Meanwhile, we were also wondering about a
pregnant lady who had come in with slight pains.
At first the CHW had diagnosed a UTI, but as the
story unfolded bit by bit we found that she had
ruptured her membranes on Friday, 5 days before,
and the pains she was feeling were akin to labour
pains, though less severe and less often. Because
she had lost most of the amniotic fluid we had
trouble figuring out what that medium-sized hard
lump in her abdomen was at first, then because a
pregnancy test was strongly positive and fetal
heartbeat was strong, the trouble became figuring
out what happened, the lie and presentation of
the baby, and what to do next. What made it more
difficult was that there probably was an element
of IUGR (she was very thin), and she was a grand
multipara with a history of 2 neonatal deaths
before this one. 5 pairs of hands tried to
ascertain the baby’s position, and with much
prodding and palpating we decided it was probably
a transverse lie (we were all certain that the
head was not in the pelvis!) and despite the
contraindications, external cephalic version was
tried and failed. She and baby were stable
though, so our plan was to keep her that way
until there was transport to transfer her to a better-equipped hospital.

One life gone, one more at the brink and could go
either way. The fight for life and against death goes on.

Ruth and I started learning the art in Kapuna
during our 3rd week there, and regretted that we
didn’t start sooner! There’s a lot of work put
into one bilum – the rolling of the wool
together, stitching the mouth then the body then
the handle, learning the different stitches, and
that’s not including learning how to do the
different patterns! Yet with our good and patient
teachers under the old dorm at Kapuna, and here
in Kikori, we’ve progressed (the extra time on
our hands helps a lot!). I’ll be carrying my
bilum around from time to time, and I’m very
willing to pass the knowledge along!

They’re definitely a testament of how versatile
the Chinese are – they came here not knowing any
English or Pidgin and had to learn as they went
along when they got here, yet prospering in
whatever situation they’re in. They take
discarded shark’s fins, which the locals don’t
have any use for, to dry to make shark’s fin
soup; the mother makes tofu (hard and soft)
They’re also very generous – they make friends
with all the “foreigners” who come, and are free
with gifts – Dr Manar and Dr Ovoi have been
invited in for Sunday lunch of the famous Teochew
porridge, or as he called it “water-rice”, and
some hospital staff sometimes get free cans of
Coke when they pass or when they buy something
from the store. They were very generous to us too
– meat of both raw and tinned variety, canned
drinks, onions, tea-leaves, etc. Very pai-seh,
yet I think we’re welcome company, especially for
the daughter who’s about our age, and spends her
time here mainly in the shop. We’re definitely
going back, to perhaps buy more things and chat
(at least Ruth will chat more than I will!) with them.

In the three days, we visited 4 villages in the
Gope region – Bavi, Buri, Ubu’o and Goilavi, and
vaccinated an average of about 80 children in
each village, most of them getting 3 or 4
vaccinations, and many of them just getting their
first doses over the age of 1, as there hadn’t
been a patrol in the area since 2-3 years ago,
and the CHWs at the nearby aidposts had been
negligent in keeping the children’s vaccinations
up-to-date. The number of vaccine vials we needed
was underestimated, as we were supposed to visit
two other villages, but somehow we had just about
enough for these 4 villages. The crowd we drew
seemed to get bigger and bigger with every
village, as well as the racket the children cried
up not only when being vaccinated, but just being
weighed! I think I got immune to their cries from
the 2nd village; it becomes background noise and
you just put your head down and work.

Patrol was the time we learnt how to really live
PNG style. Even boarding the dinghy at Kapuna
required us to take our shoes off to wade out to
the boat, and most of the time I walked around
barefoot, with the mud squelching through my
toes. One of the few times I tried walking with
my slippers I was trying to ferry our bags from
our overnight house to the boat, and just as
Suzie, one of the CHWs, was making a comment
about the mud, I slipped and fell, my backpack
and thigh taking the brunt of the fall, and I had
to go around the rest of the day in muddy jeans.
Rest assured, I was extra-careful the rest of the
trip! We ate PNG-style, with plates filled with
carbohydrates in the form of rice and noodles and
sago-coconut batons for dinner, and fried flour
cakes and biscuits for breakfast, from which we
were supposed to eat what we wanted and discard
the rest. The Chinese in me refused to waste
anything though, so every night I went to bed
with a full stomach. It’s just as well we worked
really hard all day to burn all the carbohydrates
off. We bathed PNG-style from buckets of well
water, each taking turns holding the torchlight
through the door; and toileted PNG-style, either
the drop-toilet over the river, or the pit toilet
where you could see the wriggly creatures that
fed on your excretions. At night we’d go to bed
early, after dinner, not only because we were
tired but because there wasn’t any light besides
a small gas lamp to do anything by. We’d have
slept PNG-style, on mats, as well, except that
we’d been given a mattress and mosquito-net, which we were really grateful for.

We were fortunate that we didn’t get caught in
any rain while we were traveling from one village
to another on the dinghy, rather it rained when
we were on dry land – at night for a cool night’s
sleep, when we had a solid roof over our head for
our work, while waiting for some of the girls to
finish vaccinating the school children. I shudder
to think how we’d have felt to be soaking wet and
have to face so many screaming kids! Rather, from
the first boat ride out of Kapuna I developed a
tan line around my watch, even though it was
overcast, and have steadily gone darker and
darker since. Much better than the pale colour I
had on the way back from London!

We not only immunized children, we saw sick
people and dished out family planning advice
(this also ran out by the 2nd/3rd village). Many
of the sick people we saw had minor complaints –
a cough here, fever there, and we gave whatever
we could from the limited drug supply we had.
Some were more serious and/or complex – an old
man with a funny twitch and history suggestive of
grand mal seizures and chronic backache; very
thin old men and women with chronic lung disease
more likely due to previous bouts of TB but also
could be having another bout of TB; and a young
baby boy who looked more like an emaciated old
man – all skin and bones, a deformed chest from
continually coughing and breathing laboriously,
not looking like he’s eaten or drunk since he was
born, despite the mother’s assertions that he
takes porridge three times a day. I wanted to
carry him off back to Kapuna (or anywhere else
really) where I could take care of him, but the
worst thing was that I felt there was nothing I
could do there and then that could make things
better. I hope this baby is now in Kapuna, having
been picked up by the patrol team on their way
back, and is slowly on the way to recovery.
That’s really all we could think of doing – give
small amounts of medication to see them through
till they could get themselves (or we could get
them) to the nearby hospital, be it Kikori or
Kapuna. And these were only the people who’d had
problems for a few years before realizing they
should seek help! If what are in the hospitals
are the tip of the iceberg, those we saw in the
villages are only the thin layer of ice below
that tip, and goodness who else is out there in
the villages or in the bush, thinking that
they’re alright when actually they’re not,
especially in the case of TB. Even the kids were
quite confusing – were their tummies distended
because they were well-fed or malnourished, were
they thin because they were so active or because
an illness was causing them to lose weight? It
definitely takes more than a month of practice to
be able to tell the difference.

Although going on patrol was a busy and slightly
stressful time, I wouldn’t have missed it for the
world – for the eye-opening experiences, the
opportunity to practise my diagnostic skills, and
the chance to share lives with the villagers and
our patrol-mates Olynna, Suzie, Everlynn, Tinel
and Margaret and driver Max who did everything
they could to make us feel comfortable and
useful. And most of all, to see evidence of God’s
hand guiding us from village to village, keeping
us safe and well, and seeing Him work in the villages, slowly but surely.

Children’s ward round on Wednesday afternoon had
been busy and long, but I didn’t appreciate that
until now. It was a good thing many of them were
improving on their treatment, so I could say
“continue” quite safely. Then the CHW pointed to
a child and said “He’s fitting”. Alarm bells rang
in my head! And he truly was – not in a classic
tonic-clonic febrile seizure kind of way, but in
a more subtle way, that Dr. Valerie would tell us
later was characteristic of TB meningitis.

He’d been started on his TB treatment on
Wednesday, but was still spiking temperatures and
getting increasingly stary-eyed. He was given
phenobarbital to help him sleep the night before,
and Ruth and I were contemplating giving him
another dose, when Dr Valerie appeared on the
verandah. She decided that he should have a
lumbar puncture to positively diagnose TB
meningitis, not any other kind of meningitis, and
Ruth got to perform her first LP. It was crystal
clear, which made it TB, but by then he’d fitted
twice already, and his fits were getting longer.
A dose of rectal diazepam was given, but he
promptly moved his bowels and didn’t get the full
dose, so we had to give him another dose later,
to supplement the IM and oral Phenobarbital he
also got. With all that sedation, he was just
about out like a light, and I got to pass an NG
tube for him to get his medications and fluids.
Throughout the day he just lay there,
occasionally fitting, the fits becoming more
tonic-clonic in nature but fortunately not
increasing in length. My heart went out to the
family, and going through my mind the whole day was a prayer for little boy.

There was also a 10-year old girl who’d had IV
penicillin the day before, which had brought her
temperatures down to normal. Unfortunately, her
IV line came out before she’d had all her doses,
and the nurses tried unsuccessfully 3 times to
put another in. We decided to leave her be, but
in the afternoon her temperature went up again
and we had to put another line in for IV antibiotics.

A girl I saw in the ward round couldn’t stop
crying when I tried to look at her, and I
couldn’t see in her mouth for Candida or listen
to her chest at all! I spent a good 15 minutes
trying to coax her into keeping quiet but then
just sent her off to get her medicines.
Thankfully she was asleep when ward round was
over and I could finally examine her in peace.

Evening saw us still worrying about the fitting
baby and sick 10-year old girl, and still no sign
of Dr Valerie back from Baimuru! Thankfully the
adult and antenatal wards were relatively quiet –
only the old man with the mysterious knee
effusion which had seemed to respond to TB
medication had relapsed and gotten pain and
swelling in the knee again, but he’d also stopped
his NSAID doses, and restarting it brought the
pain and swelling down again, which was good.

Hearing Dr. Valerie’s voice was a sound for sore
ears! And after unloading all the issues in the
wards on her (and half-wondering how she did this
every day of the year) and realizing that we’d
done almost all the right things (and most
importantly not killed anyone!) a small sense of
satisfaction bloomed in my heart. The day felt
like the longest we’d had in Kapuna so far, and
definitely the most tiring and worrying, but
perhaps also the most satisfying. Seeing the baby
alert and sucking well from his mother’s breast
and not fitting any more this morning, and seeing
that girl who needed the IV drip keep her
temperature down, and seeing that the man with
the bad knee could move his knee freely again,
added to that satisfaction. So perhaps this is
why I’m willing to slog it out doing medicine…

Anyway, after this weekend we’ll be off doing
more doctor-ly duties on patrol, on the way to
Kikori. Expect tales of village living, and of
lots of babies being jabbed, and lots of searching for former patients!

I’d had planned on going for TB ward round
Wednesday morning, but when I arrived the nurses
told me a snakebite victim had come in with signs
of invenomation, so Dr Valerie went to get the
antivenom. Luckily for the guy, who didn’t see
what snake it was, there’s only one poisonous
snake in the Gulf province, which is the death
adder. So he got death adder antivenom. The only
problem was that he was bitten at 3 pm the day
before, and the antivenom was leftover from
another case of snakebite, so it was only the
next day before he lost his sluggishness and slurring of speech fully.

1 hour after we gave him the antivenom, Suzie,
the CHW in the delivery room, came to tell me
that there was a primiparous lady who was just
about fully dilated and was ready to deliver.
When I heard that it was her first baby I was a
bit hesitant, not willing to put myself into a
problematic long-drawn delivery again. But she
was a great pusher, and although she needed an
episiotomy, we delivered her baby girl in due
time. I got the opportunity to sew up the
perineum as well. Ah, the sweet success of a problem-free delivery!

The next day the adult’s ward round that I went
to was quiet, but that was only in preparation
for the guy who came in the afternoon from
Baimuru saw mill. He’d put his hand through the
saw and it had cut through the base of his left
thumb, leaving it attached by only a bit of
thenar muscle and skin at the dorsal side. One
dose of IM pethidine knocked him right out for
the whole 2 ½ hours it took to figure out how to
fix him, and there wasn’t even a twitch of pain
from him! Ruth and Dr Valerie fished around for
tendons (again) and nerves (which they couldn’t
find) and blood vessels (we could see the radial
artery pulsating, thankfully, so they tied off
the severed blood vessels). There were fragments
of bone as well, and we couldn’t make out whether
it was the scaphoid, trapezium, or the phalange,
so it was just tied in place near the radius,
hopefully to act as some kind of stable structure
for what was then a floppy thumb.

After inserting a makeshift drain, I was given
the opportunity to loosely suture the wound,
jagged edges and all, and then we splinted his
wrist to allow the tendons and bones to heal in
what we hoped would be a satisfactory manner.

As of now, his thumb is nice and pink, but he has
no feeling in it, and perhaps slight movement. 2
out of 3 isn’t that bad, and at least he’ll have
a thumb for grasping things with. We’ll see how he progresses.

We had the first few modules, which were
introductory in nature- dealing with anatomical
and medical terms, an overview of the systems in
the body, general cell biology, and finally skin
anatomy and physiology. Later on we taught them
the cardiovascular and lymphatic systems. I
foresaw difficulties in taking the class about
anatomical and medical terms, especially as the
first class we were teaching, but Ruth was
wonderfully patient with them, going through each
term and concept a few times to make sure they
understood. My sessions were fast and merciful,
to me at least! I thought they all understood,
because I asked the class collectively and most
of them answered yes, but Ruth made sure each one
understood. Anyhow, out of the 5 hours for each
module, we probably used an average of 3 per
module, leaving them ample time to copy relevant
information from the textbooks and revise. Or at least I hope they did.

Picking the right word, and doing self-editing in
the milliseconds between thinking of a word and
actually saying it, was the big challenge for me.
Often I’d find my lips already forming a word
when my brain flags it up: “Wait! I don’t think
they understand that!!” but by then it’s too late
and I’ve said it, and I have to find ways of
explaining the word/term. I found knowing
something about word origins helped me here, for
example I like to think that my breaking the word
“homeostasis” down to “homeo-”, meaning
same/similar (I think!) and “-stasis”, meaning
stay, helped them remember the concept of
homeostasis as the body’s way of maintaining a
proper environment for its essential activities.
Then that came in useful in haemostasis – the
process of making the blood stay. It made sense
to me anyway, and I think it made sense to them!

Picking the right examples to use was a challenge
too. For example, how do you explain how a white
blood cell recognize bacteria as pathogens? I
ended up using the concept of antibodies as
stickers that stick on enemies of the body (e.g.
bacteria), and if you have a sticker on you the
white blood cells eat you up. Then the lymph
nodes in the lymphatic system (how do you explain
about the lymphatic system to someone?!)- I used
the analogy of the lymph nodes as gates in the
wall of an important city, and the white blood
cells in the lymph nodes as guards at the gates
who scan the incoming traffic and get rid of any
troublemakers. For some reason after I talked
about the spleen they were really interested in
how to treat an enlarged spleen. But for a nation
with a lot of malaria cases, I probably shouldn’t be so surprised.

I didn’t get to learn all their names, but I’d
have forgotten them promptly anyway. I did go
through how to feel a pulse (important skill for
CHWs!) one-on-one, and hopefully they’ll always
remember that I taught them that. Haha That being
said, I hope they don’t fare too badly after
having two guest teachers who they probably only
at most three quarters-understand, and will graduate with flying colours!

There are some patients whom you’d like to give a
bit more privacy, and the best that can be done
is a side-room in the wards. We’ve seen several
people in quite a bad way this few weeks, from a
man with a mysterious illness who died quite
unexpectedly over the weekend, to two cases of
probable malignancy where there usually average
one cancer a year. Not only does one want to give
them some semblance of privacy and dignity, I
have the frustrating feeling of wanting to give a
concrete diagnosis but find my knowledge and facilities lacking to do so.

The unfortunate young man came in with pus-filled
neck lymph nodes, which probably meant that he
had TB of the glands, and he was duly put on
anti-TB drugs. However he developed
hyperpigmented painful patches of skin in his
axilla and perineal area which ulcerated and
caused him lots of pain. His illness also left
him weak, and on top of all that he developed
acute renal failure. He’d been here since we
arrived and I had a few tries trying to diagnose
him, but couldn’t make the picture any clearer.
He was apparently getting better despite
everything that had happened, when he developed a
cough. He was tried on penicillin Saturday
morning, but he suddenly died later in the
afternoon. The provisional diagnosis was pyoderma
gangrenosum, but whether or not it was that it
was a sudden and sad way to pass away.

An old man was brought in one afternoon and I was
present to do his clerking in. He’d had problems
with swallowing for a few months, but you could
see the problem was more than that – he looked
absolutely cachectic, and when he lay down his
abdomen was a yawning cave mouth. With his
progressive history of dysphagia, and in the
absence of fevers and night sweats (which would
have made it oesophageal TB) the only other
diagnosis would be oesophageal cancer. But there
was no real way to make sure – we had no X-ray
machine or any barium to do a barium swallow, and
definitely no endoscope to put down his throat.
And he had no other signs that could lead to a
definitive diagnosis. As a last-ditch effort he
tried to swallow anti-TB meds, but it only made
him feel bad and vomit more. In the end, he
decided to go back to his home to die, and Dr
Valerie tried to tell him and his family the
gospel good news in his own language which she
didn’t really know. I hope she did get through to
him, and that he’s feeling peace now even as his body rebels against him.

The other case of cancer was an old lady from the
village down the river, and she came in with a
humongous swollen abdomen – ascites, so big that
it was causing her pain and difficulty breathing
and eating and drinking. She had no
temperature/fevers or anything to show that it
was infective in nature, so the other possibility
was malignancy (no alcohol problems here), and
that was supported by the bloody nature of the
fluid Dr. Valerie took out from her distended
abdomen. No fancy catheters and what not, just an
IV canula and loads of tape. It lasted only a
short while, because she wanted to lie on the
floor and the family hung the fluid bag above her
– fluid could have gone back in that way. Anyway,
just as quickly as she came, she was gone, back to her home to die in peace.

So although we’ve been told that our time in
Kapuna will be very relaxing, it hasn’t really
been that – we’ve had our share of interesting,
confusing, or worrying (and sometimes all of the
above) patients. And most, if not all, have a
definite need for healthcare, some of which just
cannot be given here. There is good quality staff
here – the CHWs and nurses trained here and
elsewhere do a terrific job of keeping things
together, but all this for one doctor to handle
can be an awesome challenge. Add to that the fact
that a lot of the drugs and instruments are
out-of-date and/or of questionable quality, and
many of the simplest investigative methods aren’t
available (e.g. microscope) let alone more
high-tech ones (e.g. X-ray machine), and it means
that even the best people are limited in their
healthcare giving capabilities, as is the case here.

They do their best though, and a very amazing
best it is too. (Their postnatal mothers may have
better immediate follow-up care at their disposal
than mothers in UK, for instance!) And what they
lack, they leave other more capable Hands. The
willingness of the staff to share and lay hands
and pray may be better for health than any of the medicines, sometimes.

She was primiparous (it was her first baby), and
had felt her first contractions the afternoon
before. She was progressing slowly but surely,
and to try and speed things up her membranes were
ruptured for her at 10 pm. At this point she was
about 7 cm dilated. The cervix should dilate at
about 1 cm/hour, so she was scheduled to deliver
at 1-2 am or thereabouts, and I decided to hang
around and read a book or two to monitor her
progress and hopefully deliver her baby.

Unfortunately, her progress still remained slow,
and my progress through the book too fast, and at
2.30 am she was examined again and found to be
only 9 cm dilated! By this time my patience and
that of the night call sisters was wearing thin,
and the mother was quite exhausted from the pains
as well. CHW Rita decided to start delivery at 3
am instead of waiting and letting the mother tire
more, and on hindsight it was probably a good
idea as mother was quite uncooperative! She
couldn’t push properly, either being too tired
from the long pain-filled vigil, or not listening
to our exhortations. The situation was
complicated by the fact that she could only
understand her local language which her mother
and only one of the nurses could speak, so to her
whatever encouragements the rest of us gave her was just mumbo-jumbo!

Half an hour into the delivery, she still wasn’t
really progressing so Rita decided to assist with
the vaccum pump (the classic hand-operated
version), but even then, the cup wouldn’t hold
properly and she had resorted to pushing for
several seconds then expending her energy in
crying and flailing about. Instead of bearing
down, she would push her legs into the handholds
of another nurse and I, and arch her back and try
and push herself off the narrow table she was on.
To make matters worse, she had a full rectum and
a full bladder (which both contributed to the
slow progress) and each ineffectual push was
moving the faeces, not the baby, out. What little
sterility we had quickly went out the window!
Once the poor girl got so dispirited she started
jerking her arms about and her eyes rolled into
her head, and we almost thought she was going
into seizures. Thankfully she hadn’t, but by that
time her energy was well-spent and she had to lie
quietly for a few minutes before she could be
roused to start trying to push again.

Finally, with Dr Valerie arriving at the scene,
she diagnosed an OP presentation (unnatural
presentation for the baby, which also explained
the slow progress) and properly sited the vacuum
cup. It was still hard-going, but soon the baby’s
head was out. Meanwhile, a lady had arrived some
45 minutes before and we heard the cries of her
baby in the adjoining room, born by torchlight.
The baby was fully delivered at about 4.15 am,
alive and kicking, leaving 3 nurses, 1 doctor, 1
medical student, and 1 mother quite exhausted.

I got back past 5 am, guided by starlight, but
was awoken by the chickens about 3 hours later.
So much for getting my first hands-on experience for a delivery!

However long Sunday worship seemed though, our
time spent over the stove today was longer! And
it’s probably the only day we haven’t gone to the
hospital for any medical-related work. What
started as an attempt for a small fire for lunch
and rice for dinner became a struggle to keep the
fire big enough for lunch, and enough rice to
make pineapple rice for dinner for 8 people!
Thankfully we’d experimented with cooking fires
before and have a good routine now – I’m usually
the one manning the fire, making sure it burns
properly and doesn’t die out, and Ruth rules the
pots and pans and churns out delicious food. Our
lunch of porridge with sweet potato (called kao
kao here and much sweeter than sweet potatoes
back home!) turned out fine as it was the first
thing we cooked on my merrily burning fire. Then
we tried cooking rice. We’d already been educated
about the perils of cooking rice on a stove (the
first time I cooked rice on a stove was in
Crawley and ended burning it, and the first time
I cooked rice here I made porridge instead) so I
left it up to Ruth, and almost got it correct! I
say almost because it was rice, just a bit more
gunky than usual, like when you’ve put too much
water with the rice in the rice cooker. All that
rice cooking took 3 ½ hours, with me continually
checking and stoking the fire! We took a break
when one of the Uncle Johns from the treehouse
came over for a talk about missionaries and
colonialism, and let the fire burn out a bit, but
since Dr. Valerie came over soon after to check
on dinner, we got her to restart the fire. She
was pleasantly surprised at the quality of the
embers in our fire, surprised enough to award us
brownie points for being the only medical
students to try and successfully light stove fires!

The next 1 ½ hours was spent cooking up the
pineapple rice, pork omelet and vegetables, the
last 45 minutes or so in semi-darkness, so much
so I had to train Ruth’s headlight on the eggs so
that she could see to cook them! It was a good
meal (even if the pineapple rice was more like
sticky rice with pineapple, beans and carrots),
all from our hard work, and the sense of
satisfaction from cooking up a storm on a
woodfire stove is quite a nice feeling to have.

All this starting of fires has led to several
observations – you’ve got to get everything ready
on the stove and around you, so that you only
have to strike one match to get a fire going, and
are prepared to feed the fire appropriate fuel.
There’s a progression of fuel to feed the fire
too, from fast-burning palm leaves to the trusty
coconut husk to the solid wood planks. You’ve got
to pick your fuel wisely, in order to get a
long-burning fire that won’t go out easily. It’s
all very well and good to get a lively
red-burning fire with palm leaves and twigs, but
their flames are short-lived and unless you
graduate to more substantial fuel, you’ll be left
with ashes and the need to strike another match.
Best for fires are the coconut husks which will
always produce embers once burnt, and blocks of
wood which burn merrily then become glowing red
embers which help set fire to the next block of
wood. And sometimes you need to blow out the
solitary flame you have going in order to bring
the embers alive and start flaming again. It’s
enough to get me philosophical, but I’ll leave
you to decide what principles of fire-starting are transferable to life! heh