Lightning and Cyanide

You just never know what they are going to call you about when you are on call. They often call with patients who have dehydration, malaria, pneumonia, or a chopchop, and I feel pretty comfortable with all of these. However, when I got called the other night and they said a girl got struck by lightning, I didn't feel so comfortable. I knew nothing about lightning strikes nor what I needed to be worried about, look for, how to treat, etc. I told the nurse I would be down, but first took 5 minutes to open Harrison's and read about lightning.

Thankfully, the girl did well. Her and a friend were outside when the storm came. Her friend died instantly, but she survived. The trauma in that, seeing her friend die, is something I am sure is much worse than the pain she had from the lightning strike itself. She ended up with a lot of muscle pain of her arms, and some red eyes, but otherwise was okay and went home a few days later.

In doing further reading, I have learned more about lightning strikes. There is about a 10% fatality rate of those who are struck. The majority don't get burns, but lots of other complications can occur. They can get neurological problems like neurocognitive changes, seizures, HA, and more. The biggest concern is cardiac arrest due to asystol (heart stopping), as a result of the lightning, this at times results in death, but God made our body so often we can restart our hearts again. Eye and ear complications as well as chronic pain syndromes often occur as well.

Another on call patient was a kid who had eaten a cassava root raw and now was having some SOB and abdominal complaints. I didn't field this call, but saw the kid on the ward just an hour after admission. We were concerned about cyanide poisoning in this patient. Let me tell you how much I knew about cyanide poisoning, that's right, nothing. So after seeing the kid, I went to Bill to find out what I should really be looking for in this kid.

It turns out that cyanide poisoning has occurred here before when a family ate a whole bunch of beans and most of them died as a result. Therefore, we now have a cyanide poisoning antidote kit with the important meds we can use to treat the poisoning - amyl nitrite, sodium nitrite and sodium thiosulfate. He was given amyl nitrite and sodium nitrite and apparently was doing much better on the ward than in the ER. We continued to follow him and he did just fine. One recommendation I read was to transfer cyanide poisoning pts to the ICU or to a local toxicity center - apparently our pediatric ward serves as both, with me being the doctor in charge.

So all that to say, you just never know what kind of calls you may get when you are on call here at Kudjip. You gotta be ready for anything.

Thanksgiving 08

Once again, despite having to work, we still take the time to celebrate Thanksgiving here in PNG. All the missionaries gathered together for a nice meal this evening. We didn't find turkey in town so we went with chicken and ham instead. I don't know how to make stuffing, gravy, or mashed potatoes, so I made oreo dessert, something easy but good. I even tried a little of everything as we ate including mashed potatoes, green beans and squash, but didn't do pumpkin pie. It is always nice to be with "family" at holidays and this year our family got bigger as we welcomed the Lees - Lawrence and Kim from Image, and the Kerrigans. The Dooleys enjoyed having Grandma and Grandpa Dooley here as well.

There is lots to be thankful for, let me name a few:

• - Christ and His death on the cross for my sins
• My family and friends and their support while I am here
• Luke being healthy and another little Nash baby growing inside
• The opportunity to be at Kudjip serving the Lord as a physician
• The healing, both physically and spiritually, that God has done on my patients
• Patients like Buldung, Ismeal and Nathaniel who have cancer, but have been given more days to live
• William, a patient with a pericardial effusion (more to come) who now is getting better because we drained the pus from his heart
• - All the hospital staff who are vital to the service we provide here
• - Becky joining us here for the next 2 years
• - The missionaries and their love and support of me
• - The opportunity to learn and see new things everyday
• - God's leading to continue to do mission work once my time here is up

Leprosy

As I have previously mentioned, in medicine we try and formulate a differential diagnosis as we are seeing patients. We are trying to think in our minds all the things this pt could possibly have and by asking questions, getting labs, Xrays, etc, we are ruling in or ruling out some of these diagnoses. For most patients that I see, my differential includes things that are most common and things I have some knowledge about. At other times, I have gone through everything in my differential and nothing has proven to be correct, so then I ask Bill for his help. He has been doing this a lot longer than me, so his differentials often include things I have never heard of nor seen before, which is why they didn't enter my differential. The other day I walked into his clinic room to ask him a question about my patient, but instead he asks me about his patient and what I think. Leprosy is something I have never seen before, but read about (in the Bible). I knew very little actual medical knowledge about leprosy until this week and this patient. We haven't had a new leprosy case here in quite a few yrs, which was evident when Bill was trying to find medicine for him and we found we don't have it. So for those of you who might not know much about leprosy, let me explain a little from my reading. It is caused by Mycobacterium leprae, and despite how leprosy is often depicted, it isn't as contagious as was previously thought. It typically is spread from nasal secretions of the infected getting into others nose or mouth. Direct skin contact will not pass along the bacteria. The incubation period is 6 months to 40 yrs, so it often is quite a while before someone who was infected by another shows any signs of illness. Lepromatous, tuberculoid, and borderline are the 3 different kinds of leprosy. Leprosy affects the peripheral nerves and skin mostly, and tends to like the cooler parts of the body. As a result pts can't often feel things and get ulcers or infections on their hands or feet. They also can lose the function of their nerves, get muscle atrophy, or deformities as a result. When it affects the skin they often have areas of hypopigmentation where they can't feel anything, or get lots of bumps on their skin. After cutting the pt's earlobe (cool spot) and getting some fluid for the lab to look at, Bill determined his pt has lepromatous leprosy. He does have some bumps of his face and other skin changes, and has lost his lateral eyebrows. Thankfully, he doesn't have much nerve damage presently and are hoping that won't change with the medicines (when we get them). The antibiotics we will give him will stop the progression of the disease, but can't reverse what has already been done. So after this patient, leprosy can now enter my differential as I have seen someone with it and know a little something about it too. This case illustrates for me why I am so thankful to be here. I have learned so much since I have been here because I have seen so many things I had only read or heard about. I am especially thankful to have a good teacher in Bill, who has taught me so much. He just had a birthday so he is getting older, but all those years add up to a lot of wisdom and experience to share and I have learned a lot as a result. Thanks Bill.

Becky has arrived

Becky Wallace is a Family Physician who I went to residency with in Harlingen, Tx at the Valley Baptist Family Practice Residency Program (see link on side). We were also roommates for a year and a half while in Harlingen. She has now become part of our Kudjip family for the next 2 years as a Post Resident, through World Medical Mission and Samaritan's Purse (same as me).

Due to being on call this weekend, I didn't have the opportunity to pickup Becky at the airport, but I did get to greet her when she got to her new home, just 2 doors down. The welcoming committee is pictured to the R (they really just wanted to be on the blog). I was amazed at how light Becky packed. For being here for 2 years she only came with a carry on and a backpack, this is quite impressive for anyone who knows Becky.

It is great to be the new person at Kudjip because the missionaries feed them for the first few days. If you can't be the new person, it is just as good to be the new person's friend when they get here because the missionaries feed you and your friend for the first few days. Tonight we had dinner with the McCoys, tomorrow with the Chapmans, Tues - it is my turn to cook, Wed with the Bennetts, and Thurs is Thanksgiving. Maybe someone wants to take Friday - let me know :)

So now Becky will start a bit of orientation, language training, cultural training and learning how we do things in the hospital again. She was here last November for a month, so hopefully things come back quickly. To learn more about what is happening with Becky, you can check her blog at http://drbeckywallace.blogspot.com/ hopefully she starts to update this a little more frequently for those viewers back home.

What some women do in labor

I had met Betty a few times when I have been at Gail's. She has done some work for Gail and has also quilted with her. About a month ago, I helped her finish the quilt she and Gail were making for her new baby which was coming in Nov. Her and her husband have 2 girls and were hoping for a boy.

Today Betty knocked on my door, not something she has done before, so I went to see what she wanted and how she was doing. She told me she was doing well and was 4cm dilated. She said they told her to go and walk around, so she did. Unlike in the US where most women get hooked up to a monitor their whole labor and thus are stuck in bed, our ladies here just walk around until it is time to deliver. (At times, it is frustrating as the nurses will call you about a pt in labor and when you go down there to check on them they are gone and no one can seem to find them.)

Back to Betty, so as she was walking around she passed by the Ward house and saw the basketball hoop and thought maybe if she shot baskets it would help to move things along. She wanted to know if she could borrow a basketball - sure if that is what she wants. (Personally, I don't think I would be thinking of shooting hoops when I was 4cm dilated, but she was. I was also thinking that I was pretty weak letting the little abd pain I had from a GI bug cause me to rest.) She came back about 30 minutes later to return the basketball. I was amazed at her wanting to shoot hoops. I told her so and she assured me that she wasn't feeling very strong contractions yet - sure.

Well whether it was basketball or not, she did deliver a healthy baby boy. In PNG they don't give them names right away, so he is currently b/o Betty. One of his big sisters was there when I went to visit him, she seemed excited to have a brother. Thankfully both mom and baby were doing well, maybe everyone should shoot hoops while they are in labor?

Giving Blood

On Wed, Anton came into the ER with a hemoglobin of 2. He has AML - acute myelogenous leukemia and has just received his first dose of chemo. He was suppose to come in for followup, but he wasn't doing so well. I quickly assessed him, and got him admitted. I told the family that he was going to need blood, but they quickly pointed out that he is O, and they were A and B. This is a problem.

In our hospital, we have a blood bank, but it only works when family members of the patient give blood. The family gives blood and we then turn and give that blood to the patient. Occasionally, a pt doesn't need all the blood that the family has donated, so we have some extra, but this isn't the norm, and it wasn't the case on Wed. We didn't have any O blood in the blood bank, and so we had a problem.

I started asking the student nurses in the ER what blood type they were. I know they get some sort of points or something for giving blood. Only one was O, so I told him to go to the lab, he went, but then apparently decided not to give. I knew I was O, so just before lunch, I took the time to give for Anton. While I was there the nurse from peds and the student came down to collect blood from a patient on peds ward. We started talking and they both said they had given before, but haven't since. I don't fully understand why people aren't willing to give. Even when pt's come in and need blood and we tell their family, they always say they will have to call the lain, they don't volunteer themselves to go. At times it is funny, but at times it is sad when someone needs blood and no one will donate.

Just like anywhere else, once you give blood they give you something to drink and watch you a while as you recover. I declined this offer as I was heading home for lunch, and for the afternoon. My trip to town on Tues caused some GI problems and I needed to go home and rest for the afternoon. Giving blood may not have been the best idea given my situation, but I knew Anton needed it more than I did. I am hoping that my giving blood won't affect my tennis game. After beating Bill for the first time on Tuesday, I know he will be back stronger than ever tomorrow to try and beat me again.

Luke's quilt

7 1/2 hours on Saturday was what was needed for Gail and I to finish my nephew's quilt. I had worked on the quilt while Gail was in Goroka so I had the inside done, but needed to put on the border and then finish it up. Thankfully, it worked out better than I expected. I was thinking I was going to need to put on numerous borders, but we were able to get by with the fleece and some corner squares of one of the other patterns.

Once we got the borders on, it was then time to put the layers together. We went with tying instead of doing a quilting pattern due to a recent bad outcome Gail had with trying to quilt. This worked out fine, and then we just had to sew up the binding, so we watched a movie and finished up the quilt.

Once again I was thankful for Gail's help in this whole process. Without her help, I would still be working on it. We probably could have done it in 2 days if we worked 2 long days, but instead it took 3 days of work, not bad. I will probably be making one more quilt for my new niece/nephew to come in May. So stay tuned for more quilting from PNG.

Soffit Secret Service - SSS

As I was getting my bike out to get ready to play tennis on Saturday, I noticed some water on the floor in my laundry room and a wet spot on the wall connecting my house to the McCoys. I didn't want to say anything at that time, as I knew it wouldn't be a quick thing to figure out where the water was coming from, and I wanted to play tennis. So I waited til after Bill beat me (I am still defeated, but improving and playing much better) to tell the McCoys about my discovery. I am glad I waited.

We first decided that there wasn't any pipe in that area that should be leaking. Bill went to the attic with the headlamp to find any source of water there, but found nothing. Marsha and I looked under the floor of their laundry room and just found a small area of water, but didn't see anything obviously leaking. We then decided we needed to look in the walls to see if there was something in there that we didn't know about. So using the tools we had - screwdrivers, hammer and saw, we proceeded to remove a piece of plywood that was a wall in my laundry room. Inside, we found mostly dry insulation, but the bottom of the insulation, that was on the ground, was somewhat damp. Still no source of the leak.

Marsha was happy about tearing things down on my side of the house to look for the leak, but wasn't real excited about destroying her side, if she didn't have to. I can fully understand this considering how different our 2 houses are. Although both very nice, hers is much more homey - they have been here since '96 and it is nicely decorated, painted, and redone vs mine. As a result, trying to find the source of the leak was getting more difficult as we now had exhausted most of the possibilities of finding it from my side of the house, and needed to carefully explore from their side if we were going to keep looking.

Our next suspicion of where the water was coming from was the big drainage pipe which takes water from the front gutters to the water tanks in the back. This big pipe had been outside the houses in the car port areas, but when they enclosed the houses this too became enclosed. This is now nicely hidden by the soffit in the McCoys dining room, and then exposed in their laundry room. We attempted to look from the outside of the pipe to see if we saw any water, but the small hole that we had didn't quite allow us to see accurately. Bill mentioned we needed some secret service equipment to look down there better without tearing a huge hole in the soffit. For those who don't know, we aren't the secret service, nor do we know any in PNG, but we are doctors, so we talked about using a colonoscope to look down the pipe. The only problem with this idea is it would only give us about 6 feet, we needed about 12, and we didn't know where it was (minor things).

Our alternative to the colonoscope was an indirect laryngoscope, which we knew where it was and how to use it. The problem with this is it only looks directly down and is only about 12 inches long, so we had to readjust our plan. Instead of going from the outside, we now needed to go into the soffit. A spot behind the Swaziland clock that could easily be covered up was chosen, and Bill proceeded to drill and then saw a small hole through the soffit. He used the indirect laryngoscope and found that the pipe looked dry. We all took the opportunity to look into the soffit and see it was dry and were surprised that we could see the light coming from the outside.

Once we ruled out the big pipe as the source of the leak, we called it enough for the time being - close to 2 hours later (which is why I wanted to play tennis before I said anything). We decided we would wait for a big rain to see if we could identify a source of the water, or wait for more water to come. Apparently, we didn't have to wait too long. Later in the day while I was at the Dooleys, more water came, so they consulted Mike (not part of the SSS, but still very helpful). He decided that maybe it was coming from their kitchen sink downpipe and was running under the dining room to this spot. So it looks like maintenance may need to do some exploring of their kitchen to find the source of the leak. Marsha is hoping they don't do a lot of damage, but is okay with getting new kitchen cabinets if needed as a result of of this.

Harvest Party

Friday night, we had the annual Kudjip Harvest Party. We were going to have the party at the park, but due to the rain, we transplanted the party to the Dooley's house. We enjoyed our Hobo dinners in the oven and the company of all.

The Dooleys definitely won for the best costume. They were the 5 little piggies from the nursery rhyme. The pig who went to market, one who stayed home, one had roast beef, one had none and one went we we we all the way home. Very cute. Emma, their middle daughter came up with the idea as they were talking about what they should be.

The Bennetts were an Email Attachment. Mike was a hole in one, and Diane a hat rack. Judy was going to make me a jellyfish costume out of something in the storeroom, but it proved more complicated than originally thought. I instead got to be a leaf blower. Notice the leaf attached to the hat.

Luke, although not at our Harvest Party, was a very cute turtle this year.