Always learning 

Rob Mitchell  
Senior Registrar, National Referral Hospital, Honiara, Solomon Islands 

I made mistakes last time. Perhaps that’s inevitable, but I wish it wasn’t the case. 

After 15 years of medical training, you would think it would be easy to translate your skills to a new environment. It’s not as if human physiology changes when you cross a border. 

Scientific principles may not, but plenty of other things do. When I undertook my previous volunteer assignment – as a Visiting Clinical Lecturer in Emergency Medicine at Divine Word University in Madang, Papua New Guinea – I spent a portion of my time supervising students and junior staff in the Emergency Department (ED) of Modilon General Hospital. 

I was partially through my specialty training at the time, and thought I had a reasonable grasp of emergency medicine practice. That may have been true, but what works in Australia doesn’t necessarily work in PNG.  

I vividly remember one particular patient. His name was Ben*, and he presented with a descending paralysis nearly 24 hours after being bitten by a snake. His airway was compromised and his respiratory effort poor. 

There was no functional ICU in Madang, and only in rare and specific circumstances would patients be intubated – a process that involves inserting a breathing tube into the trachea to facilitate oxygen delivery to the lungs. They would then be supported in the operating theatre’s recovery suite or the ‘private ward’, a more comfortable and better-resourced wing of the hospital reserved for VIP and higher acuity patients.  After a short discussion, the local emergency physician and I decided that this was one of those occasions. 

The intubation went smoothly. He received antivenom because it was in stock that week. Basic monitoring was implemented. Care was handed over to the inpatient team. We updated his family members. 

Ben died on the ward a few hours later. We only found out when we enquired about his progress.  

It wasn’t the news we expected to hear. Ben’s emergency care had been timely and effective, despite the Department’s extremely limited resources. His presentation even provided an opportunity for teaching; we’d demonstrated the intubation process, and discussed treatment of snakebite. 

I was never able to find out exactly why he died. There are many potential explanations - he was left unsupervised, the bag valve mask became disconnected, the oxygen ran out, and so on – but, fundamentally, the environment wasn’t equipped to support someone in such a vulnerable situation. 

I’ve thought about Ben a lot in the years that have followed. What could and should we have done differently?  

I’ve learned that, in these challenging and resource-constrained environments, less is often more. Rather than a plastic breathing tube, Ben may have been better served by the lateral recovery position and an oxygen mask. That approach would have had significant risks, but it might have limited his exposure to iatrogenic injury. First do no harm. 

I’ve also realised the importance of systems of care. Hospitals are complicated pieces of machinery, and all of the parts are inter-dependent. There is little value in developing one component in isolation.  

Although clinical care was not the focus of my work in PNG, Ben’s case is illustrative of the challenges of practising and developing capacity in an under-resourced environment. Those of us who visit from outside – and spend a few fleeting moments working and learning with local colleagues – need to think deeply about what strategies will be safe and effective. What works in Australia doesn’t necessarily work in PNG.  

For the record, I also made mistakes in the teaching component of my work. But in the classroom, the stakes aren't quite as high and there are opportunities for recovery. One of the most rewarding things about that assignment was learning to adapt my teaching skills to the cultural context.  

When I got back to Australia, I experienced a sense of guilt that I’d benefited more from my assignment than I was able to contribute. I only hope that, during my brief time in Madang, I was able to have some small impact on the health extension officer students I was teaching. They will play a critical role in improving healthcare delivery in the rugged and remote outreaches of PNG. 

Fast forward three years, and I’m sitting in a balcony hammock overlooking Iron Bottom Sound.  My (now) wife and I have returned to the Pacific for another volunteer assignment. This time we’re in Honiara, and we’re contributing to the Solomon Islands Graduate Intern Support and Supervision Program (SIGISSP). Our first task was learning how to pronounce the acronym. 

Similar to PNG, the central focus of our work is teaching and training. This time we are helping to develop and implement a transition-to-practice program for Solomon Islanders who have completed their undergraduate medical studies in Cuba. The current group of trainees have just returned to Honiara after six months of Spanish language training and six years of medical education. 

It's an exciting time to be at the National Referral Hospital. There are more interns than ever before, and there is a palpable sense of possibility. Our challenge is to help convert the Cuban investment in undergraduate education into an effective medical workforce for the country.  There are very few doctors outside of Honiara, but that stands to change in time. 

As I write this piece, the first cohort of Cuban returnees are about to complete their internship. One junior doctor who is currently working in the ED – where I am based – has just been appointed Provincial Health Director of Renbel Province. Rennell and Bellona are remote Polynesian islands, and they don’t have a doctor – at least until next week when Edwin arrives. 

Another one of our ED interns is destined for Tulagi, the former capital of the country that was essentially wiped off the map during World War Two. There’s no doctor there at the moment either, but Tony is going to change that. It must be incredibly daunting for him, but he assures me that he is looking forward to the challenge. 

In my work here, I consciously try to apply the lessons that I learned in Madang. In the intervening period I’ve been able to complete my fellowship examinations and do some deeper thinking about global health and development.  I feel better equipped to contribute this time around. 

There are still plenty of challenges though. My responsibilities are much more varied than they are at home, and again I have found myself learning new skills. In the Emergency Department, I supervise interns, but I also contribute to a whole raft of quality improvement activities - departmental teaching, writing clinical guidelines and developing policies. 

Last week, the ED implemented a new triage system – the Solomon Islands Triage Scale. Based on a South African model, it’s been adapted for the setting by the Australian volunteer nurse advisor who is also based in the ED. It’s a major milestone on the road to improved emergency care capacity. 

On the SIGISSP front, our team of Australian volunteer doctors, along with the volunteer Intern Training Supervisor and local colleagues, are assisting with the educational development of the hospital’s training programs. We’ve been formalising guidelines, developing a teaching syllabus and writing examinations. These are not tasks in which we are particularly experienced – let alone in a cross-cultural and under-resourced environment – but we are drawing on our experience and networks to do the best job we can.  

We hope that we’re doing the right thing, and worry that our colleagues are too polite to tell us if we’re not. Solomon Islanders are not only extremely resilient, they are incredibly forgiving. 

I’ve been told on many occasions that international assignments come with their ups and downs. I anticipated that prior to my first assignment, but I didn’t appreciate that the amplitude would be so extreme. 

Working in a clinical environment, the lows can seem all too regular. Death and despair are common in the ED, and sometimes the demands can be overwhelming.  

But there are plenty of reasons to keep coming back. For one, the director of my department is an exceptional leader. Having only finished her specialty training 18 months ago, she is one of the most positive and influential role-models I have ever worked with. She is leading a range of reforms that will have a marked impact on the quality of emergency care, as well as teaching and supervision, within the ED. 

The Solomon Islands are also a wonderful place to live and work. Honiara has its quirks and its charms, but a weekend out of it can be restorative in so many ways. 

There have been many mistakes and there will be many more.  I do a lot more reflecting here than I do at home, and probably nowhere near enough. My job title here is the same as it is in Australia, but the content and the context are very different. That comes with challenges, but also rewards in abundance.  

I learnt a lot from Ben’s death, and I think my local colleagues did too. I hope there will come a time in PNG and the Solomon Islands when that sort of system failure seems like a distant memory. It’s a long way off, but I hope that the Australian volunteer presence is bringing it a little bit closer.  

I strongly encourage you to become part of the effort. 

For Rob Mitchell's first article read Emergency care in PNG

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