First Day of Work

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

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

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

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

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

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

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

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

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