I got this article from the Medical Journal of Australia written by Dr Harry Poka. I think it paints a true picture for women and child health in PNG, and maybe other pacific island countries as well.
MJA 2004; 181 (11/12): 609
There are some experiences in medicine that are hard to forget. Mine took place in my second year of residency (between November 1998 and January 1999) during my rural medicine block on the volcanic island of Karkar, in Madang, a maritime province of Papua New Guinea (PNG). The Gaubin Rural Hospital, run by the Lutheran Church, serves the island’s population of over 50 000 people.
I was a relatively junior resident, having graduated from the Medical Faculty at theUniversity of PNG in 1996 and spent 23 months training at the Goroka BaseHospital in the Eastern Highlands Province. One fateful afternoon, a health centre referred a pregnant nulliparous woman with prolonged labour and splenomegaly. She was in shock, her abdomen was tense and distended, and there was a distinct non-tender mass occupying the left lower and upper quadrants — was this the spleen? The central abdomen was tender, and no fetal heart sounds were heard. Pelvic examination revealed that the woman had severe cephalopelvic disproportion, which was not unexpected, as she was only 1.5 m tall. She had a minimal pelvic bleed.
I resuscitated her and whisked her into the operating theatre to do an emergency caesarean section. I administered spinal anesthesia (there are no anaesthetists or general anaesthesia in rural PNG), then scrubbed and put on surgical shoes. The parietal peritoneum was tainted blue, heralding the presence of haemoperitoneum, and, sure enough, the peritoneal space was bubbling with blood — heaps of it. Certain that she had a ruptured uterus, I immediately felt for the uterus to examine the site and severity of the rupture, but, to my amazement, the fundus was small and well contracted and there was no fetus in the uterine body. There was, however, a huge, nasty, transverse wound on the uterine body. I was perplexed — where could the baby be? I tried to feel for the spleen and got the shock of my life when I felt the legs of the baby! The spleen wasn’t enlarged at all.
The dead 3 kg fetus was removed. The uterus was sutured and a tubal ligation was performed. During recovery the outcome of the surgery was explained to her and she accepted the fact that she would no longer be able to conceive. Seven days later she was discharged.
The health of women and children in rural PNG is still a significant problemt that consumes most of a rural doctor’s day-to-day practice. A major issue for the training of doctors in PNG is the need for senior doctors to guide and assist resident medical officers with practical on-the-job training in patient management. This practice should be continued, encouraged and strengthened.
In 1984, I was posted to Lorengau hospital (Manus Province, PNG) upon completion of my residency training in 1983. I do relate very well with Dr. Harry Poka’s experiences (nigthmares) as this was the usual scenario that junior doctors were faced with: non availability of anaesthetics, and anaesthetists. Institution of anaesthetics, then srubbing and performing the surgery, used to be the norm in most provincial and district hospitals then.The situation could be much better at this point in time, especially with the training of more ATOs (anaesthetist). However, I feel, in such situations, the young doctor being able to make a decision i.e. whether to operate or not, is the most significant determining factor in patient outcomes. In Dr. Poka’s case he made that important decision, and thus a good patient outcome.
Doctors posted to rural settings eventually develop a very good clinical diagnostic acumen.
I really value my initial postings to Lorengau Hospital (1984), Bialla Health Centre (1985), and Kimbe Hospita (1986). The experiences attained in these centres provided me with a good standing in my post graduate training in surgery.
In ending, I just want to say that the health of woman and children in rural PNG has hardly improved (as per health indicators). There is a need for genuine political goodwill from those in government, a change of cultural attitudes by men towards women, and equal participation by woman in the PNG House of Parliament.
Peter you are spot on.
One of the features of the MBBS program offered by UPNG has been its strength in clinical training. This fact was acknowledged by the World Federation for Medical Education Council when they reviewed and accredited the UPNG MBBS curriculum in 2003. To my knowledge this was the first since the MBBS program was started at UPNG in 1974.
Furthermore, as you correcty mentioned, the rural experience certainly allows the development of a good clinical diagnostic acumen.