Sunday, September 28, 2008

A Night in Paradise (Part 3)

You'll remember that I originally wrote this just over a week ago. Here's the rest of the story.

Dave went to his apartment for a water bottle, and I found a few peanuts in my locker (I always keep some there). We sat and visited for a few minutes, feasting on peanuts and water while we waited for the crew to get everything ready, then went down and did the operation. Again, it went well. This time, there was no dread ring of the phone at the end of the case. At about 4:30 we went to Labor, just to check, then made our way home.

I ate a bowl of cornflakes, then crawled into bed a little after 5. But the story doesn't end there.

The local custom here is that the doc on call Friday night will come in on Saturday morning to round on his or her own ward, leaving the rest to the doctor who is coming on call for the weekend. Judy knew that she had to wake me. It was pretty hard to get out of that warm bed at 7:45. For some reason, I didn't make it to the hospital until nearly 9. Judy had been out jogging, and told me that something was going on at the ER, but she couldn't really tell what.
When I got there, I heard that Dr. Erin Meier (click to see her blog--I'll bet there will be a story there by now) was swamped in the ER with 9 victims of a motor vehicle accident. I did rounds on my ward (Adult Medicine), checked on the patients from last night, and caught up with Erin, who filled me in on the MVA. She mentioned that a lot of off-duty nurses and nursing students had rushed in to help with the work. Before I could go home, I had promised to do something for the friend of a friend, which I did in my exam room in the Outpatient Department, next door to the ER. No sooner had I started than one of the ER nurses called me to come and help them. One of the victims of teh MVA had stopped breathing, and had no heartbeat. I went to check on him and made a brief attempt to get a breathing tube into him, but quickly concluded that he was now beyond my help.

So now I'm home, sitting at my computer reliving the night. I'm thinking of that young woman, who wanted so much to be a mom, and of that little life, ended before it really started. I'm thinking of those two healthy babies, now sleeping contentedly by their moms on the maternity ward. I'm wondering about that young man who died in the ER--I don't even know if he has a wife or kids. I'm thinking of the thousands of people who would have no health care without Kudjip Hospital. Kudjip Hospital is me. Kudjip Hospital is Dr. Erin, and Dr. Bill, and Dr. Scott, and Dr. Susan, and Dr. Jim, and the dozens of volunteer doctors and medical students who come here each year. Kudjip Hospital is those OR nurses and anesthetists who just say, “That's alright, we'll do it.” It's the ER nurses, trying to save lives threatened by violence, alcohol and bad roads. It's the labor ward nurses and aides staying long after their shift is over. But it's also you, praying and giving to keep us going.
Judy has gone to take a group of people up the river so that they can float back down on inner tubes. When I came in, the dogs told me that they love me unconditionally. My nice new coffee maker (a "going away" gift from Sam) is gurgling, and emitting the smell of brewing coffee. I don't know if I'll make it through day without a nap.


1 Kudjip Nazarene Hospital
2 Dr. Susan Myers and Dr. Scott Dooley discussing a patient
3 Dr. Jim Radcliffe on the ward
4 A scenery shot to remind you what a beautiful place this is

Thursday, September 25, 2008

Couldn't Count Them

As you know by now, the last story I wrote to post here got pretty long, and I decided to break it up. In a future episode of that story you will learn of a 9-victim MVA (motor vehicle accident) that occurred early Saturday morning. I was only involved in the care of those folks tangentially; Erin Meier did most of it all herself. Well, this past Tuesday afternoon we had another multiple-victim MVA. They were literally (and I only use that word literally) filing into the ER. We don't know how many there were. Before the last of them arrived, we had moved the first ones off to other areas. The first victims arrived at about 2:30; Scott Dooley and I took care of them while Erin saw all the regular outpatient department patients. We all worked until between 6:00 and 6:30. Visiting surgeon Salim Wahab took the most seriously injured patient to the operating room that day, and two others the next.

Surprisingly, there were no fatalities. Most of the injuries were abrasions (scrapes) and avulsions (skin or other tissue being torn away) from sliding down the pavement at high speed after being thrown out of a vehicle. One little girl and her mom both had parts of their wrists torn away, but neither will likely lose their hand. Many had "road burns" on their faces, trunks and arms. Two had skull fractures, but have not had serious neurological problems. Several had serious facial lacerations.


A Night in Paradise (Part 2)

In the previous episode we learned.... Well, just scroll down and read it for yourself.

I gave her some medicine in her IV to strengthen her contractions, and she was able to push the baby down the birth canal. But when it got to the point that the head would deliver all progress stopped. The head was firmly stuck at the outlet of the uterus. This is the reason that we try hard to never do a vaginal delivery for a first-time mom with a baby in breach position. If a mom has successfully delivered vaginally in the past, it is highly likely that she can safely deliver a breach. But with first-time moms like this one, you just don't know, and occasionally the head can get stuck. With a live baby this is a disaster, usually resulting in the death of the baby.

It was hard work, but after about 10 minutes of trying, the head delivered, deeply tearing the side of the birth canal in the process. While this was going on, the nurses told me about the woman in labor in the next bed. She was also having her first baby, but despite strong contractions for several hours, she was not making progress toward delivery. When I could get away, I evaluated her, and realized that she needed a cesarean. Fortunately, the crew had not left after my first call, so I informed them that there would be an operation after all. They waited patiently for me while I sewed up the torn birth canal on the first mom. It was well after midnight when I turned over the last bit of suturing to the Labor ward staff. The evening shift, who should have gone home at 11 PM were still there helping to finish up. I hurried to the OR while Dave went to the ER to evaluate a psychotic young woman.

The operation went well, but as we finished, the phone rang. When the phone rings in the OR late at night, it almost means that there is something else for the doctor to do. In this case it was the nurse on the labor ward, informing me that the patient that we had tried so hard to induce all day long, had gone into active labor, but was not making progress. When I could get away, Dave and I went to Labor to evaluate her. It was clear that the only prudent thing to do was to take her to the OR for a cesarean. I went back to the OR to inform the crew of my decision. As usual, they were supportive and patient. The only comment I heard was, "That's alright. We'll do it."

(To be continued...)


It's not me, and it's not a cesarean, but it's an operation in our OR, so it will serve to illustrate the story.


Saturday, September 20, 2008

A Night in Paradise (Part 1)

This was written Saturday, 20 September. It got pretty long, so I decided to break it into 3 parts. Then our internet went out, so I was unable to post it until today.

Not that I'm complaining. No, not me! After all, it really is a privilege to serve the people of the highlands, to do my best to bring a measure of comfort and healing. Sometimes my best isn't enough. Sometimes it's hard work.

In fairness, most nights on call aren't nearly as bad as this one. But if you are inclined to pity me, go right ahead. I'll take what pity I can get.

The night started calmly enough. Dave is a visiting medical student from England, and he was on call with me as "back-up." There was one patient in the labor ward that we had been trying to induce all day, and we had some discussion about how we'd manage her, but finally decided to give up, stop the meds, and resume the efforts in the morning.

I was very sleepy, and quite uncharacteristically decided to go to bed early, confident that Dave could handle the routine questions that might come up through the night. I'd been in bed for 15 minutes when he called to say that there was a patient in the ER with a spear wound to his chest. Knowing that such a wound could be anything from trivial to life-threatening, I told him I'd meet him there and hoofed it to the hospital. This particular "wound" turned out to be at the trivial end of that spectrum. I don't think that the chest cavity was even penetrated at all. And to make matters worse for my attitude, he had driven past 2 hospitals that could have easily treated him on his way here.

Leaving Dave to finish that, I headed home. Just as I was walking away, the ER nurse called out to me that they had phoned from the labor ward, and there was a mother in labor with a cord prolapse. When the umbilical cord comes down into the birth canal ahead of the baby, it can be squeezed to the point of cutting off blood circulation to the baby, and can quickly cause the baby's death. I hurried to the labor ward, and Dave arrived a few moments after I did.

The staff were already doing the basic things that might save the baby's life. The labor ward was chaotic, as it so often is. As I examined the birth canal, I found that there was a weak pulse in the cord, and that the baby was in breach presentation, the legs and bottom coming first. This is actually less often lethal than when the head is tight in the pelvis, compressing the cord. I asked one nurse to call the operating room crew for an emergency cesarean section while another was starting an IV. I was doing my best to push the baby back up into the uterus so that it would not compress it's own umbilical cord.

But over the next couple of minutes we found that the baby's heart beat first weakened further, then stopped. What a helpless feeling to be there while this baby died, just out of my reach. Even if the OR crew had already been there, and if we had run straight to the OR and done a cesarean as fast as I know how to do it, it would have been far too late. It was already too late. All I could do was to try to get the little body delivered without harming the mom. It was with a very heavy heart that I explained this to this young woman and her mom.

(To be continued...)


1. Dr. Scott Dooley, visiting with Dave Scott, visiting medical student from England

2. A grauitous photo of an exotic-looking tripical flower

3. When everything goes right in the labor ward, this is what we end up with.



To me, the spell checker is one of the great inventions of all time. Even if it often wants to do such things as add apostrophes to plural names, if I at least pay a bit of attention it keeps me from looking too stupid too much of the time. However, it apparently doesn't work on the titles of blog posts.

Wednesday, September 10, 2008

Samll things

Sometimes it's the small things that make or break a day. Today they made it.

A young lady had been in to the hospital on the weekend because she was having a miscarriage. She is from another Pacific nation, living in PNG with several members of her extended family who are in business here. She was having severe cramps, but the emotional pains probably had been worse. After trying a more conservative approach, I had had to do a D&C.

This morning she was back, smiling, and pain-free, at least as far as the physical pain goes. Naturally, she and her husband had a lot of questions, which I tried to answer for them. As the left they gave me a bag of pastries, which they said were typical of their country.

So often I deal with problems that are more complicated, and often the outcomes aren't as good. And often I don't know when patients get better. It was nice that this young lady got better, and it was nice to know. And the pastries were nice, too.

The next patient was an elderly lady, a lady who is much more comfortable in the village than at a busy place like the hospital. She doesn't speak any language but her tribal language. She looked frightened and out of place, but her husband seemed concerned and kind. She had been discharged from the hospital about a week ago, after several days of treatment for both congestive heart failure and pneumonia. She had been very ill. I reviewed the x-ray before going into the exam room. It still didn't look very good, but was definitely improving.

When I went in to examine her, she told me (through her husband's translation) that she was feeling much better. She still had some cough, but all the swelling had gone down, and she could breath easily. Then her husband said, "I had thought she was going to die. Now she is alright!" After making some changes in her medications, I reached out to give her the little clinic book which serve as our patients medical records. As our eyes met, she gave me a really big smile, then shook my hand.

Sometimes the work is so routine. This was a reminder that what's routine to me may have life-and-death significance to my patients. It was nice to have a part in her recovery, and to know how big that part was to my patient and her husband.

When this couple left, it was a bit after noon, and time to leave for lunch. As I was walking out of the hospital, a passed a man who was walking with a slight limp. He had a big bandage on his left big toe. As I passed him, I greeted him briefly. When he saw me he said, "Doktaaaa" (they tend to draw out the "a" part.) "Yes?" I said, not sure what he wanted with me. "Last week you cut my foot, and now it's much better! Thank you!"

That brought it all back to me. The toe had looked terrible, infected and draining. I don't remember how his infection had started, but it was bad by the time I saw it. I wasn't at all sure that it could be saved, but I did a small procedure to drain the pus, and prescribed antibiotics for him. I hadn't been the one to see him in follow-up, but it was great to find out that what I had done had worked out well for him.

So it was a nice way to end the morning. Nice to have 3 small reminders that our work is making a difference in people's lives. Nice to have 3 small "bonuses."

Yours and His,

#1 Me casting the leg of a baby with clubfoot.
#2 Dr. Jim Radcliffe supervising a nurse treating an injured child
#3 A dad who brought his baby to the Outpatient Department