Post Call

It could have been a lot worse. Yesterday was a national holiday, so the OPD was closed. Any number of people had been told to come back to the clinic, and they all had the option of paying 30 kina ($11) to come through the ER instead of coming back at another date and paying the much cheaper OPD clinic fee. Fortunately, nobody who came was that ambitious. I got called only a few times - spoiled, they tell me - since I stayed in my own bed from 23:30 on.
I called my backup a lot last night - practically every patient I saw I wanted someone else's input on. Most of the conversations were "hi, Steph? I feel like an intern." At which time she would comfort me and explain to me the use of medications I'd never heard of. It was quite an adventure.

I took a bunch of fluid off of a gouty knee (all by myself!), read chest X-rays, admitted several people to the hospital. Sent several people home from the ER. Happened to be in there while the nurse (nurses here do a lot, from suturing to writing meds according to "the green book" - the standard manual of treatments issued by the government - so they only call me in when people are really quite sick, or they're stumped) was suturing up a kid's head. His watchman was looking on and then suddenly just crumpled to the floor - silently, like a falling tree. There was a truly remarkable "clang" as his head hit the base of the ER lamp, and we all scurried to his side. Save nem bilong yu? He did. And after a few minutes sitting down he was all right again. And I couldn't help thinking: he'd be sent for some kind of evaluation in the US, if that had happened in our ER. But here, fifteen minutes later, Yu stap arit? And off he went.

"I need you to see this baby." I have to drive up after dark; women can't walk alone on the station. I find the nursery - three warmers with two infants each - and unwrap the little package of infant. 7 months gestational age, born at home in the morning, not feeding well. Weight is 1225 grams. The umbilical cord is tied with a string. Baby is breathing well, startles, good reflexes. Looks about 30 weeks or so, though I don't have a chart in front of me. The blue book - the pediatric standard manual - has already instructed that IV antibiotics be started, crys-pen and gentamicin, about what we use at home, so it's just up to me to order fluids and approve the baby's admission. I write an order: keep in warmer. I can't imagine them taking her out, but the nursery is clearly at capacity. Tomorrow, they'll place an NG tube and start feeds. I explain carefully to the baby's mother what the risks are, simply: very small, infections are common, and I tell her that what she needs to do is pray for her daughter. And I pray. I'm careful to keep my requests reasonable - aware of the results-oriented Melanesian culture - but I don't know what else to do here, with no NICU.

B ward comes looking for me in the ER - they have a laceration after a vaginal delivery that needs fixing; the students only sewed up the external portion. They've allocated their maximum lidocaine, so now it's my turn to close the deep portion. I do a quick check - three centimeters long at least, left paramedian sidewall. Bleeding. And patient won't tolerate more than a little exam, so it's sedation time: ketamine and valium, one and one. Nursing starts an IV. I push the drugs. Two minutes later, she's staring off into space absently and I'm opening the deep laceration tray, with sidewall retractors and weighted specula and Jackson retractors and ring forceps and an army of tools. 0-Vicryl, per request (I can use that or chromic, she tells me), and a student to glove and hold my retractors, and the process is easy. I tell Steph I'm all right and will call if I need her, and I'm surprisingly proud that I don't. Nursing watches, and makes approving noises. I think I have a friend.
I stopped to see her today. She's doing well, feels good. No more bleeding. She thanked me.

Middle of the night, I get called for a distended abdomen on a child. I come into the ward and find a tense, hypertympanic, silent abdomen that's clearly painful. Review of the chart shows a dehydrated child with gastroenteritis on hospital day 5 of IV rehydration. I call my backup. "Steph?" I'm in desperate need of a CT scanner right now. Probably hypokalemic ileus, she reassures me. Make sure he has potassium in his IV and drop an NG. It's a discussion with the parents, who don't like the way their child coughs and gags during NG placement, about how this is important. And when the doctor says, they agree at last.
I'm by his bedside drawing out fluid with a 5cc syringe. No wall suction here. I have to keep readjusting the tube as the child retches it out, pushing it back in until I get return of breastmilk and the belching sound of gastric air. Finally, I re-tape the thing and it stays put. I say a silent prayer of gratitude for the hundreds of nurses who've started IV's and showed me how to tape tubes so they don't slide, and try the belly again. Miracle. I hear bowel sounds and the distension is already less tense; the child stops crying as I rub his belly. His father leans over him. Em i pullim win? I lay his hand on the baby's chest. Em i pullim win. He relaxes as he feels the movement of quiet breathing. And we say a prayer for the baby, and both parents thank me.

Had dinner last night with one of the missionary families; Friday is unofficial pizza night and we had lots of it, along with stove-popped popcorn and Kool-aid. Miriam made friends with four-year-old Olivia, who was quite tolerant of her presence, and showed off all her books and her tent. Very restful, except for the bit when I had to leave and go see a patient.

Today has been a day for rest and recovery; Gideon, who makes art by burning designs onto bamboo, came to show off his work. We bought a few pieces, and a letter opener for Miriam that had her name specially burned into it. He also played the mouth-harp for us. It was supposed to rain, but so far only a few sprinkles - nothing like the downpour that was yesterday.
We have been promised that Diane's housemeri will let her know, she thinks there is a sing-sing next weekend and if so we will go to it. There will be native gear and dancing and music. I am thinking that I should brush up my tok pisin by then, or I will be sorry.