adjust,I was bent over the whole time, so my back was pretty sore, too.Anyway, while I was sewing, a snakebite patient came in. I didn’treally have anything to do with that, because I was bent over a guy’sbleeding head.After playing seamstress, I headed for the operating room (”operatingtheatre”, I guess), where I had to change into scrubs (they providedscrubs–essentially blue dresses made out of scrub fabric, withanother dress wrapped around my head like a turban for ahaircover. Don’t worry, I have pictures). The first case was amanual reduction of a fracture and casting, so I didn’t really havemuch to do with that. I scrubbed into the next one (scrubbing isreally not comfortable with sunburnt hands and arms, by the way),which was a cyst removal–a very large cyst. Well, since we don’thave ventilators, we can’t give general anesthesia, so we tried to dothis with local anesthetic and ketamine, which is a dissociativeanesthetic (no pain relief, but makes you forget everything) and itdoesn’t really knock you out. So our guy started screaming in alanguage none of us could speak, then started singing, and soon allthree of us (Dr. Ovoi, Dr. Manar, and I) were laughing veryhard. Unfortunately, we couldn’t get his pain under control (it’snot good when the patient grimaces and kicks when you try tooperate), so we drained the cyst and then closed it up withoutremoving the cyst wall, which means it’ll likely reaccumulate. Whenit does, he’ll have to go into Port Moresby so he can have itsurgically removed under general anesthesia.All of that took about five and a half hours, so I was ready forlunch when that was over. Fortunately, there’s nothing for thedoctors to do in the hospital after surgical cases, so I had the restof the afternoon off. I tried to bake bread (well,kinda–self-rising flour, milk powder, sugar, and water), but theoven part of my gas range (I don’t know what exactly constitutes arange, so I don’t know if that’s the correct term) refused to light,so I had to use the grilling/broiling section, which is long andflat. So I spread my “bread dough” mixture out on a cookie sheet andmade one long, thin slice of “bread”, which I’ll cut into smallersections for peanut butter (and banana–there’s no escaping thebananas) sandwiches for the next few days. Hopefully my stove willlight tonight so I can actually cook dinner (rice and vegetables).I don’t know what time rounds are tomorrow…I guess I should go askDr. Manar. I don’t want to show up late.