Saturday, February 28, 2009

Elective report for USyd

The desire to visit Papua New Guinea must have originated years ago, through a National Geographic episode or a SCUBA diving special, while I was still in the US. After starting school and seeing the elective reports of students who ended up in PNG, I finally had my reason to go. My interest led me to read some about the country, but really, I had no idea what I was getting in to. The stories from others often involved basic medical resources, obviously CT scans and advanced investigations were only available in Port Moresby, but the recurring theme was that while there you make due with what is available. When writing my elective application it was difficult to be very specific in terms of actual goals, I knew I would be in an isolated community, there were tropical diseases, trauma and births happen everywhere, and I had no real idea of what the hospital would be like.
Before I left I knew the people of Papua New Guinea were black, but I didn’t realize how much I would stand out as a tall Caucasian. When I arrived at the Port Moresby airport it took me a few moments to adjust to being in the minority. I no longer blended in with the crowd, but stood out and over almost everyone around me. The people in the airport probably didn’t think twice about it, since there is a decent sized Caucasian population, but I felt awkward and out of place. As I had an overnight layover I took the shuttle to my motel. Driving along it was incredible how many people were simply out walking, which I later found out was because of the large population of unemployed from outlying villages that take up residence in Port Moresby. Then driving through the suburbs, the massive walls topped with barbed wire around every house made me question my decision to be in such an area, but then we pulled through the motel gate, manned by security guards, to parking area in the middle of an oasis. The walls hid an amazing garden complete with swimming pool and barbeque. Things were looking up, although I was still discouraged from leaving the complex alone.
Returning to the airport I was more comfortable with my minority status, but still felt like an outsider, but then again why wouldn’t I, there I am the outsider. After an uneventful flight, I managed to settle in for my first night in Madang, which if less walls and barbed wire were an indicator, would be more hospitable. At the end of the day with the hospital close by and a big day expected tomorrow, drinking a beer, looking out over the ocean, I felt incredibly comfortable.
The next day I arrived to the hospital to check in, at which point I was given a tour. The Madang Hospital services Madang and outlying regions, it has thirty medical beds, thirty surgical beds, thirty pediatric beds, and about thirty obstetric beds. The emergency department has three active beds, three booths for observation, and various rooms that get used as needed. Originally, I had hoped to split my time between the emergency department and the delivery suite/obstetric ward, but the delivery suite was under renovations the entire time I was there, so I spent the majority of my time in the emergency department.
The emergency department is staffed with a resident or specialist from approximately 8 am till 5 pm, after which the doctor is on call. I say approximately because depending on who was working the start time could go as late as 10 am. During these hours in addition to running the emergencies, there was basically an outpatient clinic, where patients would see the doctor, the medical student (me), or a specially trained nurse. Outside of these hours the doctor is on call, if he was needed, a note was sent to his home by the ambulance driver, and the doctor would come in.
The average day therefore was split between working in the “clinic” seeing outpatient complaints and working in the actual emergency department seeing more emergent problems. The clinic ranged from headache to painful warts, and everything in between. After working for a week it became very obvious that malaria was the cause of much morbidity. Anyone presenting with fever, joint pain, headache, malaise, or delirium, had a blood slide made and was started on antimalarials. If things didn’t improve or if there was more going on additional tests could be ordered, but malaria was assumed be involved in a large proportion of the patients. It amazed me to find that malaria can cause such a wide variety of signs and symptoms. There were other conditions we saw in the clinic, appendicitis, TB, cancer, pregnancy, and arthritis, mostly diagnosed clinically, but also with the occasional use of roentographs, and the single U/S machine, which had to be hunted down from somewhere in the hospital. While in the clinic I quickly learned some of the important words in Pidgeon to help; vomiting, diarrhea, cough, blood, and pus along with phrases; take a deep breath, is there pain. Through my limited Pidgeon and most people having a basic knowledge of English, we, the medical students, were set loose on the locals to find out as much as possible then report to the supervising doctor. In addition to using antimalarials, which I had never used in Australia, it was interesting that chloramphenicol is still commonly used in Papua New Guinea, I was told, it’s cheap, it works and I haven’t seen any problems from using it. Needless to say I didn’t argue and prescribed as I was told. Something else that surprised me was the near absence of heart disease in the Papua New Guinea population, although with a shorter life span and minimal obesity, it shouldn’t have surprised me. The clinics were great and allowed me to see a wide range of patients with independence that forced me to think through cases and come up with a definitive plan.
The department also responded to emergent cases during and after clinic hours. As I had hoped, these cases allowed me ample opportunity to suture, cast, and assist with resus. Similar to the clinic there were many cases of malaria, although much more severe, which presented to the department. Additionally, it was common to see broken bones due to falling out of trees, lacerations from machetes, motor vehicle accidents, and snake bites. Weekends were especially interesting since, the doctor was on call, so there were a number of times where as a medical student I was looked on as being the most senior available until the doctor arrived (which could take 5 minutes to almost an hour.) The situation of a medical student as the most senior is dangerous. There were two specific instances, with very different outcomes. The first was a young woman who had come in with an overdose of chloroquine, the staff had seen her and put her in a bed. I go over to see her and she is not responding, not breathing, and there isn’t a pulse. The doctor had already been “called” because of the original presentation, so here I am in a resus with one other staff. We did CPR until the consultant arrived, who after a few more minutes, declared her dead. Afterward, he let me know adrenaline and diazepam were the treatment.
The second case was a traumatic injury secondary to arrow penetration. It was a normal evening in the emergency department, the doctor had gone home, and I was busy stitching up someone’s head, arm, or leg. I walked out past a man in a stretcher with none of the staff helping him, not uncommon, went to the office to grab something then returned to finish my suturing. About 5 minutes later, I came out to the man in the stretcher and try to get the story from his friends, unfortunately, their English is as bad as my pidgeon, and we don’t get very far. His friends, roughly transfer the man on the stretcher to a bed while I am trying, rather fruitlessly to protect the spine. Once he is on the bed, I realize he is not moving, breathing, nor alive. Calmly I walk in to the office and ask the medical and surgical residents to please come help me with the cardiac arrest in bed 2. They come out and we start CPR and we are about to intubate, when the laryngoscope light crosses his eyes it is obvious that he has been dead for a while. The residents get a better story from the friends, who elaborate that previously they had stopped at another medical center, where they had tried to resuscitate him, but unsuccessfully, and that the brother of the man on the stretcher, who had also been attacked was sick and they needed to bring him to the hospital. No longer in tunnel vision, I looked over and saw the brother, who was sitting in the corner, breathing at a machine gun pace, watching all the activity. The story I get about him is that he was hit with a rubber bullet to the back and was hit a couple times with a bar (later on, the real story, lost in translation, is that he was shot in the back with an arrow, which was removed before coming to the hospital.) Examining him, I have my first experience with hyperresonance to percussion, which I promptly ask the surgical resident to confirm, which she does, and then leaves. I’m not exactly sure how, but both of the residents have left, and we are now waiting for the emergency resident to arrive because of the note sent earlier. Oh yes, and although there is oxygen available, an 02 saturation monitor was not, until the doctor arrives with his own personal one. With a medical students clinical diagnosis of pneumothorax and the patient in obvious distress, I make quick trips to the office to look up needle thoracostomy in Tintinalli’s emergency medicine, then tube thoracostomy, before grabbing some 14 gauge needles and taking him to Xray. After returning from Xray, the emergency resident arrives, looks at the images, and says we’re putting in a chest tube, now. The underwater drain is made from tubing and a bottle that is taped shut, while we set up for the chest tube. The patient stays stable while I undertake the procedure with the doctor guiding me through. The chest tube drains 2 liters of blood throughout the evening, the patient recovered, and I celebrated my first chest tube.
The experience in Madang opened up a different perspective of medicine for me. The patients are truly appreciative. In Australia, the patients may or may not say thank you, but in Madang, everyone thanked you, and families thanked you for helping. It was quite an amazing feeling, having the people truly appreciate the work I had done, even after explaining I was a student. Also although the resources at times were limited we did everything possible to help, sometimes it wasn’t enough, but no matter what the people realized the doctor was doing everything he or she could. It was refreshing because even in my limited hospital experience in both Australia and the US, at times patients hide information, or give partial stories, with the perception we will judge and not help. This along with the incredible beauty that surrounds the island will make me return, eventually to give something back.


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Blogger Cassie said...

Sounds amazing. I found the blog when searching for electives in Madang, would love to know how you went about organising it because I'm thinking of going next year. If you've got any contacts please let me know at

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