Coffee, Drills, Sampson, and more

It's been a little while since my last post, so there's a lot to catch up on. I'll try to keep it short, for your sake and for mine.

I mentioned last time that we were going to a coffee plantation for a tour. It turned out to be a very good time. I'll spare you most of the details, but it was very cool to see such a huge plantation. If I remember right, it is almost a thousand acres, and right in the middle of it is a large hill with the plantation house at the top. It is a beautiful home with a huge main floor that is completely open and lined with windows. In the middle of the main floor is the stairways leading up and down to the bedrooms. The view of all the coffee fields and mountains in the background was really something. We tried to take pictures, but they really didn't do it justice. Here it is anyhow. Also in this picture are the drying fields (the tarp is wrapped up because it was drizzling) and part of the processing building/office.We also got to see how the coffee is processed, which is actually pretty interesting. Larry, the orthopod who owns the place, and his wife were very nice and are obviously enjoying their "retirement." They only spend a couple months a year here, but they are really doing a lot for the workers and the way the plantation is run. When they took over the place a couple years ago it was evidently not being run too efficiently and there was some degree of mismanagement that I'm not privy to. At any rate, they made it an attractive place to work by paying their employees more than they could get elsewhere, then proceeded to hold them to higher standards (no domestic violence, for example) and make lots of improvements. Part of the deal is also giving them a practical education. They also buy coffee from independent growers, aka the average village guy with a couple dozen trees in his backyard. This is evidently a bit lower quality, but they sell it as "tribal coffee" which has its own appeal I guess. It seems like a pretty cool thing they are doing. Oh, and apparently the coffee they grow is pretty good. They sell it to people all over the world, including Starbucks.

Also in the past week, we got a Jeep tour of a small part of the old Highlands Highway which connected the north and south coast (I think). It was a bumpy ride on a gravel road, but pretty enjoyable with some good scenery. Along the way we saw quite a few little thatched houses seemingly pretty isolated. In many of their gardens were miniature versions of the same houses. I assumed they were for pigs or chickens, but when I asked, I was told they were grave houses, or motmots. Some were more elaborate than others, which is related to how important the person was. Due to the bumpy ride, I didn't get any good pictures of these, but hopefully I'll have another chance.

Now for what you've all been waiting for: the freaky medical stuff you'd never see in the States. First, I'll give you a little warm up with stories that have no accompanying pictures. I started in the adult ward this past Monday, which has been a good experience. It is much different from peds, where I saw a bunch of diarrhea/dehydration, malnutrition, and pneumonia. The biggest difference is probably all the folks with tuberculosis (TB). Freaky Thing #1 - Hanging out with TB patients minus a mask and negative pressure isolation. It's a darn good thing my immune system works, because otherwise I'd be hacking up chunks of bloody lung right now. I guess that most of the docs here haven't even seroconverted yet (a positive PPD test meaning that your body has been infected/exposed and has mounted and immune response) which really suprises me. Okay, I can't think of anything else right now that is truly freaky, so we'll get right to the pictures.

First we have a nice xray of a young lady's (in her 30's) pelvis. Any takers on the problem? Even med student Ben picked up on the dislocated left femur and the piece of acetabulum (hip socket) that was definitely not where is should be. Apparently this lady was walking along a hill, began to slip, grabbed a tree branch, and the soil came loose bringing down the lady with the tree awkwardly on top of her. After seeing all the washouts that happen here, this story is pretty believable. Also, the husband would have had to be Hercules to inflict this damage himself. Listen to me, already jaded by the amount of domestic violence I see here.

This reminds me of non-pictoral Freaky Thing #2: domestic violence where you wouldn't expect it. The other day I was helping one of the docs cast a lady's arm which had been fractured. Nothing out of the ordinary. Then I started talking to the woman's husband who had known and worked for a missionary from the great state of Nebraska for many years! I was having a good conversation with this fellow when I casually asked him how she hurt her arm, expecting to hear she had fallen on something or been in a car accident. He sheepishly looked at me and said "Uh, it was a bit of a domestic issue." What?!? I didn't really know how to react to this, especially after such a nice conversation. After a bit of awkwardness, he asked me if domestic violence was a problem where I came from. I answered very matter-of-factly "Well, we have domestic violence in the States, but it is dealt with pretty harshly. We really don't tolerate it." This guy was going to have no repercussions at all, which is pretty awful if you ask me. The hospital does charge a domestic violence fee and a fighting fee (for chopchops), but that seems pretty minor. This may seem like it would negatively impact the woman later, but it is actually quite the contrary. Family structure is very important, and medical fees are often shared by the entire extended family. They are not happy about having to absorb extra fees, and will crack down on this activity (hopefully). So, back to the hip lady.

After my astute observation, Josh and one of the visiting surgeons, Kevin Kerrigan (who is a really cool guy and retired Navy), helped to set the hip. Unfortunately, it was very unstable due to the acetabular fracture, so we had to put it in traction. Now, for those of you who have never seen it before, orthopedic traction involves putting a pin through a bone and attaching a simple device that basically pulls constantly via a given weight on the end of a string. Anyway, I've seen this done once in medical school. I was helping Kevin set up for it, thinking I'd just stabilize the leg like I'd done before. Imagine my suprise and delight when he handed me the syringe with the local anesthetic in it and said "okay, now just make a nice wheel where you're going to start, and another one where you'll be coming out." Freaking awesome!, but also Freaky Thing #3, medical student performing orthopedic surgeon's job. Here's a picture of me with a hand crank drill going through the lady's tibial tuberosity (right below her knee). Notice the stupid grin on my face. Also, this would be done with a multi thousand dollar power drill back home. In fact, on the one I'd seen before, there was a hand crank in the kit, but the orthopod performing the procedure just laughed and made some reference to it being "Stone Age." Well, welcome to Bedrock!

Freaky thing #4: a little girl's clavicle sticking out of her skin, then sitting in a trash can. Originally I was going to post these pictures as well, but it is just taking too long to load all of these, so I'll just have to describe it to you. Basically, this little girl had gotten an infection either in her clavicle or right above it in her skin that was never properly treated. As a result, the skin over her clavicle had eroded, along with part of her clavicle closer to her shoulder, and about half of it was just sitting exposed to air. I'm talking about a little girl with a bone sticking out of her chest. Definitely freaky. Dr Susan took care of her while Josh, Dr Jim, and I were taking care of a chop chop. When we finished, I looked over to see Susan dropping the dead and exposed half of the clavicle into the trash can. Pretty crazy.

I'm really enjoying all the things we are getting to do here. It's really improving my procedural skills, which definitely need some work. As Dr Jim says, I'm a little ambisinistrous, or equally poor with both hands! He is joking (mostly). My physical exam skills are also getting quite a bit better, as we have less imaging to rely on, and I'm much more responsible for patient care. Today I felt two of the biggest livers I've ever seen. Both have liver cancer (most likely from hepatitis B) and will not live too much longer. Both would also be on transplant lists in the States. One dude's liver took up almost half of his abdomen and could be seen even before it was felt. It is definitely good to know what abnormal is, and I'm seeing way more of that here than I ever would have back home.

Caleb is doing well, though there is not quite as much for him to do here. He has been playing non-stop with his trains and track that we packed for him, and we're worried that he is getting a little obsessed! He relives many of the Bible stories and even some events of the day through those trains. One day he said "Don't worry James, I like God, I will be with you, I will protect you, said Gordon." That made me laugh, and made me a little proud. It's good to know that all the Bible stories we tell him and read to him are soaking in. You can never start too early.

One more piece of news. Earlier I wrote about the hydopower here on the station. Well, today I met Thomas, the super hero that goes down to fix it when it's "buggadup." He was in the hospital because we have been running on generator power since a big rain storm last night cause some problems with debris in the hydro generator. Dressed appropriately in huge yellow golashes, he was standing in front of our big circuit box talking about how we should be switching back over to hydro power, but we weren't. All of a sudden there was a really loud noise, all the lights went off, the breakers all tripped, and then the lights came back on. Thomas jumped just like the rest of us! We all started laughing and he said, "Well, I guess I fixed it!" He is a really nice, funny native guy who loves to speak English, which he is pretty good at. I actually met him once before, but then I didn't know the extent of his super powers.

Now, in an effort to end things on a happy note, here is a picture of me with Sampson. He's a kid with transposition of the great vessels, meaning his aorta and pulmonary(lung) artery come out of the wrong heart chambers. He would have died in utero, but he also has another heart defect (ventricular septal defect) that makes the blood in the two ventricles mix. Here, there is nothing to do for him, so unless they can somehow find a way to get him to Australia and get a cardiothoracic surgeon to operate for free, he will likely not live a long life, and will certainly be very limited in what he does. You may be able to see his blue lips from the very low percentage of oxygen in his blood. Normal O2 sats for you or I would be in the high 90's, but little Sampson lives in the 50's and 60's. On the up side, and the only reason his condition isn't Freaky Thing #5, is that I saw a lady in the States with the exact same heart defect. Normally, those kids are operated on as soon as possible, but this lady was over 50 years old and had evidently not had good medical care as a child or else was a poor candidate for surgery. In spite of this, she lived a relatively normal life. She was blue, had some characteristic physical findings, and was on a ton of meds, but she was alive. Sampson does not have the benefits of an easy life or state of the art medications, so the chances of him living to his 50's is almost zilch. However, it gives me at least a little hope for him.

Well, I said this would be short, but here I am writing a novel. In my defence, these pictures load so slowly and I just write while I'm waiting for them to load. I just remembered I have another story and picture which actually belong to Josh, but I'll save that for later. Now it is after midnight on Friday morning and time for me to get some sleep. I'm on call this Saturday and Sunday, so we'll see if I can rustle up any more stories.

Another call night come and gone

Well guys, nothing too cool out of call tonight. It is now almost 6:30 in the morning on Sat the 29th, and I don't think anything crazy will come walking into the ER between now and 8 when call officially ends. In the States, this is when all the work and school excuse people start walking in with their phantom low back pain and runny noses/sore throats. Here, people appreciate the value of their money (ER visits aren't free, even here).

There was one lady who came in just as I was getting done with a couple victims of a car accident (nothing serious) who had been stabbed a couple times. She already had an IV bag in, which meant she had been seen at an aid station and was sent on to us. She had a pretty superficial cut on her left forearm, a really shallow stab wound on her left side, and a nice bleeder on the right shoulder when I took off the bandage. I held pressure for a bit and then got a better look, and bit suprisingly, I could insert almost my entire pinky finger into the hole. Now, I didn't take a picture for two reasons: 1)my gloved hands were bloody and there wasn't really anyone around I'd trust with my camera and 2)the poor lady's breast was exposed, so I probably couldn't post the picture anyway. Good news for this lady, though, was that the wound went right along her rib cage under the sub Q tissue. There was not even much muscle damage.

One really good thing about taking call here is that it is making me feel much more prepared for my intern year. I'm getting woken up in the middle of the night and asked questions by nurses I can't really understand about patients I'm not really familiar with (call is for the whole hospital, not just my ward). I'm learning pretty quickly what the pertinent information is to ask and what quick steps can be taken to get things under control until morning. There is a missionary doctor on call with me, but I'm always the first to get a call from the hospital, and I only call them in if I don't feel comfortable. As a result, it is a good lesson in knowing your limits and making darn sure you've got your ducks in a row before you wake someone up. The docs here are actually really nice and helpful, I just hate bothering them if it's something simple I could do myself. All this is good training for next year.

Well, time to get ready for the day, round on my kids in the hospital, and enjoy a day off. Supposedly we're going to tour a coffee plantation today that is owned by a really nice retired orthopedic surgeon from the US. He comes to the hospital here periodically and helps out with whatever ortho surgeries are happening. Anyway, should be a good time, and I got just enough sleep to enjoy it.

Hospital pictures (finally!)

I have been trying to bring our camera to the hospital more often this week, and I finally have some pictures of where I've been spending my time and a couple of our little patients.

As I've said, my time thus far has been mainly in the pediatrics wing, or A ward. Here is a picture as you walk in. There are 27 beds, and today we had three kids on the floor along the middle, making 30 kids. For the most part, we see a lot of gastroenteritis which may or may not be viral. As part of the workup, everyone gets a malaria smear. One of the lab techs, a native named Johnson, was very helpful and showed me what malaria looks like and how to tell the difference between falciparum (really bad) and vivax (bad) malaria on a slide. Anyway, other things we see quite a bit are neonatal sepsis - basically babies who are less than a month old with fevers caused by anything from a virus to meningitis - and malnutrition. This is really quite sad. As some of you are aware, there are two types of malnutrition. The first is a general calorie deficit called marasmus, the second is a protein deficit called Kwashiorkor. Kwashiorkor is the kind where you get the skinny little kids with huge pot bellies from all the gas and distension in their intestines. I have seen both here. Kwashiorkor kids are generally adopted for various reasons and thus have no access to breast milk or anything similar. They are fed mostly kowkow (PNG sweet potatoes) which is a really poor source of protein and essential fats. As far as the marasmus kids go, sometimes it is neglect, sometimes some other disease like HIV, and other times adopted kids whose parents can't afford much cow's milk or formula. This is one of the many (certainly not the worst) marasmus kids I saw in the ER when I had my camera handy. He is over 7 months old and weighs less than 14 lbs. I haven't looked at a growth chart in a while, but something tells me he's on the low end. With these kids, we generally start feeds slow along with some vitamin and mineral supplements. They are generally brought in for something else, like pneumonia or diarrhea or fever, so we also have to try to treat that.

One of the sad things about the way things are here is what happens when you don't have access to care. Have you ever wondered what happens to a kid with meningitis who doesn't get treated? I always just assumed they died, but as I'm finding out, my assumptions aren't always correct. We have a boy on our ward named Edward who has been here for about a week. He came in after being "sick" for two months. When I saw him, he was unresponsive, his eyes were perpetually rolled up, and his arms were drawn up and stiff. We did a spinal tap which showed some white cells, so we figured we'd try and treat what was left of his meningitis, hoping against hope that he'd recover a bit. Well, his 10 days are almost up, and he's just about the same. The poor kid is probably going to be a vegetable until he gets some bad infection and dies. The lesson for you all is this: if your kid has a fever and a stiff neck, get him to the ER ASAP.

On a bit of a lighter note, here is a little boy who has been on the ward since I got here. He cried when he saw me for the first few days, but now he laughs and smiles. Score one for scary white guy! He has some upper airway obstruction which we can't deal with because we have no pediatric bronchoscope. He also has some underlying heart and lung disease. This is about as far as he can wander from his bed because he is tethered to the wall on oxygen! In spite of this, he does what he can to cause mischief.

A major event happened today. I got to sew up my first chopchop. I didn't really get the story, but I can only assume this lady was the victim of domestic violence. The back side of her thumb and hand were split wide open and the tip of her index finger at about the first knuckle was hanging on by a bit of skin. There was a chip of her metatarsal head (bone where hand meets thumb) that was only attached by a piece of tissue. I decided that it couldn't survive, and since she still had good thumb movement, I had to cut it out. I put in a couple layers of stitches in her thumb/hand (deep and superficial), and it turned out pretty well. Her finger tip was another story. I tried my best to reapproximate the edges, but it was pretty swollen and looked pretty rough. I'm pretty sure it won't survive (the bone was completely severed) because so little tissue was left connected. In retrospect, I probably should have taken it off and amputated a bit of bone to make a good closure, but I'll have that opportunity when she comes back in two days. In the mean time, I just put her on some good antibiotic coverage with some ibuprofen for pain. Yeah, that's about as good as it gets for pain control. It seems that either no one donates narcotics (go figure) or they are just not used here. People can definitely take the pain here. Of note regarding suturing, it is almost impossible to find the size and kind of suture you want in the ER. We don't have organized dispensers of all kinds of suture at our disposal. Instead, there is a large kitchen mixing bowl of various sizes and types. Unfortunately, the only non-absorbably suture (for skin closing) was like 2-0 braided silk on a half inch needle. (read: freaking huge needle and frankenstein thread) I ended up using some of the absorbable suture (for deep stitches) for skin closing as well after I had reapproximated with the big thick stuff. This made for an interesting look. If I see her in follow-up I'll take a picture just for laughs.

Well, those pictures took forever to load, and it's time for bed. I'm on call tomorrow (Fri) night, so hopefully I'll get some good pictures and stories. Enjoy some fast food for me!

Some PNG pics

mailing address

some of you have asked for a mailing address for us, so here it is:

Kudjip Nazarene Hospital
c/o Ben and Stephanie Kumor
PO Box 456
Mount Hagen, WHP 281
Papua New Guinea

Mail reportedly takes 3 -4 weeks to get here, which is much faster than we thought going in. Still, anything after the middle of April is probably rolling the dice a little (we leave around May 16th)

tribal dispute, the market, and more on my first day off

Saturday, March 22nd 10:30pm
As implied by the title, today was my first [most of the] day off at the hospital. I was on call last night, where I saw something pretty cool. But I’ll save that for later. I’ll tell you about my day first.

I got up early today to round on my patients so we could hurry up and get to the market. I was able to discharge a few patients who had recovered well, which is always a good thing. Another adult patient I had been called on last night who was hanging on by a thread was still alive this morning. Also a good thing. I did have to sign the chart on the baby who died, but in looking over it again, it made me feel a little better to know I couldn’t really have changed anything. Maybe better isn’t the right word … maybe just a little less bad. Anyway, after that I came back to the house and we all got ready to go to the market in Mt Hagen, about an hour away. We were escorted there by Dr Andy Bennett’s wife Judy and their teenage son Sam. They are very nice people, and actually had us all over for dinner tonight. It is great how people are reaching out to us and making us feel at home.

First we went to Best Buy, not the electronics store, but a grocery that is pretty similar to what we have back home, just smaller and with things I didn’t always recognize. Then we went to the Market, which is a huge open air market with tons and tons of people at tables selling their produce. This picture isn't really representative of how busy it was. Most places were packed, but there was a little break and I thought it was a good photo op. Vegetables have never looked so good! Everything is so fresh and delicious looking. They have some fruits and vegetables pretty unique to here, whose names I can't remember for the life of me. There were also some chickens being sold, which captivated Caleb’s attention for a solid 10 minutes. I don’t know who was more entertained, Caleb watching the chickens, or all the natives that gathered around to watch Caleb. Evidently pale blond haired kids are pretty rare in these parts! Most of the day I was holding Caleb while Stephanie did the shopping, but when I did set him down for a bit, one lady selling bananas tried to make friends with him by giving him a couple. Apparently this happened pretty often when Caleb went on Monday with Stephanie and Sarah.

For lunch we went to a really nice, modern hotel in Hagen. The food there was pretty good as well. I had a BLAT, which is a BLT plus avocados. I have never been a real avocado kind of guy, but I tried it and definitely liked it. There is a pool there, and Caleb stripped down buck naked again (same as Monday) and played around in it a bit. When it was time to eat, I asked Stephanie, “You think we should put a diaper on him before we eat?” She replied, “Nah, it’ll be alright. He’ll want to get back in soon anyway.” All was well for the majority of the meal, until Caleb had finished and was getting a little restless. He stood up in his high chair, as is his custom, but instead of asking to get down, he was acting kind of fidgety. I wasn’t paying too much attention until I smelled a very distinct smell, looked over, and saw a pretty large turd sitting in the middle of his high chair. Yeah. At least everyone got a pretty good laugh out of it, and they didn’t deport us.

When we got back home, I played basketball for an hour (the elevation here really killed me) and took a shower. After I came back into the living room, we started hearing a big ruckus coming from the road in front of the station. Evidently, there was a huge tribal clash between the Kumas and Suare (sp?). There were basically in two large groups with a well-defined line between them, yelling and throwing rocks. In the past, this has escalated to real fights with bush knives and whatever else is handy, but that is apparently rare. We heard lots of gunshots, which we are told was the police trying to disperse the crowd. It evidently didn’t work, though, because there was just more yelling. It wasn’t until sunset that things quieted down, which is evidently the unwritten rule: quit fighting after dark unless you really mean business. Josh and I were thinking we’d have to go to the hospital and help sew some people up, but no dice. Things ended pretty quietly. We were also told that if there was a real fight, the hospital only sees one side. The other must travel down to Hagen to be seen. I hadn’t thought about it before, but it actually makes a lot of sense. You can’t have fights erupting in the hospital, after all. The way they decide which side to treat? Whoever gets here first.

Oh, about the cool patient from last night. It was a lady who had just given birth at home and had come to the hospital within a few hours. She was moaning a lot and acting like she was in some distress, but she was oxygenating well, heart and lungs sounded good, etc, so we were ready to just give her some meds to help her relax and call it a night. Then a nurse asked us to take a look at her neck, because she was complaining of some pain under her jaw. Dr Erin felt her neck, then asked me to examine it. I said in astonishment, "Is that crepitus??" and she affirmed. Crepitus is basically when there is air in the soft tissue under your skin. It feels a little bit like rice crispies. Some of you may remember my prisoner blowing up his face story - same type of deal, but to a much lesser extent and not intentional. I'll save you most of the medical reasoning and everything we did next, but the end result was actually what we intended to do in the first place. Since we did a chest xray and ruled out a large pneumothorax, we decided to just help her be comfortable and let everything heal and dissolve by itself over the next couple of days. Not something you see every day.

Hopefully the pictures are a good addition. Internet here is available, but quite a bit slower than I am accustomed to, so adding pics is a bit tedious. I’ll try to do a better job!

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.