tupela pikinini for the Kumors

Well, I must apologize for my lack of updates in the past week. Part of the reason is that I have just been quite busy. I was on call last weekend and then this past Tuesday, so I have been turning in a bit earlier than usual this week trying to catch up. Combine that with Stephanie wanting to check out the housing situation back in Omaha, and you have not a lot of internet time for me. Another thing is that I am finally getting into a good routine and things just don't seem as strange to me anymore. I have to keep reminding myself to take pictures of weird chest xrays or rare (to me) conditions, because it just doesn't shock me anymore. Along with that, though, comes a comfort level that allows me to just enjoy it a bit more.

Before we go any further, I need to announce some good news (for those who hadn't heard): Stephanie and I are expecting our second child sometime around Oct 30th! We wanted to keep it a bit quiet until an ultrasound had been done, and today the three - or four, I guess - of us stopped by the hospital on our way home from the river and I got a good look at the kid. Now, my ultrasound skills are improving but are still limited, and are not helped by an U/S machine that is dated and a probe that has seen better days. That said, I could see all the major body parts, and could even see the little hands and feet waving and kicking. Of course, the heart was visible as well, and it was beating like crazy. So, Stephanie is around 11 weeks, and intern year should be very busy indeed! We are looking forward to being near family in Nebraska, and we're hoping and praying that this one can wait until closer to the due date to come say hello. We will welcome your prayers in that regard as well!

With that out of the way, we can move on to more of the experiences PNG has to offer. One thing that is fairly common here is the keeping cassowary birds as pets. Cassowaries are the PNG equivalent of the Ostrich or Emu. Basically a really big, flightless bird that kills people in the wild by jumping at them and tearing out their bowels with huge claws. Sounds like definite pet material to me. Well, they are commonly used in some parts of the country to pay the bride price at weddings, and are supposedly very sought after and tasty to eat. One of the ladies who works at the hospital, named Anna, has the biggest cassowary around. She invited us out to her village to have a look and take some pictures, which is exactly what we did. This doesn't really do the bird justice in terms of size, but you can see a bit of the color that makes them pretty distinct and cool-looking. Anna's bird was around 5 ft tall and pretty intimidating. It is kept in a little bird shed that is probably 4x4ft and 6ft tall. The funny thing was, they were just handing it bananas and grabbing its beak like it was nothing! That's Anna's husband, Joel, in the background feeding the bird. He told us he was very grateful for our willingness to come and help the people of his country. He said he had nothing to give us, but is sure God is pleased with the missionaries who come and will bless them accordingly. That was pretty humbling to hear, and it gave me just another good example of how appreciative and warm the people of this country are. Quite a bit different from what we're used to in the States. After this, we took a picture with their family, and they gave us each a pineapple from their garden to take home with us. We had some snacks in Stephanie's bilam (knitted purse) that we gave to their kids, and then we were off. Caleb, however, was not too happy with giving away our snacks, and proceeded to throw a fit as we left the village! Oh, well, he'll learn sometime.

I'm trying to pick out some of the good medical stories from the past week, but they're sort of blending together. There was one gentleman who actually spoke very good English and is pretty well educated, but it turns out has TB and HIV. He also has the distinction of being the first person in whom I caused a pneumothorax! A pneumo (for short) is basically when air gets into the chest cavity between the inside of the chest wall and the lung. Now, when I admitted this dude, he had pretty much a white-out of his right lung. We ultrasounded it, and sure enough, there was a ton of fluid in there. I was working with Dr Erin, who is in her first year post-residency, and she is really cool about teaching and letting me get my hands dirty, so to speak. We did a procedure to take some of the fluid off, called a thoracentesis. Now, we don't really have all the nicely packaged kits and sets all the time like back home, so we were doing this under less than ideal conditions. I stuck a needle into his back and pulled back the plunger on the syringe, evacuating a good amount of fluid from this poor guys chest cavity. Then, when we were pulling the switch to empty the syringe, we told the guy not to breath. Well, he did, and he got a pneumo. So I guess it was only partly my fault! We did have some stop-cocks available which I should have been using, but I guess that's a learning point for next time. In spite of all this, the guy was actually breathing better after the procedure than before it thanks to all the fluid we got off. Another satisfied customer! Here is his post-thoracentesis CXR. The nice white plateau in the right lung is all fluid, and used to take up almost the entire right side. The thick white line that is more vertical is the edge of his lung tissue. Outside of that, my friends, is the air. Hey, nobody's perfect! The effusion has recurred, however, leading us to believe it is probably TB. The positive HIV test I ordered, as mentioned earlier, added further weight to the TB theory, along with the quality of the fluid we drained off in the first place. Here, we unfortunately have to rely a lot on clinical judgement regarding who has TB and who doesn't. Anyway, before we could start this guy on TB meds, he left the hospital AMA (against medical advice) to go testify in a court case regarding recent elections here. He promised to be back Friday, but I won't know if he made good on it until I'm back in the wards on Monday.

Okay, now I need to get to the story that some may have heard from Stephanie's emails. She may have stolen my thunder a bit, but I promised the pic and story in my last post, so here it is. Josh, my good friend and fellow med stud, was on call a couple weeks ago with Erin as his backup. They were called to the labor ward for a preterm labor. They had just examined the lady and were standing outside the curtain talking briefly about what was going on, when they were quickly called back in by the nurse. This is what they saw. The baby and placenta were lying there on the bed, still contained in the amniotic sac! What you're seeing here is mostly placenta, with the baby's head and face pressed up against the membranes. The woman had (evidently) abrupted, meaning the placenta had separated from the uterus prematurely (i.e. before the baby is born) and the little baby came out in all his glory. They snapped this picture quite quickly before then breaking the sac and resuscitating the baby. This little guy was around 28 weeks gestation and weighed about 100 or so grams (~3-4 oz) less than Caleb when he was born. Unfortunately, this guy didn't make it, and died about a week after he was born. It probably would have been a different story in a major US hospital with access to TPN, ventilators, continuous monitoring, etc. We have lost a few premies here recently, some bigger than Caleb was. It's just a good reminder of how blessed we are back home, and how much further we have to go here.

Now for some happy stuff. This is a little guy named Nathaniel. Erin saw him in clinic about a week and a half ago, and this is the picture she took. He has what's called Burkitt's Lymphoma. Common in Africa and PNG, it is a cancer caused by the Ebstein-Barr virus, the same one that causes mono, the "kissing disease." It primarily affects the face in a characteristic way, and is pretty easy to diagnose. Untreated, this tumor will take over his face and eventually kill him. Fortunately, it is also highly sensitive to chemo, and the chemo used is pretty easy to get our hands on and not too technically challenging.

This space gives me a chance to comment on his mom's tatoos. Evidently, they don't really have any significance at all. No relationship to what tribe they come from or who they're married to or anything! They just sit around and tatoo themselves for fun.

Back to Nathaniel

Thus, 10 days later, he looks like this. Granted, he still doesn't seem too happy to be in the same room as a white skin, but his tumor is down, and after several months of chemo every few weeks, he has a good chance at a normal life. The problem is really going to be making sure he completes his chemo course. People here don't have a good concept of medicine or how the body works. As soon as he is looking normal, there is a chance the family will quit taking him to the hospital. Hopefully he will complete his course, or do well regardless.

In more domestic news, Caleb has learned a new trick. I think the picture says it all. He just busted out the eye brow at dinner one night totally unprompted. I, of course, was thoroughly impressed and made sure he knew it. This pleased him greatly and provided an entire evening of entertainment. He is honing his skills, and will be ready to flash the eyebrow upon command when we return home to you all.

Shortly after the eyebrow trick, Caleb came down with some hopefully not too exotic disease and has had a good fever for the past 3 days. We're not on malaria prophylaxis, so that is always a possibility. I'll keep you posted on this front. While he's on Motrin, he's been a pretty good sport, and we all ventured down to the river in the valley this afternoon. It was quite muddy, and Stephanie about lost her flip flops on numerous occasions! I was carrying Caleb's stroller - it's a loner from someone around here - and unfortunately missed a couple of good photo ops of Stephanie ankle deep in mud. There were some native boys there fishing that we got pictures of, but I'm not sure how indiginous nudity is handled on this site, so they will remain omitted. Until next time!