We also received the sad news that Morea, our eleven-year-old with the
fluid in his abdomen, died on his way to Port Moresby.  He only made it to
Kerema.  There was also apparently some kind of drama, where the father
left for awhile and there were accusations that there might have been some
wrong done by the mother.  We really don’t know the details, but we were
all very sad to hear the news and are praying for healing for his
family.  We still don’t know exactly what had caused his illness.

It is very challenging to practice in a place where you lack many
diagnostic tools.  In some ways, it challenges you to be a better physician
and learn to rely on your physical exam, yet in others it is very
frustrating.  Often, it becomes an educated guess and trial and error.  For
example, you get a patient with pulmonary symptoms and
fevers.  Immediately, they will get fansidar and chloroquine for malaria
based on the fever.  If you have abnormal lung sounds, you will try a trial
of antibiotics.  You don’t know for sure that it is bacterial
pneumonia.  There is a high prevalence of TB, and it may be hard to
distinguish.  There are some cases of COPD, with wheezing and diminished
air entry.  Regardless, you start antibiotics and see if they improve.  The
fever may go away, but was that from antibiotics or from malaria
treatment?  Lung findings persist. Even after adequate therapy, it may take
time for pleural effusions to resolve.  TB does not always cause fevers, so
then you wonder if this is a resolving pneumonia or pulmonary TB. You have
no chest x-rays to aide in diagnosis. If they don’t improve clinically, you
start a TB trial.  If they get better, you ask them to commit to staying on
the ward for two months and taking the full outpatient treatment after
that- a big commitment.  Often at the end of the trial, it is not clear
whether or not it has helped, and the decision to commit them to full TB
treatment or to stop is very difficult.  Worst of all, when they die, you
wonder if you missed something or if there was something else that could
have been done, especially when they are young like Morea.

This has impressed me with how difficult it truly is to combat TB in a
developing country where the prevalence is so high.  I will discuss this in
further detail in my next blog.

At four, we walk through the hospital and check on the patients.  Sometimes
we see new patients that have come in during the afternoon.  Some days we
do scans with the new ultrasound machine.  Yesterday, we did a paracentesis
(putting a needle into a belly full of fluid).  There is usually a little
free time afterwards before dinner. Between about 630 and 700, the main
generator comes on, which is the signal to go over for dinner.  We eat,
then usually have a little time for e-mail and such before our final walk
through the hospital at 900.  This can be short or long depending on the
patients.  We have had several sick ones, so I have been there almost to
1100 at times.  Then, I come back to the doctors house and have a
shower.  The shower is a bucket shower.  You fill a bucket up at the tap,
then pour the bucket into another one with holes that is suspended from the
ceiling.  You then stand under it, turn the valve, and shower.  It’s quite
efficient actually, but it was made for much shorter people!  I have to
duck my head quite a bit to wash my hair.  The big generator is shut off at
1000, so I usually shower in the dark or with flashlight.  Then, I go back
to the girls dormitory, crawl under the mosquito net and sleep.

Today, I delivered a baby before ward rounds.  Rather, I caught the baby as
it came flying out when no one was ready.  This was the mother’s fifth
baby.  We knew she had progressed into the second stage of labor and were
discussing who was going to deliver it when the mother said it was
coming.  I barely got my gloves on and the head was coming out.  I put some
pressure on the head to slow it down, as mom had just had a big bowel
movement.  Dr. Valerie wiped the stool away and I let up and the rest of
the baby flew out with no help necessary from me.  It was a very healthy
baby boy.

We have also had a difficult time with one of our patients for the last few
weeks.  Morea is an eleven-year-old boy who presented with profound ascites
(lots of fluid accumulates in the belly, making it very tight and
distended).  This is not uncommon with the endemic TB in the area, so we
began treating him for TB ascites, but he did not improve.  He has a
history of hepatitis, but he was not jaundiced (yellow-orange) like we
would expect with liver failure.  Despite TB treatment, antibiotics, and
drugs for amebic disease, he made no improvement.  We finally did a
paracentesis to try to relieve his discomfort.  We dipped a urine test
strip in the fluid, which showed no white blood cells (a good thing).  The
fluid was colored by rifampin from the TB treatment but was otherwise
pretty clear.  This would fit with TB ascites, but he should have been
improving based on the staff’s experience.  We did an US which showed a
normal-looking liver, a very large spleen, and no other abnormality.  A
malaria test was negative.

Poor Morea has been absolutely miserable, having trouble keeping down food
and water due to the pressure in his belly.  Yesterday he asked us to do
another paracentesis to relieve the pressure. You know a child is really
hurting when he asks for you to put a needle in his belly.  His parents are
very invested in him, and it is always difficult to watch their sorrow.  We
know that we have exhausted all our treatment options.  Without even basic
laboratory tests and a CT scanner, it is difficult to make a
diagnosis.  Last night, we typed up a letter or referral for him to go to
Port Moresby.  Often the parents will not take them because it is very
expensive to take home a dead body.  Thus, often they will simply take
their relative home to die.  This set of parents is very invested in their
child and decided to make the trip and see if anything can be done.  The
father is a teacher, so they are a little more educated and have a little
more money.  We all gathered to pray over him before they left
today.  After we prayed, the father started to tell us thank you for all
that we had done to try and help his son, and he started sobbing.  It is so
hard to watch a parent grieve for their child.  I can’t even begin to
imagine how difficult it has been for them to watch him suffer so much and
to know that he may not survive.  It brought tears to my eyes and Dr.
Valerie’s to watch them cry for their child.  We said another prayer for
them, too, then took a few pictures of him sitting on Dad’s shoulders as
they left for the boat to Kerema.  It is very sad.  We all hope that with
better diagnostics that the staff in Port Moresby  might find a treatable
cause, but his disease process is likely to be significant based on the
profound ascites.  Dr. Valerie talked with them, and Morea said that he
knew about Jesus.  She talked with his father about talking with him,
seeing if he had any little things to confess or talk about, since he may
not survive.  We hope that the whole family has been able to feel the love
of Christ through the staff while they were here.

Additionally, I thank everyone for their prayers for my safety, as they
were put to the test.  They have a contraption here called the Flying Fox,
which is pulley and handle that allows you to glide along a wire down into
the river.  It’s good fun.  Unfortunately, I had enough sunscreen and sweat
on my hands that I slipped off in the process of launching and fell about
15-20 feet into a shallow river.  I landed on my back and went all the way
and hit the bottom of the river, which fortunately was soft mud.  I had
missed the bank by only about one foot.  I have a bruised back and had a
headache for the first day but am otherwise alright.  During low tide, I
looked at the river bottom, and there were several tree trunks and branches
around where I landed but I had somehow missed hitting them and only landed
in the mud.  God truly does watch over his sheep!  Thank you again for all
your prayers!

We also walked to one of the local villages.  It was much larger than I
expected.  We met a man outside the village who then walked with us all the
way to the far side, where his house was.  He walked with me the whole
time, chatting away, pointing at things and talking in his language.  I
just smiled and nodded.  I’m not sure he ever realized that I had no idea
what he was saying!

The children also enjoyed running after us and begging for pictures.  All
in all, today was an interest picture of life in PNG.

I also feel very challenged by the language.  PNG has many
languages.  While English is the official language, many people,
particularly the elderly, do not understand it.  Even among those who speak
it, communication is difficult.  I will ask a staff member to translate “Is
there blood in the urine?”  Then, they translate the answer back as “Yes,
he made urine.”  That’s nice, but did he have blood in the urine?  My other
favorite is when you ask a yes or no question, they translate it, you see
the patient nod his head yes, and the translator turns to you and says
no.  As Dr. Valerie says, you have to ask questions several time.  You also
have to use very simple English.  I have learned to ask, “Does he have
pain?” rather than “Does he hurt?”  I am still learning how to
communicate.  The important thing is just to have a sense of humor and be
patient.  It is hard to communicate in a language that is not your primary.

We had a lady with a hernia in her groin that presented during my first
week.  Dr. Valerie had asked me to do a hernia repair, since I have had
some experience with them.  While I definitely felt comfortable with the
surgery, I was unsure of doing it without the watchful eye of a chief
resident or attending.  I also have never been involved with one done only
under local, and I have never done a signifcant operation without
electrocautery.  We decided to wait for Dr. Mark, in case he had any extra
surgical expertise, so yesterday morning we did the repair.  I was
concerned because from my physical exam, I believed it to be a femoral
hernia.  These are not as common as other types of groin hernias.  What
happens is that part of the abdominal wall and, in her case, bowel, slides
through an area between the large femoral vein and the pubic symphysis
(pubic bone).  I have never seen one of these.  Dr. Mark had actually never
done a hernia operation.  Dr. Valerie has assisted with a few hernias, none
of them femoral.  So, we read about the operation in some surgical
textbooks and then performed it, two general practitioners and medical
student going into surgery.

So, in PNG, you operate barefoot in a cloth dress with a cloth surgical
gown.  It was very hot, as there is no air conditioning, and also because I
was standing under the light.  By the end of the surgery, I had a pool of
water under my feet.  We had to be sponged frequently to keep from dripping
into the field.  The woman turned out to have a very difficult hernia to
reduce, and the operation takes place very close to the large femoral
artery and vein, which can easily be injured.  At one point we were unsure
if we should continue but just at the right moment my finger finally slid
into the hernia defect, and we were able to dilate it enough to finally
reduce the hernia. It was still very difficult, and we even discussed
cutting the inguinal ligament to make more room.  Fortunately, we did not
have to do so.  We finished this surgery on the 11th.  My birthday happens
to be February 12.  The patient has done well since the surgery with only
minor pain.  As I told everyone, that was the only birthday present that I
wanted.  Thank you, God!  I really enjoy being in a place where the whole
surgical team will pause and pray together for direction when things get
difficult or uncertain.

The Calvert family made me a little “cake” out of melted marshmellow and
chocolate candies with a candle stuck in the top.  It was so warm outside
that the candle fell down while we were eating dinner (chocolate was
getting softer).  They gave me a little PNG mug and a local seashell.  They
are very thoughtful, nice people.  While I do miss my family, they have a
way of making you feel like you are a part of theirs.

I had a sense of peace about the flight the next day.  Everyone prayed,
and, because God is good, I was able to get on the flight with everyone
else the next day.  When we arrived at Kikori, we loaded into a boat and
did the approximately five hour boat trip to Kapuna Hospital.  At this
point, I had been traveling for three days, so it was nice to arrive and
settle in for awhile.

Yesterday was my first day on the wards, and it was quite an introduction
to life in PNG.  A woman had come in the day before in labor.  The baby was
in an unusual transverse position.  To complicate matters, the woman’s
labor stopped despite a significant amount of oxytocin, a drug we use to
strengthen contractions.  By the time I was first came onto ward the next
day, the baby had died.  Normally, a woman can go on to deliver the body,
but since she had a complete arrest of labor, it became a difficult task,
particularly with bizarre presentation we had- a hand, foot, and umbilical
cord.  Fortunately, the hospital had just received a portable ultrasound
machine.  Between Dr. Archer and myself, we got it working and were able to
visualize the position and confirm that there was not more than one
baby.  With a lot of difficulty, Dr. Archer was able to finally deliver the
baby.  I will spare everyone the gruesome details.  We finished the
afternoon with a funeral service with the mother and grandmother.  The baby
is buried in a little cardboard box on the hospital grounds.  It was
pouring down rain at the time.  As Dr. Archer told the mother, it was if
God was crying with us.  We sang a couple of songs, including Jesus Loves
Me, together.  The words definitely have a new meaning to me now.  Dr.
Calvert explained to me that here, women simply don’t expect to have a live
baby, so they deal well with situations like this.  It’s just a part of
life here.  We were very fortunate that the mother had no significant
postpartum hemorrhage and is showing no signs of infection.  Despite the
difficult delivery, she had no significant tears, either.  That was my
first day working in the hospital.

Today was my second day.  I am learning the treatment protocols here and
learning about many drugs that we do not use in the US.  I have seen
extrapulmonary TB and leprosy for the first time.  All of the staff is
wonderful and so friendly.  They have all made me feel very welcome.  I
have been very thankful that Dr. Archer and her family have been feeding
me, as I would not have known how to cook here.  Sago is the local
carbohydrate, which is made from a tree trunk and is similar to
cornmeal.  It is mixed with a variety of things such as coconut and cooked
in a pan.  I also learned how to shell and eat a whole crab today.  I’ve
had a variety of greens, potatoes, and pumpkins, all of which have been
quite good.  I’m very happy that the Lord blessed me by not making me a
picky eater!

I really enjoy the fact that God is an integral part of life here.  All of
the involved staff pray over patients before procedures.  It is very nice
to be open about faith.  In the United States, people worry so much about
offending someone or, especially for teachers, being fired for talking
about God.

Thank you all for your prayers and support!

“Do all the good you can, by all the means you can, in all the ways you can, in all the places you can, at all the times you can, to all the people you can, as long as ever you can.” –John Wesley