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.

PNG diary (till got lazy)

PNG elective

December 15, 2008
After arriving in Port Moresby I felt immediately uncomfortable. It has been a while and I had totally forgotten what it felt like to be in the complete minority. I was a tall white man amongst a very large population of Papuans. I had forgotten how people do look at me just a little bit different when I am the outsider, and very obvious about it, really no good way to blend in. Deciding to save a couple hundred Kina I went with the less expensive accommodation, after all I was only going to be there for the night. Then as I catch the shuttle and everywhere people are walking around, I do mean everywhere, people were just out. It was around 2pm too, so midday. Decided it would be better not to ask the shuttle driver why everyone wasn’t at work. Then as we get to neighborhoods there is barbed wire on every fence around every house. Yeah that made me a whole lot more comfortable. We get to the Comfort Inn, the guards open the massive barb wired gate and we pull in. Checking in goes smoothly, the front dude is very nice and shows me to my room. The place is quite gorgeous, a pool, and local plants growing all around a courtyard. OK room, air con, which is wonderful. Then I ask if it is safe to go to the grocery store, which the front desk dude assures me it absolutely is, but do you want an escort, to which I say no, because he said it was perfectly safe. As I walked, I passed an open area with stands selling stuff, not exactly sure what, I didn’t take the time to check because I felt like I had the last Ice cream bar at fat camp. Much more attention than I am usedc to getting and or really want to get. Nothing happened, but it was a strange feeling.

December 16, 2008
The next day I flew to Madang, a quick one hour flight, through a bit of rough skies, but a good flight. My plan: get a cab to Hospital. Reality: No cabs to be seen. I hate to admit this, but I singled out the white guy and asked him for help. Fortunately he is a professor at the college which is across from the hospital and he would be happy to drop me off (Divine Word: gotta love the Christians and their need to help) Of course when I arrive at the hospital around 5pm the only place open is the emergency department who of course have no idea who I am or what I’m doing. But they are very nice and help me get the ambulance to take me to the hotel down the street, good I saved money before cause of course only room available is 360 Kina. Oh well, it was easy and absolutely gorgeous. On the water, pool, bar, restaurant and although not actually settled was able to relax and enjoy a beer.

December 17, 2008
Up early and head to hospital. Got accommodation, there is a family living under it I think, but bed, shower, and kitchen, what else do I need, the family is just a bonus I guess. Head to ED because that is why I am here. It is bare bones. Mostly older equipment, I was told today they ran out of sterile gloves recently, but they do what they can, which is a lot it sounds like. Suture up a knife lac on the top of a 15 year old kid, reused ECG buttons to trace a younger guys heart, and oh yes, helped hold a kids head down while the 2 cm forehead lac was sutured. Almost forgot to mention that to help stop the bleeding the mother had held a kerosene (yes kerosene) soaked rag against it. Not sure how much it helped with the bleeding but it certainly calmed the kid down. The mom brought the rag in to the suture room and by the end I was pretty calm too. Kid wasn’t, but who can blame him, one internal and 3 external stitches. Also helped plaster a Monteggia fracture-dislocation, which will go to theatre tomorrow morning. Not a bad day.

Still feeling a little awkward about going around, will need to suck it up and go to town tomorrow, on local bus…Am told it is safe, just don’t be out after dark, and if mugged, it’s not cause I’m white, it can happen to anyone. Should be good, will have time in hospital, and may not have much else to do but study at night. Will also have to check out diving situation for the weekends.

Thursday December 18, 2008
Pretty mellow. Sutured a nearly avulsed L pointer finger with distal phalangeal # after doing a digital block. Pretty much on my own. Suture needle was too small, but still managed. Also watched 2 plantar warts removed. Both under LA (local anaesthetic) totally would be theatre material in OZ or US. ED “reg” is happy to do them though, pretty major excisions. Also saw a lady come in with delayed 2nd stage of labor, most thought baby would be dead, but U/S showed heart beat, so they took her in for an emergency C section. The locals are very tolerant of pain so far, they will put up with a whole lot without any complaints. Very stark contrast to Nepean, where I have seen grown men damn near cry or withdraw in pain from a mere 30 gauge needle for LA. Did manage to go to town to get groceries, still not feeling super comfortable. Nancy the housing lady said she would take me to the proper markets later on this week if I want. Should be much better selection, I don’t think grocery stores are used like we use them.

Friday, December 19, 2008

Girls (Kate and Edwina) showed up today after running away from a dysfunctional Wewak. The staff here were very helpful in terms of letting them come and finding them a place to stay. Not a whole lot done in ED. Couple of #’s that needed plastering. Felt the doughy abdomen of TB infected mesentery, incision and drainage of infected insect bite to finger after digital block (on my own), attempted to drain 4 cm mass on 60+ year old woman’s lower thoracic back region. No LA, but lady very tolerant, especially since I didn’t actually drain anything. Asked Dr. VA opinion and he just got artery clip and went in deeper, old lady screaming, no pus, but he says she will be happy because she knows he did something since it hurt à Pain = Treatment. Wouldn’t go over too well in Sydney. Am working on pidgeon, couple of phrases here and there. Mostly if said slow words are derived from English and kind of make since. If fever and unwell = Malaria here. Given treatment, then follow up if not better. Took girls to Madang lodge for beer and dinner. We were walking back when white couple pulled over and offered a ride for the 3 blocks, they encouraged us not to ever walk around at night, especially Friday, even in a group. Interesting contrast from the locals opinion of don’t walk alone at night. Is always good to get outsiders opinion, locals don’t want to think it isn’t safe, plus, it is safe for them.