It was a long day today, starting with tok pisin lotu at 0730. I sang along with songs whose words I did not completely understand, although one of them was a translation of "Just a Closer Walk with Thee", which I sort of pieced together. And then I listened very hard as the chaplain read the passage where Jesus calms the wind and the waves:
And when he got into the boat, his disciples followed him. 24A gale arose on the lake, so great that the boat was being swamped by the waves; but he was asleep. 25And they went and woke him up, saying, ‘Lord, save us! We are perishing!’ 26And he said to them, ‘Why are you afraid, you of little faith?’ Then he got up and rebuked the winds and the sea; and there was a dead calm. 27They were amazed, saying, ‘What sort of man is this, that even the winds and the sea obey him?’There was a meditation following the devotional - about how Christ is always with us, and how He doesn't promise us a smooth ride - just a safe landing. And there was probably a lot more to it, but it was all in tok pisin and my skills are woefully inadequate for that sort of philosophical discussion. I'm more on the level of discussing children's activities: You gat wanem sameting? Ya, snake! But there was something soothing about the rhythm of the words, about the repetitive voice, about the bits I could understand. Win go down. Wara go down. It was a good prelude to a day that was tumultuous at best.
I'm accustomed to being pretty good at what I do; I've had excellent training and plenty of experience. But I feel like an intern, here. I'm slow - I was inordinately proud this morning that it only took me three nurses and two and a half hours to see fifteen patients, most of whom I'd seen before and didn't need any new changes - I'm sub-confident - checking in with the others on things that normally I would never need to staff - I'm hesitant. All of that will change, once I'm comfortable with what I'm doing. It will also help as I learn more Tok Pisin, I think. Sometimes, entertainingly enough, it's like a game of Telephone. I speak English. My nursing student speaks Tok Pisin. The patient's watchman speaks Tok Ples. The patient answers in Tok Ples. The watchman repeats it in Tok Pisin. The nursing student tells me in hesitant English. And out of all this I'm supposed to get a history. Top it off with the Melanesian concept of time - if you ask a PNGian if they've had a headache, they'll tell you yes, even if the last headache was years ago - and it's a nightmare mishmash of questions I would never ask at home.
Today, mingled among the interesting patients, were four women with menstrual complaints. One had a history of 2-week-long periods, according to the intake nurse; when I asked her, she said she'd only had one, and it was over now. One told me she bled for 3 weeks every month, with big clots. One told me she'd always had irregular periods, and that was all right, but they hurt a lot, now that she'd been treated for her chronic PID. And one was a patient billed as "a girl" in her chart who was perhaps sixteen, hadn't menstruated in five or six months, and had glomerulonephritis which we finally decided was steroid-resistant, which meant I got to decide how to taper her steroids. Not one of them had a hemoglobin less than 9 or any abnormal findings at all. Furthermore, I'm not certain any of them actually had period problems in the first place, but I did offer a short course of oral contraceptives (we have them!) which was accepted by one of the three women I considered it in.
I've done a lot of pelvic ultrasounds today. I can now successfully identify a non-pregnant uterus and do a transabdominal measurement of the endometrial stripe, and maybe even visualize the ovaries, with a little luck. Once Scott found the kidneys for me, I could visualize them as well, but the finding is still a bit tricky. They think it's funny. "Um...that's outside the uterus. I'm not so hot on it." But I can do an AFI, an estimated fetal weight, and I figured out where the color-flow and pulse-wave dopplers are on the ultrasound, so I looked at outflow tracts today. I don't think I can do cord dopplers, but only from lack of having someone to show me exactly how.
Saw my patient with the gouty knee from this weekend, first-off. He greeted me with big smiles and a big handshake. He's feeling much better after two days of colchicine. I started him on allopurinol for when he's done with his week of acute therapy. And it wasn't a septic knee, which is so reassuring to know.
There's lots of heart failure in the Highlands - rheumatic fever, malaria, typhoid, high-salt diet, idiopathic, cor pulmonale, etc. I saw some today. I managed some today - ACE inhibitors, diuretics, sometimes beta-blockade, and aminophylline. I'd never used aminophylline in patients with heart failure before I came here - but I know at least one at home that I would try it on now. A brief literature search suggests it has positive effects and decreases the frequency of Cheyne-Stokes breathing in heart failure patients. It's also used here for apnea of prematurity in newborns, since we don't have caffeine drips, ventilators, or any of the other trappings of NICU docs in the States. I tweaked some meds. That much I was comfortable with, with checking X-rays and looking at fluid in fissures and eliciting symptoms (although, slip means both"sleep" and "lie down" in Tok Pisin, so sometimes it's hard to pin things down).
Wasn't so comfortable with the woman who walked in with "a mouth sore". What she really had was a giant fungating mass on the right side of her palate, extending way back to the pharynx. And on the left side of her tongue, she had leukoplakia - firm white scaling of the skin that is in no way normal. And I looked at it and my mind said "she has cancer". And I didn't know, I'd never seen anything like it before, so I went and got Scott. And by the time I was done describing my findings, he was nodding. "She smoke?" Used to. "Buai?" Blank stare. "She chew betel nut?" Oh! Teeth and gums stained with it. He nods. "That's the killer combination."
He came with me anyway, and looked into her mouth, and clucked his tongue. Two different oral squamous cell carcinomas, extensive. ENT referral - to Mount Hagen hospital, the nearest specialist clinic. And he spoke rapid-fire pidgin, explaining to her that she must go, this Friday, to Hagen and see the ENT - and that it still might be too late. And then he did what the missionaries here do so well. Yu save Jesus? I followed enough of the flow of the conversation - the urging that she put her affairs right, the discussion that her life was more than earthly existence. And the prayer, so unlike my own clumsy words - for healing and understanding, calling in the promise of salvation, heartfelt and eloquent in a language that is not built for eloquence.
I hope she goes to Hagen, and gets treatment, and does well. I may never know. And I hope one day I can speak with that much open and unapologetic faith.
Ran from room to room most of the day, trying to spread my questions out so nobody realized I was staffing almost every patient. Saw maybe half of what anyone else did, I think. Learned a few things about treatment costs. A doctor's outpatient visit here costs between 8 and 10 kina ($3-$4). A CBC costs 4 kina, but a TSH costs 20. An X-ray costs 6, an ultrasound 12. Everything is "go buy this, then get it done."
Several chronically perforated eardrums, one with a hole I could thread a pencil through, red and draining. Dug through Pharmacy 2, then came back and wrote for eardrops after verifying I had them. I had to staff that one, to find out that I could go look in the pharmacy. And I had to ask the nurse working there to show me where the eardrops were. But I made it through.
There's a woman on the ward who came in almost three weeks ago with fever and altered mental status. Successfully treated for typhoid, she's now much less confused and wants to go home. I glance through her chart, and notice a nursing note from several days back: "patient with pressure ulcer, chart out for MD to review, seems infected." So I peek. And I call Jim the surgeon over. You can't send her home like this. And I know I can't, not after looking at a 4x6 inch wide purulent mess that is her sacrum, the fevers that are mounting, the smell that emanates from her. It's not body odor, it's the stink of infection. You can't miss it. Steve the visiting surgeon comes over, as do all the nursing students. "This is why you turn patients." Everyone stares. We'll put her on the schedule for today. Any other 'oh, by the way' folks?
No, sir.
Overwhelmed. Exhausted. And tomorrow may not be any easier. I am comforted only by the knowledge that I am helping, even if only a little bit. Wednesday I move to B ward - OB. I am strangely terrified by this idea. We'll see how it goes.
No comments:
Post a Comment