all about the Haus Sik

Well, I promised to let you know about the hospital, so here it is. It is now Friday evening the 21st, almost 9pm. I noticed that the last post was dated US time, so I'll try to let you know from now on when I'm writing PNG time.

First, a little disclaimer. Medicine here is much different than in the States, and I am still getting used to it. Much of the difference is solely the result of inadequate resources. Everyone here cares deeply for the patients and want the best for them. It just so happens that the best here is a bit different than the best in our US hospitals.

The very first thing you would notice about this hospital is the smell. People here don't really take showers, at least not that I can tell. There is the distinct odor of sweat and unwashed bodies that permeates. Compounding this, of course, is a lack of air conditioning. The second thing you would notice is the big smiles that just about everyone will give you if you make eye contact. The people here, though lacking in the hygiene department, are certainly not lacking in friendliness. The hospital is made up of two main buildings: outpatient, including the ER, clinics, xray, lab, and OR; and inpatient, consisting of four wings - pediatrics (A ward), maternity/birthing (B ward), adult medicine (C ward), and surgery (D ward). The ER and clinics are primarily staffed by experienced nurses (all nurses here are native PNG'ers), who either treat and send away or pass along to a doctor to see. Note: here I count as a doctor, even though I am probably not as proficient as many of the nurses when it comes to practical tropical medicine. Fortunately, I don't speak Pidgin, so for now I must be accompanied by said nurse or I tag along with a missionary doctor. In the ER and on wards, it is the former, in clinic, generally the latter (though that will change soon).

Note that I said xray, and not radiology. The only radiology here is xray, and the quality is not quite what I have become accustomed to in the States. Most of the time, though, it is good, and they are always willing to re-take xrays with special instructions if it is necessary. I never realized how much we rely on CT scans and MRI's back home. I mean, it is literally like taking a step back 50 or so years. You non-medical types might not understand this completely, but it's a little like the difference between a road map of a town and a full miniature model. You can tell some things from a road map, many important things in fact, but there is a lot you just don't know until you can see the buildings, the elevations and reliefs, etc. One nice thing, though, is the debate about whether to get some expensive test is gone. No more needless head CT's in the ER "just incase!"

The lab and pharmacy are also not quite what I am used to. The lab has the ability to run basic blood counts and some chemistries. That's about it. For you who are interested in such things, let me know, and I'll post more in depth about this subject. The biggest thing missing is any kind of micro lab. You can order a gram stain, which often doesn't show much, but that is the extent of it. No confirming what bacteria you are (or aren't) treating, no susceptibility testing, no cultures at all. This makes for a lot of shotgunning treatment, but it makes you much more aware of fever curves and white counts. The pharmacy has probably been the biggest struggle for me. For one, some of the medicines are known by different names. For example acetominophen, aka Tylenol, is paracetamol, which is its British name. Another dilema is that supply is limited, and medicines in stock are constantly changing. There is no such thing as a concrete formulary, though there are some medicines that are generally available. Of note, drugs here come from two sources: what is donated, and what is bought from the government supplier. The donated meds are much more hit or miss, but the supplier evidently is not great at sending meds and supplies on time or in the correct quantity. Add to this that I have never in my life treated malaria or typhoid, and you have me struggling to catch up. I'm doing much better, though, and by the end of next week I should have things down pretty well.

My typical day this week has started about at the hospital around 8am. In the morning, the doctors round on their inpatient ward, around 25 beds each, and then head over to clinic to see the hordes of patients waiting in line. Each ward is a long room, approx 50 ft long or so and maybe 20 ft wide. The cots are lined up on either side, much like you would see in a WWII movie. Their are two semi-private rooms near the entrance to each ward for patients with highly communicable diseases, the kind who whould be in negative pressure isolation back home. I have been on A ward (peds) with Dr Susan. Everyone here goes by their first names, making me Dr Ben. Here, the families don't really have a surname. They do it old school: first name is the given name, and surname is their father's given name. After that, they are identified by their tribe. For example, there could be a man named James Isaac, of the Jimi tribe. His son could be Peter James. You get the idea. At any rate, for the first two days, I rounded with Dr Susan on every patient in A ward. Then on Wed, I began seeing some myself with the help of a nurse. They are actually nursing students at the nursing college here on the station. They are all very nice and helpful, and have been working with me on my Pidgin. The patients sure get a kick out of it, and I am happy to supply some laughs. One nurse, Mark, tells me that my Pidgin is getting much better, but when he says this the patients all start to chuckle... I think I have some work to do!

After rounds, as I said, it is time for clinic. It operates much like it does in the States, except the setup is much more like an Urgent Care than a prive office. There are usually 4-5 docs seeing the next patient in line. Susan, though a pediatrician by trade, abides by this as well, which is pretty remarkable. She sees kids, adults, pregnant ladies, and the elderly, just like everyone else. Everyone breaks at noon or there abouts and takes an hour for lunch. After lunch, it is more of the same until everyone is seen. I'm not sure when they stop taking people in the line outside, but sometimes they just keep coming and coming! After this, we head home. I am really glad that Stephanie and Caleb joined me in coming here. I would be pretty lonely without them. I am definitely sapped for energy, though, when we finally put him to bed. I think I am still recovering a bit from the big trip. I was also on call with one of the docs on Tuesday, which meant a little less sleep than usual. Tonight I am on call by myself, with a doctor for backup.

Good medical stories so far.... well, there was a guy today who came in around 1pm with a chop-chop. This basically means he got hacked with a machete. His story was that he was at a family get together, he and everyone else was drunk, and he went out to get some more booze. When he was returning, he heard the voice of a man he knew and then saw "lightning", which was evidently the machete. Probably not the whole story, but the result was still a drunk guy with half his face hanging off. The cut went from about mid nose, under the eye, and down the cheek past the corner of the mouth on the right side. I unfortunately didn't have my camera handy, so there is no picture to show. It was not a strait on cut, but rather from the side and a little behind. Thus, the cut was relatively shallow, no bones were involved, but a relatively large flap of skin, including half his nose, was just hanging on.

There is also a little kiddo I admitted a couple days ago with meningitis that is doing better each day. He looked really terrible that first day, but now is starting to feed and really come around. I feel like I really made a difference for that little guy, and hopefully he will be really out of the woods after the weekend.

Not so good stories... I lost a patient today. It was a one week old baby I admitted this afternoon for neonatal sepsis. I saw tons of these kids at Children's Hospital in Columbus, OH, but never lost one. The difference is probably the amount of time between when a kid gets sick and when they go to the hospital. I started the little boy on the appropriate antibiotics, called in my backup to double check, and admitted him. This evening, during dinner, I was called to the hospital because he wasn't breathing well and had briefly stopped breathing. When I got there, he was looking worse, not responding well, cool, vitals looking very sluggish. At this time, I again called my backup, and we decided/hoped that the baby had had a seizure and was just post-ictal, so we started seizure meds and also added malaria meds in case this was causing seizures. We also made him a DNR, since it wouldn't change his outcome. I was called about an hour later and told the baby had arrested and they were trying CPR. I had to tell them to stop. Death is a very real part of medicine here, as I am just learning.