Emergency care in PNG

by Dr Rob Mitchell

 

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Australian volunteer Dr Rob Mitchell is an Emergency Medicine Registrar at the Royal Brisbane and Women's Hospital. In 2014, he worked in a hospital in Madang, Papua New Guinea aiming to improve the delivery of emergency care in rural PNG. Below, he details some of his learnings.

It’s eight o’clock in the morning, and the outdoor waiting area is already crowded. Most of the patients have arrived by public motor vehicle (PMV), but others have come by boat from nearby islands. Many have been referred from remote aid posts and rural health clinics. Some have travelled for days, enduring discomfort as well as major expense. This is a place of last resort.

Several of the patients were here yesterday, but the Emergency Department (ED) and its associated outpatients clinic were too busy to see them. They’ve returned in the hope of a fleeting review by a nurse, health extension officer (HEO) or doctor. The sickest patients are allocated one of three emergency beds, but the rest must wait in the heat and humidity.

Staff are few in number, and in constant demand. They are incredibly resilient though, and remain cheerful despite the challenging work. Inside the ED though, things are more desperate. The burden of disease in Papua New Guinea is on display each and every day here, and this morning is no different.

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The man in bed one is crying out in pain. A nurse has been dispatched to fetch some morphine from the pharmacy, but it’s not yet open. With luck, the drug will be in stock this week. 

Jack* has been lying in the bed since the early hours of the morning. He was involved in a PMV accident on the road to the Highlands, and was transferred to the hospital in the tray of a passing 4WD. The bruise on his abdomen doesn’t do his pain justice. On arrival, Jack was semi-conscious with critically low blood pressure. He’s awake now because he’s been transfused with a few units of whole blood; it took several hours to source, but the impact was swift. His family members have since been called upon to donate and replenish the hospital’s limited stocks.

Jack has been attended by the on-call emergency doctor, who was summoned by the nurse on night duty. A donated ultrasound scanner has been used to identify his internal injuries. There is a lot of blood around his spleen, and the doctor suspects it’s been lacerated. Thankfully the scanner was working today; it’s become increasingly temperamental with advanced age.

Ideally Jack would have already gone to the operating theatre (OT), but summoning staff overnight is a challenge. The hospital bus has to collect them from their homes, and it’s a slow process. In any case, the OT can only handle dire emergencies at the moment. The steriliser is broken, and stocks of clean instruments are dwindling. 

Fortunately for all concerned, Jack’s blood pressure has stabilised. He’s in considerable pain, but given his earlier state, any sensation is a blessing. Despite the severity of his injuries, things are looking up. He’s made it this far, and before long he should be in the relative sanctuary of the surgical ward.

Communicable disease

Steven*, in bed two, is confused and agitated. He’s throwing his arms around violently, and has just pulled out the intravenous cannula from the front of his elbow. There is blood dripping on the floor from the exposed puncture site. Having collapsed in town, Steven was brought to the ED by his friends. They’ve explained that he’s been experiencing hot and cold sweats for two days but was reluctant to attend the hospital because of the fee.
Steven’s just been administered an old-fashioned but reliable sedative medication - for his own safety and that of the staff.  While the drug slowly takes effect, his friends and family persist with efforts to talk him down. As Steven starts to settle, the nurse yells from the corner of the room that his malaria test is positive. An anti-malarial medication is quickly prepared and injected into his buttock. A new intravenous cannula is inserted, and a fluid drip is connected. He’s also given some antibiotics in case another type of cerebral infection is contributing to his confusion. Meningitis is common in these parts. 
Steven falls asleep, but he will need to be observed closely. Conventional monitoring equipment isn’t available, so his family must assist by keeping watch. 

Obstetric complications

The young woman in bed three, Helen*, has just died.  The delivery of her fourth baby, two weeks ago, was complicated by bleeding and infection. She had been increasingly unwell ever since. Helen had been identified as being critically ill upon her arrival at the ED. She had signs of severe infection, a drastically low haemoglobin level. In order to compensate, her heart was working at the extreme range of its capacity. 
Despite being administered intravenous fluid and antibiotics, she succumbed a short while later.  Efforts had been made to resuscitate her with the limited equipment available, but Helen was so unwell that the prospects of recovery were probably hopeless from the outset. The staff agree they did the right thing by employing all available treatments and interventions – this was an acute illness, and she was young. Besides, there might have been some psychological value in her family witnessing the team’s resuscitation efforts. 
Helen’s family are sitting devastated in the corner, occasionally wailing in despair. Much of their grief is for Helen’s two-week old daughter, whose own survival has instantaneously come under threat.

Emergency care in PNG

The ED staff at Madang’s Modilon Hospital are all too familiar with cases such as these. Most of the unwell patients eventually find their way to the ward, but the critically ill often die in the Emergency Department. Some patients are so sick when they arrive that there is limited scope to turn their illness around.

In many respects, it is not an environment conducive to healing – the sights, sounds and smells of the place can be overwhelming – but the ED offers what many other centres cannot: basic investigations, essential medications and access to an in-patient bed if required. PNG has some of the worst health statistics in the Asia Pacific, including a life expectancy of 60 for males (65 for females) and an infant mortality rate of 47 per 1000. Major challenges include drug-resistant tuberculosis, a rising burden of non-communicable diseases and high rates of trauma, including family and sexual violence. The maternal mortality ratio is at least 30 times greater than that of Australia. 

Emergency care has an important role to play in addressing these challenges. There is strong evidence that early medical intervention can be lifesaving in a large number of conditions, such as severe infections, heart attacks and major trauma.  In fact, many of the leading causes of death in PNG, as with many low- and middle-income countries, are amenable to treatment with simple and affordable interventions. For children, this includes pneumonia, diarrhoea and malaria. 

Barriers to access

One of the challenges for the delivery of emergency and other healthcare in PNG is access. Remoteness is a major issue, with vast amounts of land only accessible by foot. Roads are in poor condition and carry their own risks – pot holes, river crossings and roadblocks among them. Although some communities have access to basic primary care services, this is not universally the case. It’s estimated that there are only 0.58 health workers for every 1000 people, a figure well short of international benchmarks. The World Health Organization recommends at least 2.5 per 1000 simply to deliver basic community level care.  

Rural aid posts (staffed by community health workers and/or nurses) and health centres (staffed by nurses and/or HEOs) are scattered around the country, but often lack basic infrastructure and essential equipment. Nearly 25% are non-operational.

Although the PNG Government has introduced a policy of free primary healthcare, it is yet to be realised in several parts of the country. Costs involved in accessing hospital-based services are a major deterrent for some patients. Cultural practices also impact on access to healthcare. In certain regions, strong beliefs in sorcery and witchcraft can delay presentations to health facilities. When symptoms are attributed to a curse, it is not uncommon for patients to consult a witch doctor rather than a health worker.

Although the patients may not realise it, those who reach the ED here are in the fortunate minority. It is evident that the demand for timely emergency care extends well beyond the hospital. 

Future prospects  Dr_Rob_Mitchell_treating_a_patient_in_the_Emer_width-470

Although progress has been slow, modest gains are occurring in the availability of emergency care in PNG. HEOs graduating from university have all undertaken a term in emergency medicine, and are better equipped to deal with acute cases in rural health centres.

The country now has ten specialist emergency medicine physicians, and the provision of continuing medical education is improving.  The ED at Port Moresby General Hospital has recently been redeveloped, and there are plans for similar enhancements in selected other hospitals. 

Some of these improvements have been achieved through partnerships with Australian clinicians and organisations. Through the exchange of ideas, knowledge and skills, emergency care professionals in both PNG and Australia have much to offer one another. Despite social, cultural and economic differences, cross-border collaborations and projects will help realise better health outcomes for citizens of both countries. 

The greatest asset PNG’s health system has is its staff, and if sufficient resources are provided, they will continue to drive the necessary reforms. The stories of Jack, Steven and Helen are representative of the thousands of patients they treat in clinics and EDs across PNG each and every day. 

Epilogue

Jack was managed without an operation for his internal injuries because his condition stabilised. He spent a week in hospital until he was well enough to be discharged to the care of family members.
Steven, the young man afflicted with cerebral malaria, left hospital after three days. His conscious state improved quickly, and his fevers settled with anti-malarial medication. Given that cerebral malaria kills more than 15 per cent of its victims, Steven’s outcome was excellent.

Unfortunately, Helen’s case is illustrative of the major challenges in maternal care. With easier access to healthcare, her life may have been saved. Her sister has promised to care for her newborn girl and her siblings.

Despite the sadness of cases like Helen’s, I thoroughly enjoyed my assignment in PNG and look forward to developing a long-term relationship with Modilon Hospital and the emergency medicine fraternity. It was a privilege to be welcomed so warmly into the Madang community, and I feel I gained far more than I was able to contribute. Volunteering with Australian Volunteers International was a wonderful experience, and I would encourage other health professionals to consider an Australian Volunteers for International Development (AVID) assignment. The rewards far outweigh the challenges.

*Pseudonyms have been used throughout this piece, and certain details adjusted to protect the privacy of patients and staff. 

Dr Rob Mitchell will commence a second assignment with the Australian Volunteers for International Development (AVID) program as an Intern Supervisor - Emergency Department in the Solomon Islands, commencing February 2017.
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This volunteering assignment is part of the Australian Volunteers for International Development (AVID) program, an Australian Government initiative, see avi.org.au for volunteering opportunities.. 

Banner image: Emergency department at hospital in Madang, PNG. Photo > Darren James
Centre image: Australian volunteer Dr Rob Mitchell assisting hospital staff in the treatment of a patient. Photo > Darren James
Bottom image: Australian volunteer Dr Rob Mitchell treats a patient in the emergency department. Photo > Darren James 

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