Aims and objectives of the 2019 mission
A follow up of the SIGN program in addition to a personal follow up of Dr. Steven James in Angau Memorial Hospital in Lae was planned in advance and undertaken by Walliser / Stillhard as the first part of the 2019 Mission.
The following visitations were being planned in two teams of two surgeons following our objective to introduce more surgeons with orthopaedic / traumatologic experience into the program for future missions. During the selection process, we were looking for motivated, dynamic surgeons with sufficient experience to work under conditions in developing countries. Further criteria were communicative skills as well as the willingness to work in the program in the future.
| 1: Walliser / Stillhard: | Angau Memorial Hospital Lae,Morobe Province | 03. – 09. June 2019 |
Arriving around noon, we spent the first afternoon in the hospital (clinics and wards) to define the program for the following week. Due to problems in the radiology department, diagnostics were limited and many admitted patients didn’t even receive basic diagnostic radiographs. During the week, we experienced the already known problems with limited OT capacity and a very high cancellation rate due to various, sometimes more than incredible reasons. At least, two SIGN nails could be done beside some minor operations during the whole week.
Compared to last years visitation, improvements could be noted on the wards and the daily routines seemed more structured. Management of open fractures also improved, the number of operated patients on the wards was significantly higher and a good number of open fractures were managed with external fixation in modular technique with good alignment and fracture reduction as well as control of soft tissue and infection.
The new construction of large parts of the hospital is going on and proceeding according to plan. In addition, the new CEO seems to understand the needs of the medical staff and organization. Positive aspects for the future arise. The accreditation as an Australian educational hospital is planned in three years. Angau Memorial as a future base for PIOA modules and practical education seems to be an enticing possibility.
| 2: Walliser / Haupt: | Kundiava Hospital, Chimbu Province | 10. – 16. June 2019 |
Pickup from Mount Hagen Airport was organized, travel time on partially bad roads was about 2.5 hours. First visit and review of cases for the next day’s list on the orthopaedic ward after arrival, afterward transfer to Mount Wilhelm Hotel (a clean and quite hotel with a good restaurant) in 5-10 minutes walking distance from the hospital.
First day on the ward with short rounds and after 11:00 operations (ortho list on Tuesdays and Thursdays). Several cases could be done during our stay, simple plates, intramedullary wires in children’s fractures, also some soft tissue operations and more complex cases as for example IM nailing with bone grafting of an hypotrophic pseudarthrosis some years after GSW and intercurrent infection with dorsomedial bone-defect on the lower leg. Many smaller procedures were done in the minor OTs, including soft tissue operations, I&Ds, corrections of external fixators.
There is a daily handover meeting of the whole surgical department (all present doctors, on call team, including physiotherapy and head nurses) at 07:45 on the surgical ward. Afterwards, ED and ICU are visited. The main ward rounds taking place on Mondays, Wednesdays and Fridays are more extensive and case discussions and treatment evaluations could be done. Outpatient clinics are taking place on Monday and Friday afternoons where patients for planned operations or referrals were seen, evaluated and discussed.
On Saturday, we were organising a trip into the mountains with our two program participants Raymond and Bohu. This gave a good insight into the local situation and there was a lot of room for discussions and planning for the future.
There were some minor procedures (including a skin flap) on Sunday. Additionally, we were going over the PIOA database issues including installation and instructions about backup system and safety.
| 3: Stillhard / Ismail: | Buka General Hospital, Bougainville Province | 10. – 16. June 2019 |
Buka is located on the southern coast of Buka Island, in the autonomous Region of Bougainville, eastern Papua New Guinea. Buka and Bougainville Island are in the northern Solomon Islands archipel, but not within the nation of Solomon Islands. Buka is the capital of the autonomous region and served by an airport. Buka General Hospital is the main Hospital of the area, serves 300’000 people and was visited for the first time by members of the PIOA. The surgical ward has a capacity of 36 beds. There are 2 operating theatres (major and minor) which are both operational, depending on staff available. Basic instruments and implants for trauma surgery are available and in good quality (reduction clamps, small and large fragment sets, k-wires, external fixators, air drive, but no c-arm or intramedullary nails). X-ray, ultrasonography and even a CT-scanner are running and provide a good level of imaging.
Dr. Haynes Rasin is participant of the PIOA trauma program since this year and has been selected for the first time for a supervisory visit. He is the only general surgeon and therefore acting as HOD of the surgery department, one additional registrar completes the team. Ward rounds, clinics, bedside teaching, case discussions, preoperative planning and operations were part of the daily routine. The main goal of our visit was to evaluate und optimize main principles of trauma/fracture management by improving surgical techniques and emphasizing efficient work processes, especially in OT (including instruction of scrub nurses). The substantial travel and living expenses were again financially supported by the SST (swiss surgical teams).
The most common reason for admissions were open fractures (3rd grade), especially of long bones of all extremities. As usual in PNG, most patients are presenting late after open fractures leading to a big amount of soft tissue and bony infections. The initial treatment by debridement, soft tissue management and temporary fixation with an external fixator is the most important surgical procedure. In closed fractures, even if they are heavily displaced, closed reduction and backslabs or casts are the main treatment.
Especially in femoral fractures, skeletal traction is an alternative method of treatment. Due to a lack of intraoperative imaging and also intramedullary nailing systems, open reduction and plate fixation (3.5mm and 4.5mm LC-DCP) is the main surgical procedure for definitive fracture treatment also of shaft fractures. Although equipment would be available, ORIF is carried out rarely due to limited surgical capabilities. Unfortunately, tendon-injuries due to bush-knife injuries are frequently not treated initially, resulting in bad clinical outcomes. Another topic to be emphasized is the need for repeated debridements in persisting or progressively infected wounds.
A wide array of instruments and implants, cleanliness and a motivated team offer optimal preconditions for a good quality of basic trauma care. Patient numbers are high and the cancellation rate in OT (at least during our stay) seems relatively low. Full use of available resources, guidelines for standardized trauma care and use of antibiotics as well as future training of the local surgeons and OT personnel will be important factors and will further improve trauma care in the future.
| 4: Walliser / Haupt: | Kavieng Hospital, New Ireland Province | 17. – 26. June 2019 |
Transfer to Kavieng was delayed because of a flight cancellation in Mt. Hagen. The next day, we arrived in Kavieng late in the evening, checking in at Nusa Island Retreat (a very nice resort with an exceptional kitchen and nice rooms on an island, 5 minutes boat drive to the hospital). Work was starting the next morning with ward rounds and clinics – patients were evaluated for the weeks OT program.
Small and large fragment sets (limited in screw lengths and plate designs and sizes) as well as K-wires and Externa Fixateurs are available, unfortunately there is no C-arm and no access to intraoperative imaging. The supply of implants is limited due to outstanding payments to UMA medical as main provider of the implants. Most implants are organized in collaboration with PIOA. The OT team is motivated, cases could be done until late in the evening, whereas starting operations was hardly possible before 10:00. Various cases were done during the OP days of the surgical clinic (Tuesdays and Thursdays). Due to limitations in implants and equipment, not all cases could be done as planned under given conditions.
The situation of the surgeons in Kavieng Hospital is difficult at the moment, Viola (the PIOA trainee) as experienced registrar is running the surgical clinic together with Walter, a registrar in his first year. The head of the surgical department (Dr. Harrison) is actually out of clinical work due to not further described internal affairs. This means permanent on call for the small surgical team, going on now for three weeks with no solution in sight.
The emergency department is actually reduced to a small replacement clinic due to constructions going on, obviously for the next couple of months.
Due to this situation, we focus our work on recognizing absolute indications for operative treatment (eg open fractures, paediatric fractures) and safely operating fractures where the necessary implants and experience are available.
| 4: Stillhard / Ismail: | Nonga Hospital Rabaul, New Britain Province | 17. – 26. June 2019 |
Dr. Kevin Lapu, HOD of surgery in Nonga Hospital, Rabaul, has already been visited twice by members oft he PIOA in 2018. This visit was planned as a continuation and further training especially in the field of plate osteosynthesis. Three additional consultants, 1 registrar and 1 resident complete the surgical team. As in the previous stays, daily ward rounds, clinics and operations were part of the routine in our ten days stay. With an additional lecture about the importance of clinical examination and team work, especially in the OT and in complex trauma cases, we tried to underline those important issues. The capacity of the surgical ward (60beds) didn’t change over the last year and there are still 2 operating theatres (one major and one minor) which can both be used. Instruments and Implants for basic trauma surgery are available and in good quality, but there is still lack of a c- arm or intramedullary nailing systems. As an advance to last year`s visit, there are new microbiological lab facilities. This year’s visitation was also carried out by two visiting doctors, enabling an increase in efficiency of the stay. Travel conditions, security and accomodation were good and the previous organization of Dr. Lapu. Two personal highlights were a hike up on a vulcano and a fun boat trip organized and accompanied by hospital stuff. The substantial travel and living expenses were again financially supported by the SST (swiss surgical team).
As stated in previous reports there’s a huge amount of forearm fractures in the area of Rabaul, mostly due to bushknife injuries. This injuries come naturally with a severe defect of soft tissue with high rates of tendon-injuries as well as cutted neurovascular structures. We could operate on several cases, emphasizing a surgical, anatomic approach. Fractures were anatomically open reduced and fixed with standard small fragment plates (3.5mm LC-DCP). The accompanying soft tissue defects were repaired as much as possible. We could have done much more cases, but unfortunately we had a few issues in the operation theatre such as cancellation of booked cases due to medical reasons, failed nitrous oxide in both anesthetic machines and non functional portable sterilizer machine. Those issues affected our appointed time for each case.
Nevertheless we could do also some special procedures as an external fixation for pelvic fracture or a complex distal humerus fracture with olecranon osteotomy. Dr. Kevin Lapu and his registrar showed commendable team work.
Nonga hospital is serving a very large population with a heavy load of trauma patients. It’s therefore still a very important place for continuous educational projects within the PIOA. The support and acceptance of us as visitors was commendable and the dedication of the local team makes Nonga Hospital important for future visits. Further improving of surgical techniques, especially soft tissue management and continuously implementing guidelines for standartized trauma care should be the main goals for the future. Because oft the large amount of shaft fractures an image intensifier and the introduction of an intramedullary nailing system would be very interesting.