Singing

Singing with Papua New Guineans is inspirational. This is fellowship meeting during the week at the hospital. All of the people are staff and family and they are singing in Pidgin. Enjoy!

In the jungle

I spent several hours with a PNG family going into the jungle or 'the bush' as they call it. While digging for bushhen egg, we encountered this turantula.


This is the boat ride to 'the bush'. In the background, you can hear Isaac's family speaking Pidgin and of course you hear the engine for the boat. 'The bush' is as virgin as it gets. Interestingly there are no monkeys. I know they have wild boar, snakes, turantula of course, lots of butterflies and birds.


Above is a picture of Esther as she gathered firewood 'in the bush' for cooking


Above is a picture of Isaac and Esther's family in the neighboring village


Isaac's family. I find this picture endearing.

Clinical cases

Above is a picture of a middle age lady who presented with foot drop. As you can see she has some skin lesions which was treated for fungal infection but never got better. She has leprosy. She took 3 months medication but never came back for more. Then she came back again only because her husband was very sick. Now the whole family is on TB medication. Her husband has 2-3 wives. That is quite common to find a man having several wives. One patient I had was the 7th wife.


Above is a closeup picture of a 10 year old girl who has had years of scabies. It seemed like almost all the patients have scabies. You know in GP land in London, a small skin lesion comes up and everyone jumps up and down, but here it's so common that if you don't have any skin lesion then you're abnormal. I was abnormal when I arrive but now I've got all these mosquito bites, and I think there is a bed bug in the bed. Now I also developed all these bites on my trunk. I was in denial and thought initially it was just mosquitoes that somehow found it's way on my abdomen and back but now every morning I get more bites on my body so I know it's either scabies or some other bed bug. Now I look like any other person in PNG. I've gotten over very quickly on examining someone with scabies. Now I can even examine a hairy smelly man's armpit without wearing gloves. I'm very proud of myself for that actually. Sometimes there is just no gloves lying around.


The above picture shows two brothers. One is 3 years old and the other is 5 months old. You could probably figure out which is the sick one. Despite being breast fed and it seemed like he is always hungrily breast feeding, and also feeding additional food, he is still not gaining weight. Oh and of course he is on TB meds as well and if it's TB he should be putting one weight by now. Next we're going to counsel mom and get permission to do an HIV test to see if that is cause why he is not putting any weight despite all the feeding.

Vehicle in Kikori

Above is the picture of the truck I use to go to the oil company. It was donated by somebody and it is old but it still runs. To get it started, first I need to get a few strong men to push the truck everytime I start the truck. Then the part when you change gears keeps pulling off, and if I'm lucky it will go back into the right place so that I can change the gear properly. Or I try to stick to one gear..........


Above is Father Paul from the catholic church. He has a better and 'cooler' vehicle. He also runs an HIV counselling and testing clinic paid by the catholic church.

Market and Store

Above is a picture of the market place. Anybody can sell anything here at anytime. No license needed. The market is right by the banks of the river so people come by their canoe to shop or to sell.


Above is a picture of some crabs being sold. There are plenty of crabs and they are cheap--something like 30p per crab.


Above is the picture of the biggest and main store in Kikori. It's quite a dismal place, it has an oppresive feeling when you enter. In this picture it looks bright but I think it's the camera and the flash. In reality, there are no windows to this place, all the goods are behind bars. So you go to the bar counter (kinda like the bank in the developed world where you cannot get to the person behind the glass or bars in this case) and point or tell the person behind what you want. This is the affect of poverty. The reason they cannot have a normal grocery store is that people will steal. The person who run this store is a white Australian and she is one hard woman. They have guns to protect themselves. The delta store has a generator that provides electricity all the time. When you go on the river, it's quite a good landmark because you know you're in Kikori from the store.


Above is a picture of the only TV in town. It is owned by the Delta store and this is right outside the store. See how the TV caged.

Playtime

This is what you do when you don't have TV, XBox or computer.




Above is a machete used by everyone including kids. Not only do they use during meal time, looking for food but play items for kids. The first week I was here, I saw a 3 year old boy carrying a machete in the corridor, I got the machete out of his hands and handed it to his parents. But minutes later, the boy had the machete in his hands again. The parents thought why is the doctor taking the machete away from his hands. Interestingly you would have thought there are more accidents but they learn at a young age how to handle this sharp object. There are no lawn mowers here in PNG, they use the machete to mow their lawn. I've seen kids as young as 6 years old being put to use and helping out with house chores such as mowing their lawn with this machete. It's hard work. I can't be bothered to cut the grass by the house I'm staying in. Nature shall take it's course.

Snakebite

What a day again. Today I had a snakebite and he was envenomated and had all the neurotoxic affect. He had droopy eyelids, weak limbs, slurring of speech, double vision, drooling…etc… He presented to the hospital 10 hours after the bite. He first got to the nearest health center but they don't have antivenom so by the time he got on the canoe and got to Kikori Hospital it had been 10 hours after he was bitten. The snake was a death adder. Well we started the antivenom but he started developing an anaphylactic reaction with wheals, coughing, wheeze. Normally I would totally panic but because everytime I did anything with the patient, I begin with prayers with the staff and it really makes a difference even when things don’t go right. Well of course I had to give the adrenaline, steroids, antihistamine…etc… and eventually the reaction went down. The problem is that he needs the antivenom so even with the reaction, you have to restart the antivenom. That was hard and thank goodness after restarting, he did not react. Phew!!! He then stopped slurring and was able to speak somewhat clearly. So I knew he would be ok. While all of this was happening, there were four other admissions, an axe accident, a cachetic lady, and domestic violence. Well no one died and everything was under control by midnight. Praise God!!!

Survival-Hunting for food

There is no concept of saving or planning for the Papua New Guineans. Mode of life is survival here in Kikori. Some of them don't even know what they will be eating that day. The coastal area (Kikori) are more hunter gatherers. I am told in the mountains, they plant and have gardens so most of the fruits and vegetables comes from the highlands. When they have found more than they can eat, they bring it to the market sometimes to sell it. The money they make, they can buy other items at the market or go to the store. There is a dismal store in Kikori. I will post a picture of the store some other time.


Above is a picture of a boy with a bow and arrow looking for food.


Above is a boy fishing from the bridge. He caught some shrimps.


Above is the whole family looking for food. The father is carrying a machete to cut whatever he finds. While driving on the road when I go to the oil company, I see people on the roads with their machete, bow and arrow, spears--looking for food. So you can imagine you hardly see any obese people here in PNG--only in the city and the politicians (^_^)


Above is a lady making sago which I've mentioned before is their main staple which is from the palm tree. It's a starch and it's from the trunk of the palm tree. The lady have to sieve the sago with water over and over and it just sounds like a very labour intensive process. Alternatively you can buy it from the market if you have the money


Above is sago being sold at the market. They use this sago to make sago pancake, sago roll, sago with coconut...etc..


Above is Esther (one of the PNG family I have gotten to know) digging for a bushhen egg. Basically in the jungle, if you see a mound of dirt/branches..., the bushhen lay their eggs in there. There maybe no eggs but there may be up to 5-6 eggs. It's basically the size of one bushhen egg is equivalent to 2-3 chicken eggs. So you dig and dig and dig. This time Esther and the gang found about 3 eggs. Most of them were right in the middle of the mound. If it was up to me, I wouldn't bother with the bushhen eggs. Too labour intensive. But I guess one egg is still food and better than no food. The PNG don't have concept of time as they have all the time in the world as most of them don't work so life is looking for food, hanging out with family..etc.. As there is no electricity, you sleep when the sun set and get up when the sun rise. Incredible that people still like this huh.


The hospital cooking area for the patients. There are no electric cooker or anything sophisticated like that. It's BBQ everyday. They have to hunt for wood to use for cooking. Some of them don't even have pots or pans, so they use hollowed bamboo or leaves to cook their food.


Above is a on the hospital corridors where patients store the wood and bamboo they have gathered.

Tuberculosis

There are so many patients with Tuberculosis at the hospital. They all stay for 2 months to complete their intensive treatment. After the two months, hopefully with the routine, they will be compliant and continue another 4 months of TB treatment at home. So far the TB treatment seems to be working so no resistant yet in PNG. In the short time I've been here, I've seen all forms of TB--lung, spine, joint, lymph nodes, abdomen...etc.... Here are pictures of some of the obvious ones. They still present quite late. The problem is they keep coming back because the primary case prob the coughing grandmother or grandfather is still at home. So once they're treated, they go home and get infected again, or later their siblings gets admitted. So we're trying to do contact tracing but it's hard as some of them live in villages far away and it's difficult to get them to come to the hospital for a review. I belive the TB problem with get worse. And if resistant arrives as it has done in Africa already, and with the increase of HIV, it can become a very serious problem.


This man above has enlarged lymph nodes everywhere. This is probably one of the worse ones because he left it so long and not got any treatment that he developed discharging sinuses from the lymph nodes. I have so many kids with enlarged lymph nodes in the neck which are resistant to antibiotics, and when you put them on TB drugs, it starts softening and reducing in size. It still takes a good few months for the lymph nodes to disappear. On ultrasound, these lymph nodes look cystic (looks like they are filled with fluid)


Above is a picture of a middle age woman who could barely walk. She weigh about 40kg. She definitely have TB as the only clinical symptom is on examination there is bronchial breathing in her left supraclavicular fossa. Other part of the lungs were completely clear.

Above is a picture of a healed TB of the Spine (Pott's disease). There is a hump which she has to live for the rest of her life. At least it's healed and she can walk and there are no more symptoms.

Strangulated Hernia

A 4 year old boy presented with a 2 days history of strangulated hernia (part of the bowel protruding through a small opening out of the abdominal cavity, if it;s so small, the bowel cannot get back into the abdominal cavity and therefore lose blood supply and part of the bowel could die. He came by canoe costing the family their savings 240kina which is about £35 pounds for the petrol for the canoe. It took them 6 hours on canoe. When we saw him he had a swollen, red, tender hernia which basically means he needs to be seen by the surgeon now!! if he presented in A&E in UK. As it was two days that he has had it, it may mean that the bowel had already died. There's a trick to reducing hernia I have learned, which is pulling the hernia (of course once again using the amazing ketamine anaesthetic to put the child asleep so he will not scream and fidget), then the content of the bowel slowly drains away and slowly by slowly the bowel goes through the small opening and so the hernia is reduced. It still means he needs surgery to close the opening as he has risk of the bowel coming through the opening again. Well luckily this time the hernia was reduced, it was not red or painful anymore. As I said the family has already used all their savings to get to Kikori, so there is no way they have money to go to the capital general hospital to get the surgery. This is where the oil company comes in handy. After discussing with the doctor there, they agreed that the risk is high and he should be transported to Port Moresby. They will pay for the return plane ticket to Port Moresby. Praise God! And I was so happy to see him have a bowel movement the next day (which means part of that bowel had not died).

Pulled elbow

A 2 year old girl came in at about 9pm at night while I was trying to reduce another child's forearm fracture. Her mother said she has not been using her left arm. Her left arm was just hanging there-motionless. She was pushed over by an older child and landed on her left side. Even though history does not suggest a pulled elbow it was the way it looked and on palpation of her whole arm, she was not in pain at all. I hadn’t done Emergency as part of my rotation and I have no idea how to fix it. So I had to go to the books. Since it was 9pm that night and I don't know how to fix it, I sent them home and told them to return in the morning. There’s a really good surgical book that a friend had recommended to bring ‘Primary Surgery’ and sure enough, it had great instructions and pictures. That's what I do a lot of the time. I read during my free time, not leisurely books but medical books. I read up on how to reduce fractures, what to do in obstetrics emergencies, and I do that all before bedtime as that is the only time I have. The power goes off around 10pm so after a shower, I wear my headtorch and get to reading. The next morning, mom and child turned up. I practiced first on one of the nurses and then I attempted on the child to put that elbow back. I had to try twice because I wasn’t sure if it worked the first time. There was no click and I didn't feel anything. The child didn’t cry at all. The next minute she gave me this huge smile and started moving her arm. It was the most beautiful smile and she made my day!

Daily Living

Above is a typical close up view of a canoe. You can sit or stand quite a few people. This is the main mode of transportation besides walking. Sometimes we get patients who come from some village half a day away on canoe. Obviously sometimes some of these patients do not make it to the hospital. The other day I heard wailing coming from the morgue at the hospital. I was told that there is a junction on the river that narrows and there are rapids. Somehow there was one boat whose motor broke and at this junction, the boat overturn and all 4 adults and one child did not make. Three of the adults' bodies floated downstream and landed about 40min away from the hospital and the bodies was brought over to the morgue. They had not found the body of the child. Whenever someone dies here, the people wail very loud for many hours. I am told that if you do not wail loudly then people may think that you were the reason that the person died. They are quite superstitious and even here there is the peer pressure. If one does not wail, one maybe accused for causing the death one way or another. I think wailing is great way to mourn the loss but the pressure of how loud and how long one wails should not be judged.


Above is a picture of a mother who is carrying her little baby. There are no prams but they make a 'bilum' to carry their baby.
Look below to see how they make a 'bilum'


Above is a picture of how they make the thread for the bilum. They take what looks like dried straw and they roll small strings into threads


Above is a lady weaving a 'bilum' from the thread the grandmother has made. Once completed it can be a regular bag that one carries around, bags to put pots and pans in the kitchen, or as the earlier picture shows a bag to carry their babies

Bednets

I was very impress with all the bednets being used. Mind you these are bednets not provided by the hospital but from the community and patients bring their own bednets to the hospital.

Creativity

Above is another use of the Coca-cola bottle. This is a spacer I made for Paul for his asthma inhalers.


Above is another traction for a 5 year old girl with fracture of her thigh bone. As you can see we use coconut shell as part of the traction. She was up and walking after 3-4 weeks of traction. Bless her it was hard for her to keep still like this in this position for 3 weeks.


Creative ways to scrape coconut using a shell

Theatre

This is a picture of the operating theatre, which is not a bad one. The staff in the picture is Luke (male nurse) sitting, Warapai (female nurse), and Joshua (male community health worker--kinda like health assistant in UK). This patient had a foot ulcer which he got from falling into the fire (for cooking) under the influence of drugs. We needed to do some debridement as his ulcer was not looking good and taking forever to heal.

Anaesthesia

It has been very busy-- Lots of interesting cases. I cannot believe the things that I’m doing such as reducing fractures, putting cast on, doing xrays including developing the xray films in the darkroom and ultrasounds (there is a portable ultrasound in the size of a large laptop). I’m even giving anaesthetic to reduce fractures or to do incision and drainage or debridement. A month ago I would have said you’re mad. The anaesthetic I use here is IV Ketamine. It’s one of those anaesthetic drugs that I only read and heard of during medical school. That is no longer used in western world. It’s quite an effective anaesthetic. The only nasty thing is they don’t close their eyes, and they have this glassy eye look and sometimes they get bad reaction when they get up from the anaesthetic--they can get hallucinations. So far everything has been good. No one has reacted badly. One 8 year old girl got up making jokes and was quite funny really. She had a difficult rare fracture and I tried as much as I could to try to reduce it. There’s a couple of difficult fractures. Another one is a 15 year old girl with a femoral (thigh bone) fracture. We really need a Steinman pin to give her traction but we have no Steinman pin here and so we are using skin traction. All my non medical friends, sorry for this sort of boring information but my medical friends would appreciate it.

The above is the skin traction of the femoral (thigh bone) fracture. As you can see the weight for the traction is a tin bucket with sand and water in it. In the end I had to re-do this skin traction as the previous tape was too elastic and came off her skin, so we got a better tape to stick to the skin, and we had to add more weights so two iv fluid bottles were added to the tin bucket on the side.


This is another attempt to reduce a fracture. Her fracture was caused by a big branch falling on her arm. As you can see this girl is still in the xray room. It's not a bad xray room and even has air condition when the power is on. When the xray work, it has a battery so you could still do xrays even the power is out. The only problem is developing the film because then the dark room is literally dark. One has to be careful as I've got the chemicals onto my hands in the dark before. I've used IV fluids for weight for this girl. Her poor mother cried when she saw her child under anaesthetic as I've said their eyes are open with a glassy look (not very settling)--I always see their chest to see if they are breathing and they always are. She's the one that got up from the ketamine anaesthetic making jokes of all sorts.