Wednesday, March 24, 2021

Karen, Bill and Rose

 

I wanted to share a few stories of patients I have taken care of while here. These are by no means representative of the people here, or even necessarily my work here, but rather stories that have touched my heart in one way or another.

 

My second day out of quarantine I did my first C-section here in PNG. The patient’s name was Karen, and she was 30 weeks pregnant with twins. She had been hospitalized over a week before due to severe preeclampsia (a condition in pregnancy where the blood pressure goes up, the kidneys spill protein into the urine). She had been treated with steroids to help her babies mature faster so that they would be ready for a premature exit and treated for her high blood pressures, but that day her blood pressures were not responding to treatment and the team was worried that she might develop seizures or other serious complications from preeclampsia.

 

The first twin was in a breech position where the legs and butt are down instead of the head, so the decision was made to proceed with a C-section. Not having done a C-Section for about 7 months since the end of residency I was nervous heading into the surgery. As we prayed for Karen before starting the case, I tried to take a few deep breaths to steady my hands, and my prayer took on a greater sincerity. Dr Ben, the general surgeon at the hospital, was my overqualified assistant and helped me orient to doing surgery here. Thankfully the surgery went well and both babies were delivered safely.

 



 

 

A few weeks later I returned to work on our OB Ward. To my delight, I was able to resume care for Karen and her two babies, a boy and a girl. Over the next several weeks I was able to watch them grow, learn how to breast feed, no longer require the NG tubes (tubes through the nose into the stomach used for feeding) or the oxygen. This last weekend they had both made it past 2kg and were growing well by just breastfeeding. I was able to send them home. It was a bittersweet departure, joyful at their progress and ability to go back home but also sadness that I would not be able to see these twins grow and see Karen’s shy smile every morning.

 

 

……

 

I was convinced that Bill would not survive when I saw his mother carrying him into the emergency room. She was trying to breathe into his mouth while carrying him in, a sign that he was not breathing. I rushed over with the nurse and helped her lay him on a patient bed. Amazingly he still had a pulse, but he was not taking any breaths on his own. We started using a bag-mask to help him breathe while the nurse took vital signs and attempted to get an IV. His mother stated that he had been having bad diarrhea for weeks. After 5 minutes he began to take breaths on his own and after 10 minutes he no longer needed our support to breathe, just some oxygen. We were unable to get an IV so I had to place an IO-a needle that goes into the marrow of the bone to allow us to give fluids.

 

That night I walked up to the hospital two more times to check on him, each time a little surprised but also thankful that he was still alive. That night I prayed, trying to trust Bill to God. In my work here and in Malawi I have seen many kids die. Sometimes they came in like Bill, malnourished and dehydrated on the verge of collapse, only to die within a few minutes of arriving despite our attempts. Others suffering from malaria or trauma or premature birth would last a little while longer only to succumb to the overwhelming pathology. But thankfully, by God’s grace, his attentive mother and the nursing staff, he not only made it through that night but also the next one and the next one.

 

I checked on Bill several times over the next few days, every time seeing him more alert and interactive. A week after he was brought in, I took this picture.

 


 

 

Seeing children die can be overwhelming, heartbreaking and discouraging. But thankfully we are able to make a difference for many. And for Bill that difference means the world.

 

….

 

Rose was brought into our hospital by a helicopter from the Jimi valley, a large valley north of our hospital, that despite not being a long distance away (40-60km), can present an often-insurmountable barrier to access for our patients that live there. With a reliable car, it is a 4-5 hour very bumpy ride out to our small health outpost in the Jimi Valley. For many of our patients it can be a trip of several days. Luckily for Rose, she was able to be brought in by a helicopter for obstructed labor.

 

Rose had been in labor for 2 days but had not been able to deliver her infant vaginally. Our hospital is the only health care facility for our province of 350-400,000 people that has surgical capabilities and can provide blood products. As such, we see a large number of complicated obstetrical cases.

 

We brought Rose back quickly for a C-Section. The baby was difficult to extract due to the length of her obstructed labor and the moulding of the head into the pelvis. There was thick meconium (baby poop) that had obviously been present for some time. Thankfully Dr Ben was available to help me with the delivery. I scrubbed out of the case to help resuscitate the baby while Dr Ben started to close the uterus. After about 10 minutes of resuscitation the baby was crying and breathing on its own.

 

Over the next few weeks, I have been able to care for Rose and her baby. Rose initially healed very well; however, she subsequently developed a wound infection and has required further care and antibiotics in the hospital. As she is not able to get wound care near her home in the Jimi Valley, we have kept her here to continue to help her heal in a safe environment. Her baby has done very well and seems to get bigger every day.

 

Every morning Rose greets me with a soft, shy smile. She has been so patient throughout her time here. I am so glad that she was able to arrive when she did. If she hadn’t and if this hospital weren’t here, both her and the baby likely would have died.

 


 

I hope these stories encourage you as much as they have encouraged me. Sometimes seeing the health disparities here can be discouraging, but there are bright lights like Karen, Bill and Rose too that give me strength to keep working to help the people here. I am so thankful for the staff here who have been giving of their lives to help this community for years and years.

 

I would really appreciate your continued prayers. We are in the midst of our first large outbreak of Covid in the province and there is a lot of fear and uncertainty. Many patients are not coming into the hospital due to this fear and we know that this is probably leading to a number of patients, especially pregnant women, not receiving critical care. I’d also appreciate prayers for finding community amidst a pandemic and perseverance as I continue to have so much to learn, language, culture, tropical medicine and especially learning to make diagnoses/decisions in the face of uncertainty.

 

I want to end with a Henri Nouwen quote from a devotion today, “Learn the discipline of being surprised not by suffering but by joy. As we grow old…there is suffering ahead of us, immense suffering, a suffering that will continue to tempt us to think that we have chosen the wrong road…But don’t be surprised by pain. Be surprised by joy, be surprised by the little flower that shows its beauty in the midst of a barren desert, and be surprised by the immense healing power that keeps bursting forth like springs of fresh water from the depth of our pain.”

 

You all are in my prayers. I love hearing from you!

Thursday, March 4, 2021

I do actually work too

Thus far I haven't really shared about my work in the hospital so I wanted to reassure you that I am actually working too :) Kudjip Nazarene General Hospital has 4 different wards-Pediatric, Medical (adult), Surgical and Obstetric. I have and will continue to rotate through working in all of the wards except Surgical. Pediatric and Medical Ward have around 32 beds and Obstetric Ward has more than 45. In 2018 there were 55,000 outpatient visits, 7000 admissions, 2643 deliveries (376 C-sections) and 908 major surgeries. I work with a staff of over 230 from all parts of PNG as well as a team of doctors from PNG and the US (sometimes Australia and New Zealand as well).

 

A normal day for me involves rounding on one of the wards starting at 9am. Once this is over I go to the Outpatient Department (OPD) or to the Emergency Room to see patients for the rest of the day. I take call overnight every 3-5 days. I did my first call shift by myself on Monday.

 


 

For my doctor friends (and other interested friends), this is a quick picture into my call shift last Friday. I don’t know whether or not this is representative of a busy call (or even if my experienced colleagues would call it busy), but I found it challenging but also fulfilling.

 

The day started with rounds on our Medical ward. Conditions that I have seen on our Medical Ward range from CVAs (strokes) and MIs (heart attacks) to TB meningitis and malaria to endometritis and incomplete abortions. I then went from there to the ER.

 

My first patient was a 13yo F with one day of confusion and fever. She was agitated and did not tolerate an examination. Fearing meningitis, I gave her some ketamine and did an LP that showed a high opening pressure and mildly turbid CSF. I started her on ceftriaxone (antibiotics) and dexamethasone (steroids) and admitted her to the Pediatric ward. My next patient was a 5yo M with a large abscess of his left calf and significant swelling all the way to the ankle, indicating pyomyositis, a common condition here where an abscess extends deep into the muscle and can spread along the underlying bone. He also had to be put to sleep so I could do an I&D (incision and drainage) and was admitted to the Pediatric Ward. Dr Mark then helped me to reduce a radial head fracture in a 20yo M that we then splinted until he could come back for casting in a few days.

 

Later that morning I took a pregnant mother who had been admitted with mild preeclampsia (a condition in pregnancy where there is elevated blood pressure and protein in the urine that can progress to severe disease marked by maternal seizures) who had breech twins for Cesarean delivery. I was assisted by Maxwell, a PNG native who is doing his rural health surgical rotation at our hospital.

 



 

After the surgery, I had a short pause that allowed me to run home for a quick lunch. As I was finishing lunch I was called back to the Obstetric Ward for a mother who had been complete for 2.5 hours but unable to deliver the baby and now the baby’s heart rate was low. I ran back up to the hospital and was able to assist the mother in delivering the baby by using a vacuum. Both the mother and baby did well.

I returned to the ER where I had a couple more patients to see, including a pregnant mother with malaria and a hemoglobin of 5.2. She also had had a positive VDRL and rapid HIV at a rural health outpost before she had been transferred to our hospital.

 

I had a brief reprieve after this before I was called back to see a mother who had spiked a fever and whose baby’s heart rate was in the 180s remote from delivery. After failed resuscitation attempts and starting antibiotics, I made the decision to proceed with Cesarean section. While the team was getting things ready, the ER asked me to evaluate a patient with a large bush knife wound to the head. I had to ask Dr Mark (one of the experienced doctors here) for help again, as the skull had fractured and was depressed where the knife had cut. Thankfully the patient had a normal mental status and we were able to close the wound and put the patient on antibiotics and anti-seizure medications. We then proceeded to the OR for the second C-section of the day. Mother and baby did well.

 

As I was getting ready for bed I was called back to the ER for a patient with a hemoglobin of 8 who was having significant vaginal bleeding. A quick look with the ultrasound diagnosed an incomplete abortion. The patient was symptomatic from her blood loss and we had to act quickly to transfuse her and do a D&C (dilation and curettage) to help stop the bleeding. Thankfully her bleeding stopped following the procedure, her vitals returned to normal with the transfusion and fluid resuscitation and she was admitted to the ward.

 

I was then able to sleep until early in the morning when I was again called to the Obstetric Ward for fetal distress during labor. The baby’s heart rate had dropped into the 50s when I had arrived (normal is 120-160). With help from a vacuum, the mother was able to deliver a healthy baby within 2 pushes.

 

After morning rounds, I was able to go home and get some more sleep.

 

There are a lot of new things for me here and I am learning a lot from the very experienced staff and doctors. Every day there is a new challenge. But I hope and believe that we are making a difference for the patients here. When I was out with Pastor Apa I talked to a lot of people, but one was a man along the side of the road near the Waghi river. He yelled out hello to me and then became a little sheepish as he was holding a beer bottle that he had been drinking. I tried to put him at ease, and we began to talk. He mentioned how having a hospital like Kudjip in the region brought pride as well as helped everyone who lived there by bringing access to a higher level of care than would otherwise be available. I’m proud of our team and what they are able to do and thankful that I get to be a part of the work here.

 


 On a run with my mentor Dr Matt (and a few kids)

1 Year Update

This weekend I was able to get away up into the mountains around Mount Hagen. I had time to rest and reflect on the almost full year that I ...