Update: Nason

A few weeks ago, I introduced you to Nason. Nason is a young man, about 20, with metastatic testicular cancer. We had been waiting for the chemotherapy to arrive and for his path report to come back. The path report diagnosed him with non-seminomatous mixed germ cell cancer. We knew he had metastatic disease, so this has helped to tailor his chemo regimen. In the time we were waiting a few things happened. 1 - his cancer grew, especially in his liver. When I first met him, I had been able to see part of his liver in between the metastatic disease, but now it is all tumor. 2 - he became a christian! Praise God for His grace. Once I knew he had cancer, I talked with him and his mom about the Lord. His mom was a christian, but Nason wasn't. We talked about life after death, and about our sins and Jesus's payment for them. I gave him a tract to read, and prayed for him. When he returned, I brought it up again. He told me he wanted to become a christian. I talked with him to find out what he believed, shared with him some more, then I prayed for him before taking him to the chaplain. Chaplain Moses, spent some time with him and his mother, and later reported he believes in the Lord Jesus, and is a christian. I was so happy, so thankful for the Lord's work in his life. I have started to give him chemotherapy. We are on the 1st cycle of 3. I am thankful that he is tolerating it well. He feels like the cancer has gone down some and a recent ultrasound agrees with his assessment, but we have a long way to go. I want the chemotherapy to work and to cure him. I continue to pray for Nason to live. I don't usually let myself get attached to patients, but Nason and his mom, Rose, have worked their way in. I know the cancer is very extensive throughout his body and there is a good chance he won't make it despite our efforts. However, I plan to keep trying. I am thankful knowing that if he loses this battle with cancer, he will be in a place without illness and where the Lord will wipe away his every tear, and I will one day meet him again. Pray for the chemo to work. Pray that he continues to be strengthened by the Lord each day. Pray for the rest of the chemo medicine to become available to us so we can finish the treatment that he needs.

Fractures and Gideon

We see a lot of fractures at the hospital. Many are the result of violence of some sort, but we also see a bunch of kids who have fallen from one thing or another and sustained a fracture. We don't have an orthopedic surgeon, but have Jim, a missionary surgeon, who can do almost anything. However, given the number of ortho cases that we see in a week's time, if every fracture needed an open reduction (surgery) that is about all he would be doing. His days are already full of bowel obstructions, hysterectomies, tendon repairs, hernias, pelvic laparotomies, and more, adding 5 open reductions a week, would be asking a lot. So when we have a fracture, we always try to do a closed reduction. I understand, this is not the optimal choice in the US, but it is how we are able to keep Jim going and doing all the surgeries he does and not get totally burnt out. So typically when a pt comes in with a fracture, we get an xray and then try a closed reduction under Ketamine/Valium. We don't have a flouroscopic xray unit, so we reduce it, cast it, and have them come back in 1-2 days for a rexray, and retry if needed. Typically when I look at an xray, not only do I look for a fracture, but also how far the bones are off, how much swelling the pts has, and how far I will need to move them to put them back in place. I do this in order to determine if I am going to be able to do this myself, or if I need reinforcements, typically Jim or Bill. My 120lb frame is strong, but so are bones, and lots of swelling around the fracture makes it even worse. This weekend, I was on call with Alan, a med student. He called that we had a kid with a fracture, so I met him in the ER. The only thing going for us was that the fracture happened that day, but it was a bad one. Gideon's radius and ulna were fractured just below the growth plate, only about 10% of the bones were overlapping, and there was a good bit of swelling. In my mind, the chances of me reducing this weren't very good, but I was on call and thus was the reinforcement. So Alan and I got him under Ketamine and gave it a try. Despite manipulating the wrist as much as I possibly could in an effort to straighten them out, I didn't really feel the bones move. However, I had tried numerous times, and I didn't think it was going to get any better, so we casted him and told him to return on Monday. Fully expecting to need reinforcements come Monday am, I showed the xray to Bill when he happened to walk through the hospital on Sat afternoon. He agreed it was bad, and when I told him I didn't feel the bones move, he wanted to give it a try, but the pt had already left. I even mentioned it to Jim on Monday am rounds telling him I would likely need help. The patient was outside xray when I finished rounds and was walking to my outpatient room. I quickly walked into the xray room to find his film. I was pleasantly surprised to find the radius and ulna almost perfectly aligned, well not exactly perfect, very close anyway. I was very thankful and Gideon seemed happy too.

What is it?

I recently got a chest xray on a patient who has having a cough. As I was looking at the xray, I found a calcified something in the area of his stomach/spleen. I hadn't seen this before and really wasn't sure what it was. I asked the pt if he took off his shirt for the xray to make sure it wasn't something in his shirt - it wasn't. I repalpated his abdomen and back to see if I felt a mass - I didn't. I ultrasounded him to see if I could find a mass - I didn't. I had them redo the xray - it was. Bill walked by and I showed it to him, he didn't know what it was either. We reultrasounded him and found something calcified anterior to his L kidney as we were looking from his back, but still didn't know what it was. Bill asked, "Is this why he is here?" Nope. So after everything I did, I spent 10 mintues trying to explain to this guy that he really is ok - it went something like this. Yu no gat bikpela sik. Taim mi bin lukim piska, mi lukim wanpela samting I stap, tasol mi no save wanem samting em. Mi bin pilim bodi bilong yu, tasol mi no pilim dispela samting. Mi bin lukim long computer scan, tasol mi no painim dispela sik. Mi bin lukim narapela piksa na dispela samting yet i stap, tasol mi no save em. Mi bin askim narapela dokta sapos em save, em no save. Em bin lukim computer scan, na mipela bin painim samting, tasol mipela no save wanem samting em. Tasol mi save, dispela samting em no mekim dispela sik yu gat. Mi bai skelim sampela marasin long helpim dispela kos yu gat. He didn't seem to believe me, but can you blame him? He returned from xray, got reexamined, got ultrasounded, got sent back to xray, got examined by Bill, got reultrasounded and now I am telling him he is ok and not to worry about it. I had to explain it a couple times in different ways before I got him to leave the room and go get his meds. Maybe next time I will think twice before I "keep looking" for answers to something I want to know, but maybe not, as this is what makes medicine, especially here, fun.

Picture from church

New Hospital

I hadn't been in the new hospital since our dedication, but last week I went to see how the progress was coming. We are getting closer to moving into the new hospital, but aren't there just yet. The date of moving seems to change all the time, but it shouldn't be that much longer, I hope. The major stuff seems to be done, but now they are trying to finish up all the little things that still need completed. The company who had been building the hospital, is finished with their work, so now it is up to Mike and his guys to finish what has been started. We received a shipment of new hospital beds from the States about a month ago, and they are occupying our maternity ward, it is a big ward for lots of moms and babies. The OR light has been installed, but still has more work to be done. I enjoyed seeing the landscaping that we started as we were getting ready for the dedication back in Jan. As I was walking between 2 wards, I saw some grass and retention wall that looked really good. I remember when it was a tall pile of clay that we were shoveling out, it was a lot of work, but it sure looks good now. Keep praying for the completion and for the move as we get ready for it.

Anita

Anita, maybe 10, was carried in by her family. She laid on the bed with her knees bent and her hips flexed, not wanting to move anything. She had significant pain on her L hip, so at home had been laying on her R hip and subsequently developed a pressure sore on that side. She had sores on both sides of her mouth and ulcers on her tongue, she hadn't been eating for at least a week. She kept her R arm bent, as she had swelling of her R elbow and cried when I touched it and tried to straighten it. She had increased frequency of urination, but on exam had a very distended bladder. I tried to get her to move her legs, but she said she couldn't due to the pain. She allowed me to move her R leg minimally and evaluate her hip joint, but cried and grimaced as soon as I touched her L thigh. She also had some swelling of her R ankle, and 3rd L finger. When I first looked at her, I wasn't sure exactly what was going on, but (as Bill would/did say) she looked like she was a POW. She was malnourished and very sick. Finding pus in her elbow gave me the answer to what was wrong with her. Pus and subsequent sepsis makes people very sick, if untreated. Everything that was swollen had pus in it that we were able to drain - her elbow, her R foot and ankle, her 3rd finger, her L femur, and her bladder. Yep, you read that right. We put the foley in to drain her bladder, and got out about 700 cc of urine, then the nursing student, Stacey, told me there was blood in it. I went to look and wasn't real concerned by what I was seeing, until I started to see pus, frank pus, coming out of the foley. I found the US machine and looked at her bladder and sure enough, found a lot of pus sitting in the bottom of her bladder, I had never seen this before. I got Bill to check it out, he hadn't seen it before either. We irrigated the foley and got out more pus, hopefully all of it. Thankfully, she is here now and we will do all we can to help her. I pray that after draining all the pus, giving her antibiotics, and fattening her up she will get better, but she has a long road ahead of her, pray she gains strength from the meds and from Him.

Dinner Guests

Prior to living here, I didn't really cook. I still don't cook a lot, but I am learning and have learned how to make a handful of things that keep me going through the week. I occasionally have folks over for dinner, but not too often, and when I do, it is usually limited to a small number - one or 2. The thought of cooking for a large number of folks is quite intimidating, as is cooking for people who can really cook, but the other night I thought I would give it a try. I had Becky, Jessica, Cilla, Stacey (visiting nursing student), and the Bocks - Alan and Lynsey (med student and wife) - 7 people. I had to borrow the McCoys folding table and chairs in order to have enough room for everyone. Becky helped by making tortillas and beef tacos, and Lynsey made some cookies for dessert. I made a bunch of other Mexican food - chicken tacos, spanish rice, a corn dish, and all the fixins for tacos. It seemed like it took me forever to cut up everything, but it turned out well. At least it seemed that way because there wasn't a lot left over as we were cleaning up. I also made a berry cobbler from the blackberry like berries we have growing in the garden. Marsha gave me the recipe and although it didn't look as nice as hers does, it tasted pretty good. So although I don't really like to cook, I now am able to cook a number of things and so I may be having more dinner guests in the future, we shall see.

Something I had only read about

Warning - this blog contains discussion of a medical condition - read at your own discretion It was the end of the day and Maria, our HEO - Health Extension Officer (like Physician Assistant or Nurse Practitioner), came and said she thinks she has a case of appendicitis in the ER. Ok, I finish my patient and Rebekah, new med student from New Zealand, and I go to check her. A 13 yo girl complains of 5 days of abd pain, still eating, no nausea, no fever - doesn't sound like appendicitis. On exam, she has a fullness and tenderness of her lower abdomen. On ultrasound exam, I find a large 10x10 cm mass in her pelvis, but I couldn't identify what it was, or where it was coming from. I asked her when her last period is, and she said she had never had a period. Huh. She had other signs of maturing that would make you think she should have had periods at this point. I explain to her and her mom that I needed to do a female exam. They agreed. On exam, I find a bulge of the skin covering her vagina, but no opening. When I push on the abd mass, this bulge gets bigger. She has an imperforate hymen. The hymen is the skin that covers the vaginal opening in women. Typically there is an opening in the hymen, which gets bigger as a girl matures. However, in rare instances (between 1 in 1000 and 1 in 10,000), there isn't an opening, and the blood that should come out each month in a women's period, gets trapped inside. This is something I have read about many times, but have never seen. She seemed to have a classic presentation and exam for it, which made it all the better in a medical sense. I was excited about the medical aspect of it, and was sharing it with Susan who was also in the ER. We were relooking at the ultrasound, when Jim walked in the ER. I told him what I had and Stephanie overheard and came over. I was asking Jim what we need to do, thinking when can he do this surgery, and Steph said she had done one in fellowship. Jim, to my surprise, said that we can do it. Steph was going to take the see one, do one, teach one approach and teach me how to do it. Wow - this case is getting even better, lets go for it. We got everyone and everything we needed and set off for the Minor Procedure Room. Typically one person could do this procedure with minimal help. Not so in our case. Besides myself and Steph, we had 2 nursing students (one from the US and one from PNG), one nurse, one med student, one OT person, and one nurse anaesthetist, and in the room to see this rare medical condition. With Steph's guidance, I was able to make the necessary opening in the hymen and we got out of the way as the chocolate syrup like fluid poured out of her like a fountain. As I was reading more about this later, the medical literature talks about making sure you have the most experienced gynecologist with expertise in these procedures do the surgery. I am certainly no expert in hymenotomies, or in anything, I still have much to learn. I am a missionary doctor who tries to do the best I can with the resources available, who wants to learn what I don't know, and who is trying to serve the Lord and His people in Papua New Guinea. Thankfully, her parents didn't care that I had never done it, they were just very thankful that we were able to help their daughter. Numerous times as we were doing the procedure mom thanked us and prayed God would bless us for our work. I was blessed just knowing I was helping this young girl by doing a simple procedure. Missionary medicine is great.

The Bennetts are back

Yesterday Judy and Andy returned from their home assignment to the States where they got to visit with family and speak at many churches. We are glad to have them back and now our missionary family is complete once again.

Ice Cream Shop

Lydia and Priscilla Radcliffe have started their own Ice Cream Shop. They are usually open every other Saturday afternoon and serve a variety of homemade ice cream flavors. For just 2K you are able to get 2 scoops of cherry guava, black rasperry, lemon sherbert, vanilla and peanut butter, or whatever the flavors happen to be. They are good at using ingredients that are available to them, i.e. cherry guava, black raspberry, etc. They usually make between 3-4 flavors that we get to choose from. They also give free samples, which is nice. It typically turns into a big social gathering for everyone on station as we come and enjoy ice cream. It is especially a social gathering for the 3 new puppies on station. Brutus, the black one, is Steph and Becky's, Buckeye belongs to the Radcliffes, and Copper belongs to the Dooleys. I am not sure how much money Cilla and Lydia are making in having their ice cream shop, but we are all sure enjoying it. Thanks girls.

Itet

While on call, the majority of activity occurs in the ER or in the labor ward, my last call was no exception. I had just come home from the ER when my phone rang - labor ward. A patient was referred from the Jimi with premature rupture of membranes and she concern for prematurity. The Jimi Valley is part of the graphical location that we care for, but it is far away, and for someone to be transferred from the Jimi on a Friday night, means it must be pretty serious. So I had them meet me in the ultrasound room. I got to the ultrasound room first, but shortly thereafter our staff was wheeling the patient into the room. The patient had delivered 5 babies previously at the health center in the Jimi, and this was her sixth. When she stood up, I couldn't believe how short she was and that she had previously delivered vaginally. I asked her again if she had delivered 5 babies and she said yes, I still didn't believe her, so I did a quick check of her abdomen for a scar - none. Unbelievable. We have this red line in the delivery area (see pic on R), which designates 147cm (4'8''). Moms below this line, statistically tend to have more Csections due to having a small pelvis. Our labor ward calls us when patients are below this line and wants us to do a Csection on them, often before they have even labored. Not only was Itet below the red line, she was way below the red line. I am not that tall, 5'4" on a good day, and I towered over her, she was about (4'3"). I was amazed that she had previously delivered the 5 babies in a health center, which is staffed by folks with very little ob training. So she proved that no matter how short someone is, God has still made a way for some moms can still deliver vaginally. Despite having delivered 5 babies previously, this time Itet needed a Csection because she wasn't progressing well. The baby had a lot of meconium and a really short nuchal cord, but came out crying. We also did a tubal ligation that her and her husband wanted, so the health care center won't have to worry about referring her for problems with deliveries anymore.

Meet the Hellars

Cliff and Martie Hellar have been in PNG for 47 1/2 yrs serving as missionaries. Martie flew in on the helicopter this past weekend, which gave us, here, an opportunity to get to know them. This afternoon I went to visit them and found myself drawn to them and their stories. At one point they asked about my story, but I just wanted to hear more about what they have and continue to do for the Lord.

They serve the Keyagan people in the Eastern Highlands Province (a 7.5 hour drive from here). When they first got to the region, there wasn't anyone who knew of Christ. In their 47+ years, many have heard the truth of the gospel and have come into the family of Christ. They shared a story of a young believer from their area, who traveled to Banz (about 10 minutes from here) and saw a bunch of his people not going to church on Sunday. He told the people that Sunday was the Lord's day and that they should be in church. When he got back to his place, he shared with the Hellars that he was feeling God calling him to start this church. So he did, and now 20yrs later, that indigenous church is still flourishing.

Cliff is fluent in the Keyagan tok ples (language of the village) and now works to translate the Bible into their language. He has finished the New Testament, and after 15 years is about 40% finished with the Old Testament. They have given their lives to the people of the Eastern Highlands Province, and want to continue to serve until the Lord calls them home. They originated in New Jersey, but now consider PNG their home and have made arrangements to be buried here. They raised 4 kids, 2 of which are also missionaries in PNG - one in the Gulf Province and the other in the Morobe Province.

As a young missionary just starting out, it was truly an honor to meet the Hellars and to gain a glimpse of what their service to the Lord has looked like. I trust God will continue to provide for them and help them finish the work He wants them to while they are on this earth.

Aerial Photos

For a while, Bill has wanted to get aerial photos of the station and new hospital for future use and has talked about chartering a helicopter to do it. On Saturday, a SIL helicopter came with a patient so Bill got his chance to get the photos he wanted. While Bill was attending to the patient, Mike Chapman (our expert photographer on station) and Josiah (who wants to be a pilot) got to go up and take some shots. The helicopter did need jumped first, which was interesting, but once in the air, they has smooth flying and got some great shots. On the left, you can see the hospitals. The cross shaped hospital is the old hospital, and the new hospital is the bunch of buildings to the left of the old hospital. On the right, you can see the duplex I share with the McCoys. The very last house on the top right is ours. The top half is mine, the bottom is the McCoys, and the garden around us is what Bill and I are tending to. If Google Earth worked where we are, this is what you would see.

Tubing

Last weekend, the little guys on station were playing in the Radcliffe's yard with all the inner tubes. This weekend, the big guys took those inner tubes down the river. 14 of us ( 5 Radcliffes, 2 Myers, 3 Dooleys, 3 volunteers, and myself) walked to suicide rocks and then enjoyed rafting down the river. The water seemed to be at just the right height for us to enjoy the rapids. The damage of the hydro dam caused the river to forge a new route, which enabled us to raft even longer. The longer route provided some challenges in downed trees we had to duck under and disentangle ourselves from, but it was worth it. Thankfully, other than a few scrapes and bruises we all survived and are talking about doing it again - soon.

Challenges of working at a mission hospital

There are many challenges that arise in working at a mission hospital

• daily running out of medicines, IV fluid, IV tubing, blood in blood bank, sutures, staple guns, reagents for the lab equipment, and not being told about it until you are out
• power outages
• equipment that breaks down because it has been jerry-rigged together
• not enough resources to fix or obtain the things that are needed to keep the hospital running (i.e. hydroelectric plant, sewage plant, etc)
• not having access to labs, radiographical studies, or other tests that would make caring for a patient or making a diagnosis better, easier, and less uncertain
• not being able to trust what others do or report, or what patients tell you

All these things you just take in stride, knowing that you can't really fix most of these things, so you learn to live with, make do, and adjust one way or another. You carry your headlamp in your bilum at all times, just in case the power goes out. You learn to improve your physical exam skills and improve your ultrasound skills in order to make a diagnosis since you don't have the lab/mri/ct that you want. You continue to ask for money from supporters and government until the needs are met. You check your own blood pressures when it is really important, and ask your own important history questions.

Recently, there has been a new problem. Our lab is usually able to give us a complete blood count, malaria smear, some chemistries quite reliably. At times our CBC machine is down, and then they do it by hand and that adds in lab person error so at times it is off, but recently it has been more than off. I had a patient with a white blood count of 51,000, hemoglobin of 18, hematocrit of 59, and platelets of 328. The WBC was high, suggesting possible infection vs leukemia. The next day it was retested - wbc 55, hgb 3, hct 9, plt 12. This is quite a change in just a day when the pt isn't bleeding. The pt looked quite pale and so I thought this 2nd one could be right. I talked to the lab, and they assured me this second one was right. I also asked to see a blood smear to look for leukemia - which he does have. I gave him blood, and we checked his hgb again to see where it was at after the blood - now his wbc is 6 and his hgb is 10. Where did this come from and what am I to believe? If I hadn't looked at his peripheral smear myself, I would be doubting that he had leukemia and that his wbc was 55. So despite what the lab says, I am sticking with my diagnosis and treating him as such. But what am I to believe in the future?

The lab also came to me today and told me that they needed to redo their stains for acid fast bacillus (AFB) staining. We use this to check for pulmonary tuberculosis in patients. We had a period of time, where we didn't order them because they were always negative in pts who clearly had TB. In the past few months, that problem was fixed, and we were getting positive smears, so we started ordering them again. Now, we have another problem, too many positives. I have a patient on the ward with an abnormal chest xray, that I really wasn't thinking was TB, but the AFB came back positive, so I started him on treatment. Today, with the new stain, it is negative - great now what?

Just another challenge to add to our daily care of patients that we must overcome.

4th of July Celebration

Today we had our 4th of July Celebration at our English Lotu service. All the missionaries in the area came together to enjoy food, fellowship, and fun. Jeff Myers and Scott Dooley helped to remind us of the freedom we have in America, but also of the freedom we have in Christ, because of what He did for us on the cross. We learned about the men who sacrificed their bodies to hold up the flag at Fort Henry, which is how Francis Scott Key came up with our National Anthem. Those men died for their country, they wouldn't let anything stand in the way of that flag coming down, even if it meant their lives. The question we were asked was, are we doing the same for the Kingdom of God? Are we willing to risk our lives for the sake of the cross? Are we as passionate about the Kingdom of God as those men were about their country? I know I could do a better job of sharing Christ's love with others, what about you?

After our devotional time, we enjoyed some games that Becky came up with. We had a 3 legged race, sack race, towel volleyball game, shoe relay, and wiffle ball on a badminton racket relay. Lydia and I put up a good effort on the 3 legged race, but fell at the turn. Scott and Allison edged out Alan and Josiah for the win. The boys beat the ladies in the wiffle ball on the badminton racket relay, but we all enjoyed playing, and had a lot of laughs.

Buldung

Buldung came in about 1 year ago, hiding under a blanket because he had a huge tumor coming out of his face. After completing chemotherapy, he is all smiles. His tumor hasn't completely gone away, but he, his family, and I are thankful with where we have come. We just found out that he has NonHodgkin's Lymphoma, I had been treating him for Burkitt's Lymphoma while we were waiting for the biopsy result from Port Moresby. The chemo I gave him, wasn't exactly what he needed, but was pretty close, close enough that it did shrink his tumor, and at least now we know what we are fighting when it regrows. If/when his tumor gets bigger we will need to consider restarting chemo. For now, Buldung will go home with his family and continue to enjoy the life of a 5 year old that he has been embracing for these past 9 months. What a blessing to be a part of God's healing.

Nason

I came to PNG 21 months ago to care for patients who were sick and to share Christ with them. Today was my first day back in clinic after being in the US and Nason was a great reminder of why I am here. He is a young man of about 20, who lives in a nearby village, who has had testicular swelling for about 6 months. He was ashamed about it, so he didn't go get it checked out. He also has developed an abdominal mass and neck mass 2 months ago. On exam, he had a testicle about the size of a softball, a large mass in his LUQ, and a large L supraclavicular neck mass. Upon further evaluation, his ultrasound showed multiple huge liver mets, and pulmonary mets on xray. Nason has metastatic testicular cancer.

I wish he would have come in about 5 months ago, and it would have made treating him a lot easier. Jim was able to squeeze in a biopsy this afternoon in order to send the pathology specimen back to the US tomorrow, and we are talking with some of the doctors in Port Moresby to find out what kind of chemo meds they have to treat him with, and if they can send us the meds. I am not sure if we are going to beat his disease, but we are sure going to try.

I also got to introduce Nason to Jesus. After talking to him about his diagnosis, I asked him if he went to church or what he knew about Jesus. His mom is a christian and goes to church, but Nason does not. I got to talk with him more about Christ and share the gift of salvation with him, and we prayed together. If we can't win his battle against the cancer, I pray we can win the battle for his soul. Pray that Nason would come to know Christ, and that we would be able to shrink his cancer with the meds.

Back in PNG

I safely arrived back in PNG on Monday afternoon. It was nice to be home after being on an airplane for so long. I had a nice welcome by the missionary family upon my return, and have been enjoying the dinner invites I have received. It has been good to catch up with the missionaries and what has been happening here while I have been gone. I've enjoyed working in the garden and playing tennis as well. I was also pleasantly surprised by the warm welcome I received from the national staff. So many folks came up and gave me a hug and said how happy they were to have me back here when I went to work on Tues am. I really felt appreciated, loved, and at home. One thing that hasn't been good, is the jet lag. I woke up at 3am the first night, and 345 the second. Hoping tonight will be better - we shall see.