Joseph went to the nearby clinic in his village. A few days of amoxicillin did nothing to reverse the relentless progress of the TB. Finally, Joseph's relatives realized that he was dying. They found someone who would drive them to a nearby government hospital. There they were told that there were no doctors to see him. In PNG, it is the privilege of all senior doctors to take "Festive Season Holiday"; basically 2 months off. The junior doctors who are supposed to keep things going want to be like the senior doctors, so they take some time off, too. Joseph's family headed toward Kudjip.
When they brought Joseph into the ER, I was working on another man. I saw that the nurses were checking him. One asked to use my pulse oximeter. This showed that Joseph's blood was carrying adequate oxygen. I did not fully appreciate just how sick he was. I listened to his lungs and heard good air movement, so I left him for the nurses to "screen". He was making a lot of noise, and I thought maybe he was just being dramatic. A little while later, the nurse told me that Joseph was ready to be seen. I examined him more carefully this time, but didn't find anything specific, except that his heart beat was rapid and soft. I ordered a chest x-ray.
Some time later, I was informed that his x-ray was ready. Here it is:
By this time all of the patients in the Outpatient Department had been seen, and doctors were starting to home. I felt that we needed to drain some of that fluid out of the pericardium, but I'd never done it before. I knew that Dr. Erin Meier had done several, but she had left. I found Dr. Steph Doenges, who is on call this evening. She had helped on a pericardiocentesis once. She agreed with my idea of involving Erin. After sever failed attempts, I reached Erin, who came right in. The three of us began to assemble supplies. It was decided that since I had never done or even helped with one before, that I should be the one to do this. This may seem like backward logic to some of you, but it makes complete sense to us.
"Wow, we're past 100 ml!" one of us commented.
A few minutes later, "hey, that's almost 500!."
Then Joseph began to quiet. With her free hand, Steph felt his pulse. "Stronger", she said. We could see the movement of the heart on the ultrasound screen returning to normal.
Joseph began to talk to us. Erin and Steph asked him about his wife and children. A boy and a girl, ages 5 and 3. The brother and I were counting and adding. The tally was nearing 1000 ml. A liter! Now we began to have to manipulate the catheter more often, but still the flow came.
At some point someone (yes, it was me--the mood was much lighter as we watched Joseph improve from moment to moment) began to speculate as to whether the Guiness Book of World Records had a category for the largest volume of fluid removed in a pericardiocentesis. Probably not.
Thanks to Dr. Steph for her photos!