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.

C/Section for Beginners

Our time in Papua New Guinea has offered many “firsts”. This past week I had the opportunity of assisting Scot in a c/section delivery. This was a “first” for me. It was a wonderful experience to be on the front line with Scot during a surgery. The woman that was operated on had given birth to the first of twins by vaginal delivery; however, the second baby was foot first and needed to be delivered by c/section.  I had mentioned to Scot prior to this that I was interested in assisting him on a surgery. He called the house in the afternoon and told me to get up to the hospital quickly.

Upon arriving at the surgical suite, I put on scrubs, shoe covers, a mask and a head covering. Then Scot showed me how to wash my hands and arms. We went into the surgery room and the patient was lying on the table with a spinal anesthetic. The scrub tech helped us gown and glove.

Next, we placed sterile drapes on the patient, and then Scot asked her name and a prayer was said for her and her baby. After this, he used an electric scalpel for the incision. It wasn’t working very well, so he asked for a regular scalpel. My job was to sponge and wipe the blood away. After he cut through the layers to the uterus, I had to hold the edges on the incision open wide and use a suction to remove pooling blood.

The uterus was opened. The baby was delivered and the cord cut. The baby was then transferred to the “baby catcher”, a nurse from D Ward. She took the baby and left for the nursery. I continued suctioning blood out of the way as Scot cleared the incision site of clots. Scot reached into the uterus and pulled out the placenta. It was huge because there were twins. When everything looked clean, I held the uterus out of the way and he began suturing. (The uterus was hard and about the size of a small cantaloupe.) There were three layers of tissue and lining that he sutured together to close the uterus. Once that was completed he pushed the uterus back in place and closed the peritoneum and fascia. After that, I was allowed to staple the skin closed and dress the wound. 

It was all very interesting and I would be happy to assist Scot again. I didn’t faint or vomit. (I think Scot expected me to.) I found it to be a very interesting and an amazing experience. I had two c/sections of my own and found being on this side of the table preferable.

Tyronza

PS. Yes, the count for sponges and instruments was done.

PS 2. Both babies were “pikinini mons”, baby boys.

PS 3. Thank you, Scot for assisting with medical terminology.

Back in PNG 2014

Saturday, February 8, 2014

Dear Friends,

It has been more than nine months since I last penned a blog article. I have been very busy with home and family responsibilities (and duck hunting/ added by Tyronza), but now I find myself at home again in Papua New Guinea and ready to expound.

Tyronza and I found safe passage around the world to our second home. This time we took 13 days to get here. We spent four days at a vacation spot in Thailand for some R&R and then a week of scuba diving off the coast of Thailand. The scenery both above and below the ocean was spectacular. Thanks for all your prayers for safe travel.

This year we plan to spend February – May 1^st in Papua New Guinea and then be at home (or at least in the states) for the summer. We will return to PNG for September and October. (Scot is needed to help cover the furlough of medical missionary, Dr. Jim Radcliffe.) We will return home for duck season. This sounds pretty ambitious for a couple of 60 year olds, but with God’s help we will get much accomplished.

At this moment, Tyronza is busy preparing supper. We are having four friends from here on the station over for supper and an evening of “Zilch” (dice game). She is making moussaka (Greek eggplant casserole) and, of course, a pineapple and plantain fruit crumble. After 40 years of marriage, she has really turned into an accomplished chef. Her “made from scratch” dishes are very good.

I have come back to medicine in a hurry. I have been in PNG for less than a week and have already performed 4 major gynecologic surgeries, 3 tubals, an ectopic surgery, 2 c/sections and 2 deliveries. I will be on call again tomorrow, so that number will likely go up before the week is over. One of the c/sections was for cord prolapse and I am happy to report both a healthy baby and mom. This year my clinic work is blessed with a full-time interpreter, Sophi. I am able to see nearly twice as many patients. The interpreter is a good thing since my pidgin has not improved.

This year, we have one new missionary doctor, Mark Crouch, but I am sorry to say, we also have one less, Stephanie Doenges. Stephanie has gone back to the U.S. to get married. The rest of our station friends are much the same, just a year older. It is good to be back to a slower lifestyle and simpler life. We look forward to a productive time on the mission field. We do miss our friends back in America, but with all your prayers and God’s help, we will soon see you again.

Please pray for us.

Scot & Tyronza

Lukin yu behain

Our time here in Papua New Guinea is nearly gone for this year. It has been eventful to say the least – new friends, new patients, and new experiences. God has placed a never ending parade of life that files before me. What a blessing it is to pray with those I treat and those I meet here on the mission field. Some I can help and others are blessed only by God’s miracles.

Hope all of you are staying safe and healthy while Tyronza and I have been away. Sounds like your weather has been much harsher than last year, but with a good bit more rain this April than last. Here it has turned off dry, no rain for the past six days. It must be a record!

Nothing else major to report. We will be flying your way soon, leaving PNG of the 8^th of May. Please pray for our safe travel. We have been missing all of you.

See you soon,

Dr. P

Maternal Mortality

It has been a while since I last communicated with you folks back home. All is well here in Papua New Guinea. Tyronza and I have been healthy and enjoying the nice weather in the mountains. We have not had any further natural disasters. The temperature here has been nice with sunny days and rainy nights. My cistern has been full, so regular showers continue to be nice. Hope you are enjoying an early spring. We have only one more month before we start back home.

I believe I have written concerning this before, but it needs to be mentioned again. PNG is such a medically primitive nation that many of their health care statistics are woefully bad! Such is the case when talking about maternal mortality. When I last looked, this sad piece of data was the worst on the planet and it seems to be sinking even further!

During my career of nearly 30 years doing obstetrics in Cape Girardeau, I never experienced a maternal mortality. I would like to believe it was because of something I did right, but maybe I was just lucky, or maybe God was looking out for my patients.

The record here has not been so stellar. The first year I came to PNG there was one death under my care. She arrived on Labor & Delivery following a home delivery with considerable blood loss. She was fully arrested and, unfortunately, so deep in shock, I could not bring her back.

The second year there was three deaths. One had postpartum cardiomyopathy. Unfortunately, there is little that can be done with that diagnosis and death is inevitable, at least in the highlands on PNG. The second patient had taken poison. That, too, was ultimately fatal, although it took 3-4 days. The third patient developed acute hepatic failure and died. We were never sure of the cause and lacked the ability to diagnose or treat the problem.

This year I really was feeling good about the situation, until this past week. The woman’s name was Nancy. She had delivered a live child in a nearby village five hours before she arrived on L&D. She had lost much blood and had a retained placenta. Her hemoglobin on arrival was 3.7 gm, but she seemed stable. However, shortly after I got 2 units of blood going she arrested. We worked on her for 45 minutes, but were not successful. I have been a little depressed over this situation, but really don’t know what else I might have done.

On a positive note, a family member is adopting the child. She has come in and is being given ”Lactogen/Lamictal” to start lactation.

You folks stay healthy. Looking forward to seeing you soon.

God Bless You,

Dr. P & Tyronza