“Do nothing from selfish ambition or vain conceit, but in humility count others as more significant than yourselves. Let each of you look not only to his own interests, but also to the interests of others. Have this mind among yourselves, which is yours in Christ Jesus, who though he was in the form of God, did not count equality with God a thing to be grasped, but emptied himself, by taking the form of a servant…”Philippians 2:3-7
“For it has been granted to you that for the sake of Christ you should not only believe in him but also suffer for his sake…”Philippians 1:29
This past week, a patient unexpectedly died while I was caring for them in the emergency room. He was an older man who arrived at the ER with three weeks of right knee pain, fever, and shortness of breath. When I first saw him, he was awake, talking, and seemed uncomfortable, but I was not expecting what would happen next.
He showed me his right knee, which was severely swollen with overlying infection. I looked on ultrasound and could see a large pocket of pus and infection around the knee joint. He had a fever and a high heart rate. I explained to him and his wife that we would need to drain the infection, give him antibiotics, and admit him to the hospital. I asked the nurse to set up for an incision and drainage and went to see another patient.
A short time later, his nurse waved me over. He was lying on his side, eyes closed, pulling at his IV, and no longer responding when we talked to him. We gave him oxygen, obtained an ECG and ultrasound, and administered epinephrine, but a few minutes later his heart rate slowed down and he died. His wife and sons stared at me with a stunned look. In the U.S., I would have started CPR, put in a breathing tube, placed him on a ventilator, administered vasopressors, and very likely have been able to keep his body alive until he went to the ICU. I would have felt powerful.
Instead, I felt powerless. We have no ICU, and our only ventilators are in the operating room. We don’t have the resources to do CPR and place breathing tubes in patients that are not likely to quickly recover. Questioning eyes stared at me as I leaned back on the curtain enclosing us together, wishing I could float through to the other side.
“I am very sorry. His heart has stopped, and he has died.”
His wife fell to her knees and wailed. I was so startled at his sudden demise, and wondering if I had missed something medically, that I didn’t even offer to pray. Some missionary.
It is hard to believe we have been here almost two months. Days have blurred together such that it feels like a much shorter time; yet we have had so many new experiences that it is hard to believe it has been only two months. It is funny how time works.
I can say that I have stepped off the mountain of perpetual exhilaration and novelty onto a more realistic plane. I still revel at the blood pink torch ginger that adorns our yard, and the shapeshifting cloud cloaked mountains that enclose our valley, and the fascinating medical pathology I encounter each day. But some things I am wearied of: someone has been sick almost every day since we’ve arrived. Milo stabbed his eye with rebar, Harvey contracted Chikingunya, the word “pus” has been spoken more times than I care to count, and multiple children (and Genae) have required abscess drainage.
Turns out that one does not just need to orient to a new language and culture, but to a new microbiome! For the last week, I’ve felt chilled, exhausted, been at war with my digestive tract, and wanted only to sit on the couch doing my best Jabba the Hut impersonation when I come home from work.
Being sick is a shrewd deflater of emotion-fueled passion. Yet, in all our microscopic trials (pun intended), which hardly merit the word “trial”, I am encouraged by the example of Christ. The mighty hand of God was marred by earth and splintered by the wood he created with a word, all because of a heart brimming over with grave-shattering love and service. As I’ve read in Philippians this week, I’ve pondered the gift of service and the mystery of suffering, motivators which aren’t tarnished by an unsettled stomach or the lack of ventilators.
I am on call tonight, which means that at any moment, our home phone will ring, and I’ll be summoned to the ER or to the labor ward. I do not like call. I much prefer spending the pitch-black hours between my bed sheets than in the hospital, but call is an opportunity to participate in the suffering and service of Christ, even if my head throbs with lack of sleep when I round the next morning.
I have already spent several call shifts almost entirely in the hospital, all day and night, travailing as a fickle human with an imperfect heart of service. Last week, I had one such call shift. I spent the day doing rounds in our obstetric ward and caring for people in our outpatient clinic. We induced labors. Babies were born. Fractures were reduced and casted in clinic. A sweet old woman thanked me for her medical care by pulling a gift of passion fruit and cucumbers out of a bag slung over her shoulder.
In the afternoon, I was called to the ER for a man who had been stabbed through the arm and was bleeding out from a transected axillary artery. He was pale and spurting blood on the ER floor any time pressure was released from his wound. There weren’t any scissors to cut off his clothes, so a nurse used a scalpel blade (without a handle) to saw off his clothing. Thankfully, the patient did not sustain any further lacerations from this!
We applied our ER tourniquet, but it was too large to get proximal to his wound. Drawing on my wilderness medicine days, I helped MacGyvre a narrower tourniquet by tying together and twisting blue OR towels. With the bleeding arrested, we gave him blood transfusions, and he then went to a life-saving surgery with our two general surgeons.
A short time later I was called back to the ER for a missionary couple from elsewhere in the country that was in a serious head-on car accident. They were covered with dried blood and bruises. I worked with the nurse to repair their lacerations, obtain radiographs, and ensure they had no life-threatening injuries. After patching them up, and searching for crutches in a dark pharmacy, it was around 7:00 PM, so I went home to eat a quick dinner and give our kids a kiss before bed. I did the five-minute walk from the hospital to our home and noticed a pack of PNG children who had ascended a nearby orange tree and were cackling from within it like a flock of birds. They laughed and waved at me as I walked by.
I managed to sleep for about an hour after dinner, before the phone rudely interrupted my dreams. A nurse on D ward had a question about oxytocin dosing for induction of labor. Something didn’t sound quite right, and I am new, so I decided to walk into the hospital and check on the patient. Crickets serenaded me as I paced through the nightfall. It took only a few minutes to resolve the issue, but I decided to check on the ER before walking back to bed. I asked the nurse, the sole staff member in the ER overnight, if there was anything they needed.
“There is a patient over there you should check on. She is about 20. Her family brought her in for a headache, confusion, and abdominal swelling.”
I noted a small group of people in the corner of the ER. A young woman was curled in the fetal position. As I approached, I could see her protuberant abdomen, and I thought, “She is either pregnant or has a lot of ascites.” The patient could tell me her name and follow a few basic commands, but she had a dazed look in her eyes. Her sister said the patient, who I’ll call Sarah, had a bad headache, and seemed confused for the last two days. Sarah had previously assured the family that she was not pregnant.
I wheeled over the ultrasound, and within two seconds could clearly see a baby’s head down in the pelvis. A quick biparietal diameter suggested that Sarah was about 34 weeks pregnant. I looked at the set of vitals the nurse had collected and noted a blood pressure of 175/110.
Third trimester pregnancy, hypertension, and headache clearly suggest one thing: severe pre-eclampsia. I informed a very surprised family that Sarah was pregnant; I suspect she herself knew. She was unmarried, and I wonder if it was something she was hiding from her family. Regardless, I was discussing how we would need to give Sarah medications and admit her to the hospital, when she started to have a seizure.
Her whole body stiffened and rocked the bed. A panicked family member pulled out a silver spoon and tried to force it into her mouth.
“She has had these ‘fits’ multiple times today!” One family member exclaimed in Tok Pisin.
“Well,” I thought, “it looks like she has eclampsia, not pre-eclampsia.”
Eclampsia is a life-threatening complication of pregnancy. I have never seen eclampsia in the U.S., but I did care for a woman with eclampsia once before while doing missions in Kenya. The treatment is not terribly complicated: eclamptic patients primarily need magnesium, and lots of it.
We rolled Sarah on her left side and applied oxygen. I asked our nurse where our magnesium was. She pulled out a glass vial from a medicine cabinet, but there was not a concentration on the vial, so I couldn’t calculate a dose. Like most seizures, the patient’s had stopped after about a minute. Rather than give an unknown dose of magnesium, I decided to go to our labor and delivery ward, which was right next to the ER, and which I knew had plenty of magnesium.
I walked out of the ER and opened the door to the labor ward and was immediately met by the agonized cry of a mom delivering a baby. That is not uncommon; babies are delivered all day in our labor ward. Women get Tylenol for deliveries. No epidurals or narcotics. The nurses and midwives do all the deliveries, and only summon the doctors for complications.
However, as I walked by the laboring mom, I saw a blue head sticking out of her pelvis, with a suction cap on the crown of the head. The nurse was trying to pull the baby out using a vacuum device, but the baby wasn’t budging. I pulled back the curtain and stepped into the delivery room.
“Shoulder dystocia.” The nurse said, with a calm tone honed by experience.
I quickly put on gloves and went to the bedside. I hyper-flexed mom’s knees and applied fundal pressure as the nurse pulled. About ten seconds later, with a loud cry from mom, the baby was delivered. Unfortunately, the baby was blue and limp.
We picked him up and rubbed him vigorously, suctioning out his mouth and nose. He didn’t cry or breathe. I put my hand on his chest and could feel a heart rate above 60, so I reached for the bag-valve-mask that the nurse brought into the room. I put the mask over the baby’s mouth and nose, and started to deliver rescue breaths, watching to make sure there was some chest rise. About fifteen seconds later, the baby began to move, and then cry. That first vigorous cry from a newborn baby is like the wheels of an airplane touching down after a turbulent flight. Relief. Within a minute, the baby was crying heartily, had turned pink, and was being rubbed down with a towel and delivered to mom.
With that unexpected interruption resolved, I recalled my primary task. “Where do you keep the magnesium here?”
The nurse directed me, and I quickly retrieved several vials and headed back to the ER. I took the glass vial and tried to break it open. In doing so, I broke the entire vial, and magnesium leaked onto the countertop. The ER nurse came to my aid and showed me how I could rub the neck of the magnesium vial on a worn louvre glass window, wearing the vial away to make it easier to open. I drew up the amount of magnesium I wanted and gave it Sarah.
After writing admit orders, I helped the nurse and family pick Sarah up and move her to another bed. She was limp, vomiting, and confused. We pushed her between the ER and D-Ward (where our pregnant and post-partum patients stay). Night stars flickered overhead and illuminated her roving eyes. I said a prayer for her as we entered D-Ward. We rolled her to an open bed among forty other sleeping women, some of whom stirred and looked at Sarah as she was laid on a sheetless blue bed with no monitoring. I prayed again that she and her baby would do okay and started to walk home.
It was 4:30 AM. I made my way through an empty ER where a leaky faucet trickled. My only companion was a mouse, who had run in from outside and was hiding under an ER bed. I bent down to look at him and he scampered back outside. A brief journey through twilight and stars brought me back to my bed, where my adrenaline eventually waned, and I slept two hours.
The last seven weeks have been an amalgam of elation, exhaustion, and enteritis. We have relished many of the experiences we’ve had, and the opportunity to serve the rugged and openhearted people of Papua New Guinea. We have quickly bonded with the other missionaries here, who inspire us with their examples of service and love. Several days have been far from “easy”, but we never signed-up for easy. We signed up to try, failingly, to follow Christ’s example of service and suffering. Where, and how, is Christ asking you to follow his path of service, a path hedged with risk and travail?
Sarah had a nerve-wracking course with several more seizures and delirium. Yet, within 24 hours, she gave birth to a healthy baby. The next day, her seizures, delirium, and hypertension completely resolved. Our chaplains shared with her about the love of Christ, the same love that extended into the medical care that helped save her life and the life of her baby. She and her baby were discharged home two days later.
Where, and how, is Christ asking you to follow his path of service, a path hedged with risk and travail?
The patient stabbed through his axillary artery underwent artery repair, subsequently developed compartment syndrome, and had a somewhat complicated hospital course, but ultimately has a well-perfused arm. His arm will be weak, but functional, and his life was saved by our general surgeons and our ER care. He smiles and waves at me every time I see him in the hospital.
The little baby I helped deliver and resuscitate is, as far as I know, doing completely fine, and is likely home with his mother by now.
We are grateful for the role God has given us here, to share the love of Christ and serve others through the gift of medical care and missions. Thank you to every one of our ministry partners who helps make all of this possible; your impact is extending into the far reaches of the world.
If you want to join our team of ministry partners, and support the work God is doing here through financial giving and prayer, please click here! We are grateful for you!
“Let each of you look not only to his own interests, but also to the interests of others. Have this mind among yourselves, which is yours in Christ Jesus, who though he was in the form of God, did not count equality with God a thing to be grasped, but emptied himself, by taking the form of a servant…”