Ectopic Pregnacies

Hello Friends and Family, reporting from equatorial Papua New Guinea:

It has been a fairly quiet time here. I have been sick with the viral crud, but I am now on the mend. I hope none of you have been sick, and if you have, I hope you are feeling better.

Surgery and clinic have been running fairly smooth as of late. I had two ectopic pregnancy surgeries soon after we arrived, but nothing else until a few days ago. I have now had three ectopic cases in the past five days. The one today was exciting; the woman had 3.5 liters of blood in her abdomen. She looks good, so that may be enough. Her hemoglobin is now 8 grams.

She reported feeling bad for the past six days and came in today after fainting. So far, I have given her 4 units of blood.

There was another exciting case two weeks ago. The patient had the usual fulminate case of PID with secondary bowel obstruction to complicate. She tolerated surgery, but arrested in recovery. Following resuscitation, her pulse ox was stuck in the 40-50% range – even on 100% O2. She was on dopamine and received large doses of diuretic. We felt she had shock-lung and without a ventilator I did not give her much hope. When I arrived the following morning, she was still with us, had revived from her coma and was looking around. Her pulse ox was now in the mid to upper 80s. She recovered rapidly and went home 7-8 days later. They say miracles happen every day, and I must say that is the only explanation for her recovery. God was surely watching over her.

OB has also been fairly quiet. I did have a problem with a nurse giving a mistaken dose of vaginal cytotec to a premature labor patient. Thankfully, she only gave 25 micrograms and the premature labor medication quieted her down without incident. We also discovered her to be a newly diagnosed case of HIV. I have been seeing two new cases each week with retro-viral problems. It is very sad to contemplate the prospects for unwitting victims.

Hope you are doing well and enjoying spring. My second batch of sauerkraut is nearly done. The first batch was very tasty.

Bye All,

Dr. P & Tyronza

Female Nemesis of the Thirld World

Hello Friends and Family from the paradise of Western Highlands, Papua New Guinea, the land of perpetual spring!

Sorry it has been such a long and cold winter for you. I am glad to be missing out on all of that. I hope spring arrives soon for you too.

All is wellF here. Tyronza has been busy working in the storeroom (sorting stuff) and other odd jobs. She has also been busy with bread making and other “from scratch” cooking. Our current culinary project is making sauerkraut. I tasted it yesterday and it is coming along nicely. We plan to invite friends over this week for homemade sausage and sauerkraut.

I have been busy with the clinics, labor and delivery and surgery. I am trying to bring some of the other new family doctors up to speed on their surgical skills, and teaching what I can to the nurses and medical students. We are supposed to have a new PNG resident doctor in the next few weeks. That should be interesting and different.

I would like to spend a little time discussing the problem of cervical cancer in PNG with you. I had reported on this subject three years ago in this blog, but it merits another go. Cervical cancer is a major problem in all the third world areas around the globe. This is a particularly nasty problem in PNG. There is rampant human papilloma virus, multiple wives, multiple partners, lack of basic health care, non-existing pap smear screening, slow diagnosis, and poor treatment facilities. The patients scarcely stand a chance!

Cervical cancer is the number one cancer among women in PNG. It has the highest cancer mortality among women in PNG. It is slow to be diagnosed and treated. As a result, it is often quite advanced when first discovered.

There are precious few pap screening projects here, mostly due to medical manpower shortages, limited funds, and poor follow up. A pap smear must be sent off to Australia for interpretation. Eight or more weeks are required to get results back, and when you do get results you are dependent on the patients remembering to come back. Trying to track someone down who lives in one of the hundreds of tiny jungle villages near the station is nearly impossible.

From my perspective, I must rely on how the cervix looks and feels on exam. I have a very limited number of speculums and even if I did do a pap smear on every patient contact, I would probably have returned to the U.S. by the time the results came back.  When I do diagnose cervical cancer, the primary complaint is usually bleeding or pain. This means the lesions are almost always advanced (stage II or III) by the time the patients enters the system. I can sometimes operate if not too advanced, but usually the cancer is already in the nodes by this time. Surgery is of some help, and will usually add a year or two before the patient hemorrhages to death or dies of uremic poisoning, secondary to kidney obstruction.

Papua New Guinea does have a single irradiation treatment facility. It is a ten hour drive over some of the worst roads I have ever seen. Very few families can afford the trip. Because there are so many patients with advanced disease, the oncologist screens pretty tight. If the kidneys are already partially obstructed, the patient is often rejected for treatment. Most of the time, all I can offer is prayer for comfort or a miracle.

One such patient crossed my threshold four weeks ago. She had stage III/IV disease with tumor involving the cervix, vagina, base of the bladder, the parametrium, and nearly eroding into the rectum. She was also 29 weeks pregnant with her fourth child. She was brought into the clinic by her husband and the first wife. The patient is the second of four wives. My mission was to get her to viability before she developed kidney obstruction or hemorrhaged to death. I saw her weekly, gave her extra iron and monitored the kidneys. Unfortunately, at 33 weeks she had a major hemorrhage and the baby died in-utero.  She obviously couldn’t deliver through the vagina and I had to do a c/section. She now has significant kidney obstruction on both sides. Barring a miracle, she likely has only a few months left in her life.

Pray for us and please pray for my patients.

We miss you all,

Dr. P and Tyronza

p.s. I have requested the other three wives come in for screening.