Tennis

I have played a lot of sports in my life, but tennis was never one of them. I did learn some basics during gym class my senior year of high school. I remember Megan and I hitting the ball a little too hard over the fence and often having to go and get it. (We were use to hitting a softball and were trying to get home runs.) Other than that, I think I played once or twice with my little cousins when I was in college, but they were like 8 and 10 at the time, so it doesn't really count. Well, all that is changing due to the mass exodus of missionaries on station (secondary to home assignment). Bill and I are the only ones left who use to play basketball. Despite 1-1 being about the only thing I can beat Bill at, it can get old after a while, so we have taken on a new sport. Bill played a lot of tennis on furlough, and when he came back we thought we would give it a try.

The court we use, is our basketball court. Changing it to a tennis court is quite a process in itself. 1st we have to move the large rocks from the portable basketball hoop, and then move the hoop, which is quite heavy, to the side of the court. Then we get the net from the mail room and set it up. After that, we try and move any rocks, sticks, and trash from the court. The court use to be a smooth surface, but over the years it has gotten a lot of wear and now there are lots of holes and rough surfaces to contest with. These extra obstacles make playing more challenging, especially for someone who is learning. At times, you think the ball is going to bounce one way, and it bounces the other and you have to quickly change from forehand to backhand, or change where you were planning on contacting the ball.

When the weather cooperates, we have been playing 2 times a week. Recently, the rainy season has come, so if it rains all night the court is too wet to play in the morning before work. We have been playing for about a month now, and I am definitely improving, but have a long way to go before I beat Bill (the goal). Today he beat me 6-0, 6-3. He wanted to quit after we got to 4-2, but I said no this is my chance. He was on call last night and was tired, both sleepy and physically since we had been playing for a bit. Needless to say, we kept playing and he quickly finished me off.

I learned today that patience is a part of tennis. We had a good volley going and then I got impatient and tried to finish the point off and hit it into the net. This wasn't an isolated event. I often want to try and make the spectacular shot that will get me a point, instead of just trying to keep it in play and waiting for him to make a mistake. Maybe someday I will beat him.

Faces of the Pediatric Ward

Rheumatic Fever

Rheumatic fever is caused by Group A Streptococci, a bacteria, that causes many different kind of infections, including pharyngitis (infection of the throat). If patients with pharyngitis, due to Grp A Strep, don't receive antibiotics against Grp A Strep, rheumatic fever can develop. Rheumatic fever isn't seen in the US as much any more because the majority of pts receive antibiotics for throat infections. In PNG, most pts don't come to the doctor for throat pain. I think in my 1 yr here, of all the patients I have seen, and I have seen quite a few, I have only treated 2 patients for pharyngitis. As a result we see a lot of patients with sequelae of rheumatic fever, mainly rheumatic heart disease, especially kids. Once they have rheumatic heart disease we can't reverse it, we just support them with medicines for heart disease.

Bepi, is a patient I saw recently who has acute rheumatic fever. I had seen her a few weeks ago, and her main complaint was joint pain of her L hand. She had a fever, and was having some shortness of breath. I examined her, and got a chest xray, where I found a huge heart (on R). It was like she had 2 hearts, it was so big. I did an ultrasound and found she had a pericardial effusion, which accounted for some of her cardiomegaly. She had a sed rate of 68. She came back this week and her jt pain has now resolved on her hand, but is now in her lower extremity. She also has 2 distinct heart murmurs. On repeat CXR, the cardiomegaly is significantly reduced (on L), and her US shows a minimal pericardial effusion. This is quite a change in a few weeks time.

For the medical folks out there, the Jones criteria is used to diagnose rheumatic fever, it consists of arthritis, carditis, subcutaneous nodules, erythema marginatum, and syndenham chorea. You need 2 for the diagnosis and she has carditis and arthritis. She also has some of the minor criteria, elev sed rate and fever. We don't have the ability to do an ASO to check for evidence of strep infection, but given all we have, we assume it would be elevated and are treating accordingly. She currently is resting on the ward to try and give her heart a rest.

PE - kickball

PE is different this year, mostly because the kids are younger. I have three 1st graders (Lorena, Elena, Jerome - front row on R), two 2nd graders (Emma, Remo - standing), and one 4th grader (Allison - front row L). The rest of the kids are in the States on furlough, so we are doing a lot of basics for the time being.

I have forgotten what it was like to be in 1st and 2nd grade and not know how to throw, catch, run, kick, etc. I have decided to do a lot of basic things to teach basic concepts of throwing and catching so that when the bigger kids get back, the younger kids will have some idea what is going on. However, this is proving challenging.

The kids are so cute, but some are definitely more athletic than others. Some have quickly grasped the concept of throwing and keeping your eye on the ball to catch it, while others close their eyes everytime it comes and run away. We are using kickball as a basis for teaching some basic concepts. Last week, when the ball was kicked, if it didn't come directly to them, they didn't go get it. They stayed in their position and let the ball go in the outfield by itself until I got it. This week I wanted to try and get them to understand the need to go to the ball. So we played 500 (get 100 pts for catching a ball in the air, 75 for catching on one bounce, etc). Well, a few kids really understood and were running all over for the ball, at times knocking others out of the way. I was excited about their aggressive play, but at one point someone fell and scraped their knee and tears were shed. Maybe they were a little too aggressive, or maybe we should have played on the grass. Despite the injury, they did somewhat better when we played today. However, now a new problem has come up - we catch the ball, but don't understand throwing it to first, we hold it, or run back to our position, but don't tag the person or the base. This makes for long innings. Thankfully, the kids are definitely learning, and seem to be having fun with it.

Motor Vechile Accident

I am on call this weekend. Normally, I go in at 8, make rounds on the wards and then head home for a period of time before I get a call from the ER to see pts. Today when I got to the ward, they mentioned that there was an MVA and there were lots of pts in the ER. I kept rounding, knowing they would call me when they needed me. Not 5 minutes later, they called for help.

I find 9 patients in the 5 bed ER, they were on the floor, on stools, and anywhere there was room. There were nurses from the wards, college of nursing students who weren't working, and CWHs from the wards all helping out. As a result, things went pretty well. I triaged the pts based on severity and made my way through them all, leaving orders for the nurses to do on each. I went back to the wards while I waited for the Xrays to be done, and to give some of the head injury pts time to see if they would improve or not.

When I got back, I found one pt, who had a head injury, open tibia/fibula fx, and obvious fx of his R humerus, had died. The others were doing somewhat better. Of the other 8 patients, 2 were admitted with head injuries, 2 sustained arm fractures, many had small lacerations, abrasions, and musculoskeletal pain. All were thankful to be alive.

The story I got from the patients was the driver was drunk. They came up to a car, and were passing it, but hit some potholes. When they hit the potholes, the car kind of jerked and the driver tried to pull the wheel to straighten it, but then the car turned over. The guy who died, ended up underneath the car. I am amazed that there aren't more MVAs here based on the conditions of the roads and the way folks pile into drive, but thankfully there aren't. This is the first major MVA I have seen. Previously, I have seen one or two pts come in from an MVA, but never something like this.

In case you were wondering what the ER bill is for 9 MVA pts in our hospital - it came out to 580K. This is approximately $238 - not bad for an ER visit.

Pediatric Neurosurgery Anyone?

There is only so much one can learn in 3 years of a Family Practice Residency. Family Practice is one of the most challenging fields of medicine because it requires you to be competent in pediatrics, ob/gyn, adult medicine, and all subspecialities associated with them. Despite a great training experience at the Valley Baptist Family Practice Residency Program, pediatric neurosurgery wasn't something I got a lot of experience in. Today, was a day where I wished a knew a lot more about kids, neurosurgery, and radiology.

This kid is about 3-4 months old and has this misshapen head. I was quite surprised when I first looked at him. He has an obvious abnormality of the bones of the skull, but what exactly, I am not sure. I got this Xray and it shows overriding bones, but not sure if this is craniosynosytosis or something else. Craniosynosytosis is something I did learn about in residency and the only thing I would know to put in my differential. However, it is where the sutures are fused and so the brain doesn't have room to grow, but this doesn't quite seem like that. But then again, I can be wrong.

Another pt today was a baby of about 5 months old, who otherwise is developing normally, but has this swelling of the back of her head since birth. I had seen this previously in a 8 yo girl, or what looked similar. I knew enough to get a skull film to look for a defect and I tried to US it to see if I saw a defect or anything in it, but it seemed okay to me. However, this is only the 2nd time I have ever seen an ultrasound of an occiptal mass, so I am not sure I am highly qualified to say it looks okay. Again, my differential is not that large. (In medicine, the size of one's differential often shows how much one knows or doesn't know about a certain problem or condition. Obviously in these 2 instances, I know very little.) I have heard of an encephalocele, as we talked about it the 1st time I saw a pt with this, but that is about all I know it could be. An encephalocele is where some of the brain and meninges are herniated through the skull where a cranial meningocele is just the meninges. So it seems like it maybe just a cranial meningocele, but not really sure.

Cases like this are a great reminder of my own limitations. There is a lot I know about medicine, but SO MUCH more I don't know. I am thankful for my colleagues, both here and in the States, who continue to teach me, help me learn what I don't know, and answer all my questions. I am thankful for the Great Physician, who knows all our sicknesses and deformities and is able to heal us from it all by using doctors or not.

The garden

Bill is back working in the garden, and he is graciously, allowing me to help him. I thought I had broken both the weedeater and rotatiller, but thankfully the guys in maintenance were able to fix them, apparently they just needed cleaned. So we are back and fully operational now, which is good. Turning all that soil with a shovel was a lot of work, but it was fun. We have turned all the plots and most are already planted, so we are working on keeping the bugs out and waiting for the vegetables to grow. I have learned a lot about gardening since Bill has been back. I never realized how much work gardens are, but they are a lot of work. We recently have gotten some rain, which is helpful as we don't have to go and water everything ourselves as often, but does make for more weeding since the weeds grow better with water.

Numerous folks come to the fence and talk to Bill as he gardens, they don't usually talk to me, as they don't know who I am, which is fine. Today, a lady came and was telling us that we shouldn't transplant the cucumber plant or it will die. We were just looking at the cucumber plant and the little cucumbers growing and had no idea of transplanting it, but we thanked her for the advice. Then she said we weren't doing a very good job of keeping the grass from the plots. In the national's gardens, they have deep barrets (ditches) to keep the water out, and no grass at all. So she didn't think we were doing a good job, since all our barrets are full of grass. She was wanting to come and work and help us get the grass out. Bill told her I wasn't strong enough to get it all out, but I would keep trying, and thanks but we would do all the work we are able to do.

We currently have lots of pumpkin (squash) and cherry tomatoes that are ready to eat, but everything else is in the growing phase. We have cucumbers, watermelon, zucchini, lettuce, onions, cabbage, cilantro, carrots, beans, peas, pineapple, basil, bak choi, potatoes, tomatoes, and more growing. I am still holding out on liking beans and pumpkins, but otherwise I might enjoy most of the other foods that are growing. I keep trying to tell Bill we don't need to plant more beans, but he keeps planting them, not wanting any time to pass from the harvest of one group of beans to the next.

It has been 1 year

It has been one year since I came to PNG. It is hard to believe it has been that long already, but at the same time it seems like I have been here a lot longer. I have grown a lot this past year, and am thankful for the opportunities I have had. I look forward to this next year and what God will do in it. I continue to pray and seek His will for my life when my time here is up. I thought I would share some of the ways I have changed over this past year.

• I eat tomatoes, potatoes, sweet potatoes, zucchini, corn, and asparagus
• I can speak, pray, and sing in Tok Pisin
• I teach PE, garden, play tennis, play Settlers of Catan, and drive a standard on the wrong side of the road
• I have climbed Mt. Wilhelm, gone snorkeling and spelunking
• I do CSections, D&Cs, ultrasounds, colposcopies, thoracentesis, paracentesis, reduce fractures, and drain abscesses regularly
• I regularly treat patients with typhoid, malaria, HIV, Tb, chopchops and cancer (giving chemo)
• I am use to wearing a skirt outside my house (but still prefer shorts or pants), not walking alone at night, not going off station by myself, and sitting in segregated seating of guys/girls
• I understand the importance of rain for daily use of drinking, washing, etc
• I own many bilums, a meri blouse, and a bushknife
• I am no longer surprised by cockroaches inside my house or at the hospital
• I said goodbye to my Grandma until heaven
• I have a mission family that loves, supports, encourages and feeds me
• I have seen God's faithfulness, prayers answered, His mercy, grace, and love for me while I have been here over and over again

Buldung

Buldung came to us about 2 weeks ago. An ER nurse asked me to see a patient, and initially all I saw was a lump of a kid underneath a towel in the ER. I removed the towel and was, initially, quite surprised at what I saw. Buldung, about 3 yo, has a very large tumor which has distorted his face. His family told me, he has had this for about 5 months. He was treated at a nearby hospital where they did surgery to try and remove the tumor, but it came right back. They said he was having trouble breathing as the tumor extends into his mouth pushing his palate down, and also in his nose. He also was in quite a bit of pain, and wasn't sleeping. I wasn't really sure what kind of tumor he had, they did a biopsy when he had surgery, but with how things go here, it can be 6 months before we get anything back on the biopsy. At the time of admission, I knew we could treat Burkitts lymphoma to the point of curing it, and despite the possibility of it being numerous other kinds of tumors, I felt like it was his best shot if it was Burkitts. Waiting on the results of the biopsy wasn't really an option, since he could easily die before we know what he has. I talked to his family about not knowing what kind of cancer he really has, and not being sure if this poison medicine (chemo) will really help him, and that the medicine in itself could kill him. His family was looking for anything to help, and were okay with me trying the chemo. I did consult our experience oncologist (Bill), who agreed that it was our best option. Initially, when I looked at him, I saw his tumor, and had a hard time seeing the rest of him. In a few days, that all changed. He was sitting, talking, eating, playing, shaking hands, smiling, laughing, and I soon fell for this sweet kid. I know longer saw the tumor, but saw Buldung, the kid. One day when I was done praying for him, I opened my eyes to find him with his eyes closed, a huge smile on his face, and his hands covering his tumor. He looked so cute. I know his mom doesn't see his tumor, but just loves him because he is her son. One day, I had to give him Ketamine, an anesthetic, so I could do an LP and give him chemo in his CSF. He was crying after I gave him his shot, and his mom just held him and wrapped her arms around him trying to comfort him. When I saw that, I thought of God's love for us. We, too, all have our own large tumors - sins, that to some are quite offensive, are all people can see, and cause people to want to run away. However, God loves us despite our tumors. As a result of that love, Jesus died for our tumors, and God no longer sees our large tumors, but sees each of us as His son/daughter and loves us just as we are. Please be praying for Buldung. His tumor seems to be shrinking, his pain is down, and he is sleeping better - all of which are good things. He recently got a fever and we are treating him for an infection with his low wbc. Each day will be a battle. I pray that he and his mom, Tres, will know God's love all the more through this, whether the tumor resolves or not. *I just found out that his name is Buldung, not Bulung. They don't always know how to spell the names, they just say them and leave it up to someone else to spell. So his chart initially had Bulung, but it really has a d in it. He, his family, and the nurses had a good laugh as I tried to pronounce his name correctly today (9/18)

New Hospital Construction

Since I got here, we have been working on building a new hospital. It has been almost a year, and we are getting a lot closer to being done, but still are some months away. Mike Chapman is a missionary who is here to oversea the building of the hospital and other buildings here on station. He has been very instrumental in getting the project as far as it is, and has worked closely with the construction crew to build relationships and encourage them in their work. Shortly after Mike got her (in Dec), they started having daily devotions each am before work, and a number of the guys are now Christians, Praise God. When the hospital is completed, it will be quite a bit bigger than our current hospital, with at least 10 extra beds on each ward, and the addition of more delivery bays, and ER space. At times, we have to close the hospital to longwe patients, when we have patients sleeping on the floor, but when this is completed, that likely won't be a problem. We still have to build a new sewer system before we can open the new hospital and have been praying about funding for it. We recently heard reports that we got funding, and are just waiting to see if it actually comes through. Keep praying for the completion of this project.

New Ultrasound Machine

Previously, I mentioned that we were looking to get a new ultrasound machine to replace ours, which was aging quickly. While the McCoys were on furlough, they were able to raise a lot of funds, and some of you contributed as well, so as a result we now have a new ultrasound machine. It works great. We have only been using it for 2 days, but things are much clearer. I have seen more ovarian cysts in these past 2 days that I ever did before. Lots of patients come in everyday asking for an ultrasound for their back pain, reflux, or any complaint they have. Part of what I do everyday is to educate them that not everything needs a "scan." At times, this is frustrating as they insist on having a scan for things that I can't see. (This is also why we won't get a CT scan, the whole country will be here wanting a CT of everything.) The colon is something that isn't well visualized on US, but with the new machine I am amazed at how well, at times, I can see the colon. Hopefully, this machine won't throw my whole I can't visualize it objection out the window.