One week of posts, before one week of patrol

26/2/2009: Day 15, Kapuna Hospital

A bunch of patients had gone across to Kikori
over the weekend for X-Rays to be taken, when
transport was sent for the VIPs for the
graduation ceremony, and they'd arrived the day
before. This morning they all turned up for ward
round, and after dispensing with the normal ward
round duties we quickly gathered a crowd while we
squinted at those fairly well-produced films
through natural light. I say well-produced, but
nothing beats the electronic system (I'm so
pampered :P) and while development of most films
were good, some were streaky and of poorer
quality, and the long boat ride over didn't help
matters. Other patients and family members,
especially the children, looked on as if they
knew what we were trying to identify, but I guess
it was more of the novelty of seeing X-ray films.
It was probably also the natural inquisitiveness
of the people, who don't know what privacy is and
will ask about anyone's condition if they wish to
know. They live very communally here- they all
cook at the communal kitchens, sleep in the
mini-halls that are the wards, and hang out
mostly on the ward verandahs where it's usually
cooler, quite like their villages I suppose,
where everyone knows and is expected to know
everyone else. In several ways it's good, but
surely people need privacy some times? (Of
course, from the books I've been reading about
near-death experiences of heaven, we probably
won't have any privacy up there, so they're preparing well for the afterlife!)

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.

27/2/2009: Day 16, Kapuna Hospital

We've been giving lessons in applied anatomy and
physiology to the CHW students these few days.
The class, 16 girls and 8 guys (I think), are
from many different backgrounds and English
proficiencies, and not knowing where they're
coming from makes it hard to determine how to
explain which way to go. There were many times
when I looked into the sea of blank faces after
trying to explain a relatively simple concept
again. Thankfully there are some bright buttons
in the bunch, and a nodding head is a much needed
shaft of light in the dark cave.

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!

5/3/2009: Day 22, Kapuna Hospital

Sometimes some things just come in waves – in one
ward round I'd see all the ones with enlarged
lymph nodes, then in the next I'd see all the
ones with urinary troubles. Deliveries come in
waves too, as well as some special cases. Periods
of busy-ness also come in waves, and there was
one of those waves these two days.

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.

7/3/2009: Day 24, Kapuna Hospital

The children's ward round was in our slightly
incapable hands on Friday, because Dr. Valerie
was going to Baimuru for some HIV teaching, and
to bring Robbie and Debbie Petterson and another
medical student, Brent Cumming, back to Kapuna.
Thankfully for PNG timing, they didn't leave till
past 9, and she was around after all during the
ward round to deal with the terribly sick patients, which there were.

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!