Caesarean Sections

It has been several weeks since I last used this pen. I thought some of you might wish to know what has been going on across the Pacific. Tyronza and I are fine and enjoying our stay in Papua New Guinea. You have probably heard that we have had several earthquakes, which is true, but not much damage.

Last Saturday during the very early morning, I was in the OR for an emergency caesarean section and things started to move around. It was about 12:30 am here and a 5.4 magnitude quake hit the area. It lasted about 20 seconds and moved the OR lights and rattled some equipment on the counters, but did no damage. There was a short after shock and then all was quiet. When I asked Tyronza if she had felt it, she said, no, that she had been asleep. Then on Tuesday mid-morning we had another quake. This one was 6.7 and lasted about 30 seconds. I was standing outside the hospital and noticed a ferocious growling sound and then the ground shook. Tyronza was at home and said things rattled and shook enough that she hurried outside. I don't think there was any major damage on the station, but one of the neighbor's banana trees fell down.

We have been on several interesting outings since I last communicated with you; a church service at a home for HIV/Aids orphans, a service at a bush church, rafting on the river and a visit to a tea plantation. Tyronza and I met an Indian couple at the monthly English "lotu" service. The first Sunday of each month there is a worship service conducted in English at the hospital and people come from the surrounding area to attend.

The Indian couple, Priap and Elizabeth invited several of us to come for tea and a tour of the plantation. He manages the tea plantation and factory. We were allowed to visit the harvest and also were given a guided tour of the manufacturing process. It was quite an operation. All together they had over 2,000 acres of tea plants and harvested tea 281 days each year. This is the largest tea farm in Papua New Guinea and they ship tea in shipping containers all over the world. Our guide told us that their largest customer was Russia. The tea plants produce a new crop of tea every 25 days, so harvest and pruning goes on constantly. This plant produces black tea only. This type of tea is the most common tea product. There is only one type of tea plant (which is really a tree). The different types of tea you may drink:  green, white, red are all just different types of processing. After the tour we went to their home and had refreshments and some interesting Indian cuisine.

Medical work goes on as usual. I have had several interesting on call days. Friday, a week ago, I had two routine hysterectomies for bleeding problems. The third case was a C/S because the baby had hydrocephalus. On pre-op ultrasound, the baby's head measured AP-21 cm and BPD-12 cm. It was a bit of a struggle to get the head out. The baby was very abnormal and only survived for a few minutes.

My fourth case was also a C/S for twins; two boys - both breech. I let the medical student, Andy Peters, do that one and he did an excellent job. We thought she would name them Scot and Andy, but no such luck!

I had one patient come into clinic late Friday afternoon that had not felt fetal movement that day. On ultrasound I could see fetal heart activity, but no fetal movement and there was reduced amniotic fluid. I called for a stat C/S, but was not able to get started for a little over an hour which is typical for PNG. The baby was very acidotic, with thick meconium. I hand bagged the baby for 30 minutes, but got minimal respiratory effort. We had to give up, as we have no ventilator. I feel the baby would have been badly damaged anyway.

Later on that same call day, I had a mother come in with active labor. She was complete and breech. The baby looked large and I called for another C/S. This time it only took 45 minutes to get ready and she did not deliver during the wait. I was on call with a Papa New Guinea resident physician, Dr. Imelda, and let her do the honors. The baby and placenta were delivered without problems and then she reached in with ring forceps to pull some membranes out. She pulled down a second set of toes! Both babies were healthy, again another set of boys. Neither of which were named Scot! Oh well, maybe next time.

Bye for now,

Scot & Tyronza

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When the Power Goes Out

Hello again, coming to you from paradise, well, almost paradise!

On some days it is difficult to remind myself that I am living and working in a third (or fourth) world environment. The doctors working here are very conscientious, well trained and qualified. The clinic, though dirty, moves patients through in a productive and orderly fashion. The x-ray department provides good quality films and the portable ultrasound machines are nearly as good as what I am used to working with back home. The surgical suite is clean, well stocked and air conditioned. Anesthesia service functions much the same as in the states. All is well, until the doors fly off. Here is the tale of my last night on call:

The daylight hours had gone well with 3 major gynecology surgeries and a late afternoon Cesarean. I was able to stop work at 5:30 and come home to relax and have one of Tyronza's fine suppers. I was tired and went to bed at 9:30pm only to be awakened by the telephone at 11pm. The emergency room was calling with a patient that had an acute abdomen and they were requesting my presence, so I hurried in to the hospital.

The patient was indeed in great distress with a rapid pulse and low blood pressure. A quick urine pregnancy test was positive and her hemoglobin was 7.6 gm. A few steps over to the clinic allowed me to retrieve my portable ultrasound machine and two minutes later her problem was obvious. An abdomen full of blood confirmed my fear of an ectopic pregnancy. We started two IV's and requested two units of blood for "stat" cross match. It seemed just like the big city; but that was when reality struck and the third-world medicine thing came home to roost.

The power around here is notoriously unreliable. It seems to go off and on multiple times each day and we are use to the big generator kicking on when this happens. This time when the power went off, the big generator didn't come on. A quick check showed that Dixon, one of the station's trouble shooters, was on generator call. He only carried a cell phone, which was also out and so I had to send the hospital guard out to find him. Meanwhile the patient in shock is needing blood; but, without power the cross match is stalled! Dixon was finally located and was able to start the little generator. The big generator could not be resuscitated! I thought my problems were solved. I had power in the ER and in surgery, but soon discovered there was still no power in the lab. The lab guy, Andy, was sitting over there in total darkness and was still no help. He reported that he could do a group and Rh on the patient, if he had a flashlight. I retrieved my headlamp from the clinic and gave it to him with my blessing. In a few minutes , he discovered that the patient had 0 negative blood. He handed me two units of blood and I headed back to the ER. On inspection, I discovered there was no Rh factor on either unit. Both the ER staff and Andy said this was alright, because all people in Papua New Guinea are Rh negative. Andy said, "We never check the Rh factor on any blood we use." I had seen several locals that looked like there was a "honky" in the wood pile, but said nothing. We finally gave the patient the two units without difficulty and surgery, two hours late, took care of the problem. By 2 am I was back in bed, only to be awakened at 3:30.

This time it was a nurse in delivery who had just delivered a term baby with meconium aspiration. The power had again gone off at a strategic moment and she was not able to suction the baby very well. I tried to suction the child out and do percussions and drainage as best I could, but he was retracting a lot and I felt sure he would die. In the third world there are no respirators; even if we had reliable power to run them. The baby would have to "take a chance".

The next morning, the nurse seemed pleased and the baby did seem to be breathing easier. I peeled back the diaper for a closer look and was met with a big stream of urine followed by a full arrest. He would not resuscitate!

Life is cheap here in the bush and with unreliable power it doesn't show any sign of getting better. It is fortunate there is always reliable power with God. He is always there to make our light shine; we need only to believe and ask.

I hope your day goes better than mine. I think about you guys a lot.

God Bless,

Scot & Tyronza