I idly flicked through it until I came to a chapter on the characteristics of the leader of a community health project. After an introductory preamble came a bullet-pointed list of qualities. The first one was, ‘is genuinely committed to facilitation’. Was I? I wondered. I hurried on, lest reflection revealed that I didn’t even possess the first attribute on the list, and the chapter turned to the more comfortable topic of the requisite qualities of other team members. Quite rightly it pointed out that many people who join the team might be doing so for personal gain or perhaps they were chosen because their relative was someone important. Obviously it was less than ideal to have such people on the team and the book advocated giving further education sessions about the role of a community health worker if people seemed to be choosing based on spurious reasons. However, the author also felt that it was important that the health workers should be chosen by the community which they would serve. This seemed to me something of a double-standard. On the one hand you should allow the villagers to choose their own health worker but, on the other hand, if they were about to choose the “wrong” person then you should try and “educate” them to do otherwise. It seemed to me that educate was just a euphemism for something short of coersion. How could this be compatible with facilitation?

The final section of the chapter laid out the stages through which a typical health programme progresses through. First there is the inital burst of energy, then the hard work comes in the second stage. This is followed by a period of decline, where all the people who didn’t want to be health-workers really start to leave, but, with any luck, this finally leads to a core of true volunteers who will carry the programme forward and are committed to its success. I found this quite a comforting message. Many of the staff at Gaubin and Baum Memorial (Amselhafen) hospitals seem to me to be those who would leave at Stage 3. Except that it’s so hard to fire them that they can effectively do whatever they like without any repercussions, so they stay and are paid for doing their work half-heartedly. Knowing this state was “normal” in the life of an insititution and that there was potential for a Stage 4 gave me hope.

I went back to my first question. Was I really committed to facilitation? Could I bear to watch people make decisions that I thought were terribly wrong, despite all my attempts at gentle persuasion? Was I so committed to facilitation that I would rather a project collapsed completely than I started taking a more active leadership role? The truth is that I think I would find that very hard. Wanting to make a difference can be both altruistic and selfish. It would be hard to work for years in a place and then have nothing concrete to show for it at the end. Most of us want to leave a legacy. If a commitment to a pure facilitation role is what is needed then I do not think I am ready. (However, I wonder how many people would truly satisfy that criteria. A minority of tropical health volunteers I would imagine.)

Two days later I was walking up a mountain path with the three (New Guinean) members of the hospital Mother and Child Health (MCH) team. It was a glorious day and the walk was made all the more pleasant by the fact that the previous day’s downpour had turned the path to sludge and so it became easier to walk barefoot through the mud than to try and avoid it in sandals. I love the tactile nature of walking in bare feet. Furthermore, one of my ambitions of the trip has been to learn to walk like a Papua New Guinean. No matter how many times I see them, I remain in awe of their sure-footed gait and ability to walk across any terrain in bare feet. This would be good practice and the soft, warm mud meant that any discomfort would be diminished.

After an hour and a half of walking we arrived in the village of Gaweng Labu, little more than a handful of huts clustered round a central quadrangle of brilliant orange soil. We sat in the large haus win (a meeting house with half-open sides – literally, house of the wind) and waited for the mothers to arrive with their children. The aim of the clinic was simple. We were to vaccinate and weigh the children, check they were growing appropriately, and educate the mothers of those who were malnourished. If the child had an illness that was amenable to treatment by one of the five basic drugs we had then we would dispense medicine and if the child was seriously ill then we would bring them back to the hospital. To run the clinic all we needed was, a set of scales, a book in which to record the statistics, the five drugs and a cool-box of vaccines. (Patients look after their own health records, which contain a growth chart if they are children.)

I remained as hands-off as possible, preferring just to observe how the staff worked. The clinic ran like clockwork. It was beautiful. First the child would be weighed, small children placed inside one of their mothers bilums (traditional string bags), the larger children reaching up to hang off the large hook at the base of the scales. After this they would move to the table where their weight would be plotted on the growth chart and recorded in our statistics book. Next the child would be examined quickly and the mother interviewed about any problems. Finally vaccines were given if needed. At the end of an hour we had seen all the children and it was time for the long walk back to the road and the equally long wait for the hospital driver to collect us. That day was pobably the most satisfying day of this entire trip: we set out do something that will have a big impact on the health of that community and we did it well. The contrast to inpatient work (small impact on the overall health of the community, a great many things done imperfectly) could not have been more pronounced.

If I had turned around on Monday evening and gone back to Lae, my trip to Amselhafen would have already been worthwhile. As it was I spent a pleasant week, gently working in a comfortable hospital environment in the mornings and relaxing, exploring the neighbourhood or battling the pig in the afternoons. Germany, as the pig is called*, seems more like a dog than a pig. His eternal quest is to escape from his sty and it is not uncommon to be standing in the garden and suddenly feel a wet nose nuzzling the back of your leg, in the search of food or affection. If you bend down and rub his belly then he will immediately drop to the ground and roll onto his back, his eyes half-closed in ecstasy.

It was easy enough to end his escapes by raising the height of the sty fence, using bamboo cut from a thicket near the river bank. However, the problems started when I took on the task of replacing the rather tatty chicken-wire gate. I fished around the pieces of lumber that Matthias kept in his garage and came across what looked like the side of a baby’s cot (several bars surrounded by a frame). Happily this had exactly the dimensions to act as a gate if stood on its side. I decided to use this as a sort of portcullis, reasoning that it would be hard to fix a hinged gate securely to the bamboo fence and I wasn’t sure if we even had hinges. With Matthias’s help I drove to gateposts into the ground and fixed some cross beams near the top and bottom, between which the gate could slide up and down. It was easy to use and seemed quite sturdy. The only problem was that Germany, who was roaming around the garden, could not be induced to go back into his sty, even when his favourite bananas were thrown in. He seemed to be quite inhibited by the lower crossbar. We were just about to give up when I had the idea of covering the red paint with mud and this seemed to do the trick. In the future I will avoid wood painted red when building pig sties.

Sadly I had underestimated Germany. He worked out how to raise the gate and wedge it open after only one night. So I passed a length of bamboo between the slats of the gate and underneath the top crossbar. The gate was now impossible to open without removing the bamboo. It only took another day for Germany to work out how to dislodge the bamboo and open the gate. From then on every day became a battle of wits with Germany, with a new fastening method tried each day and each day Germany learned how to get round it and scamper out into the garden. I’m afraid to say that I never won.

I may not have helped him with his pig but by the end of the week I began to feel that I might be helping Matthias in other ways. I was not the only one who needed some release. It seems that whilst there are three doctors at the hospital they have quite different ideas about what were the priorities and how they should be tackled. Matthias is interested in public health programs, where you do basic (and therefore cheap) things (like the MCH clinic) which affect a large number of people, whilst the other two are much more interested in their inpatient work and building up the hospital facilities. This is expensive and only benefits a relatively small number of people. Unfortunately the dialogue between the three doctors about the best way forward was not always effective.

Listening to Matthias’s stories of frustration and conflict I finally realised why many NGOs have the air of being something close to religions, an aspect that I find quite off-putting. The model of healthcare which relies on a steady stream of expat doctors to run the hospitals also relies on those doctors being not only competent but also having the same ideas about how healthcare should be provided. If they don’t then the project tends to be taken in a different direction each time an new doctor starts. One way of ensuring this does not happen is to have a very strong organisational ethos so that you only accept people whose beliefs coincide with those of your organisation. The Lutheran Health Services seem to have only two criteria for choosing who they put in posts: first that they are a doctor and second that they are a Christian. This is not the best way to ensure smooth transitions and continuity. In fact it tends to result in a huge waste of time, money and effort as one doctor sets up a service and then his successor neglects it because it does not interest them.

The week was full of small insights like this. Nothing earth-shattering but all the same they provided food for thought and offered an interesting context within which to reconsider my experiences at Gaubin. It was exactly what I had come to Amselhafen hoping for. Throughout this trip I have been battling with the various ethical dilemmas that are presented on an almost daily basis by what I see and hear and because many of the questions do not lend themselves to a simple answer I had ended up tied in knots, never able to reach a satisfactory conclusion. By the end of that week a sense of peace had come over me.

I think much of the turmoil comes from the fact that the service we provide in these hospitals is not fully supported the facilities available. The MCH clinic worked well and was satisfying because our means matched our aims, whereas in the hospital we aimed to treat diseases using a healthcare model that broadly corresponds to the Western model but without resources of a Western hospital. So, for instance, I found myself in a real hole with one patient that we had diagnosed with tuberculosis of the spine and lymph nodes, a diagnosis made on examination of the patient rather than on any lab test. She started to get terrible pain in her liver when taking the medication and seemed to be deteriorating. The medication can cause liver dysfunction but it can also cause liver pain without dysfunction. The former demands that you stop or change the medication, running the risk of letting the tuberculosis become resistant to the drugs. However, if the liver is not actually malfunctioning then you would try and keep the medication going and relieve the symptoms by other means.

On top of this there was the question of whether the pain was caused by the medication or by the disease infiltrating the liver – the liver was certainly enlarged. In a Western hospital you would be able to use various tests to answer all these questions and come to a satisfactory conclusion about the best way to proceed. Here, that is not possible leading to the agony of indecision. It would have been easier to accept from the outset that we could not treat this woman, and that our job would be more palliative care than cure. Does that mean that we should not have started the treatment? Just because it is emotionally easier for me not to treat does not make it the right thing to do. If we had ensured that we had appropriate monitoring techniques in place when setting up the TB treatment programme then this situation would be made much easier. (The problem is that if we had waited for appropriate monitoring before setting up a treatment programme then many more patients would have died of tuberculosis.)

It was a real gift to have some time and space to consider these things but before long the week had come to an end I was back in a PMV trundling across the magnificient Ramu plains. This time, knowing what to expect, there was a lot less frustration, especially as I had something to read. On my return to Lae, I had had the good fortune to meet a German expat who had discovered a second-hand clothes store that also sold books.** In a country seemingly bereft of bookshops, save for Christian book stores, this was a gem of a find indeed. She was kind enough to lend me a few novels from her collection and so I was able to pass the journey most pleasantly.

My last few days in Madang were spent with a Swiss family, Marc, Emmanuelle and their three young children. I had only met them once before*** when they had come to Karkar to say goodbye to Sophie. At that point they mentioned that they had a spare room if I ever wanted to stay. This generosity and instant rapport between expats is very much a feature of life here. Marc and Emmanuelle are both doctors by training but are working on a malaria research project with the PNG Institute of Medical Research, a reasonably well-funded and well-run organisation. It was interesting, though not surprising, to hear that many of the problems encountered in running the Lutheran hospitals were also mirrored in the running of their research projects. What was surprising was that I would act as a doctor one more time before I left PNG. The patient was Zoe, the eldest daughter of the family.

I awoke on my final day in Madang to find Marc and Emmanuelle in a state of high anxiety. Zoe had developed a fever the night before. It was a mild temperature but, as her parents had told me, she is inordinately sensitive to fevers and tends to feel very sick. Despite being given antibiotics for the infected insect bite on her arm, which was almost certainly the source of the fever, poor Zoe had spent a large part of the night vomiting and this was worrying Marc and Emmanuelle greatly. The family had planned a trip to Goroka, a town in the highlands, leaving that morning. Marc had an important meeting there and the rest of the family had been looking forward to spending some time in the mountains. However, now this was all thrown into doubt. Should they all go or should Marc go alone? He was frantic by now and didn’t want to leave Zoe’s side.

They tested Zoe for a malaria with a rapid test. This displays a positive result in a similar way to a pregnancy test, with a coloured bar appearing across the strip if it is positive. The test was clearly negative but by dint of holding it up to the light at a certain angle they could see a hint of a shadow of what might be a line. This was enough to start them down the road of considering malaria. Could the test be reflective a very low-level infection that it was only just sensitive enough to pick up? Should they take her to the hospital and get them to look at Zoe’s blood under a microscope? I listened to their plans with a sense of bemusement but did not feel it appropriate to intervene, apart from saying that the malaria test seemed negative to me. Eventually Marc turned to me and asked if I would mind having a look at Zoe to give them a second opinion.

Zoe was lying on a mattress on the floor of her parents’ room. I started examining her gently, explaining to her what each test was for, in an attempt to allay her nervousness. I gradually moved through the examination sequence until I came to checking the lymph glands under her armpits. As I was checking them I suddenly tickled her, resulting in a squeal of laughter, and click, there it was, the moment of connection between doctor and patient that makes all things possible. From that point on everything was easy. Zoe was fine, the vomiting had passed, and in the end all I did was act as her mouth-piece, articulating what she felt so that her parents could actually hear it and feel reassured.

I may not have made a clever diagnosis or instituted some complex treatment but treating Zoe (or Zoe’s parents, to be precise) was just as rewarding as treating any other patient that I have met here because there was that click. For me that is where the real joy comes and that human connection can happen anywhere in the world. To recognise that, if nothing else, has made this trip worthwhile.

*I was quite surprised by the name at first, as I imagined that the German Keller family would one day enact the strange scene of sitting around a table eating “Germany”. However, they informed me that when the time comes to eat him, they will swap him for a pig from one of the villages so that they don’t have to eat their pet.

**This seems to be quite a common combination. Sadly the second-hand clothes shop in Madang only sold second-hand magazines. Had I wanted to I could have bought a copy of Time magazine from 1997. Nothing is wasted in PNG.

***But I had actually seen them twice. The first time I had seen them was at the Madang festival. The sight of a family of white people was about as arresting as all the dancers in their traditional costumes and I very nearly went up to them to find out who they were and what they were doing in Madang.

A slight rustle at the door announced the arrival of the board chairman. To knock loudly seems to be against the New Guinean culture, with the result that many a time people have waited at the front door for ages without me realising that they were there. I invited the chairman in to join Eliza and I for a farewell drink and he gladly accepted. I was so engrossed in tea-making that I did not hear the further rustling that signalled the arrival of the nurses. Luckily PNG ears are far sharper than mine and Eliza let them in.

The nurses entered hesitantly, almost too afraid to cross the threshold of the Big House. It was the first time that any of them had been inside and for them it seemed to be an experience akin to me being invited inside Buckingham Palace. (When I tell you that I am treated like royalty here I mean that quite literally, with all the advantages and disadvantages that this relationship entails.) The nurses had come to present me with a bilum, the traditional token of thanks and farewell. They had woven one in the Silsil fashion, which involves using fibres stripped from the long, fleshy leaves of a local plant which are dried and then dyed magenta and purple. To cement the bilum’s status as a ceremonial gift, a stick had been placed inside to fan it out and fresh flowers had been woven into the tassels. It was a princely gift indeed.

24 hours later I was packing away the bilum into a bag to be left in Madang. I had just about got everything prepared when Sussi, the guesthouse manageress, reappeared to let me know that she had called a PMV to take me to Lae. Unfortunately she had called it far too early and it was only a quarter full. If I had known what was to come I would have asked the driver to return later but at that stage I had not fully appreciated the process of filling the bus.

PMVs going on long journeys will only depart once they are completely full. To fill the bus the driver does not merely wait at the PMV stop, he drives around, with the bos cru (boss crew, ie: conductor) hanging out the side of the bus shouting the destination, “Laelaelae! Laelaelae!” This behaviour sounds reasonable until you realise that the circles are about 25 metres in diameter and there are three or four other buses making exactly the same circuit. At times they are pretty much nose-to-tail. Strangely there is no animosity between them nor attempts to poach each others passengers. Occasionally the driver would get bored, or perhaps dizzy, and break off to drive around town but quite frequently his route would take him down several roads almost completely devoid of any pedestrians. On these trips the bos cru would optimistically call out to people crossing in front of the bus, as if someone would suddenly decide to take a 7 hour bus ride on a whim.

There is one final twist to the process: the bos cru will often fill up the bus with his wantoks (friends, clan members) so that it looks like it is full and thus nearly ready to go. This attracts customers, because no-one wants to drive in circles for ages if they can avoid it. However, when the genuine passengers get on the wantoks get off. I wasn’t aware of this at first and couldn’t understand why the bus always had two empty seats, no matter how many passengers we picked up. The bus is filled agonisingly slowly by this method.*

By the time we had been circling for three hours I was almost at exploding point. I had expected some delay in filling the bus but not three whole hours and we still were not full. Thankfully I managed to drift off to sleep and when I awoke we were speeding out of Madang. Only to stop 10 minutes later for a break at the closest out-of-town market. I dissipated some of my agitation by wondering aimlessly through the stalls. Quite unusually some of them were selling pre-cooked meat and fish. I found this discovery diverting enough to occupy me until it was time to go back to the bus and back to sleep.

The next time I awoke we were in the mountains with the engine sounding close to breaking point. We were inching up an impossibly steep road and for a while it looked like we would not make it. The driver was clearly accustomed to driving these roads, however, and he started driving in zigzags across the whole width of the road to flatten the gradient enough to permit the bus to keep moving. Eventually we made it to the summit, only to hurtle down a precipitous downhill and then to be faced with yet another equally steep incline. The Romans, I thought, would have approved of these roads: no concession to geographic obstacles, just the straightest route possible.

To relive the tension the bos cru started telling a series of stories which soon had all the passengers shrieking with laughter. I drifted in and out of sleep, waking at intervals to find us crawling up another hill or speeding down another descent. Sometimes we would pass vehicles broken down by the side of the road but we never stopped to help. You never know if it might be staged by raskols who want to rob passers-by. On one occasion we passed a huge container lorry lying on its side at the base of a hill with scores of people sitting on top of it. I wondered how they would right it again, they would need a crane with a pretty powerful engine to get it there in the first place.**

Shortly after the stricken truck we came to the crest of the final hill and the great Ramu Plains, flanked by majestic mountain ranges, spread out ahead of us. An involuntary, “Ayo-o-o!” (Pidgin for wow) escaped my lips, causing my neighbour to chuckle. From that moment there was no possibility of sleep and I sat pressed up against the window in rapturous contemplation as we descended into the valley and started our long journey across its floor, past sugar cane and oil palm plantations, past the scruffy town of Ramu and its tired inhabitants, past mills and isolated little huts and past slanted columns of smoke billowing from the burning fields. All against the background of glorious mountains; some crenelated, soft and verdant, as if they had been covered in a layer of green velvet, and others distant, craggy and blue, promising hidden adventure.

The plains took an age to cross but when the driver turned on the radio I knew that Lae must be close and indeed shortly afterwards milestones appeared, indicating that Lae was only 30 miles away. The final stretch of road was measured out by markets and shops named after their proximity to Lae – 10-Mile Market, 8-Mile Motors and so on – and with each mile my excitement was mounting. Nine hours in a bus is more than enough for anyone. However, my excitement was premature: I had not anticipated the oddities of the drop-off procedure.

Most PMVs in PNG will take you directly to your door, with the exception of short-route town buses, and so it was with this bus. I decided to follow the route the driver took on my Lonely Planet map of Lae to try and give myself an idea of how the city was put together. To my utter despair the driver took the most illogical route imaginable; several times we were tantalsingly close to the Lutheran Guesthouse, only to turn around and drive back to within a block of where we had dropped off a previous passenger. After an hour of eddying around it was finally my time to be released. Freedom has never tasted so sweet.

The day and a half that I spent in Lae was more than enough. In colonial times it was known as The Garden City and indeed there still remains a sign proclaiming this by the side of a shorefront road. Ironically this is surrounded by rubble and detritus washed out of the litter-choken harbour but these piles of rubbish are almost ubiquitous in the town that locals now jokingly refer to as Pothole City. The roads here are so awful that drivers frequently mount the central reservations to avoid gaping craters and the trucks are contantly surrounded by clouds of dust which become strangely picturesque around sunset.

Notwithstanding the photogenic Lae traffic, I was glad to be disembarking at Amselhafen on a balmy Thursday afternoon to be greeted by Dr Matthias and his wife, Angela. My pleasure only increased when I discovered that there was no space in the cab of the pick up so I would have to balance on the tailgate as we sped down the unsealed roads from the wharf. Give me sun, some scenery and the chance to sit in the back of a pick-up and I am immediately transported to the seventh heaven.

Amselhafen turned out to be my idea of paradise: mountains, jungle, caves and rivers. What more could anyone want? However, these delights and the joy of exploring them by foot and outrigger canoe were all but eclipsed by the relief at finally finding someone with whom I could fully discuss my Eichel experiences. Matthias and I chatted about the various aspects of medicine in PNG almost non-stop throughout dinner preparation and consumption. I had just finished describing the cardiac arrest of the week before when the phone rang and Matthias left to answer it. He came back about a thirty seconds later. “That was hospital. A patient has come into the outpatient department with a cardiac arrest. How’s that for a coincidence?”

We reached the hospital about five minutes later to find a man even younger than my Eichel patient lying on a trolley. He had come from an island in the vicinity of Amselhafen and had been ill for a few days before the health worker had finally decided to bring him over. Despite the fact that they had radioed ahead from the ship, the ambulance had not been waiting for them at the wharf and they had been obliged to wait for an hour and a half for a PMV to take them to the hospital. The patient had died five minutes before they had arrived. This resuscitation attempt was even more futile than the last and after about ten minutes we stopped.

The family were the sole occupants of the dimly-lit waiting room and I watched Matthias as he emerged from behind the curtain to deliver much the same speech as I had started the week before. The wife looked numb with shock and her only response was to clutch her sleeping baby ever tighter to her chest. The silence was broken by the father’s high-pitched wail, a thin, sharp sound that cut me to the quick. Strangely, despite all the pain and suffering I have seen here, it was the first time I’d heard a New Guinean cry spontaneously.

We walked back to the truck and drove home in silence. Above us thousands of stars glimmered in the indigo sky and around us the jungle was alive with chorus of a million insect voices singing their nightly song. One day all this will be gone; the stars blotted out by the glare of street-lights, the trees felled to make way for tarmacked roads and the chirping insects drowned out by televisions, radios and the siren of an ambulance racing a critically ill man to hospital in time to save his life.

*Nevertheless my experience tells me that there must be some advantage to this method which outweighs the waste of fuel. There is always a good reason that people do things and whilst it is sometimes tempting just to dismiss things as stupid it is only because one hasn’t fully understood the thought processes of the locals.

**Obviously such cranes things exist because the container and lorry had disappeared a week later.

I was interrupted in the middle of explaining to the family that the patient had died by the patient’s heart spontaneously restarting, its beat visibly pulsating through the man’s chest wall. So we restarted the resuscitation. I intubated the patient (put a tube into his lungs to deliver oxygen and to protect the airways from secretions and vomit) and after a few minutes of proper ventilation the man started breathing on his own. His heart rate was now normal, his blood pressure was normal, and our sole item of electronic monitoring, an oxygen saturation monitor reported sats of 98%, also normal. The patient was even moving a little. It was about as close to a miracle as I’ve ever seen. Flushed with the joy of witnessing the first successful resuscitation of my entire career, I removed the tube from his lungs and started making preparations to transfer the patient to the Intensive Care Unit on the mainland.

Sadly it was a false dawn. Whilst we were in the back of the ambulance truck, mucus mixed with saliva, and possibly bile, started coming out of the Guedel airway guard that I had placed inside the patient’s mouth. It was only at this stage that I discovered that our emergency bag did not contain a syringe with a nozzle that fitted onto the suction tube. I could not reintubate the patient because his teeth were tightly clamped around the Guedel and none of the drugs in the case could be used to sedate the patient effectively. The only option left was to roll the patient onto his side and let gravity do the work. When we went uphill the sputum-bile mixture would spray out of the airway, not infrequently into my face, and when we went downhill it would merely bubble resentfully. Incredibly the oxygen saturations never dipped below an acceptable 90% and most of the time they were completely normal.

Given this situation, I was feeling quite anxious by the time we reached the airstrip but this anxiety quickly transmuted into a bitter anger when I realised that no plane had arrived, even though we were half an hour late for our rendezvous. Luckily the driver had a mobile and Telikom, the monopoly land-line telecoms company, had finally reached an agreement with Digicel (the only mobile network with reception on Silsil) so that the two networks were finally linked and we could call the hospital and ask the administrator to find out what was going on. A fortnight before it would have been impossible to make that call and we would have had no way of communicating with the hospital whatsoever.

Whilst the administrator made his enquiries we had to wait. We sat for an hour in the back of that truck, surrounded by a cloud of flies who had come to feast on the sputum spray as well as the pool of blood that had accumulated where the drip had disconnected during turning the patient. By the end of the hour the anger had subsided into a tired resignation. There were no drugs worth a damn in the emergency box, the blood pressure cuff had burst when I tried to use it and the patient had begun to display an abnormal stiffness of the muscles so that the only way to keep him on his side was to put his head in my lap and sit in the pool of blood, water and secretions that had trickled down the metal stretcher.

When the plane finally came it seemed too small to fit the patient in but we managed it eventually by collapsing all the seats, save for those of the pilot and co-pilot. When I clambered in myself I was delighted to find an oxygen cylinder, a suction machine and a sensible emergency box. I suctioned out the patient’s airway and then focussed on giving him oxygen during the flight. The cylinder was only small so instead of running continuously it had a small button which needed to be pressed every time the patient breathed in. When he exhaled I had to let go. After a while I got into the rhythm of the man’s breathing and the whole procedure became almost automatic.

Amazingly, an ambulance was ready and waiting at the airstrip when we arrived at the mainland airstrip and the driver rushed us to the hospital. We burst through the doors of the Accident & Emergency department to find a solitary nurse. There was no on-call doctor present, let alone an on-call anesthetist. According to the staff, the emergency doctor had gone home, which was at least 15 minutes away, so the driver had to be despatched to find him. Except it turned out that he was not at home and nobody knew his mobile number. After I had given him a few drugs that I found in the emergency room, the patient was as stable as I could make him so I decided to inspect the Intensive Care Unit that was adjacent to the A&E.

It was staffed by a single nurse and contained only one patient who was sitting upright in an armchair, looking in a better condition than I did at the time. A shiny new ventilator was carefully tucked away in the corner under a dust sheet. I doubt it was ever used. I felt like such a fool. How naive of me to think that the Intensive Care Unit would run anything like the ones back home. How silly of me to bring the patient all this way. There would be no sedation, no intubation, no monitoring of blood parameters.

The on-call doctor came after about an hour. Had he cocked his leg up against the wall and pissed on it he could not have made it more clear that he wanted to establish the hospital as his territory. He listened to the patient’s history and the progress of the resuscitation and when I had finished he declared without a moment’s hesitation, “We’ll treat for malaria. It can present like this.” The patient died a few hours later.

He was doomed long before the time of death though. A whole litany of obstacles prevented him from ever having a real chance of survival starting from the moment he fell ill: his family had tried to save money by not bringing him to hospital until he was on death’s doorstep, the hospital equipment was inadequate and faulty, the staff was not trained in resuscitation, the emergency box was put together without an understanding of what should go in one, the plane was late, the doctors on the mainland were as unreliable as the rumours suggested and they had little or no expertise on Intensive Care. All ultimately due to poverty. And what had my contribution been to the situation? I had further impoverished the hospital by however many hundreds of Kina it had cost to charter the plane and I had further impoverished the patient’s family as they now had to buy a coffin to bring the patient back to the island. The road to hell truly is paved with good intentions.

The final irony of the whole situation is that when I first arrived at Eichel and Elisabeth had told me that their policy was resuscitate patients I had argued against this practice, pointing out that without a defibrillator to give electric shocks and monitor the heart, most resuscitations would end in failure and for those where we did get the patient back we did not have an easily accessible intensive care unit, which is where such patients should go. However, Elisabeth remained quite convinced that it was the right thing to do, if only for staff training. In the end I decided to bow to her opinion as she had been there longer than I. Anyway, it was all academic, I’d never seen anyone actually come back from an arrest…

This episode also serves to highlight the other theme of the week, the relationships that I have built up during my time here. Later that night the ambulance driver came to the Lutheran Guesthouse along with the relative that had accompanied the patient and a note which informed me that the patient had died and I would need to organise getting the body back to Silsil. I had never done this before. If someone had given me that note a fortnight ago I would have probably been quite worried. As things were, I merely thought to myself, “Oh well, tomorrow should be interesting.”

Over the last two months I have built up relationships with all sorts of people, both expats and locals, both hospital workers and non-staff. My Pidgin has also improved to a state of fluency. These two factors have made life here so much easier: it is true of any place in the world, but especially of Papua New Guinea, that once you know people then all sorts of doors are suddenly opened to you. However, more important than the ease of life is the joy that comes with forming these relationships. When on a trip like this there is a certain tendency to focus on the differences between yourself and the people of the culture that you meet. This provides a constant source of fascination and wonder as you learn a different world-view. However, a deeper pleasure comes from travelling half way around the world, meeting a person who is as different from you as can be and reaching out to him and in doing so acknowledging the common humanity which you share.

I am reading A Divided Self at the moment. I have only got 40 pages in but already a wonderland of new ideas and insights has been laid out. One sentence has particularly struck me so far: ‘Here we have the paradox… that our relatedness to others is an essential part of our being, as is our separateness, but any one person is not necessarily a part of our being.’ More than anything, I have felt that to be true this week. The most wonderful thing about the practice of Medicine is that you get the opportunity to experience this hundreds of times a day, as it is an integral part of being a doctor to approach each patient with openness and to acknowledge that relatedness between you. Without it you are little more than a mere diagnostician and pill-dispenser.

I saw the patient’s family again when I returned to Silsil. It was a chance meeting as I was walking along the beach past their village. I did not detect any resentment or anger in them. Maybe they looked had beyond the outcome and seen my intentions and gained some small measure of closure in knowing that everything possible had been done to save their relative’s life. I hope so. I hope it was enough.

Sadly Dr Antoine is no leader. His problems start with the language barrier. Despite being in PNG for five months now, his English and his Tok Pisin are still very poor, sadly. His communication difficulties are compounded by his tendency to think rather tangentially, which often means that you are unsure that he has understood what you are saying. To give an example, one of the nurses complained in the handover report that the security guard was nowhere to be found and they had had a confused, psychotic patient trying to break into the hospital and drag a tree into one of the wards. The nurses had had to fend him off themselves, which they did successfully, but they were rather shaken up by the event and upset that the security guard had not been around. Dr Antoine’s first response was to ask if the man was still here because he would like to see him. However, when rendered in broken Pidgin it gave the impression that he had not understood at all. After all, the nurses’ problem was the lack of security. Eventually it transpired that what Dr Antoine was trying to say was that if the patient was mentally ill then he should be found and treated, quite a sensible thing to say. However, had he started by addressing the nurses’ concerns and then moved on to the medical message he would have carried them with him. As it was, I think his message fell on half-open ears as the nurses were more interested making sure they had reliable security. When motivated and guided properly, the nurses are capable of excellent work. However, when a guiding hand is not present they tend to lose their drive and focus. I can’t help but notice that since Dr Elisabeth’s departure the attendance at morning handover has become rather sporadic, not helped by the fact that sometimes Dr Antoine himself wanders off halfway through it.

The communication with patients is also pretty haphazard. The villagers are often too polite or too scared to show that they do not understand so they will almost invariably nod as you talk to them. It is only by looking at the expression in their eyes that you can tell whether they really understand or whether they are just humouring you. Dr Antoine seems oblivious of this and I can only imagine what his ward rounds must be like. Maybe the nurses translate what he says for every patient, though sometimes they do not understand what he is saying either so this would not work in every case.

Most difficult for me personally is the third way in which patient care is impacted by this poor communication. It is impossible to have a discussion of any complexity about patients because Dr Antoine’s thinking either spirals off onto tangents or into repetitive eddies, and that is if you get anything sensible out of him at all. This means that for adult patients on the medical wards, the patients I feel most comfortable treating, it’s pretty much just me and the textbooks. This does not bother me too much as my pre-existing experience of treating adults with medical problems has given me a reasonable clinical judgement in this area. The problems come when I am trying to deal with patients who are not adults or have problems requiring surgical treatment.

There is a certain machismo about many Tropical Medicine anecdotes, with the heroic doctor bravely struggling to save a patient’s life, operating with one eye on the patient and the other eye on the textbook. What these stories fail to explain is that, in many of these cases, the doctor is operating only just outside his field of expertise and so the textbook becomes a reasonable aid to extend the doctor’s capabilities. However, when the doctor is firmly outside his area of expertise then he is bereft of the experience that gives him that all-important clinical judgement. If textbooks and the ability to read really were all that was needed then any medical student with a good textbook would be just as capable of managing patients as an experienced doctor. This clearly isn’t the case. The problem is that textbooks often outline the possibilities but are either not detailed enough in terms of the practicalities or do not assign any weight to the various management options, leaving you unsure as to what to try next. At this point, unless you have the backup of an experienced colleague, any further management decisions you take are little more than experimentation. Sadly at Eichel my backup is less than perfect. The case of the child that came in on Wednesday will illustrate why.

I was on call on Wednesday night and came to the paediatric ward to find that a 5 month old baby had been admitted with a distended abdomen. From the story it was pretty clear that the child’s bowel was obstructed, a relatively common problem in young children whose bowels can telescope in on themselves, a condition called intussuception. I have read about intussuception but have never actually seen a case so I was quite relieved when I came to the notes and found that Dr Antoine had already seen the child and written a plan. The boy was to have intravenous fluids, a nasogastric (NG) tube and to be referred in the morning to the mainland. I went back to the nurses to check the plan was being carried out and found that all that remained was the insertion of the NG tube. I had a few goes and then the experienced paediatric nurses all had a few goes. After seven attempts which all ended the tube going into the lungs instead of the stomach I told them to stop trying as the child was not vomiting and seemed reasonably well, all things considered.

I came back just before lights out to check on the child and he was still comfortable so I went to bed. The nurses did not call me until 7:45 the next morning when they burst into morning devotion to say that the child was vomiting yellow liquid. I came to the ward with Dr Antoine and Scholar to find the child much worse, with an abdomen that had distended further. In addition he was dehydrated because the drip needle had fallen out overnight and the nurses had had trouble getting another one in but had not called me.

Dr Antoine took one look at the child and declared, “We must operate!” “Don’t you think we should try an enema first?” asked Scholar a number of times but she got no reply as Dr Antoine had moved his focus to putting in an NG tube. Unbeknownst to me, the ward now stocked three types of NG tube (two weeks ago the hospital had only one type in stock) and one of the more rigid tubes went down quite easily. It was then that the recently-inserted drip needle fell out again.

Sadly the nurses had tried most of the baby’s veins during the night and, having been punctured, they were now unuseable. A series of increasing desperate attempts at inserting a drip needle began: at one stage three people were at various stages of inserting three needles into three limbs. The efforts of the staff were getting increasingly ridiculous but everybody was too hellbent on sticking needles into the child to answer my query about whether we should try putting a needle into the bone marrow (an option in children). I have never actually seen one of these interosseus needles done, maybe it really is a measure of extreme desperation and thus a ridiculous suggestion to make at that stage. I did not know and so upon receiving no response to my suggestions I shut up and contented myself with handing things to people who thought that they could see veins. I myself had given up a long time ago as i could find no viable candidates. Eventually Dr Antoine straightened up. “I will do a cut-down,” he announced.

Cut downs are a pretty archaic procedure in which you make a deep cut in one of the patient’s limbs to reveal the deep veins, at which point you can put a needle straight into one. They carry a risk of infection and they ruin the vein for future use so they are very much a last resort. Nevertheless, despite Scholar pointing this out and suggesting that we try and interosseus needle first, Dr Antoine appeared hellbent on doing a cut down. I chimed in, agreeing with Scholar but nonetheless we got little reply, just some mubling about how a cut down makes it easier to find the vein. In the end I figured that the best procedure was the one that he was most familiar with and so we started the cut down.

The procedure had all the features of a Dr Antoine procedure; carelessness, poor communication and the inevitable muttered, “This is very difficult”. I have yet to see him do an operation where he does not drop a piece of sterile equipment on the floor and snap the suture thread when tying knots. However, these are minor flaws compared with the fact that his carelessness means that he often does not plan ahead or make adequate provisions to guard against mishap and so it was with this cutdown, which just ended with a T-shaped cut in the child’s ankle and a vein multiply punctured because the iv needle had gone through the side wall. Subsequently I have looked at a textbook and the method they recommend, through it requires some dextrous operating, avoids the risk of making multiple holes in the vein. (You make a small nick in the wall of the vein with a scalpel and thereafter everything introduced into the vein is blunt.)

One ankle vein ruined, Dr Antoine shifted his attention to the other, at which point I protested ever more strongly that we should try inserting an interosseus needle, which Scholar said she had done twice. Of course, we don’t have the proper needles but you can do it with standard needles according to the PNG paediatrics guidelines. Dr Antoine actually responded this time but only to ask whether Ketamine could be given via the interosseus route. I know that fluids can but I was not sure about drugs, especially anaesthetic drugs, where the time of absorbtion and the distribution in the body is very important. I had to admit this and so he started on his second cutdown, which failed too. Scholar came and tried the interosseus needle but obviously hadn’t learnt the technique well enough because her attempts were unsuccessful.

So, after 5 hours of work, we had achieved little more than dehydrating the baby further by putting it under a hot operating lamp, damaging all visible veins and cutting into both its ankles for nothing. By then the administrator, who is the the only one who can organise emergency transport to the mainland, had gone to court (to defend himself in a rather ridiculous libel case) so there was no possibility of discussing transfer options. The child would have to wait for transfer to the mainland the following day getting ever more dehydrated in the meanwhile.

I accompanied the child on the boat the following morning. We hired a special boat to go an hour earlier than the normal ferry, with an ambulance to pick us up on the other side. I was not in the least bit surprised to find no ambulance waiting for us but after an hour of waiting (this is PNG time) I called the administrator and asked for the number of whoever was providing the ambulance. Sadly, the responsible clinic officer was was more interested in sleeping than working, judging by the confused button pressing that preceded my call being redirected to voicemail, and so when a PMV (bus) turned up I decided to use it as our transport. We reached Modilon Hospital without any further mishaps. I handed over the patient and slunk away as fast as I could, ashamed that all we had done is make it harder for the paediatricians to help the child properly. After leaving the hospital I met up with Dr Elisabeth, who was still on the mainland, dealing with a few final affairs (made harder by the fact that the province’s (country’s?) entire banking system has been crippled by a failure of the telecoms equipment). I recounted the sorry tale and as I did so she was continually interjecting, suggesting countless things that we could have done or should have done.

Given that the judgement of the person who is meant to be supervising me is often questionable I am disinclined to go and ask him for help, unless I have to. This in itself poses a problem and brings me to the next flaw in the whole “no guts no glory” approach. The one type of doctor who is worse than the one who knows very little, is the doctor who thinks he knows something when he does not. Buoyed up with false confidence he will end up making poor decisions and endangering patients. In the heavily-supervised Western healthcare system this sort of mistake is usually caught relatively early because most people’s work is checked by their colleagues at some stage. When that supervision is absent then the safety net is gone.

I was reminded of this rather forcefully when I saw a boy whose arm I’d sutured up unaided on the weekend that Dr Antoine was travelling back to Madagascar with his wife. The boy returned with his father, complaining, with typical Papua New Guinean understatement, of liklik swellap (a little swelling). The banadage was tough to remove but when I finally pulled the last turn free I was horrified to see pus gushing like milk out of the suture wound. The swellap in question was an abscess under the skin flap and I had to get Dr Antoine to come and drain it.

The problem had arisen because I had closed what is classified as a “dirty wound” too early. I had previously read that dirty wounds should not be closed immediately but had misunderstood the term “dirty wound”, thinking that as I had cleaned the wound thoroughly and put some iodine on it, I had transformed it into a clean wound. My error will seem terribly basic to anyone who has done any time in Accident and Emergency but I never did an A&E stint and the textbook that I read to try and learn about the management of cuts did not go into details about the definition of a clean wound and a dirty wound. In this case I was fortunate that my mistake will not have any long-term sequelae but it haunted me all week. The most important rule of doctoring is Primum no nocere (first, do no harm) and I had broken it.

I had already been quite nervous about seeing paediatric cases on call, as I feel bereft of the comfort of my clinical judgement. Children respond to illness in a very different way to adults, so when they don’t seem to be responding to the treatment I have instituted I am never quite sure if I just need to be patient or whether I have missed something. Seeing this child was a realisation of my worst fears and it sent me into a vortex of self-doubt. What about the other paediatric cases I’d seen? Were they surviving more through luck than judgement? I did not come here to experiment on people, especially not on children. My low mood was compounded by feelings of isolation as I have no-one here that I can discuss these complex matters with – Pidgin doesn’t allow for any nuance or subtlety so if people here wanted to have this sort of discussion will revert to their Tok Ples (local language), which I cannot speak. Furthermore this sort of ethical and conceptual discussion is not something that most people here seem very comfortable with*. I could not even get solace from those back home as the internet connection was down for most of the week.

So I was left with myself and my often ineffective pep-talks: “Pull yourself together and stop being such a wimp. None of your other Tropical Medicine friends needed to email you for support, did they? Don’t be so pathetic.” Having been in similarly isolated situations before, I knew that I had to fill my evenings will relentless activity so I wouldn’t have time to wallow in self-pity and self-criticism. Fortunately, my sister-in-law had been talking about needing a new logo and I decided to focus on trying to design one. My nervous energy transmuted into an unexpected but totally delightful burst of creativity, which resulted in, amongst other things, the much improved logo for this page. My mood started to improve and the final turnaround came on Thursday night.

I was standing in line to buy tea from the hospital store when a nursing student called me away. “Emergency, dokta.” “Wanem emergency?” “Snekbite.”

As we hurried to the ward I couldn’t help marvel at my luck. The snakes on Silsil must be angry because this was the fifth snakebite this week. They go to the surgical ward so I don’t normally see them but my ward round had been interrupted the previous day by an anxious nurse coming to ask me how to give anti-venom. Apparently in the past Dr Elisabeth had always adminstered the anti-venom but Dr Antoine had just written it up and walked off and, as is often the case, he was nowhere to be found. I looked in the textbooks, talked to Scholar and determined that it the only special measure was that it had to be given slowly because there is a risk of anaphylaxis, a severe (and sometimes fatal) allergic reaction, when giving the drug. I gave the anti-venom uneventfully and mentally filed away all I’d learnt about snakebite and what signs to look for when trying to determine whether the bite had been poisonous. Now it looked like all that information was going to come in very useful.

Even if I hadn’t read the guidelines I think I would have suspected envenomation. Even from the end of the bed, it was clear that this man was seriously unwell. All trepidation and doubt fell away, there was no time for that. The experience gained from years of treating sick adults made the initial stages automatic. Airway, breathing, circulation. The heart rate was slow at 40 beats per minute. I started giving instructions to the nurses: “Check the blood pressure. Get me a big drip needle and some fluids. Matron please go and find the keys to pharmacy and get the polyvalent anti-venom from the fridge. Lavlene, please draw up 200mg of hydrocortisone.” Back to the patient. Carry on assessing him for other signs that venom had reached the circulation. “Joe are you feeling any pain? Have you vomited? Does anywhere feel numb?” His legs felt numb. There was now absolutely no doubt that venom was in his system.

The nurses were working smoothly and efficiently, galvanised by the emergency in front of them. The hydrocortisone came, shortly followed by the all important anti-venom. I sat by the patient with the syringe squeezing in small amounts every minute or so, whilst continuing to guide the nurses. Everything was going well except, even as I was giving the anti-venom, the patient’s heart rate and blood pressure continued to drop. His heart rate was now 36 beats per minute, worryingly close to a cardiac arrest, and his blood pressure had dropped to a horribly low 70/40 despite all the fluids that were running into both arms.

How long would the anti-venom take to work and what was an adequate dose? The guidelines in the books and the leaflet that came with the bottle of anti-venom talked about giving the whole vial but yesterday Dr Antoine had only prescribed 5ml for one his patients, whilst Scholar had talked about giving 10ml. I’d already given 10ml but nothing seemed to have happened. I decided that giving too much was better than giving too little so started infusing another 5ml. Still not much effect. “Please go to to the emergency box and get the adrenaline,” I asked one of the nurses. We had no facilities for monitoring the patient’s heart rhythm or delivering an electric shock if his heart stopped, so I wanted to avoid a cardiac arrest at all costs. If things got much worse i would start giving him small doses of adrenaline to try and maintain his blood pressure and heart rate. I had just finished drawing up the adrenaline when blotches appeared on the patient’s chest and he started vomiting blood. He was having the much-dreaded anaphylaxis (compounded by poor clotting due to the venom).

Thankfully the mainstay of treatment is adrenaline, which I had in my hand. I followed this with a few more drugs to calm the vomiting and the itchy weals. With this treatment the patient seemed to improve, his pulse and blood pressure rising. However, his tongue still seemed a bit swollen and the oxygen saturation monitor started showing that his oxygen levels were dropping. I suspected this was probably an error, as the patient’s hands were cold which makes the machine give a falsely low reading but it was better to be safe than sorry and we got the oxygen cyclinder. This was great, except there was no mask. The normal way oxygen is given on the wards here is via a small tube inserted into a single nostril. This is not ideal as it only delivers a low concentration of oxygen and, furthermore, it irritated the now semi-conscious patient who kept pushing it away. I insisted on a mask, which, to my consternation, caused some debate as to whether we had any oxygen masks at all. However, eventually one was found and a little while later, as the patient’s hands warmed up, the reading on the machine returned to normal. We could relax.

This was an important case for me for two reasons**: firstly, it was quite amazing to see the nurses working so efficiently and made me realise what a difference proper motivation makes to their work (their motivation in this case came from the recognition of the emergency, not from anything I did) and secondly, it was a perfect contrast to the fiasco of the little boy with intussuception. It showed that I can be useful out here, over and above just treating the patients in a kind and thoughtful way, but I do need to work in an environment where I can get sensible support when I stray outside of my areas of expertise, because I am not happy to blindly stumble through the management of patients, hoping that I did not miss a relevant chapter in the textbook. Seeing this with clarity helped me make a decision I have been pondering for the last fortnight: in a week’s time I wil go to Braun Memorial Hospital, another Lutheran Hospital staffed by some of the German doctors I met when I first arrived. Not only will I have more medical support but also people to discuss things with and the pleasure of seeing a hospital whose history I have read much about.

So, after leaving Silsil next Monday, I will travel overland to the Birmingham of PNG, a town called Lae. From there I will catch a boat to Finschafen. The hospital is actually on the mainland but you have to go by boat because no road connects it to the outside world.

It sounds interesting, doesn’t it?

*The closest that I’ve heard to a discussion of the abstract is when people stand up and give sermons in morning devotion. Most of the time they are in Pidgin and I am afraid to say that I do not always make the effort to mentally translate them but there was one delivered in English the other day. The sermon was on a reading from the beginning of the Gospel according to John (”In the beginning was the Word and the Word was with God” etc). The sermon started conventionally enough with the speaker talking about the power of the word of God and what it can do when it enters a person. However, I was surprised to hear him explain that the way it works is that the word of God enters the body and goes to the bone marrow, because that is the place where blood is made. From there it can then go all round the body. Based on this, I wonder whether the abstract is often made concrete for the purposes of discussion.

**Well, three reasons actually. The third reason is that I get a tale, where I can cast myself as the heroic doctor, saving lives with one eye on the patient and the other eye on the textbook. You wouldn’t believe this was a proper Tropical Medicine blog otherwise, would you?