Random musings

October 24, 2008

Hi again everyone

I sit down not really knowing what I’m about to write, but I haven’t written in a few days so I think it is about time.  So, I make no apologies for the potential meandrous nature of the following.  There will be some medical content, and I’m too lazy to explain it to the non-medicals at the moment, so I will apologise for that.  Besides, God made Wikipedia for a reason.

I guess I should start out by filling you in on the last few days.  I have been in surgery and I must say that the more I am here, the more I think that this is my niche.  There is something so satisfying about dissecting out a defect/lesion/hacking off a foot that I just don’t get from the physician’s side of medicine.

Yesterday we took out an enormous cystic hygroma from the side of a kids neck; it was about the size of a grapefruit and involved his spinal accessory nerve and a good part of his brachial plexus.  It was a very difficult operation but the surgeon was nothing short of a magician, dissecting most of it with an artery clamp.  This was in categorical contrast to surgery on Karkar.  The doctor over there was a reasonably good doctor, but if I could use one word to describe him it would be rough.  He did a laparotomy for a patient with a uterine mass under spinal, and when the spinal wore off he kept going under ketamine sedation, despite the fact that the patient was moaning and trying to move.  I started to get a bit short with him and made him stop whilst we gave some more sedation.

Actually, I should tell you more about that operation.  I got to scrub in on it, and previously I hadn’t met the patient.  She had a mass in her lower abdomen that felt a lot like uterus.  On ultrasound she had a big uterus.  It had been this way for a couple of months, and in that time she had not had a menstrual period.  The natural question one would want to know is whether or not she is pregnant.  So I asked about the pregnancy test before we started, and the doctor didn’t answer me – I thought he must have assumed it was a stupid question and didn’t bother to answer, but alas when we removed the uterus and something that looked very much like products of conception came out, I asked again.  His answer – “I don’t know if we did one.”

I felt sick.

Besides the fact that there is one unbreakable rule in gynaecology – MAKE SURE THE PATIENT IS NOT PREGNANT! – I thought I had just assisted in removing a gravid uterus from this woman, ending the life of the unborn child inside.   The doctor was confident that his diagnosis made from ultrasound was correct (even though he didn’t know if it was a fibroid or an ovarian cyst) and that the uterus was ’empty’ from an obstetric point of view.  I’m no ultrasonographer, but telling the difference between a circumscribed fibroid arising from the myometrium and a pregnancy from the endometrium with an old ultrasound machine would be very difficult for me to do.  At the very least, with that clinical history, I would want a pregnancy test to confirm my findings.  This doctor was much, much better at ultrasound that me, but I think the point still stands.

Anyway, after a rather pensive half an hour of closing her up, I braved a look inside the uterus and found out that it was a rather large mass arising from the myometrium – the stuff I thought was products of conception was the insides of that mass.  I’m still not quite sure what it was, but a big fibroid would fit the picture.

Anyway, since I’m on the topic, the medicine on Karkar was very exciting.  We had a fair bit of responsibility taking care of two wards each.  Ian had kids and post-natals, I had antenatals and one of the medical wards.  I found some patients that had been mismanaged for years and years.  One man, who I suspect had rheumatoid arthritis or similar, had been treated with indocid for 25 years with no resolution.  He couldn’t walk due to the pain.  I started him on some steroids and some methotrexate and he walked out the door after we left – very satisfying.  I also diagnosed another man with psoriatic arthritis.  The lack of psoriasis was only a mild deterrant to my brilliant diagnosis.

Also on that ward I had a bunch of TB patients (TB isolation over there is basically isolating yourself if you don’t want to catch TB) one guy with a complete bowel obstruction that we sent to Madang, another guy with a very suspicious looking liver lesion on ultrasound who also had obstructive jaundice (we sent him to Madang too) and a bunch of other cool stuff.

Ian had some very, very interesting kids on his ward.  TB meningitis, another kid with TB but bacterial meningitis (great catch from Ian), one kid who I’m nicknaming megaly – spleen, liver and heart, massive oedema and an Hb of 1.9 but not haemolysing.  We sent him to Madang for the specialists.  There was also an FLK (technical medical term – funny looking kid) with failure to thrive, chronic cough, secretions everywhere and constipation.  Not sure what was going on there but I think he had Down Syndrome with a TOF and Hirschprungs disease.  We also managed a neonatal sepsis and a bunch of other boring things like malaria.

The kids were beautiful and some of them were so so sick.  It was very satisfying to get some good results and also to realise that the medical training actually did some good.

There was also a bunch of trauma, fractures/dislocations that needed reduction and heads that needed stitching up.  I actually got to do the foot-in-the-armpit thing to reduce a posterior shoulder dislocation.  It was neat.

Also neat – for the first time in my life, I’m tall.  I have met about 3 PNG nationals who are taller than me.  The rest are little.  It is awesome.  Amanda, if you come here you will be average height, how cool is that?

John Whitehall, director of neonatology, Christian friend of mine and all-round nice guy, arrived here on Wednesday with two students for the tropical health course.  The rest are coming tomorrow or sunday.  It has been great hanging out with those guys, it has given me a much needed boost.

Still, with only 3 weeks left I can honestly say that I am well and truly over my homesickness, and that I will miss this place when I’m gone.  Australia is always going to be home and I will always long for it, but despite the fact that the heat and humidity threatens to send me into anuric renal failure on a daily basis, this place is growing on me.

Also, big win.  Today I handed in all my assessment and forms for med.  The last ones ever.  That means, barring some unforseen incident, I will finish medical school in a very short 20 days.  The reality of that hasn’t sunk in yet, I will have to leave it slosh around in my brain for a little while.  After handing in my forms I had a celebratory Friday afternoon nap – always a winner.

Told you it would be random.

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2 Responses to “Random musings”

  1. Thanks for a great article – have used this link as an item in the next PNG Gossip Newsletter fr the benefit of the readers.

  2. Phoebe said

    My goodness! I can’t believe they hadn’t checked if she was pregnant! I would’ve felt sick too. But thank God she wasn’t.
    Have really enjoyed reading your blog Joel, you’ve got some amazing stories! It’ll be an experience that you’ll carry for the rest of your life.

    God bless,
    Pheebz

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