Pop!

One of the things I enjoy about Family Medicine is the variety.  There is always something new to see, do, or learn.  In PNG this is very true.  Most days I see something that I have rarely dealt with or is completely new.  I have learned to adopt a “can-do” attitude.

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The first x-ray

I was working in the outpatient department (OPD) when a middle aged male came in.  He had fallen two days before and had pain over his thumb.  His thumb was deformed and he could not flex it.  I sent him for an X-ray and he came back with a film showing dislocation of his distal phalangy.  Well, I’ve never fixed one of these before but thought it should be simple enough.  I injected lidocaine around the base of his  finger (digital block) making his thumb numb.  As I held his hand in place, I gave the tip of his thumb a firm, steady pull.  Pop!  Like magic his thumb popped back in place,  looked normal and was moving normally.  Post procedure film was normal as well.

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After popping it back in place

Nursery Reflections

One night in July:

I had come to the hospital to evaluate a young mother with appendicitis.  After finishing in the ER I walked into Labor & Delivery to check in before going home to bed.  I peeked in the nursery.  The Baby of M is having apnic spells.  The child is already on 2 IV antibiotics, IV fluids, and medications to stimulate breathing.  His mom is gently rubbing his jaundiced hand as the photo light casts a blue glow on his tiny body.  The bag and mask sits near the warmer ready for use.  My heart sinks.  What more can we do?  It’s an all to familiar story in PNG.  Respirations go  down and we slowly lose the child.  Of all the things I saw and did today this got to me the most.  Not the 2 C-sections with floppy kids that turned up all right or the multiple broken bones or lacerations.  Even the hand amputation I took in stride but looking at a little helpless child in a nursery warmer breaks my heart.  What more can I do?  Pray.  And so we did.  I left the nursery with a grateful mother who knows we are doing all we can and that we care.  A mother who knows we do our jobs because we love Christ.   As I walk home through the cool night air many questions race through my brain.

This morning as I rounded on Pediatrics, bed 9 was empty, the little 7 day old child had died in the night.  Bed 29 had an episode of respiratory arrest in the early hours of the morning. Her situation is guarded  Does our work matter?  We keep losing patients.  But as I looked down the Ward there were many more kids who were improving.  Some were going home today healed.  Its easy to get down with the losses but without Nazarene General Hospital and its staff many more would die.  And so one week ends and a new one begins. IMG_0540

A Day in the Outpatient Department – Part 2

On my return to the office a young female came in with pelvic pain that was worse with sitting.  After a brief history she laid down on the exam table.  “Are you pregnant” I asked in Pidgin.  “No,” was her response.  She looked pregnant and had something firm in her abdomen.  Off to ultrasound we went.  Hmmm . . . that’s a head . . .  and there’s a heart beat.  “Yep, you’re pregnant and about 36 weeks.”  “I know” was her smiling response.  Well, I guess I botched my Pidgin on that visit.  I will keep working.

No time to wallow in language doubts I headed back to my exam room.  A middle aged female came in with years of pelvic pain and vaginal discharge.  It did not take long to figure out she had PID (Pelvic Inflammatory Disease) from prior STD exposure.  This is far too common in PNG with promiscuity, domestic violence, and rape.  I gave her antibiotics to treat her symptoms.  Hopefully not too much scarring has occurred and the pain will resolve.

Then the watchman (a friend or family member who comes to the hospital with the patient) of a patient I saw last week came in asking my advice on his esophageal cancer as the patient was too weak to get to the hospital.  “Could your surgeons remove the cancer?” he asked.  Dr. Jim Radcliffe and I explained that the surgery would either kill him or prolong his suffering.  The best we could do was remind him of his hope in Jesus.

Next came a child vomiting water with occasional blood.  He also has watery diarrhea.  Off to the lab.  Mom and Dad return later with the blood test which looks alright.  Medications given for dysentery.  His parents are happy with his care.  His dad, it turns out, is the pastor of a Nazarene church a few miles up the road.   I cheerfully turn to my translator and say “Hey, one of my brothers in Christ.  Can you see the family resemblance?”  The dad and I laugh.  They head home with their fears released.

A new mother with Chronic Migraines, a young man for a school physical, then an elderly woman, deaf and blind from cataracts.  The afternoon was flying by.

I poked my head out the door for the next patient.   “One pela kam” I called.  A 30 year old female stood up and slowly walked down the hall.  She had temporal wasting (loss of muscle and fat), was pale, and moved slowly.  “Man, she looks sick,” I thought.  TB?  She sat down in my room.  “I’m here with a cough, short of breath, my belly is swollen, and there’s something on my back where I was stabbed one year ago,” she says.  She had fluid in her abdomen on exam and a hard mass on her right posterior chest wall.  Cancer.  We made our way to the ultrasound room.  I scanned her back and abdomen.  Liver cancer with ascites (fluid in the abdomen).  I sat facing her and her young husband.  “I am truly sorry,” I said and explained, “You have cancer of the liver.”  I paused as she and her husband sat in shock.  I slowly went on, “There is no cure.”  Tears began to stream down her face and the husband’s face tensed.  I was fighting to hold back the tears as I talked.  “Have you given your life to God and trusted Him?”

“Yes,” she replied, “my spirit is in His hands.”  I asked if I could pray with them.  They nodded yes.  I slowly began to pray in Pidgin.  They headed home to see their pastor and will come back if they need us.  She probably has 3 months or less to live.

No time to morn I moved onto the next patient.  A young man with  seizures. Then an ultrasound  of a pregnant patient that is 28 weeks.  “Congratulations.  You have twins!” I said with a smile.  One of the labor and delivery (L&D) nurses poked her head in the ultrasound room.  “Dr. Nathan we need you in L&D.  We have a laceration that needs suturing.”  No time to celebrate with this patient for now, off to L&D.  And so my day ended.

It’s not always easy but I am thankful for the chance to show the people of PNG the love of Christ.  Sometime that means sharing in their brokenness and pain and other times celebrating life with them.  Sometimes that means using my skills to help ease their suffering or being able to heal them.  Each one of you who is partnering with us through prayer and finances is also helping to treat every person that walks through the hospital doors. Thanks for all you are doing.

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A Day in the Outpatient Department – Part 1

Practicing medicine in PNG is very different than anything I have seen in the United  States.  The following is one weekday I had in April to try and give you a feel of what a typical week day now looks like for me.

Each day we see our patients that have been admitted to the hospital and then head to the Outpatient department (OPD) to see patients who have traveled near and far to the outpatient clinic.  Our time in the OPD is often interrupted by trips to the emergency room or back to the hospital wards.

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Wednesday at 9:30am I walked into the OPD and headed for my exam room.  “One pela kam,” (one come) I cheerful called in Pidgin to the line of waiting patients.   A mother and her 7 or 8 month old son came in and sat down in my room.

The young boy had a cough, fever, and was short of breath at times.  After his exam I diagnosed pneumonia.  His mother and I discussed admission but elected for him to go home.  She could not stay as she had to breast feed his twin.  Since he was breast feeding well, I gave antibiotics and sent him home with a promise from his mother to return in the morning.

Next an elderly gentleman came to my room.  He did not know his age which is common in PNG.  He had received a foley catheter a few weeks ago because he was having trouble urinating.  This helped but he’s also having trouble with his bowel movements.  His exam revealed a very large nodular prostate.  My heart sank.  Prostate cancer and rather advanced.  I graciously explained his diagnosis and that there was no good treatment available in PNG.   All I could offer was to pray with him and remind him of our hope in Jesus Christ.

Again I poked my head out the door of my office “One pela kam” I called.  A middle aged lady slowly came into my room.  She had weakness when walking for one week.  I suspect she has spinal stenosis (a pinched nerve in her spine) but we don’t have an MRI to confirm my diagnosis.  I gave steroids and she will come back in a few weeks.

Next came a 3 month old girl appearing very malnourished with diarrhea.  Her mother was young and not mixing her formula correctly.  Admitted to treat the diarrhea and teach her mother proper feeding.

Then I saw a 10 year old with jaundice and presumed acute Hepatitis.  Discussed his care with his parents and sent them home.  The hospital has limited tests so not sure which form of hepatitis but suspect Hepatitis A.  Something we get vaccinated for in the USA.

He was followed by a 70 year old male with a Inguinal Hernia.  He is not a surgical candidate as he has advanced congestive heart failure and COPD.  I adjusted his meds and sent him home after an echocardiogram with the help of Dr Bill McCoy.

Next came a 20 year old male with chronic back pain. I reviewed his X-ray.  Destruction of the L-2 vertebra from past boney infection with TB.  I then head to the ER to help Dr Mark get a sample from a sedated child with fluid around her lungs.  Was it lunch time already?

In the next, blog I’ll finish with the afternoon of patients.

 

Nathan’s Notes – Oops!

Mistakes happen, especially when learning something new. Kudjip Nazarene General Hospital has very few diagnostic machines. Thankfully, we do have an ultrasound machine. Unfortunately, I have not been trained in the use or interpretation of these machines. So . . . mistakes happen!

One night as I walked into the Labor & Delivery ward at the hospital, a nurse asked for an ultrasound on a woman who was in labor. This mother was quite large in her pregnancy and the nurses thought they heard two heartbeats, so we suspected she may be having twins. A look at the ultrasound images would let us know if this suspicion was correct.

I scanned the mother’s abdomen with our ultrasound equipment. After looking at the images, I congratulated the mother with the news of twins. Several hours later, the surgeon decided she would need to have these children by C-section. The surgery staff delivered baby #1. Because of the ultrasound diagnosis, they looked for baby #2. They, the mother, and I were surprised that there was no baby #2!

I realized that I never did see both babies in the womb; I just saw the same baby at two different angles! Mistakes happen and everyone had a good laugh. And the mistakes continued.

We suspected our new patient’s baby was in a breach position. I did a quick ultrasound to confirm our diagnosis. The baby’s bottom was down and the head was up. As I ended the scan, I was glad to see that, despite the breach position, the baby’s heartrate was good. Because of the breach presentation, the mother was sent to OR for a C-section. An hour after the delivery, Dr. Jim Radcliffe (her surgeon) saw me in ER and congratulated me on my fine ultrasound notes. “However,” he said with a smile, “this mother had twins!”

“Wow!” I replied, “So that’s where the other twin went!”

I continue to grow in my ultrasound skills and understanding of tropical diseases and their treatment. Each day brings new challenges and opportunities to learn.

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Nathan’s Notes – Driver’s License

A few months prior to coming to PNG, I received a notice from the Oregon Department of Motor Vehicles (DMV) that my license was about to expire.  I hopped in our minivan and drove to the local DMV, presented the notice, paid the small fee, had my picture taken, and walked out with my updated driver’s license. A small miracle happened on that visit – an often hours-long task took less than 15 minutes!

Since arriving in PNG, I have driven the station’s Land Cruiser on a couple of occasions. Because I am a resident of PNG, I needed to get my PNG driver’s license.  After a 45-minute drive to Mt. Hagen, we arrived at the police station where I asked for an application.  “Are you from Kudjip?” asked the police officer.  “Yes,” we replied.  The police officer’s face spread into a big grin.  “You work with Dr. Jim.  He saved my life!”  (Dr. Jim Radcliffe is a surgeon who has spent over 30 years at our hospital.)

A clerk helped me with the paperwork and asked me to wait while the application was processed.  Thirty minutes later, the application was completed.  Two more steps were required – a photo (I was assured the photo machine was in working order) and a trip across town to the police barracks to pay for the application fees.

After a quick lunch, we were on our way to the barracks. Bureaucracy is different in each country. Some countries don’t offer the luxury of completing a task in the same location. In this case, our excursion to another office had a nice perk; we had the pleasure of meeting a fellow missionary who works with the Wycliffe Bible translators.

As we returned to the police station, we were hopeful that our task was almost completed. The application was processed and I had my application fee paperwork with me. The final hurdle was to have my picture taken.  We were encouraged that the progress was going well, expecting another DMV miracle.

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Imagine our dismay when we were greeted by a long line of people waiting to be served at the police station! Our hopes for a miracle were fading.  An officer poked his head out the door and told us to come back tomorrow since all the blank ID cards were gone!

I didn’t get my plastic driver’s license that day, but I can legally drive as I have paid the application fee and have the paperwork with me.  We will have to return to Hagen another time to get my actual plastic license.

I am reminded of our cross-cultural training.  We were continually told to be flexible. Please continue to pray for us as we serve the Lord in PNG. Also pray for the work at Kudjip Nazarene Hospital as each day brings new challenges, experiences and the need to be flexible.

 

A Smile

It was a sunny Saturday afternoon as I strolled in the front door of our ER.  At a glance I was able to survey the large white brick room with its 7 beds.  About half the beds were full at the time which is fairly common.

I had come at the request of the nursing officer to evaluate several patients.  Bed six had an 8 year old little girl.  I grabbed her chart and headed over.  Her big brown eyes showed fear as I approached.  She looked very ill, dehydrated, and uncomfortable lying on the exam table.  I began talking to her parents trying to determine what had brought them to the emergency room.  She had a fever, diarrhea, and vomiting for several days.  It was an easy call to admit her to the pediatric ward for antibiotics and IV fluids to treat her Typhoid.

While fever, diarrhea and vomiting are not fun to suffer through in the United States,  in the developing world death from dehydration secondary to diarrhea and vomiting is a very real concern.  With recognition and treatment lives can be saved.

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Esther Crouch giving a devotional for the patients

I finished my call early Sunday morning.  Then, around 10:30AM, my family and I made our way back to the hospital for church.  We were joining other missionaries to do an outreach Sunday service on several of the wards.  I walked onto A ward with my baby girl strapped on my back and holding the hand of my little guy.

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As my eyes scanned the room, there was the little girl I admitted.  She was sitting up in bed with a huge smile across her face, her eyes popping with joy and cheerfully waving when she recognized me.  A very different little girl than the night before.  Because she was able to receive medical care here at Nazarene Hospital, she will make a full recovery.

Nathan’s Notes – Thank you!

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The end of March I was on the Internal Medicine ward with Dr. Bill McCoy and Dr. Erin Meier.  Erin walked on the ward a few minutes after Bill and I had started to review our patients.  She was preparing to go home for 3 months of home assignment.  Erin asked if any of the patients would like to send a thank you to those in the USA who pray for our work and help partner with the hospital.  Hands went up all over the ward as patients and staff eagerly jumped at the chance to say thank you to all of you for your prayers and support.  Here are just few face.

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A hospital could to function without its nursing staff

 

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Nathan’s Notes – Christ is Risen

I walked briskly up the dark gravel road dodging mud puddles heading toward the hospital from our home.  My mind was racing over the scenarios I would find on arrival at B ward.  Minutes before I had received a phone call asking me to come quickly to the internal medicine ward, they were doing CPR on a patient and needed me.  There really is only one way to prepare for this kind of emergency,  to pray.  My pace did not slow down but my mind calmed as I talked with God   With 50 feet left to my destination I could hear the loud wails and knew there was nothing more I could do, the patient had passed away.

I slackened my pace and calmly walked onto the medicine ward.  One of the nursing staff met me at the door and filled me in on what had happened.  Mrs. K, 70y/o female, was admitted earlier that day for an obstructed small bowel.  She then aspirated and fell into respiratory failure and the staff had valiantly attempted CPR.  Despite their care she slipped away.  Would I talk to the family please?

After briefly reviewing her chart I met with the family and explained what had happened to their mother.  Next I asked the family if Mrs K had give her life to Christ and trusted him.  There were affirmative nods all round the large group gathered round her bed.  We talked about how we were sad she had passed away but glad she was now with Christ and that she had no more sickness, or pain, and was happy in the presence of Christ. My heart ached for the family’s loss.  They had not had time to say goodbye given the sudden parting of there mother.  In PNG culture it is very important to say good bye and mend any hurts.  I then prayed with the family in Pidgin and English.

I left the family, signed the death certificate and left the hospital with a heavy heart.  As I walked home alone down the dark road I continued to wrestle with the events of the last half hour.  I didn’t know Mrs. K, but it still hurts to lose someone under your care.

After completing my night’s work I had some time off the next morning.  I was listening to Matt Maher’s song Christ is Risen and reflecting on Mrs K’s story.

Christ is risen from the dead,

We are one with Him again,

Come awake, Come awake,

Come and rise up from the grave.

O death, where is your sting?

O hell, where is your victory,

O church, come stand in the light,

Our God is not dead, He’s alive, He’s alive!

 

O death, where is your sting?  The heaviness was replaced with joy.  In the midst of pain and death, there is hope.  Our God is not dead, he is alive!  He’s Alive!   Happy Easter.

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Sunset at the hospital

Nathan’s Notes – Mr. J

 

On my first day rounding for internal medicine service I met Mr. J.  Mr. J had an ascending paralysis.  This left him unable to move his arms or legs and he could only sit up with the help of his watchman (a family member who comes to the hospital and helps the patient with their needs while in the hospital).  Dr. Bill and I are pretty sure he has GBS.  It is thought that GBS is a rare side effect of some viruses.  The problem is that if the paralysis extends to the muscles of the chest the patient will not be able to breath and then would require a ventilator.  Kudjip does not have a ventilator.  We were quite concerned.   Despite Mr. J’s dire situation he always has had a huge infectious smile.

After 5 days rounding with no change we stopped to talk with Mr. J.  He could move his little finger and raise his hand off the bed.  There is no easy way in Pidgin to explain such a complex illness.  Dr. Bill began to share our earlier fears, that his lungs would stop working.  That it was as if God had drawn a line across his body and told the paralysis to stop there and go no further.  The smile on Mr. J’s face grew bigger as he more deeply grasped the situation and the goodness of God.

This weekend I had the opportunity to see Mr. J again.  He smiled as I walked onto the ward and showed me he could lift a foot and his hand.  There is no mediation to treat GBS.  All you can do is support, provide oxygen, and pray.  We serve a big God.  Please pray for Mr. J that he will continue to regain his strength and be able to walk out of the hospital soon.