PNG: Emergency

As I sit in my comfortable home, reflecting on a month of my life that leaves itself almost impossible to summarise in only a handful of words, it is the music playing that takes me back. While away, my travel buddy played on repeat and at maximum volume the new Mumford & Sons album. Babel, both the title of the album and the most moving of the songs, often helped unravel our thoughts and emotions at the end of the day.

Emergency is, the world-over, the over-flow bay for the wards. Patients sit for days waiting to be moved up for surgery or to a medical ward. The Emergency department is also a reflection on both the best and the worst of a place. The horrors of physical injuries and severe infections sit next to outpourings of love and families doing all they can to care for their own. In PNG, amongst the frail and struggling patients were the wails of those who had recently lost someone. Rushing between it all are the nurses, who hold fort in a system where doctors can be hard to find. The Emergency department can be overwhelming for those who understand the system; I can only imagine what it must feel like to watch the chaos unfold around you.

Emergency was also where we first got to know both POM Gen and Goroka Hospitals. In POM, it was too overwhelming. We knew too little to be helpful at the start. We didn't understand the language; no-one seemed willing to take us under their wing and we couldn't even find the materials necessary to do the most basic things. We ran away to Paediatrics and only came back once we'd picked up skills and an understanding of how things work. In Goroka, we jumped right in.

Port Moresby

At POM Gen, Emergency was in the old Children's Outpatient Clinic. If you used your imagination, you could imagine how it was designed to work. And you could almost imagine small children playing with the box of toys that seems to find its way into paediatric spaces, parents watching over. You could almost imagine doctors popping out of their consulting rooms to call for the next patient. You could almost imagine it, if you had time to pause amongst the rushing bodies, the demand for your attention and the new cases that seemed to stream through the triage desk.

We learnt quickly that things work differently in Emergency. With no real separation of patients and long waits for care or admission to a ward, boredom is rife. When the first Triage Category 1 (that's urgent treatment required) rolled in the doors via a St John's Ambulance, all who were well enough trundled up for a little bit of entertainment. We watched as the doctors asked the patient's name. We stared as if watching a movie as they went through ABCD (Airway, Breathing, Circulation, Defibrillation). And we stood in disbelief as we put together the story - a workplace injury that had compressed the person's chest, a lack of CPR from the paramedic team and twenty minutes without oxygen to the brain. This person was no longer alive. Defibrillation unsuccessful, they called time of death and dispersed to take care of other patients. We were in a state of non-medical shock. Here was a person just in front of us who, only an hour before, had been part of a family, part of a workforce, part of a nation. And now they were covered up by a sheet, to have a family arrive in a daze minutes later to begin the wailing process. A wail that struck us to the core, though we'd made it to doing more useful things by this point. It wouldn't be the last time we found ourselves distracted by others' anguish.

The resident to whom we'd been assigned was often running around with jobs half-finished behind him. There were too many things to do and not enough time on his hands. We soon realised that, in a confined space and a busy setting, following him around was neither practical nor conducive to patient care. So we tried to find something we could do. A small room with two beds and a sink seemed to function as a patient dumping ground. There were some rather bedraggled looking individuals who we could help and an untidy bench with a random assortment of medical supplies. We set about making the space our own - organising the supplies, cleaning the bench, restocking things that were missing. The patients needed new saline attached as they'd been severely dehydrated. They had wounds that needed cleaning and bandaging. We would find a doctor to assist with stitching up wounds. I'd like to say we were surprised at the causes of these injuries, but we'd quickly learnt that anything goes in PNG. There was a young security guard who'd been attacked with a screw-driver while trying to help a woman being robbed, a soldier who stepped on a broken beer bottle left on campus, a young man who'd had a fight with his cousin that left him with huge and painful grazes all over his body and the cousin in the surgical ward with a sliced-up abdominal cavity, a hospital staff member who'd tripped and fallen. People from all walks of life made it into that room. It was there that we learnt a great deal about the nation and its people.

Goroka

The first thing we laid our eyes upon in Goroka A&E was a spear. Not just any old spear, but the part of a spear that was poking out of a young man's abdomen. We looked at the young man and hoped he'd soon make it up to surgery. We looked again at the spear and wondered at it's trajectory - either he'd been quite a way from the person throwing the spear, or they'd been at different heights. On our third glance, we guessed that he'd been very lucky - the spear appeared to have missed all major vessels, his kidney and his large bowel. Our guess proved correct. The surgeons had been very happy with the spear's position and, luckily, this patient could go home after a few days.

Emergency goes smoothly until it doesn't. One morning, all the doctors disappeared by 10am. Night shift had gone home but day shift never came in. We made sure everything was running smoothly and everything was clean and tidy. The afternoon rolled around without the return of our teachers. And then the ambulances started arriving. Four patients rolled in our door at once. Confused, we tried to get the well-ish patients to shift elsewhere so we'd free up some beds. What had caused this sudden influx of patients, we wondered. It was only later we learnt that ambulances from health clinics wait until they have a full car before heading down. Our motor vehicle accident patient, who was suspected of a basal skull fracture when assessed by the surgical team that I frantically ran upstairs to almost drag by the hair down again, had fallen out of the back of a ute around 7am. It was maybe 2pm when he arrived. And when I left ten days later, he had only improved from a GCS of 4 to that of a 6 with solely supportive care. A man was carried in by his relatives, completely unable to move. We took a history that looked neurological and looked but didn't look at like a stroke. We knew it was something else but couldn't quite pick it. Running upstairs again, we dragged some of the medical team down to help. They looked at our patient and picked the second differential as Guillain-Barre Syndrome. Following the patient for the next few days, it turned out he had a perfect textbook case of GBS. As it turned out, he was related to the lady recently admitted with cerebral malaria, a disturbingly common diagnosis from our experience. A few days later, we heard had passed away. A family mourning for the member that they'd thought more likely to survive. A few more patients came in and with limited space on the wards above us, the doctors could hardly decide who to take up for further assessment.

Once again, Emergency was calm. It was still too full and the nurses were still over-worked. Eventually, the afternoon shift doctor turned up and we could take our exhausted selves home. We'd learnt a lot of medicine...and a lot about life.

If you've made it this far, congratulations. And, as a reward, here's the brand new POM Gen emergency department, which opened on December 24, 2012. I never got to see it but this report makes me grin ear to ear. There is still much hope in PNG health.

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