A different world: On call

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

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

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

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

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

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

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

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

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. 10You water its furrows abundantly,    settling its ridges, softening it with showers,    and blessing its growth. 11You crown the year with your bounty;    your wagon tracks overflow with richness. 12The pastures of the wilderness overflow,    the hills gird themselves with joy, 13the 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

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

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

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...

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.