Saturday Call

I was on 24 hour call Saturday, and it was fun! The theme of my entire visit continued---learning, learning, learning.

When I take call here, as an internal medicine trained person, I am not trained in peds, OB, ortho, or trauma, so to bridge the gap there is always a back up person on with me. Yesterday that was Dr. Bill. As I intend to do many more of these types of trips in the future, I have tried not to be closed minded to learning these other specialties. However, I will say it's been fun doing new things and learning so much here, although my heart is still in IM.

The first great surprise of the day is that Dr. Bill showed up to rounds, which he did not have to do. Do you know what a sweet gift that is? How rounding works with the weekend is the Friday night person will see their whole ward and the surgeon sees their whole ward, which leaves me with the 2 wards left. In my case, it was the medicine ward (GREAT) and the OB ward (you want me to take care of pregnant people, are you crazy?!). I do want to learn, but have surprisingly not done too much OB here, so it was going to be a stretch to have me round there. As it turned out, the ER was packed when I arrived for call, and ultimately sweet Dr. Bill rounded on the entire OB ward for me!

The theme of the daylight hours was the ER. I admitted at least 10 patients, alot of kiddos and a few COPDers. What makes peds actually not that bad is these standard treatment books in PNG. It's a Sanford Guide sized book, that lists all the common illness in PNG, and standardized approved treatments. PLUS in the back, it lists all the common meds with doses by weight. Therefore, I haven't been doing any complicated math or calculating, I merely turn to the guide page and look on the table with the weight. I did end up with a really sick kid that we could not get IV access on, and ended up putting in my first IO (and later that night my second IO).

Sometime during the day, I got called that a first time mommy was in labor with TWINS! One baby was breech. Called Dr. Bill, and due to another sick kid, missed the first birth, but helped with the second. Just to make matters interesting, the OB ward ran out of OB trays, and had 2 other deliveries going on (the doctors only perform complicated deliveries here, the staff does the rest). So basically, Dr. Bill had to tell me what he needed, and I had to scour all over to find whatever he needed, mainly using supplies from a D&C kit. Mommy and twin baby boys are doing great! Dr. Bill walked me through sewing up tear in Mommy. There is a project in the US that sends these bundles for each delivery that includes an outfit and blanket, so you can see in the picture, the twins decked out in their new outfits.

Then in the evening, I got called for a penetrating stab wound to the back. When I arrived, it was exactly that, a man was drunk, and I believe got stabbed by his wife or girlfriend. When I walked, he had a BP of 60/40. I immediately realized that my finger could reach lung, and called Dr. Bill and then Dr. Kevin (our surgeon). It was a funny presentation, as I had no CXR or Hgb, you have to wait for security to find the X-ray tech at home to get that done. I did attempt U/S to look for a hemothorax, but Dr. Bill and I weren't successful in that endeavor. I asked Dr. Kevin, if he'd show me how to put a chest tube in, and he let me do it, which was fun! It was a hemo/pneumothorax. That is the top picture.

Simultaneously, another woman walks in with chops to her b/l cheeks and head. She was bloody, but really her injuries weren't too bad. And thankfully, the nursing staff can sew up lacerations here, so I could do the chest tube.

I got to sleep through the night, but then at 6 am this morning, I was called that another mother needed a C-section, so I ended my call assisting a C-section with Dr. Bill. We ended the day rounding on medicine ward together, and to leave a sweet present for Dr. Steph, we even conquered the peds ward (ok I saw like 3 patients, to his 20 or so on wards).

As my chief has always said, when your busy, you have plenty of learning opportunities (that's for you Sarah)! I am trying to take advantage, while I can!

Oddities plus a sweet addition

So there are on occasion things that just make me chuckle or perhaps go mmmmmm....I thought it was time to share a few.

First off, to some viewing this picture you see a drive train to a car (or to me it's just a car part, but I believe it has been identified as a drive train), to the PNG recyclers, they see a church bell. This bell belonged to the Hydro Church, not too far from station. I have also seen wheels and an oxygen tank (personal favorite) used as church bells.
We have fantastic security guards on station, which I am thankful for. Just last night, they were quite helpful controlled the ER crowds (in fact locking the doors to the ER---until sanity was restored). However, I cannot help but chuckle at the patch on their uniform. (Hat and left shoulder)
PNGers love to have their pictures taken, and sometimes they don't know how to smile. I was joking with this woman for not smiling, and this is the picture I got! The entire ward erupted in mayhem when I showed them the picture.

Finally (something SWEET) Jordan, who is the jack of all trades, (his wife teaches at the MK school) made a porch swing for the Barnabas House--where I live. He ran into a bunch of obstacles, but the swing was finally hung! And as someone who adores porch swings, I cannot think of any better addition to this place. This is Apa and Jordan enjoying the first seat on the swing!

And the lame shall walk...

Dr. Andy has taken an interest in talipes (clubfoot). He just says the need presented itself, and he found himself reading about it after a patient presented with clubfoot. Then he started internet searches, which eventually led to a trip in the US to learn the Ponsetti method (and meet Ponsetti himself). Now one morning a week, he has a talipes clinic. Through a series of stretching, castings, tenotomy (cutting the Achilles), then splinting, he is able to take a foot like shown above, and straighten it out to walk. It's pretty amazing work if you ask me.

The most interesting part to me is actually the splinting. Clearly there are limited resources here, but Dr. Andy found away around the fancy equipment/shoes in the US to make a PNG version. Essentially he make a wooden base with a certain incline to it, and then screws shoes to it. He said they brought back a suitcase full of shoes from the US. It works!

Call Day Notes

(Clearly I did not take this picture, but this is an aerial view of the station. The large cross shaped complex is the old hospital. The even large mass of rectangular buildings is the new hospital. Then if you follow the road that comes from the circle down to the bottom of the picture, I live just a few hundred feet out of view)

Another fun and interesting time on call, full of learning. Learning, learning, learning---this experience has been chock full of that! Of course, as per my usual in the US, all that learning came at the cost of little sleep last night.

• As some of you may know, I have a distaste for LPs (lumbar punctures, where you sample the CSF fluid). My distaste started in Africa, where I did my first LP late at night on a little baby, who seized in the middle of it. Ultimately I got it, after I shed some tears, mommy shed tears, and well baby seized (and likely cried before that). I have done this procedure a bunch of times, but just don't like it even though it is so simple. I walk into the ER in the middle of the night last night, to a toddler who needs an LP! I got it first try--and it was a CHAMPAGNE tap! (For nonmedical people, that is a good thing, it means I got no red blood cells during the tap, and tradition says that I get a bottle of champagne for doing it--which will be a tall glass of apple cider when I get home) Praise God! I was suspecting malaria vs meningitis (which can also be from malaria)
  
• I also had a fracture to cast last night, which I get some help with. BUT then today in OPD another fracture came in, and I thought I would spread my wings and cast it myself. I had Dr. Andy check on me, but I did it all myself. As you can see from the X-ray, that it was a tib-fib fracture, a kiddo fell out of a tree playing.
• I had 2 codes last night. Here a code is referred to as "going off." I find that kinda a cheeky phrase. Surprising to me, we actually do have code carts here, but really it is no where near the same as the US. Not to mention, that I have to await someone to call me, to know that it is going on. Frequently by the time I arrive, nursing staff may have been working on the patient for 10-20 minutes (imagining a code like we run in the US is the completely wrong imagery for a PNG code). What I have gathered is that my main job appears to be praying with the family.
  
• I still lack confidence with the ultrasound machine, but I am finding the more I force myself to use it, the better it is getting. Case in point, the surgeon and I needed to look at a patient's belly last night. It turns out I had more experience than him with ultrasound, and both us felt very confidence we were not missing any large fluid collections in the belly, which was what we were looking for.
• Ok my peds and ortho skills are improving, but OB is still a large void in my head. I am making some slow progress, wrote for oxytocin last night, and it worked.
• Finally, my driving on the other side of the road and this huge vehicle skills are also improving! To be fair, I really only drive like a 1/4 mile and am the only one on the road, there is a station rule that women cannot walk outside by themselves after dark. So when I am on call, I am given a station vehicle. I am still struggling with randomly hitting the horn, which is kind of annoying in the middle of the night! Opps! I haven't stalled the car once though.
  

Susie Homemaker

As many of you know, I am not exactly fond of cooking or most any kitchen related skill. The first full day I arrived in PNG, I was brought to Mount Hagan to do my grocery shopping for the month--yes, month! I would imagine that would be a challenge for some experienced homemakers, but for someone who does not consider herself good at this, this was a tall challenge. In the US, I would likely struggle with this task, but add to it a developing country, and yes it felt daunting to me. However, after few prayers, I thoroughly scoured of our kitchen, and found a trove of cookbooks, I was able to make myself a list. Of course, the fantastic help of Judy and Becky, who have 8 years experience cooking in PNG, was also a big help.

Well, that was really only the beginning of the challenge. At least in the US, I can buy box items or stove top cookers. Here, not so much. Cooking from scratch is the norm. I've had lots of help, being that my next door neighbor (Elaine, her husband is a surgeon) the first two weeks, I think fed me 3-4 times. Last week, I lived with Leslie and Kevin (he is a surgeon, replacing Elaine's husband, as they had been here the past 3 months), and Leslie might as well be crowned the PNG Martha Stewart.

I have ventured out on my own too, and surprisingly I have come up with some pretty tasty treats. I have made hand squeezed lemonade, and, in fact, even upgraded to strawberry lemonade. I did make my own bread (ok, yes I did have a bread maker, but it's the first time I've ever used one). I used up old bananas in yummy banana bread. I made a tuna casserole, in fact even hosted some girls to dinner. Tonight I made a very tasty curry chicken with broccoli and cauliflower over rice (yes, Margaux I managed to cook rice by myself).

I have found myself cutting up pawpaw (papaya) and pineapples. I did have some sugarfruit, which was described to me accurately as resembling snot, but tasting yummy. For breakfast, I have homemade yogurt (Judy had the entire setup needed, so I can't say I made the yogurt) and muesli. As soon as Reni returns from a conference, I have promised her homemade pancakes.

Of course, we don't have a dishwasher, so then I get to wash the dishes too. And there is no dryer for my clothes, so I also hang everything out to dry. Elaine also got me started on enjoying fresh arrangements of flowers on my table. Surprisingly, I am finding alot of joy in doing it all.

(despite the fact the photo is facing the correct way on my computer, blogspot is not cooperating)

Patients

Everyday I round of half of the B ward, which is the medicine ward. I have 15 patients. I round on them in the morning, and whenever I finish I head to the OPD (outpatient department) for the rest of the day (breaking for lunch). Every day is a new adventure with more to learn daily and I am treating a wide variety of illness. And although I lack confidence, I am learning alot of ultrasound skills.

Anna had to be sent to Hagan Hospital (we actually have our own ambulance). She has been with me for a week with abdominal pain. We saw free fluid in her pelvis, and I was treating for PID. Frankly, she never looked very sick, and daily her abdominal pain was rather nonspecific. However a few cultural miscommunications, I finally got a positive urine pregnancy test. Repeating the ultrasound, I found a mass outside of the uterus, which was consist with an ectopic pregnancy. Unfortunately, our only surgeon was ill today, so to get the surgery she needed I had to transfer her.

Monica is another patient who has been with me for about a week. She is elderly, with a very large spleen, and quite cachetic (in fact, as a measure of that, I have personally picked her up to transfer her). Her left lung continually fills up with fluid, which I have had to drain out. The working differential is TB or cancer. We pray together daily (she's pictured on the right with the yellow shirt). Her prognosis is poor, and likely we will not come up with a specific cause of her sickness, but we are treating what we know how to treat here.

I forgot my next patient's name, but she's pictured on the left. She has myasthenia gravis, a disease where your muscles fatigue extremely easily (including your respiratory muscles). I was shocked last week, when her scale book said myasthenia gravis, and even more shocked when I found appropriate medicines to put her on. In the US, we would have consulted neurology, here I am the neurologist. She came back today, and I am attempting to titrate her steroids and neostigmine (we don't have mestidon, and even most of the docs were shocked when I found neostigmine in the pharmacy).

Thousands of miles away, yet so close to home...

I was going about my business Friday afternoon, when my next patient walks in with a UNE sweatshirt (my undergrad and medical school)! I am pretty sure, even after a mini-geography lesson he has no idea where Maine is on a map, but it sure tickled me pink to see his sweatshirt.

He came to see me after a motor vehicle accident, and he had fractured his clavicle twice.