No lazy Sundays: Doctoring PNG-style

Identifying human remains fished from a river is just another challenge for the Olding sisters as they volunteer in a PNG hospital.

It's Sunday morning and Dr Melanie Olding, relaxing on the front step at home, is about to hear a story, PNG style. 

It's a story about something unexpected, gory and very smelly, but she has no sense of that yet, as Pius, the emergency nurse, strolls past the high mesh security fence and down the boggy driveway towards her. 

Having spent five months in Namatanai, the second largest settlement on the remote island province of New Ireland, Melanie knows she's probably in for a long-winded account of something that may, or may not, be urgent.

The volunteer with Australian Doctors International, a not-for-profit medical aid organisation that focuses entirely on PNG, drops any Australian-based expectations of how things should be, and nods, encourages and listens respectfully to the end.

Pius tells her about someone with a bedsore he's seen that morning and spends 10 minutes detailing his treatment. In a seemingly random offering, he adds that people have been fishing off Number Two Bridge. 

He does a bit of scene setting, explaining who was there and why, and says a fisherman hooked something and dragged it in.

With no increase in animation, his story suddenly gets interesting. The catch is human remains. Melanie is required at Namatanai Hospital, where a crowd thinks someone has been killed, and at least partly consumed, by a crocodile. They are waiting for her to identify the deceased.

"I'll identify it as bits of stuff," Melanie confides as we walk to the hospital, just minutes up the road. The 32-year-old emergency registrar from Darwin has passed her primary emergency exams and hopes to start studying for the ­ACCRM fellowship next year. 

She's no expert in forensic pathology. But that's no bother to the 30-odd people standing expectantly near a rice bag of entrails, tied with string. The fisherman asks for DNA testing. Others ask whether it was a man or a woman. Can she tell them who it was?

Melanie is hosing down expectations -- "I'm happy to look but I won't be able to tell you much today" -- and trying to call the coroner when her sister, Belinda Olding, comes tearing around the corner. 

Belinda is wearing a pair of latex gloves and has come from the delivery suite, but she is no doctor. The 30-year-old from Newcastle has a construction background and is saving lives in other ways.

Her main aim at the moment is to install four water tanks to get running water to hospital wards, which should significantly reduce infection and prevent deaths. 

Patient transport, PNG-style.

The 56-bed hospital in Namatanai, which sees about 77,000 patients a year, has four small rainwater tanks -- each with a tap.

It's not enough to provide drinking water for patients during the dry season, let alone wash, clean, or flush toilets. Earlier this year, a patient walked down the hill behind the hospital to a creek so she could wash after giving birth. She slipped on the way back up, haemorrhaged and died.

Installing extra tanks would be a no-brainer for Belinda in any Australian context, but here it is a slow and tedious process that will take far longer than the Olding sisters' six-month stay, which ends in August. 

Between battles with dysfunctional bureaucracy and noble attempts to vanquish corruption, Belinda is putting her project management skills to use across a range of other projects.

She's trying to introduce a triage system at the hospital (patients are currently given a number according to when they arrive and are seen in that order, even if their child is dying) and a system for unpacking AusAID boxes (when the sisters arrived, the hospital had run out of supplies, but 500 boxes were sitting -- unpacked -- in a storeroom). 

Her fundraising efforts have paid for the construction of seven pit toilets (patients previously defecated on hospital lawns and in the backyards of staff homes) and solar lighting (many night-time emergencies and births occurred in the dark).

The situation in Namatanai is far from unusual in PNG. The country has fewer than 400 doctors, only 51 of whom practise outside the capital of Port Moresby.

Working in the dark
Dr Melanie Olding will never forget the night she sewed up a seven-year-old child with 13 puncture wounds from a crocodile bite, by the light of a head torch and a kerosene lantern.
Called to the hospital at 1.30am, Melanie tracked the chest wounds and found that some were the depth of her index finger. One tooth had punctured the child’s skull.
Melanie supervised a hospital colleague as he flushed the wounds, administered antibiotics and stitched in makeshift drains made from urinary catheters, sterile gloves and tape.
Knowing that no surgeon was available at Kavieng, a bumpy five-hour drive away, Melanie bent the rules and evacuated the patient by boat to another province, where there were three surgeons.
The child made a full recovery.
Photo: Belinda Olding

In New Ireland Province, there are just seven doctors serving a population of 160,000 -- all of them based in the provincial capital, Kavieng, despite 91% of the population living in rural areas.

On this not-so-lazy Sunday, while Melanie has been dealing with the fisherman's catch, Belinda has been touring the maternity ward.

She's under no illusions about her (lack of) medical qualifications. But she knows that feverish children are automatically treated for malaria, sometimes repeatedly; it has become instinctive for her to feel little heads for bulging fontanelles. 

Belinda also knows many viable newborn babies die at the hospital, having been put aside, unattended, while medical staff focus entirely on the new mother. So she's also a regular at the maternity ward where, today, she's found an unattended newborn in trouble. That is why she has made haste to get her sister. 

Melanie follows Belinda to the flat, cyanotic baby with excessive secretions and obstructed breathing. Within 20 minutes, Melanie has stimulated, suctioned, bagged and masked the baby, and it has brightened and settled. 

Melanie has no obstetrics training or experience. This is her least favourite part of the hospital. 

There's no fetal monitoring and no chance of a caesarean or blood transfusion. Humidicribs are made with glad wrap.

There's no ventilator, autoclave or phototherapy lamp, or regular electricity to run them. Even taking a woman's blood pressure can swallow half an hour; it's a struggle to find a sphygmomanometer that achieves pressure and isn't spilling balls of mercury.

It's a depressing place, where patients lie on putrid, torn mattresses that have absorbed decades of bodily fluids.

"The wards are filthy so we have enormous amounts of maternal and neonatal infection and mortality," Melanie says. "In a lot of cases, women would be better off taking their chances in their village."

Melanie is making her final assessments on the revived newborn when a woman bursts forcefully through the door, rips off her sarong and makes a beeline for a delivery bed.

Wisely, she avoids the bed with exposed foam poking through cracked vinyl and a mysterious big hole, placed, it seems, for newborn babies to fall through.

This woman has had contractions for days. They stopped after she was treated for malaria (which she'd caught while in hospital) and an STI, but it's clear her baby is finally on its way.

Melanie and the nurse do their best, but don't manage to save the woman's perineum as the baby is born, dark blue, without a heartbeat, in a flood of meconium. 

Without the luxury of a laryngoscope, Melanie resorts to deep, blind suctioning and wishes she had the support of someone who could put in an umbilical line. 

Intramuscular adrenaline doesn't achieve a heartbeat. For the second time in her life she tries a single shot of intra-cardiac adrenaline. Within 30 seconds the baby's heart rate is perfect and there's a short-lived burst of euphoria.

It's ridiculously humid. Sweat runs down the Olding sisters' arms for the 90 minutes they try to resuscitate the baby. But the baby's lungs have stiffened. This baby will never draw her own breath.

Belinda walks the hospital in search of staff and brings five to stand around the baby to learn an essential new skill.

The mother watches on as Melanie teaches each of them how to use the bag and mask, encouraging them to reposition the mask each time its seal breaks.

Calmly and gently, she cycles each of them through the process twice, mindful that in Australia no mother would watch on so patiently, waiting to hear their first child's fate.

"I feel horrible for that mother," Melanie says later.

"But I think it's a price worth paying because there are now potentially five staff members who could save a baby, when yesterday I can assure you they couldn't.

"You have to find silver linings or it's just too sad."

She says the hospital has three rotating on-call midwives, but they rarely attend deliveries because there is a culture of not calling for help.

Compounding that, hospital staff are paid when they don't turn up for work, and are unwilling to engage with a rostering system or find someone to fill their shifts.

"If you're lucky, babies are delivered by a nurse with some obstetrics experience, more likely by a community health worker, which is similar to a nursing assistant. In many cases, because of the rostering system, they birth without anyone present."

Melanie leaves the last staff member to continue with the bag and mask and walks over to the woman still lying on the delivery bed. Gently, Melanie explains that her baby is very unwell, was not breathing when it was born and had no heartbeat.

"We managed to get the heart working again, but the baby's brain has gone to heaven and because of that, the baby can't breathe anymore," she says. 

"So we will stop breathing for the baby now and we will bring the baby to you for cuddles. Would you like to cuddle your baby?"

The woman smiles, reaches out to hold Melanie's hand and says thank you. 

Melanie has been so composed and so sensitive it's a surprise when her voice gains a terse edge. "She holds the baby for as long as she wants," she instructs the nurse, before leaving the room.

Melanie does ward rounds before facing the morgue, where the rice bag and its followers await her. She opens the bag, which challenges even her clinically hardened stomach, assesses the decaying contents and scratches out a note for the police.

"Intestinal remains bought to me. Indeterminate -- possibly human, unable to tell if male or female. Possibly large animal. Recommend coroner's involvement. Please call me for clarification. Dr Melanie."

Melanie then wanders home, where she debriefs with Belinda about the death of a baby who likely would have lived had it been born in Australia.

She provides an entertaining account of the vile smelling entrails -- "Holy mother of God" -- while downing a quick 3pm lunch of two-minute noodles. 

'That was heartbreaking’
Soon after arriving at Namatanai Hospital, Dr Melanie Olding realised children were dying of cerebral malaria and meningitis, and so made this the focus of her regular staff teaching sessions. She was thrilled when staff could parrot the sessions back to her. The quality of admissions was improving, the correct drugs were being used more often and fewer children were dying.
“I was feeling really great that people were starting to take it in,” she says.
“And the next day I stumbled onto the ward to find this child who had presented and been turned away.”
The 18-month-old had been brought in twice by well-educated and concerned parents. But he had been given IM penicillin and sent home both times. By the time the baby was admitted to hospital, where Melanie discovered him a day later, it was too late.
“I worked on the baby for ages. It was severely dehydrated, end-of-the-bed septic and non-responsive,” she says.
She gave him the correct antibiotics and fluids, but the baby arrested two hours later.
“That was heartbreaking, because it was the one thing I had been trying to focus on with the staff and it was such a textbook example.
“You could see when you walked into the room he was septic. He had a bulging fontanelle.”
Melanie, who delivered 70 interactive teaching sessions during her stay, says she sobbed and had a moment of wondering, ‘What’s the point?’
“It was heartbreaking. You understand people don’t have the education, knowledge or skills. People here genuinely want to do the right thing, but the frustration of everything going wrong despite everything you’ve tried to do — that’s the worst.”
Emotionally exhausted, Melanie headed back to the hospital later that afternoon. She found a healthy baby to model the case on, pulled out the whiteboard and ran the education session again.

When Melanie first arrived at Namatanai, she wanted to tackle and change everything that was wrong, but she soon learned that was futile, a one-way ticket to burnout.

"I see so much that is wrong, every day," she says. "What I have to do is pick the problems that I can make meaningful change to, otherwise I'd go crazy." 

In a culture heavily focused on personal relationships, she spent the first three months listening, building the respect of hospital staff and trying to understand why strange things happen. 

"It's easy to walk in and say 'That's not right', but you have to sit back and learn. Sitting back is the hardest thing you can do."

Makeshift drains for a crocodile victim.

The sisters say they wouldn't have coped in this place, where nothing makes sense or goes to plan, without having one another for support.

"You can't keep an emotion for an hour," says Melanie. 

"Just when you hit rock bottom, something wonderful happens and just when you have a win, everything comes crashing down. 

"Any win is always short-lived and any loss is just surpassed by something else. You need a familiar face to bounce things off and say, 'Did that really just happen?"

Australian Doctors International is currently recruiting volunteer doctors to work at Namatanai Hospital and/or health patrols in New Ireland Province, PNG for 2014-15. Visit adi.org.au

This article was originally published on Australian Doctor on 28 August 2013.