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.