I sit in an office on my GP rotation. My insides burn, courtesy of my morning doxycycline. The patient, who has come in with fever and a sore throat, coughs. I flinch. My eyes fly across the room, searching for a face mask. Then I remember I am back in Toowoomba, and not every fever is likely due to an unpronounceable parasitic infection. This is perhaps a slight dramatisation of my GP block, however, I cannot help but cast my mind back to when a cough could signal something far more sinister than an URTI.
I was recently given the opportunity to spend six weeks at the Kiunga District Hospital in rural Papua New Guinea (PNG) as part of the Griffith Rural Medical Education program. Every rotation block, four students are given the opportunity to spend six weeks in Kiunga hospital. For those as unfamiliar with Papua New Guinean geography as me prior to my visit, Kiunga is a town in the western province of PNG, on the banks of the Fly River. The hospital serves a town of approximately 13000 people, in addition to being a referral centre for the region, with approximately 45 beds spread over numerous wards (medical, surgical, women’s), as well as a pathology lab and an emergency department/outpatient department (OPD). The wards are managed by a physician and a surgical/obstetrics and gynaecology doctor, health extension officers, community health workers and nurses. As medical students we were well accustomed to being at the bottom of this hierarchy; however, in PNG we were given far greater responsibility.
Common things occur commonly. This phrase had been thrown at me all throughout my clinical years. Most coughs are probably not cancer, most sore throats are not the harbinger of quinsy. However, the medical ward showed us just how context-specific this phrase is, with the words ‘common things occur commonly, therefore, this is probably tuberculosis or malaria’ heard at least once per ward round. Ascites was probably due to abdominal seeding of tuberculosis, a headache was probably due to cerebral malaria. We quickly learned to appease the ward doctor by suggesting tuberculosis as the cause for nearly every presenting complaint. The range of tropical diseases surpassed my expectations, from tuberculosis, malaria and malnutrition, to less common cases of severe AIDS and Buruli ulcers. I was even exposed to diseases I had not even fathomed I might see, such as toxic epidermal necrolysis as a result of leprosy medications.
Our time in the general ward consisted of a morning ward round followed by jobs, and it was eye-opening to see how health care could be limited by a lack of resources. Intramuscular antimalarials often ran out, meaning that oral antimalarials had to be followed by an ondansetron chaser. There was no adrenaline in the emergency room, meaning it was necessary to trawl the hospital to find some before it was needed. A lack of funds for staff meant the occupants of the tuberculosis ward were at the far end of the general ward, placing the rest of the patients at risk of nosocomial infection. Consequently, we soon learned that ward rounds began by applying appropriate PPE as soon as we entered the building (Figure 1).
One patient made a particular impression on me. M was a 7-month old female admitted due to malnutrition. Throughout the week, she slowly gained weight and started to take an interest in the strange pale humans trying to make her smile with a toy koala, and was eventually discharged. The next week she returned with a cough, initially thought to be viral in origin. However, common things occur commonly, and imaging suggested M had tuberculosis. While unable to pinpoint the exact cause, it was possible that her long stay on the ward could have been the source. It was incredibly frustrating knowing that if the hospital had funding, these incidents could be prevented. Nonetheless, the case of M is not an isolated one, and the lack of resources was evident in all the areas of the hospital during our stay.
Having heard of other elective experiences, I expected that surgery in a developing country would be exceptionally hands-on, however, this was not what I experienced. The reasons for this were unique. A number of issues, such as the surgeon having malaria, or the building having no functioning water with which to sterilize equipment, resulted in my group having relatively few surgeries to attend. Something I was exposed to, however, was overcoming challenges in a resource-poor setting. In the absence of K-wire cutters, garden pliers were sterilised with alcohol wipes; on another occasion, an abdominal drain was secured in place with a tongue depressor snapped and taped together. The persistence shown by the staff to make the most of what was available was inspiring, especially given they face these challenges continually.
In my third year, I was placed in a rural hospital in Australia which did not see a huge amount of obstetrics. You could say I was unprepared for obstetrics in Kiunga. Caesarian sections were an uncommon event, meaning that we witnessed births which probably would not have happened in Australia. Examples of this include a mother with malaria struggling to give birth due to severe lethargy, or the two breech births occurring during my six weeks.
In an Australian setting, we are used to working under the guidance of a senior team member, especially in a high-intensity situation. However, in PNG we were expected to step up and start to manage situations ourselves. In the maternity suite births were usually facilitated by one midwife, and if something went wrong, the focus was on looking after the mother. This meant that care of the neonate typically came after the mother’s situation was controlled.
Therefore, on a number of occasions, a routine birth would end with the midwife handing a limp neonate to two medical students. Prior to coming to PNG, I was aware of the debate regarding medical students overstepping their boundaries while on elective. However, in that moment we had to make a choice to either stand by and watch the neonate die due to a lack of resources and staff, or give it the best chance it could have in the circumstances by applying pre-departure training in neonatal resuscitation. It is hard to imagine the situation where there are no medical students to assist, but sadly due to lack of staffing that is the situation this hospital faces every day. We were involved in three such scenarios during my time in PNG, and I am thankful for the training we received on resuscitation prior to departure. In saying that, the unsuccessful resuscitations were amongst the most confronting moments in medical school, but I am glad we were present to intervene when no one else was available.
Not all births were intense, and even in uncomplicated births we were routinely supported by the midwives to assist the mother in delivering the child. The midwives in PNG are incredible, managing most births without intervention of a doctor, and even performing procedural skills such as perineal repair and vacuum-assisted delivery.
Emergency and Outpatient Department
Although other areas of the hospital were perhaps more confronting, I felt most out of my depth in the OPD. We were expected to independently see patients and prescribe medications, with no guidance offered unless required. While the OPD allowed us to practice our Pidgin, the language barrier remained a significant issue. Personally, I felt very uncomfortable prescribing anti-malarials according to a guideline I did not know well, to a 4-year-old whose parents I could not explain anything to, a situation I found myself in on our first day in the hospital. The staff were probably annoyed by my constant questions, however, I was worried about overstepping my boundaries as a student and potentially causing significant harm. In saying that, the range of presentations was diverse (although malaria was exceptionally common), and the chance to practice our newly-acquired language skills was excellent.
Similar to the obstetric department, we were forewarned that if resuscitation needed to be performed, we would potentially be in charge. Even with this in mind, I certainly did not expect to be performing compressions one Sunday afternoon while wearing thongs and board shorts. Due to a lack of staff on this particular weekend, three medical students who had been playing soccer with the local kids were now attempting to resuscitate a man who had been in the ED since the morning. Eventually the doctor arrived to take control, but it is hard to imagine students in Australia ever being in such a situation.
Aside from the clinical experience, one of the highlights of the placement was the chance to become involved in the local community. We stayed in a house a close walk away from the hospital, meaning that we often had spare time in the afternoons/weekends. Most afternoons we played sport with the local kids, and every Sunday we played a movie for them at the hospital. Not all of the children were so keen, however, as one particular girl started crying as soon as she saw us, a sobering reminder that foreign faces are still uncommon in such parts of the world.
One of the most surreal experiences was going to a local club and listening to Justin Bieber while meeting locals over Papua New Guinean beer. A local gentleman was adamant Justin was in fact a Papua New Guinean artist, but in his defence the local brew was quite potent. At the end of the night we were even offered a lift home by the police chief, provided we let him finish his drink first. Another highlight was being shown wild birds of paradise by a guide who had taken David Attenborough to see them years ago. The people were exceptionally welcoming, often stopping on the street or in the markets to talk to us and see how we were finding the experience.
There were a few main lessons I took away from this experience in regards to students experiencing a global health elective. The most striking point was the issue regarding medical students on electives in resource-poor settings. This issue deserves a review unto itself, but suffice to say it became very apparent to me how easy it could be for an overconfident medical student to abuse the level of trust placed in them by the local population. Particularly, in a poorly-resourced setting with a lack of supervision, students may be placed in situations that are beyond their level of knowledge. However, in certain circumstances, capable students, and especially those in their final year, may be able to have a positive impact on their chosen placement. Such an experience highlighted how aware students must be before embarking upon such an elective, and to have these issues in their minds while on the placement to avoid overstepping their scope of practice.
Such difficulty is exacerbated by the challenges of healthcare provision in resource-poor settings, and this placement was invaluable in showing me how it differs compared to Australia. The shortage of staff, medications and equipment was evident throughout the hospital, and it was clear that the entire health system could be improved by further funding. It was confronting seeing individuals suffer because the medication they needed was not available, however, it was inspiring to see the ways staff attempted to overcome these barriers. Additionally, the attitude of the staff continually stayed positive, even in the face of these challenges.
Finally, it was evident to me throughout the placement that global health challenges in developing nations are changing. While infectious and tropical diseases were rife, the impact of chronic conditions such as cardiovascular disease, hypertension and diabetes was evident during my time in Kiunga. These conditions were often poorly managed due to lack of proper medications and monitoring. Their increasing prevalence coupled with the lack of resources to manage these conditions mean students doing a similar placement in the future will face a host of different conditions.
In summary, this elective was an excellent experience. Not only for the clinical exposure, but also for the chance to see how healthcare functions in a resource-poor setting. At times it seemed like the health care workers were battling their way upriver against a tide of financial constraints and poor government support, however, the enthusiasm and dedication shown towards the people of Kiunga was inspiring. Additionally, the chance to experience life in a rural town in PNG was a highlight in itself. This placement has, undoubtedly, been one of the most motivating placements of medical school, and I strongly urge anyone considering something similar to take the opportunity.
Nick is a final year medical student from Griffith University. Throughout his degree he has been interested in gaining clinical exposure in a variety of settings, ranging from a rural experience in Warwick to furthering an interest in global health in Papua New Guinea and India.
QRME and Graeme Hill for continual support of this program; Aisha, Ryan and Emily for sharing the experience and for support throughout difficult times.
Conflicts of interest