Third World Medicine Up Close and Personal

Hello again from Papua New Guinea,

Hope all is well for you folks in the USA. Tyronza and I are doing well. I have been having problems with my back, but Tyronza found a lumbar belt for me and helps a lot. We will be coming home in just under two weeks and I thought I would tell you about the filth involved in third world medicine.
Most of you have never been to a third world hospital, so let me tell you the two hospitals in Cape are very clean and well maintained. The hospital here is less than two years old, but seem to be well worn already. If anything is broken, it takes forever to get repaired.

The floors are usually filthy, even though they are dry swept twice daily and wet mopped two-three times a week. The patients are mostly barefoot, and most of the feet are caked with mud. It usually rains each evening so the mud is particularly bad early in the morning and the dust is bad in the afternoon.

The sinks in the hospital only have cold water and half of the faucets don't work. Often the sinks seem to be full of used gloves, dirty instruments and wet scraps of paper and dressing materials. There is usually a bar of soap at each sink and a used towel to dry your hands with. I have taken to carrying a small hand towel in my pocket to dry my hands with.

The counters are often cluttered with dirty gloves and used syringes. Sometimes there are ants and bugs crawling on the beds, floor and counters. I have started trying to tidy up whenever possible, but it seems to be a losing battle.

The OR is a much cleaner place, although I did see an ant crawling on the

drapes during one case. Anesthesia commented that it was probably a sterile ant! All patients having surgery are given both pre-op and post-op antibiotics, usually chloramphenacol. I have had only one wound infection so far, and it was very small. One day I was waiting for a surgery to start, sitting in the surgical lounge. In the space of 15-20 minute, while I waited, I was able to kill 50 ants and 3 cockroaches.

Surgical instruments are sterilized just like they are in the US. The hospital has two large autoclaves that are kept busy. Surgical gloves are washed in bleach water and recycled as non sterile gloves. Lap sponges are washed in bleach water and re-autoclaved. The bovie cords and grounding pads are all recycled by washing in a chemical soak and then rinsing in sterile water just prior to the case. I have been using the same vacuum extractor since I arrived. Each time it is soaked in chemical and then rinsed in sterile water. I have probably used the same device on at least a dozen deliveries. Medicines and suture material are almost always expired, but they seem to work well and cause no ill effects.

Lighting is a problem. The OR area does have good lighting, but the wards have only sparse florescent lights. I have taken to using a head lamp for most of the obstetrical repair problems and that seems to work well.
The ultrasound transducer is usually gooey from the previous exam. I have found that a roll of paper towels works well to wipe the patient off and keep the machine clean. I try to wash the transducer head with soap and water, whenever it is available.

The nurses have an interesting technique for checking patients in labor. All laboring patients are allowed to labor on their beds in the ward. When they need to be checked, which is only occasionally, the patient walks back to delivery bay #1. Each mother has her own bowl of betadine soap sitting out on the counter with her name attached. When she is examined, I put on a sterile glove, then ask the patient what her name is. I then dip the glove in the bowl with her name on it and do the check. When the exam is over, she goes back to her bed in the ward and her bowl, along with the other six or so women in labor , is left on the counter in bay #1 ready for the next check.

That's all for now,
Dr. P
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Patient Care

Greetings from Papua New Guinea:
Today was a particularly exciting day, as I wound up doing four caesarean sections along with vaginal deliveries and rounds. About half way through rounds, a patient was brought in on the back of a small truck. She had been laboring out in the bush. She was obviously very pregnant and seizing. Her husband had used his cigarette lighter to place between her teeth, so she had a good airway; but she was seizing almost continuously. She looked very swollen and obviously had eclampia. The nurses told me this happens three to four times per year.
My nurses were quick to respond with an IV and we immediately gave her 6 grams of magnesium sulfate and valium. It took a total of 25 milligrams of IV valium to stop the seizures. Once she was stable, we took her straight to surgery. There was thick meconium, but the baby was fine.
After surgery, the patient continued to have problems. Although there were no more seizures, her blood pressure and urinary output gave me fits. By midnight of that day, she was only making 5 cc/hr of urine. I called the pharmacy to request some manitol, but was told none was available. They also did not have any plasma. I thought about using serum from the blood bank, but felt the risk of AIDS and Hepatitis was too high and I would try to do without. The following morning, I went over to the pharmacy and was finally able to find some German manitol, "osmofundin." After I gave the osmofundin and some lasix, her output was great and she seemed much better. Her blood pressure remained high and required hydralazine IV to keep it down for the next few days.

Around three hours later, a woman came in with rupture of membranes and she was breech. She had also had a previous C/S. Although we had been delivering v-backs and breeches, I discovered there were no Pipper forceps available and I did not feel good about a breech v-back, so we did c-section #2.
Later that same afternoon, one of the patients in labor ruptured her membranes and the umbilical cord washed out. The baby was in distress, but with oxygen, salbutamol, and knee chest position it soon sounded fine. A crash c-section around here takes one hour to get ready. We kept the mother in knee chest for that hour and the baby came out looking good.
I had just finished the third c-section, when another mother came in with ruptured water and another cord prolapse. This time the patient was not contracting and the baby did not sound distressed. We took our time and finished the fourth c-section of the day without incident. This baby was also fine.
Obstetrics around here is just like in Missouri - either feast or famine! Thankfully, there are not too many days like this one. We do around 30 deliveries a week in Kudjip and approximately 4-5 of these usually are c-sections. The section rate is slightly less than 15% and outcomes are good, unless the babies are too small. If you have read my other blog notes, you may recall the small babies I have told you about. The 1200 gram baby has survived and is now nearly ready for discharge, but the 1000 gram baby died of necrotizing enterocolitis.
No other exciting news to tell you and we are now just three weeks away from our departure to come back home. I hope to see you soon.

Dr. P

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PNG People

Another day in paradise is at a close and I thought I might reflect on the people and some of their idiosyncrasies. People here are much the same as elsewhere around the world. Some things about them reflect well and others not so good. Sounds like home, doesn't it?
Most of the folks in our area of Kudjip are called highlanders. They are a mixture of Solomon Islander and Aboriginal. These people have occupied the highland area for close to 50 thousand years. I don't think there was much change until the last 60-70 years. These people are only one or two generations out of the stone age.
The original highlanders have a rather primitive look about them with sloping foreheads and prominent brows. Their skin is medium dark and hair is bushy and black, although the children often have light colored hair, secondary to protein deficiency. They are very clan and tribe oriented. For many centuries, they have lived rather segregated lives in small villages. The villages often had only limited contact, usually, related to tribal warfare. For this reason, there was a lot of inbreeding and most people, male and female tend to look a lot alike. This is a real problem for me in clinic and on rounds. I keep thinking I have already seen this person, when it was really their neighbor.
The tribal thing is very prominent in elections and disputes. They seem to always take the side of their clan no matter what, even if the person is not particularly good or representative of their views. They will still vote for them, simply because they are from their tribe. (Tyronza thinks this is similar to Republicans and Democrats back home!) This leads to conflict and tribal warfare and machete injuries.
The favorite weapon and tool here is the machete. They are always attacking one another or someone from another tribe. This keeps the Emergency Room busy with "chop" injuries. One fellow had both feet amputated - courtesy of the neighboring tribe. (He was drunk and went into another village bragging about being involved in another chopping incident on one of their tribesmen. They retaliated!) Most people seem to survive the chop injuries. Thank the Lord there are few guns!
The children here seem very happy, even in abject poverty. Most are well cared for by parents, relatives, or other members of the village. Childhood mortality is high, secondary to illness (i.e. pneumonia, dysentery, typhoid and malaria). In the clinic, we see the usual illnesses, but also some of the worst skin ulcers and infections I have ever seen. Newly diagnosed osteomylitis is a daily event around here. Some of the injuries are also rather spectacular. I believe I already told you about the young boy who impaled his chest falling out of a guava tree. He recovered and has already gone home.
Most of you would not like the average highlander PNG diet. Meat is fairly rare, but fruit and fresh vegetables abound. The staple is the "yam" or "kaukau". This is similar to the sweet potato, but much more bland and starchy. Other things commonly grown include: pineapple, coconut, banana, guava, mango, greens, beans, tomato, tree tomato, broccoli, cauliflower, carrots, english (white) potatoes, onions, corn, avocado, asparagus and squash. They do raise chickens and pigs, but are more likely to sell them rather than eat them themselves - same with the vegetables, other than "kaukau" and corn.
Pork if usually consumed at a feast or "mumu". The pig is roasted in the ground with hot rocks and vegetables. This can lead to a condition called "pig-bel" in the young children. Sudden consumption of a large amount of poorly cooked pork is the cause. When the body does not see much meat it lacks the enzymes to digest the meat. As a result the undigested meat sits in the small intestine and grows gas-gangrene organisms, which invade the gut wall and makes the child sick. This problem may require surgery and can cause death. I have seen two cases since my arrival.
The women here in the highlands are a sad story. Most are purchased for "bride-price" from their father for a few pigs and several thousand kina. A kina is currently worth $0.40 and is similar to our dollar. In years past, a kina was actually a sea shell that was used to adorn the neck. The bride-price is usually paid by an older villager, usually from a neighboring village or tribe. A man's wealth is determined by his kina and also by the number of wives and children. The wife seems to be responsible for most of the cooking, cleaning, gardening and child care. If the woman is not able to bear children, they are often cast aside or replaced with a new bride. Most infertility is the result of pelvic infection, probably courtesy of the husband. If the husband is displeased with the woman's performance, she may be beaten. This results in cuts and bruises and may also result in a ruptured spleen. I have been involved in several spleenectomies since my arrival. I have also helped repair several machete wounds to the woman. The favorite injury seems to be a chop across the achilles tendon. Domestic violence is also a major contributor to tribal violence when the woman comes from a different tribe as the husband. Not all domestic violence is from the husband, much is a result of polygamy. The "sister" wives can really have it in for each other! They also know how to use machetes.
So long from PNG. "I will catch you later." (Mi bi kissim yu behain.)
Dr. P
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Girls Day Out

Last week I had two special opportunities to further experience the culture. On Wednesday, Dr. Stephanie Doenges (medical missionary), Pamela West (volunteer x-ray technician from South Africa) and I went into town, Mt. Hagen, for a girls day out.
The drive to town takes approximately 30-40 minutes and there are numerous potholes that have to be dodged on the narrow two lane road. This road is the highway between the coast and the interior; it is basically the only main road. The driving here is done on the left hand side of the road; however, due to the pothole situation much of the actual driving is in either the middle or right side of the road. There are also numerous (hundreds) of people walking along the edge of the road, or have their vehicles stopped along one side to load or unload cargo or people. It is quite precarious and I am glad that I did not have to drive. There are a number of car accidents and hit pedestrians, but not nearly as many as you would think from the driving conditions. Before we leave the compound, if it is only women going to town, we have to pick up a watch man. This is usually a man from the maintenance area of the hospital with a baseball bat. He will remain with the vehicle to guard it, and us, and to offer any assistance we might need. This sounds rather ominous, but I have never felt threatened or at risk.
Stephanie had made a hair appointment in Mt. Hagen for Wednesday afternoon. She and Pamela were going to make a day off it, with shopping and eating at one of the few restaurants in town. I asked if I could tag along and also get a hair appointment. The three of us left for Mt. Hagen about 8:30 in the morning. We drove the 30-40 minutes and did our shopping at the grocery store.
It was lunch time by then and we headed to the Highlander Restaurant which is located in a hotel. The hotel is under remodeling construction, but the restaurant was open and we had a great lunch - club sandwiches and french fries. It was great and I didn't have to cook it myself, or clean it up afterward! Fantastic!
After lunch, we had time for a little shopping and headed for a thrift shop, where we had fun looking through used clothing! Pamela found a couple of things that worked for her and Stephanie found a large t shirt for sleeping. Then it was on to a stationery shop where I found several articles about PNG that I purchased and hope to share with you when we return home.

In the afternoon we had our hair appointments at Jeyleen's hair salon. It was a rather interesting place, a one person shop. Both Stephanie and I received haircuts and were very pleased with them. It was great to be rid of the shaggy look I had been seeing in the mirror for the past couple of weeks. After the hair appointments, we had time for a quick stop at the local market. We purchased fresh vegetables and also another bilum (purse). There is usually a good selection of both at the market.
By that time, it was close to 5 pm and we needed to be back at the hospital compound before dark. The missionaries try not to have anyone out driving after dark unless absolutely necessary. Both the road conditions and bands of young trouble making men, called rascals, can be a problem best avoided. All together it was a fun day and I really enjoyed getting better acquainted with Stephanie and Pamela.
On Saturday of the same week, I was given the opportunity of flying with MAF (Mission Aviation Fellowship). They are a nonprofit, nondenominational group of pilots and mechanics that fly support to mission stations.
I was able to fly two different circuits. I had to hang around the MAF terminal until there was a flight that had room for me. I few first from Mt. Hagen to Simbai to Kamanbu and back to Mt. Hagen. The two locations were at bush airstrips, mainly grass and mud. I flew with pilot, Mike Bottrell (from Australia), in an Air Van. The airstrip at Kamanbu was 437 meters, a less than 1,500 feet with a 2 1/2% slope. I was glad to just be along for the ride and not trying to land. On takeoff, we were airborne in the last 20 feet.
The second flight was after lunch. Again, I had to hang around the airport until there was an available flight. It was fun visiting with both the MAF pilots and the PNG staff that work with them. They thought a female pilot was rather strange and unusual. The second time around, I flew in a Cessna 206 with Phillip Sutterer; he and his wife are from Switzerland. We flew from Mt. Hagen to Dusin; a grass strip on the peak of the mountain with 460 meters of runway, a 10% slope and at 5,800 ft elevation. The next stop was Singabe and then back to Mt. Hagen.
The weather was rather cloudy and the last two stops had drizzle; I hope to be able to right seat another couple of flights when we return next year. It was great fun and I really appreciate the training and the dedication of the MAF pilots.

I will be posting pictures with a link from facebook. I hope you will be able to see them. We are having a wonderful time with new experiences, new foods and of course, new friends. It is hard to believe we will be returning home in three weeks. We look forward to seeing our Cape friends and family and sharing our tales and photos.
Tyronza (not Dr. P)
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Easter

This past Sunday was Palm Sunday, with the week leading into Easter Sunday. I thought I would take some time to share about the beauty of this place. Please take a moment to study the picture I have taken of the "resurrection flower." Look carefully at the cross and you will see the tiny face in God's creation, to act as a reminder of why we are so privileged to serve in his name.
This country is so diverse in both its climate and topography that allowances have been made for many different species of plants and animals. The elevation varies from sea level to 14,780 feet, the top of Mt. Wilhelm.
Beginning at the sea, Papua New Guinea is well known for its coral and beautiful fish and sea life. There are over 60 species of colorful parrot fish, along with many shades of star fish and sponges. Tyronza and I are hoping to go on a short scuba trip before we return, but that depends a great deal on the call schedule. We don't have that worked out yet. (We will definitely plan for scuba on our return trips.)
Inland from the coast is a vast network on marshes and swamps that are inhabited by monkeys and other swamp life. Not many humans live it this area because of the mosquitoes. This area is fed by multiple streams that drain down from the mountains. The largest of these streams is the mighty Sepik River, which allows for navigation far inland from the north coast. Most of the swamps are mangroves which act as a breeding ground for various marine life, including the salt water crocodile.
Along the rivers are the tropical rainforests with towering mahogany and other rainforest trees. Some of the world's largest ferns grow in these areas. There are even some humans that live in the tops of these trees, though they are mostly on the Indonesia side of the island.
The rainforests continue up the mountains so thick that land navigation is nearly impossible, until you get to the high valleys at about 3,000 feet. These high valleys continue up to 8,000 feet and act as the perfect living area for over half of the population of New Guinea.
It is in one of the valleys that the Kudjip Nazarene Hospital is situated. We are at 5-6,000 feet, and are surrounded by vast areas of coffee and tea plantations. Both the coffee and tea grown in this area are very tasty. Every morning I have a big mug of PNG #1 black tea. It is very strong with caffeine and the first brewing is darker than most cups of coffee! Most of the people live in this area, because the climate is so perfect, 60 degrees each night and 80-85 degrees each day. The sun shines most days and it usually rains only at night. This valley is beautiful with all of the tropical foliage and vegetable and flower gardens of the native folks. It is called the Wagi Valley and it was first discovered by explorers in 1930. If you are interested in more information, you can read about it in the book, "First Contact". There are still a few elderly people around who remember that first contact.
Further up the mountainsides, the foliage thins out. The mountains are covered with many small streams of clear, very cold water. At about 10,000 feet, the trees change to evergreen conifers. It occasionally freezes above 10,000 feet and at higher elevations there is a chance of snow. It is rare to see the peaks, as most are cloud or fog covered.
Animals are few and far between here in the Wagi Valley. A tree opossum called a cuscus is common and is eaten or kept as a pet by the natives. There is also a very large bird in the area called a cassowary. It lives in the forest and has been known to attack and kill humans with its sharp talons.
The rain forests are alive with both large and small insects. The butterflies are spectacular. One species is an iridescent blue and about the size of the palm of your hand. This is the home of some 50 different species of the Bird of Paradise. Tyronza was able to get some good pictures of several of these birds and one video of their courtship dance.
This entry began with my desire to share the beauty of the "resurrection flower" with you. Please take time to acknowledge Christ and His great gift to you during this Easter season.
That's all for now. See you soon.

Dr. P


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PNG Ultrasound

Hello Again from Papua New Guinea Paradise,

Tyronza and I are well and working hard. I thought you would like to know what the ultrasound machine that we brought along has been up to.
For the trip over, I placed the ultrasound in a laptop case and took it along as a carry on bag. We had no problems getting it through customs, and I was able to protect it and keep it in eye sight.
Once here, I was able to cannibalize and old ultrasound stand for easy operation. I keep the ultrasound with me in the clinic and can easily scan anyone I have examined in just a few minutes. (We thought Tyronza would help in this aspect, but she is working in other areas.) It has proved to be of great value in diagnosing pelvic tumors and abscess, as well as for OB screening. I have gotten quite adept at OB screening, which can be done in less than 5 minutes.
I regularly roll the machine over to the OB ward, as well as surgical and medical wards. I have diagnosed abdominal tuberculosis as well as several liver tumors and bowel abscesses. The ultrasound is really a very valuable tool. The one I brought is quite similar to the one that was already here, so all the doctors know who to use it. I plan to leave it here, as it seems to work fine. If it breaks down, I can easily portage it back to the states for repair on our next trip.
Thanks a million to all of you who contributed to this purchase.

Papa God bai blesim yu,
Dr. P

photos can be seen: http://www.facebook.com/album.php?aid=19428&id=100001961413037&l=a20582723c..

http://www.facebook.com/album.php?aid=19532&id=100001961413037&l=0b5634e363

Have been telling you mostly about things going on in the medical end of this trip. I thought I might begin this tale with a word about the BUGS. They say you can tell who has been here the longest by their eating habits. Newcomers refuse to eat, because of all the bugs crawling around on the table. If you have been here a week, you are likely to pick the bugs off your food and eat it anyway. Those who have been here for six months eat the food, bugs and all. Those who have been here for years, pick the bugs off the table and throw them in with the food - extra protein, you understand!

Really, the bugs aren't that bad, although we do have these tiny ants that seem to get into everything. We have discovered they don't do  well in the cold. When they are discovered in something, a quick trip to the freezer will allow you to pick them off easily. All food must be stored in sealed containers or in the fridge.

Papua New Guinea is known for some of their large insects. Butterflies and moths are very spectacular. There is also a beetle here called a rhinoceros beetle. The large ones are 2.5 inches long and 1.5 inches wide with big pinchers or horns coming off their heads. Chickens here are called kakarukas which should not be confused with cockroaches (which are nearly as large)! Another interesting bug is the resident spider. They are about an inch across and jump several inches, if you try to step on them. I have seen larger, two inch versions in the gardens.

Mosquitoes are not very numerous at this elevation, but are thick at lower levels or along the rivers. The other night there was one loose in the bedroom and I did not sleep very well thinking about malaria. As a medical problem, malaria is number one around here. Daily, I request several malaria smears on the clinic patients. All hospital admissions are screened and placed on Chloraquin at admission. If a transfusion is necessary, they are given a one week program of other malaria meds. If they develop a fever, malaria treatment is started immediately, along with antibiotics.

Enough from me for today. You guys stay safe; we miss you.

God Bless,

Dr. P

p.s.  Photos can be viewed at:

http://www.facebook.com/album.php?aid=19428&id=100001961413037&l=a20582723c

and

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OB Care in PNG

All is well here, I hope you are all enjoying a nice Spring there is the USA. Here, one day is mostly just like the rest. It continues to rain most every evening and is sunny and nice each day. I have on occasion heard thunder and seen lightening, but not most days. All-in-all, it is rather like paradise.

Thought I would talk a bit about the obstetrical care in Papua New Guinea. Care here is much like it must have been 50-60 years ago in the US. The post partum/anti partum floor, or ward as it is called here, consists of a small nurses station and a large room with 28 cots or beds. Each bed sits approximately 20 inches from the next. The hospital provides the bed with rubber coated mattresses for 50 kina or $17 dollars. The patient must supply the sheets, blankets, pillows and food. Some patients simply sleep on the rubber mattress or sometimes even the floor.

Each patient arrives at the first sign of serious contractions with their watch-merri, or female observer. At the time of arrival, they may be complete or it may be several days prior to delivery. They are worked up and examined by the nurses. If everything is routine, they stick around in this area till hard labor begins. At this point they move to one of 5 delivery bays where, the actual delivery will occur. The nurses screening sometimes detects problems. Hypertension, toxemia, twins, abnormal presentation, premature labor, etc… just to name a few. If anything out of the ordinary is found, then a doctor is called and the patient is evaluated by a physician. Most days, I have several mothers with toxemia or some other problem to evaluate and treat. Nursing supervision is scarce, so I must constantly keep checking to make sure no one falls through the cracks. Several  times I have discovered patients with ruptured membranes that sit unattended for days waiting for labor to start.

When a patient moves to the back, they are usually very near time for delivery. All routine deliveries are done by nursing staff, that includes the delivery and any stitching up that needs to be done. I get called for breeches, most twins, arrested labors, or any large stitching up that needs to be done. I have a head-lamp  that I use for light. Most deliveries are done on a flat bed without stirrups or foot pegs. Shoulder Dystocia would be tough in this position. Thankfully, most babies are 6-7 pounds and Shoulder Dystocia is not likely. I have had to go in to repair a few "blow-outs". The nurses are reluctant to do episiotomies other than medio-lateral, so you can imagine some of the awful tears I have had to repair.

As far as anesthesia goes, it is pretty much cold turkey! There are no spinals or epidurals for labor or delivery. Once delivery has occurred, a local is usually given for episiotomy repair. On occasion, I have had to use ketamine and valium for a really bad stitch up job.

Most minor obstetrical surgeries are done in delivery. I have done many D&C's, including three molar pregnancies. I like to start an IV and then give ketamine and valium for the procedure. When the surgery is done, the patients lies there until they are alert enough to go home, usually unattended.

Prenatal care is also very sparse. I do see patients in the clinic that are pregnant. I usually treat their medical problem and then take a little time to look their pregnancy over, no one here seems to have any notion of a due date. A quick two minute ultrasound can really give a ton of information. I am making much use of the portable ultrasound that I brought.

Records are very sparse. The hospital record for a labor/delivery/recovery is usually 7-8 pages. when a patient is ready for discharge, a short note is made in their "scale book" about the delivery This book is maintained by the patient and taken to all health events in their lives, i.e. clinic visits, ER visits, hospitalizations, etc. All treatments and medications are recorded in the "scale book" and presented to the pharmacist, doctor, or clinic each time health care is rendered. This does provide a nice record of health events in a patient's life. Unfortunately, not all entries are legible or complete.

Enough for today. Please pray for us and the patients we are seeing. Hope to see you in a couple of months.

God Bless,

Dr. P

p.s. I hope to see you soon/ mi bi lukim yu behain.

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Hello Again from PNG

Hello again from Papua New Guinea It is raining again as I write this note. I believe it has rained every evening and night for the past two weeks, probably 15-20 inches in that time. It seldom rains during the day, so I expect sunshine tomorrow. The rain is actually a good thing as it keeps our cisterns full. All the drinking water is filtered, but we wash the clothes and bathe in rain water. It is really very clear and clean.

Medicine is much the same as at last report. I have finally convinced the nurses on Labor and Delivery that every patient needs to be seen and reviewed by the doctor every day. When I first came I would sometimes find a patient that had had ruptured membranes for several days and was not being induced. All things happen in their own time around here, but that was more than I could stand. Last evening, I had a patient come in from the Jimmi Valley (about 25-30 miles away - but many hours by car, or days on foot). She reported being in labor for six days, but the mud slides had kept her from coming in and the baby delivered on the way to the hospital. When she arrived the baby was in respiratory arrest, and was too far gone to bring back. I had another baby earlier in the day that our nurses had delivered and were trying to resuscitate with an adult mask. I intubated the baby and with a little oxygen he was doing fine in short order. I guess some in-service training is needed. I also received a woman yesterday afternoon that had delivered "in the bush." She had a retained placenta. No bottles or banana fronds hanging from this one, but the mother had lost a lot of blood and required two units and a bottle of fluid to bring her back around. No wonder maternal mortality is the worst on the planet here in Papua New Guinea and according to the missionary physicians, it is getting worse. Gynecology is going strong. I see a lot of advanced pelvic tumors and pelvic inflammatory disease that has progressed much further than I am use to. I currently have two women on the ward that had the most horrible abscesses I have ever seen. Folks here must be a lot tougher than in Missouri, I thought both might die, but drains and chloramphenocol works wonders. I have also been helping Jim Radcliffe, a general surgeon, on some of his cases. Today, we had a small child that fell out of a guava tree. He was impaled through the chest. We cleaned a bunch of splinters out of his pericardial sac, but his heart was untouched. What a miracle! My 1300 gram baby is doing very well. He is still in the nursery but feeding and growing well. Last night,  I delivered a 1000 gram baby who is still alive, but the other doctors feel she has only a very small chance of survival. Enough from me. I hope and pray you are all well. Tyronza and I are fine and experiencing all we can from this new culture. See you in another five weeks or so. God Bless, Dr. P Pictures can be seen on: http://www.facebook.com/album.php?aid=19428&id=100001961413037&l=a20582723c

Continuing tales from PNG

Today is the third day of April, and again I, "ask where is the time?" It is hard to fathom how quickly each month flies by! We have six weeks remaining for our time in PNG!

We are doing well and enjoying our stay here and are beginning the process of signing up for a return of three months next year. It will probably be February through April.

A typical day for Scot, has him walking up the road to the hospital at 8 a.m. He sees inpatients on the wards and then goes to the outpatient clinic to see patients. On Tuesdays and Thursdays, he tries to schedule any surgeries he will be performing. Of course, emergency C-sections or other procedures are added to the schedule as needed. He comes back to the house for lunch and then returns to the hospital for afternoon clinics. He is typically finished by 4:30 or 5:00. He is on call for C-sections or other gynecologic emergencies on a three day on and one day off rotation. This allows the permanent physicians to have a break. So far it hasn't been too bad. He frequently comments on the non-sterile hospital setting and the low level of nursing skills. Patients are usually given large doses of antibiotics and they appear to get along well with the PNG system. The Nazarene Hospital in Kudjip is considered the superior hospital in the country!  Scot says he receives patients frequently that have walked away from other hospitals in the country. They had been in the hospital for several days and were never treated and so they come to Kudjip.

The following is directly from Scot:

Hello again from Papua New Guinea,

Hope you are all healthy and holding down the ship in the good old USA. Tyronza is busy in the store room, teaching, cooking and doing laundry.

I continue to be busy. Here is a list of activities for the first four weeks:

                vaginal deliveries                                             10 (2 V-BAC's/vaginal birth after C section)      Most vaginal deliveries are performed by nurses.

                Cesarean section deliveries                          12

                Ectopic pregnancy surgeries                        6

                pelvic mass surgeries                                      5 (2 tumors were over 10 pounds/2 malignant & 3 benign)

                abdominal hysterectomies                          6

                clinic consultations                                          200-250

                hospital consultations                                   6

                ER minor surgeries                                           3

                D&C                                                                       6 (2 molar pregnancies)

                tubals                                                                   3

Two of the ectopics had over 2500cc blood loss. There are many deliveries that happen in the bush (the villages). Five times I have had to remove a placenta left in from a bush delivery. Once a beer bottle was hanging from the cord and another time a banana frond was hanging from the cord. On the latter case the woman had lost so much blood that she was arrested on arrival at the clinic. I worked on her for 45 minutes, but in the end I could not find blood fast enough to save her.

 On the brighter side, I told you last week of a young mother 28 weeks pregnant with rupture of membranes. We kept her pregnant for nine days beyond rupture. I gave her steroids and when she delivered a 1300 gram baby it required no ventilator and no extra oxygen, which is good since we have none! The baby seems to be perfect. Thank you Jesus!

Be safe and God Bless You, (Papa God bai blesim yu.)

Dr.P

From Tyronza:  On Monday, I will begin a new experience. I will be working in the mornings at the mission school. This is the school for the children of the missionaries. I have committed for 3 hours in the morning and will be teaching reading and phonics for 1st and 2nd grade.  I have also been doing some typing at the Nursing School. They need to have a manual transferred to the computer, so I go over and type for a couple of hours as my time permits. I am enjoying cooking and have experimented with many new vegetables and fruits. I made a dessert from tree tomatoes - strange, but edible. We've cooked and eaten many new types of greens, new types of kaukau (yams) and some of the best pineapple we've ever had.

I went for a wakbot (a hike) yesterday, the countryside is beautiful. It's been rainy lately, so it was rather muddy - but fun. Papua New Guinea is a beautiful country and the people friendly (at least to us.) There is plenty of work and projects to do, but it is a slower pace. I am enjoying my time here. As a I prepare to post this entry, I am sitting on the back porch of one of the missionary families (their internet service is working) and I am looking across a small valley to the hillsides. I can hear the river in the valley and the various birds singing. It is lovely and I am thankful to the God of creation for all the colors and diversity He created.

Praying God's blessings and Spirit on each of you,

Scot & Tyronza

for pictures go to:

http://www.facebook.com/album.php?aid=19428&id=100001961413037&l=a20582723c

PNG Mission Lesson

This is a copy of the lesson I, Tyronza, gave in one of the local churches this morning.

I am happy to have the opportunity of being with you today and of being in your beautiful country. The people here have been very friendly and kind to us. Thank you for asking me to speak to you this morning.

My husband, Dr. Scot Pringle, and I arrived in Papua New Guinea over a month ago. Dr. Scot is working at the hospital and we are here for our first visit of three months.  I was with a group that had made arrangements to go for a hike to a waterfall. Isaiah was one of the men that guided our group. Along the way, the path was steep and difficult. He would take my hand and help me over the difficult parts and we began to share with each other that we were both part of the Nazarene Church and that we were both part of Nazarene Mission International. I have been privileged to be the NMI president at my local church for 18 years.

The NMI mission statement is "to mobilize the church through praying, discipling, giving and education." The Nazarene denomination has almost 800 career missionaries worldwide and has thousands of short and long term volunteers. NMI is the same around the world. NMI is formed to help share the message of salvation through Jesus Christ with others around the world. Three weeks ago, I attended an evening service at Immanuel Church in Kudjip. It was their time for NMI service and the Alabaster offering. Alabaster is an offering taken twice a year. The money is gathered to help buy land for churches and to help purchase the building supplies to build the church. My church at home in the US had just taken this offering.  Money from Alabaster offerings are often used along with Work and Witness groups.

 One of the departments of NMI is work & witness. These are groups of people that pay their own way and go for two weeks away from their homes to help other people.  My church and district are able to send W&W teams to other countries to help build churches. I have been privileged and blessed to be able to go on many W&W trips. I have been seven times to Ecuador, once to Peru and once to Guam on W&W trips. Each time has been to help build a building to either train pastors or a church building. Working with the local people, getting to know them and to know that we are brothers and sisters in our love of Jesus Christ is always a special blessing.  We receive a blessing from God when we are able to help local congregations build a structure for their church.  Another area of NMI is Compassionate Ministries. Compassionate Ministries is a tool for the Nazarene Church to help communities that have had disasters. When there are major disasters around the world, the members of the Nazarene Church want to help. Aid is given through our denomination to help with medical supplies, food, water, and basic needs when there is a major disaster.

But giving money and helping to build churches is not enough, we have to be willing to share the truth of Jesus. In Mark 16:15-16, Jesus says, "Go into all the world and preach the Good News to everyone, everywhere. Anyone who believes and is baptized will be saved." Also in Acts 1:8, Jesus says, "When the Holy Spirit has come upon you, you will receive power and will tell people about me everywhere - in Jerusalem, throughout Judea, in Samaria, and to the ends of the earth." When Jesus said Jerusalem, Judea, and Samaria, he was talking about his village (Jerusalem), his country (Judea) and the neighboring country (Samaria) and then he says to the ends of the earth. This means that we are to share the news of Christ with our family members and our friends. We are also to share the news of salvation through Jesus Christ with our neighbors and with other villages and throughout Papua New Guinea. We want all to hear the story of forgiveness and salvation. It is only through the love of Jesus and his gift of salvation that lives can be changed. It is only through the love of Jesus that husbands can love and respect their wives as Jesus teaches. It is only through the love of Jesus that wives can love and respect their husbands. It is only through the love of Jesus that people are able to forgive each other. Jesus said in Mark 12:29-31, "The first command is: The Lord our God is the one and only Lord.  And you must love the Lord your God with all your heart, all your soul, all your mind, and all your strength. The  second is equally important: Love your neighbor as yourself. No other commandment is greater than these."  Jesus is telling each of us that we are to love and care for those around us as we would care for ourselves. We are to treat each other with love, kindness and respect. When we are able to obey Jesus in this way, then he is able to use us as Christians to show his love to others and share his salvation with them.

This is the true goal of missions, to bring the peoples of each land to Jesus; to teach people of his death for our sins, of his resurrection from the dead, and of the forgiveness he offers to those who believe in him. As a Christian, this should be the goal and mission of each one of us.

Being a part of NMI and supporting missions is an important part of who we are as Nazarenes. I encourage each of you to take an active role in reaching out to others about the love of Christ.  As I leave you today, I would like to give you one more scripture, Psalm 28:6-7, "Praise the Lord! For he has heard my cry for mercy. The Lord is my strength, my shield from every danger. I trust him with all my heart. He helps me, and my heart is filled with joy. I burst out is songs of thanksgiving." I am truly thankful to serve a living God; a God of love and forgiveness, but also a God of holiness, who expects my obedience to his Word. This is a great honor for me and for you.

Thank you again for allowing me to speak to you, I pray God's blessings on each of you and your families.

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Tales from Scot

"Another Day in Paradise" pretty well sums this place up. The weather is near perfect every day. The nights are cool and comfortable (just right for sleeping), and three or four nights a week it rains.

The practice of medicine is another story! I am very busy. They have put me in charge of the labor & delivery floor. Most days, there are 10-12 deliveries and a C-section or two. The nurses do most of the deliveries and repair the simple lacerations and episiotomies. They do a good job most of the time, but could stand some improvement. So far, I have had 8-10 C-sections, a breech delivery and have repaired a half dozen bad lacerations. The nursery does not have a ventilator and that is a great frustration to me. I have had an emergency C-section where the baby was resuscitated, but expired for lack of a way to provide any long term ventilator support. I am currently waiting on a delivery of a 28-29 weeker that I know we can't do anything for. Please pray for me; it is very difficult. I do miss all of the nice perks of qualified pediatricians, neonatologists and especially a high risk nursery. The nurses here are addressed as "Sister": Sister Sylvia, Margaret, Mary, etc.

As for Gyn, they do a nice job here. The surgery is well stocked and the personnel seems well trained. Cancers seem further advanced, but I have not seen anything I could not handle, yet. Ectopic pregnancy is a popular diagnosis. I have operated on 5 ectopic cases in the first three weeks. Most are caused by P.I.D. , which is also a popular diagnosis. Last night, I operated on a woman who had a ruptured ectopic for five days and had walked in from a distant village. Her hemoglobin in the emergency room was 3.7 grams. I was able to give her four units of blood and operate.  She had 2600cc of blood in her abdomen.

Aids, hepatitis, and tuberculosis are also very big around here. I have had one HIV positive vaginal delivery and one HIV positive C-section. Most days in the clinic I see fresh cases of tuberculosis, malaria, and hepatitis. My ultrasound machine is in use constantly. I have diagnosed several large pelvic tumors, three sets of twins and several cases of abdominal TB, so far.

Enough about me for now. I miss you guys. God bless you,

Dr. P

p.s. Thanks to Cindy R.'s mom for the hats. They are a big hit.

PNG Adventure Continues

Today is Sunday March 20th, and we have been in Papua New Guinea for more than three weeks. The days are going by quickly, Scot is at the hospital each day. He is seeing quite a variety of patients: many tubal pregnancies, many tumors, 3-4 TB patients every day, 2-3 malaria patients daily, has delivered 2 patients with HIV, several C sections, one set of twins, and has had one fetal demise - there is no fetal respirator. He is also beginning to spend time in the ER stitching up machete wounds. Unfortunately, there is a lot of domestic violence and a machete is often used. Husbands cutting wives, wives cutting each other - amongst the non Christian people there are multiple wives.

Scot enjoyed giving out the baby caps that Cindy Rigdon's mother made. The patients were very thankful to receive them.

Tyronza is continuing to cook, and is amazed that she actually enjoys doing it. The shopping experience is very different. You have to travel about 30-40 minutes into town for groceries at the store and the large vegetable market. There is a small market available just outside the hospital compound, but you never know what will be available. (Actually, that is true in town also!)

The money used here are kina and toea. The exchange rate is currently about 2.5 kina to the dollar. Except for locally grown produce and vegetables, everything is quite expensive. Tyronza bought 6 kilos of ground meat for 125 kina, two small rolls of paper towels for 30 kina.

The electric system here has many power spikes and is sometimes out for a period of time. It has not been a major problem, however. You do learn to keep the candles and flashlights handy.

This past Sunday, was a very interesting day for us. The previous week Tyronza met Isaiah on a hike. He is the Nazarene Mission Zone Circuit president for this area of PNG. He has 28 churches on his Circuit. He became very excited when Tyronza told him that she was the mission president at their local church and invited her to speak in one of the churches on his circuit. She accepted and transportation and translation were arranged. On Sunday morning, we were picked up by one of the missionary families and were taken to the church where Tyronza spoke about Nazarene missions in general and about sharing the news of salvation and forgiveness through Jesus Christ to your family, your friends and your village. After the service, we were given fruits and vegetables as a thank you. It was a wonderful experience.

On Thursday night, Tyronza attended the District Mission Convention for the Western Highland Province. It was an exciting time and very interesting. On Friday afternoon we were able to take some time off and were taken to an orchid garden. It was beautiful with lovely flowers, butterflies and birds. The man and his wife have been working on the garden for fifteen years and he said he has 300 of the 3,000 species of orchids native to PNG. On Saturday morning, we were able to leave the compound again for a hike up to a Catholic mission. It was a gorgeous day and many pictures were taken. The link site is

http://www.facebook.com/album.php?aid=19428&id=100001961413037&l=a20582723c

Arrival in Papua New Guinea

Praise the Lord after several months of frustrating efforts the Papua New Guinea Labor Department finally sent the work permit for Scot and the entry permits for the two of us. There was one last hurdle with the PNG embassy. I (Tyronza) was not aware that our passports had to be sent with the visa application. When I called on Friday morning, February 18th, I was told they had everything they needed except our passports. We were scheduled to fly out Tuesday morning, February 22nd. To make a long story short, I FedExed the passports to the home address of the embassy employee; she took the visa approval home with her Friday night; she received the passports Saturday morning and inserted the papers into our passport and overnighted them back to me. I received on Monday morning at 9 am and we left for St. Louis on Monday afternoon. I am thankful for overnight delivery and Mary, a flexible embassy employee.

We travelled through Tokyo and arrived in Port Moresby, Papua New Guinea on Thursday, February 24th. We arrived with three of our four bags, but amazingly the fourth bag showed up the next day.

Scot began seeing patients on Monday morning in the clinic. He is being used for referral, so the patients are first screened by the family practitioners. Routine deliveries are handled by the nursing staff. Scot has performed several surgeries and has seen one patient with malaria. He's back in the swing of things. Scot is working very hard in the clinic, has already diagnosed one molar pregnancy, two ectopic pregnancies and three large ovarian tumors. One of the ectopic pregnancies had an estimated blood loss of 2,500 cc!
The largest tumor removed was nearly 20 pounds! He has had only limited obstetrical management, but has performed several deliveries and repaired several lacerations. Care here is very basic; sterile technique is not very high. The patients seem to do well and are grateful for the care received. The hospital's motto is "We treat. Jesus heals."

The patient care given here is very different from the states. The nursing staff primarily administers medications and any physician orders given. The patients or their families take care of themselves and their needs. They have to provide their own bedding, food and toilet tissue! I was told each patient has to purchase a roll of tissue, otherwise all manner of substances are used and flushed through the toilet.

I began working in the storeroom yesterday and will probably spend my mornings there helping with inventory. Judy Bennett, one of the missionaries, will be leaving in a couple of weeks on furlough. I am to follow her around while she is still here and take on some of her responsibilities when she and her husband leave.

Pictures are being posted through Facebook. The Internet connection here is torturously slow and unreliable. I can receive but not send emails.

Tyronza W. Pringle

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October 2010 in Licto, Ecuador

Team One

Scot retired on July 31, 2010 and in October we spent two weeks in Licto, Ecuador with a Work & Witness group from the Missouri District of the Nazarene Church. Over the years, we have been on several of these construction projects. Each has been special and meaningful, many of you have helped support this ministry over the years with the purchase of pies from our church. The church in Licto was built in memory of Barb Bouldrey, the District Mission President for many years prior to her death.

The indigenous people of Licto, Quichua Indians, are kind, lovely and very hard workers. We had the privilege of working with them building the walls and pouring the floor of their new church. A second group from the Missouri District arrived after us and put up the roof trusses, roofing tiles and the electrical wiring. The Nazarenes of Licto are now worshiping in their new sanctuary!

Pictures from our time in Licto can be viewed at this site:  http://www.facebook.com/album.php?aid=17008&id=100001961413037&l=350be064c2

Heading to Papua New Guinea

Dear Friends,

After waiting numerous months, we have finally received approval for our work permit from the Labor Department of the Papua New Guinea government. We have now applied for our entry visas, and God willing, we will fly out of the U.S. via Tokyo on February 22nd. Now I know the meaning of "wait upon the Lord."

Current plans are to spend the next three months at Kudjip Nazarene Hospital and return mid May. Kudjip is in the Western Highlands of Papua New Guinea (which is north of Australia). It is a small hospital in a village setting.  We had originally planned to stay for four months, but with the delays in obtaining the work permit it is now shortened to three months. We still want to return as our children, Keara and Gavin, complete their semester.

Scot will mostly be involved with Gynecology, although he will be on call for Cesarean sections. Tyronza has had a crash course in basic ultrasound and will work with Scot at the gynecologic clinic and whatever else is required of a missionary "go-fer". 

For more information regarding our ministry in PNG, you may check on us at www.storktale.blogspot.com. Thanks again for all your support and prayers. a special thank you for all of you who have made the new portable ultrasound machine possible.

God bless you and your families,

Scot & Tyronza Pringle