‘Papua New Guinea: Land of the Unexpected’, it’s a phrase that has rolled off the tongue of so many people that I almost began to wonder whether it was the official national slogan. Initially I took it to be a euphemism for “PNG: expect things to break down” (or bagarap as they would say in Pidgin) but this week has demonstrated that the title is well earned: I certainly did not expect to find myself here today, all alone in Sophie’s house.

The first surprises of the week were only surprises for me. One of the disadvantages of not speaking a language fluently is that, even if you can understand people when you are spoken to directly, you tend to miss out on information carried in peripheral chatter that you do not make the mental effort to translate. So I was somewhat bemused to be told that Wednesday afternoon’s ward round was starting at the front of the hospital.

After a hurried lunch I arrived at the entrance to find one of the hospital trucks waiting. Dr Sophie (as I have now got into the habit of calling her, because all the staff do) appeared shortly after me, carrying a cardboard box of assorted medicines. She explained that the ward round was not of the wards in the hospital but of the three health centres dotted around the island, each of which caters for about 6 inpatients with minor complaints not needing a hospital with full facilities. Before long a few nurses arrived and, as no truck ride in PNG is complete without one, there was someone with a large bilum of food to sell at market.

The afternoon was spent in a most pleasant fashion driving around the entire circumference of the island, stopping off for 20 minutes or so at each health centre. The most time-consuming patient of the day, however, was not found in a health centre but in a large house on one of the island’s many cocoa and coconut plantations. Sophie had apparently received a stream of panicked phonecalls that day from the (Australian) wife of the plantation owner and so we can come to investigate.

We found our patient lying in bed, not in the clutches of some deadly tropical disease, but rather from dizziness, probably brought on by overenthusiastic prescription of medication for her blood pressure. We stopped one of her medications, spaced out the others and our work was done. The real healing came in the reassurance and discussion that trickled on over the course of half an hour and climaxed with coffee and cake in their sitting room, soothed by the gentle breeze wafting in off the sea. The whole interaction might have come straight out of a Jane Austen novel with the country doctor going to visit the local gentry. All that was missing was a trio of somewhat frustrated daughters sewing and playing the piano.

If I thought that Wednesday’s ward round was exotic, Thursday’s surpassed it in every way. Thursday’s ward round started on the beach, an hour after sunrise. This time Sophie stayed at home and Dr Antoine, her Madagascan successor-in-waiting, lead the team of doctors, nurses and joyriders to the banana boat that was to take us on the hour-long ride to the health centre on Bagabag Island. The sea was choppy enough to be exciting without being too rough and by the time we disembarked we were all covered in crystals of salt from the spray. The trip was further enlivened by the accompaniment of shoals of flying fish. I’d always imagined the “flying” that they do to be short leaps out of the water. In actual fact they can fly for about 20 or 30 metres and could easily outrun the boat, even when it was powering along at top speed.

From the white sandy beach and azure sea it was a short walk up to the health centre where we arrived to find not a single patient awaiting us. The health centre director promised to send word up to the local villages to summon the sick and, whilst we were waiting, one of our nurses suggested going to visit the local school. I was slightly mystified by her choice of tourist destination, the beach seemed like a lot more attractive option, but I figured that she must have her reasons so I trotted along with the rest of the team to investigate.

The school consisted of a single long building on stilts, with a large football field separating it from the beach. The headmaster invited us into his office for a chat. Rather comically, all official letters, whether they were of any relevance to others or not, were fixed to the wall under a section marked Memos. They seemed to me to be there more as a status symbol than to disseminate information. My mind wandered as the headmaster conversed with the head nurse at length in Pidgin and I was glad when we finally we were ushered outside after being asked to sign the visitors’ book. I remained confused about the purpose of our visit until we got back to the beach where one of our two Papua New Guinean doctors explained to me that the school had been expecting us to vaccinate the children, except we had not brought any vaccines with us. To quell their disappointment we had apparently volunteered to give a health promotion talk once they had assembled all the children. The designated subject was HIV/AIDS.

I looked dubiously at the gaggle of small children who had followed us, wide-eyed with curiosity, down to the beach. “How old are these children?” I asked. “Oh, about 10 or 11,” came the reply. I pointed out that it was difficult to talk about HIV without mentioning sex and these children seemed a bit young. The native doctors agreed and we decided to change the topic to smoking. Ten minutes later I found myself standing in front of 120 pupils, aged from 10 to 16 years old, starting my health talk.

One of the constant frustrations when trying to explain medical information to patients here is that people have very little concept of what goes inside their body. This is reflected in their language by the dearth of Pidgin words to describe the organs. My talk, whilst ostensibly about the dangers of smoking, was really a tour of the organs of the body (in English), starting from the head and working downwards, explaining what each organ does in a sentence or two. This approach had the advantage of ending with the bowels and urinary systems so, just when they might be getting distracted I could make the younger children giggle by saying “piss piss” and “pek pek” (pooh). My whistlestop tour complete, I asked them to guess which organs might be affected by smoking and, in doing so, we went through all the organs again. My talk was followed by Maylin, one of the PNG doctors, reiterating some of the things I’d said (but translated into Pidgin) and also applying them to the dangers of alcohol. Interestingly her talk came from the angle that the body is God’s holy temple and you should not defile it.

When she had finished both the children and teachers looked quite satisfied and I was about to wrap it all up when Dr Antoine stepped forward and announced that he wanted to talk about HIV/AIDS. The message that he delivered, in his characteristic heavily-accented mumble, was so hilarious (unintentionally so) that I had to bite my lip several times. Apparently you can avoid HIV with the simple act of avoiding pre-marital sex and the easiest way to do this, according to Dr Antoine, is to commandeer another girl to come along with you whenever your boyfriend encourages you to slip out on a romantic stroll. “Never one boy and one girl,” Dr Antoine intoned sternly, “Always one boy and two girls.” He finished up by announcing that HIV testing is free and so the children should come along and get tested – he and his wife had been tested and they were both negative. The latter fact prompted the teachers to making the students give him a round of applause.

Dr Antoine’s novel approach was followed by Scholastica, the second indigenous doctor, delivering the more orthodox ABC (Abstain, Be faithful, Condom) message that is the official PNG line. I was heartened to hear that it included a bit on the need to respect your spouse, which is an important message here.

Our labours earned us lunch on the beach, courtesy of the school, which consisted of several giant bowls of fish, rice and plaintain, with coconut milk to wash it all down. Then it was back to the clinic to find that 30 patients had arrived for our ministrations. Of these, 20 or so were middle-aged women came with a 1-2 year history of lower back pain caused by the way they carry their bilums. These huge bags have a single strap which the women place across their forehead. It gives them two hands to work with but over time plays hell with their spines. I have never prescribed so much paracetamol in such a short space of time.

Out of the remainder of the patients there were a few interesting cases, the chief of which was a lady who came with pale patches of her skin which were devoid of sensation. There was another person in her family with a similar set of symptoms. I made a diagnosis of leprosy and asked her to come over to Eichel Hospital because we did not have any anti-leprosy drugs in our box. She put up a lot of resistance to coming and, as she has to come of her own free will and with her own transport, she may not come at all. Here again come the frustrations of a doctor working in a foreign language – you have no skill or subtlety in your communication. It wasn’t the diagnosis that scared her, if any of you are wondering about that. There is no Pidgin for leprosy: all I could tell her was that she had ‘bigpela samting’ and I only used that phrase after she refused to come. Even after comandeering native Pidgin speakers to help she remained reluctant but they were unable to discover why.

After the drive round the island, the trip to beautiful Bagabag and the joy of encountering a rare disease (well rare in the West, anyway) I thought that the week could not get any better. I was wrong. On Saturday evening, just when Toni was about to show me his recipe for homemade pizza bases, something even Sophie couldn’t have predicted happened; a small helicopter landed outside the hospital. Being good Papua New Guineans we did what any indigene would do, we went to stare at the people who might emerge. Out stepped the former health minister, Sir Peter Barter.

It turned out that he and Sophie were good friends and, as he knew that she was leaving imminently, he had decided to come in his helicopter-bearing yacht to say goodbye and would we like dinner. Well, exciting as homemade pizza is, we felt that we might forgo it, just this once. About an hour later we were on the starlit shore of the lagoon, in which the boat was anchored, flashing our torches to indicate that they should come and get us. This confused the local fishermen somewhat, who also had a group of their friends flashing torches at them, but we managed to get on the right boat in the end.

Aboard the yacht there were a number of friends and extended family, many of them already tipsy. The chef had been dragged off the boat earlier in the day by his wife, who had tracked him down and harangued him soundly for neglecting his family but the food cooked by one of the sister-in-laws could have hardly been bettered. It was so incredibly surreal to spend an evening, whose schedule would normally be determined by the generator and the duration of running water, in a plush air-condition yacht sipping chilled white wine. Eventually it was time to say our goodbyes and I reluctantly got up to leave. As went aft Sophie nonchalantly asked, “Can you drive us home, Tim?” “Oh yes,” I replied sarcastically, “The dinghy looks quite easy to drive.” “No, I mean, drive the car. We have been invited to go to the Sepik.”

The Sepik is to PNG what the Amazon is to Brazil and the chance to cruise down it in any boat, let alone a luxury yacht, was an amazing opportunity, especially as the Kleins had never been there and only had two more weeks in PNG. They needed to pack some clothes and they planned return immediately with me as their chauffeur so that there was someone to take the truck back home afterwards. And that is how I found myself at midnight on Saturday night driving alone, along the most treacherous part of the island’s unlit road, in a car whose lights would spontaneously turn off. My mind was whirring with the thought that I was going past the site where the car had previously got stuck (albeit in wetter weather) and my ears were filled with Toni’s warning not to stop the car for anyone, lest they hijack it.

Well, the potential for hijack was expected, so of course it didn’t happen. This is the land of the unexpected you kn–

Eichel Hospital was set up about 50 years ago by a man named Edwin, an Australian with German ancestry. Interestingly, though he practiced as one, he was not trained as a doctor but rather as some sort of medical orderly in the army. The army provided him with three things, exposure to medicine, organisational skills and a take-no-prisoners attitude. This weekend I was sitting across the breakfast table from the chairman of the Lutheran Health Services board who recalled with a smile how Edwin would start Monday mornings by, in the chairman’s words, “kicking the arse of anyone who hadn’t been to church the previous day.” Well there’s no arse-kicking these days but the fact that this is a Christian hospital is very much emphasised. This has two effects, the first is that Christian ritual is part of the daily workings of the hospital and the second is that the staff are told that, as members of a Christian hospital they have to attain higher standards of practice than those in the secular hospitals.

Every day starts at 7:45 with morning devotion in a big hall opposite the hospital. A number of songs are sung, some in English, some in Tok Pisin, and there is a prayer or Bible reading, usually delivered at a volume inaudible to me but obviously quite fine for the other staff who all respond in the right way at the appropriate times. There are no instruments used for the morning hymns but the Papua New Guineans have an amazing ability to spontaneously harmonise and they sing with great warmth and feeling. The singing is truly beautiful; sometimes I feel that I could listen to it for ever.

Devotion completed we cross over to the hospital for handover from the two night nurses who cover the 9 wards. The main hospital building is laid out in the shape of a stuttered huff ( H-H- ) with wards branching off a central walkway that has a roof but is open-sided. Each ward contains about 25 beds, most of which are occupied at any one time. On the bed itself lies the patient and underneath the bed sleeps at least one family member who is expected to do the main bulk of the caring for that patient. The nurses dispense the drugs and take everybody’s temperatures but the relatives wash, dress and feed the patients, both providing and cooking the food. It is only in this way that the hospital can run with so few staff.

However, it is not only pragmatism that has given rise to this solution but also culture. The Western paradigm of leaving your sick relative in the care of strangers (albeit professionals) whilst you get on with your day-to-day life is incomprehensibly neglectful to the Papua New Guinean mindset, where your wantok, your family, is everything. This also gives rise to situations which I, in turn, find difficult to imagine living through. For instance we had an old man who needed to be transferred to the big district hospital on the mainland for an operation we could not do. I was surprised to see him still on the ward two days later and asked what had happened. It was only then that I learnt that whether or not he has an operation is not his choice. His family decide if and when he will have the operation. They are the ones who decide whether the little money they have should be spent on house-keeping or whether they can afford the fare for the boat trip, bus and subsequent treatment. Treatment here is nearly free, with each patient merely paying a 2 Kina (40p/$0.20) ‘bed fee’ irrespective of how long he stays or what treatment he recieves. Nevertheless some patients struggle to find this money, leading to the strange situation where they are forced to stay in their hospital bed (thereby blocking it for a new patient) until they pay their bed fee. The reason being that once they leave for the village there will be no way of bringing them back to pay the money. But I digress, I was talking about the night report.

I always find the night report quite funny as it starts with a list of meaningless stats: number of patients with a fever, number of bags of iv fluids put up, number of patients catheterised. In the same meaningless litany some significant events are also reported so for instance I was shocked out of my reverie the other day when the nurse started with, “Night duty report Wednesday. Fever x4, IDC (in-dwelling catheter) x2, NG tube x1, death x1, iv fluids x2.” Death? Death! Hold on a second, just back up there!

It was the first death in the hospital that had occured since my arrival. The patient had been a young girl in her mid-twenties who had been admitted to the medical ward with fever and delirium. In the UK she would have received a battery of blood tests, an urgent brain scan and a lumbar puncture at the very least. In Eichel I have no routine blood tests of any use available to me. The lab can do a screen for malarial parasites and a white blood count (raised numbers of white blood cells are a marker of infection usually) but both are pointless in practice because by the time the blood is taken for the malaria screen the patient has already received artemether, a drug which clears the blood of parasites rapidly, and the white cell count will not really affect my decision to give antibiotics either way if the patient has a high fever. Furthermore the blood tests are only done at times when there is power and the nurses have time to take the blood. This means that they are usually done 24, if not 48, hours after admission.

I contented myself with a lumbar puncture as this is advocated in the PNG National Guidelines handbook. A lumbar puncture is a procedure where the some of the fluid which bathes the spinal cord and the brain is taken. In the UK we would examine it under a microscope to look for the number and type of white cells, the presence of blood, bacteria, fungi or viral DNA and levels of protein and glucose. All these taken together would allow us to come to a diagnosis of whether a meningitis is present and if so, what the cause is. In Eichel I have none of these so I had to content myself with looking at the colour of the fluid. If it was clear I could tell nothing but if it was cloudy then bacterial or TB meningitis was likely, and if it was heavily bloodstained then I would know one of the arteries to her brain had ruptured. Sadly the fluid was clear so I gave her, like we give virtually all our patients, antimalarials and chloramphenicol, an old antibiotic not used much in the West but one with an ability to kill many different sorts of bacteria. Over the next day she seemed to become more lucid, though she complained of some generalised abdominal pain for which I could find no obvious cause. Overnight she had suddenly deteriorated and died, despite interventions from Sophie. Even now we are none the wiser as to what her illness was.

The next day, being a Wednesday, was a ward round day: Mondays, Wednesdays and Fridays are ward round days. On Tuesdays and Thursdays we do surgery in the morning and see the TB patients in the afternoon. I am covering the medical wards and so my ward round that day was carried out to a background of haunting ritualised wailing coming from behind a screen erected around the dead lady’s bed. I finished the round and was just leaving the ward when her father arrived. “Me sorri tru long pikini meri bilong yu, em dai pinis (I am so sorry that you daughter has died)” I managed to get out. He did not seem at all upset and replied in rapid Pidgin. I wasn’t sure that I fully understood but I made what seemed like appropriately positive noises and shook his hand. When he was gone I turned to the nurse.
“What did he say?” I asked.
“He said that it’s not your fault. He says they should have brought her sooner instead of keeping her in the village. The medicine didn’t have time to work.”
Later I saw three flat-bed trucks, each with a red ribbon running in a V from windscreen to bonnet and each overflowing with people. “What are these?” I asked a bystander. “Funeral cars,” she replied, “Come to take the body away.”

Most of the patients and relatives in the hospital must have known that the lady had died. There is no privacy on a PNG hospital ward. There is no real privacy on a UK ward but we generate the illusion with the aid of curtains around the bed. In Eichel there are no curtains and the screen is a scarce resource so only used on special occasions. Hence all the patients and relatives can see and hear everything I do. My ward rounds are often accompanied by giggles from other beds when my Pidgin is faulty. Sometimes they even help me find the correct word or scold a patient if they are not answering my questions – ladies not infequently just smile bashfully when I ask them questions, either confused by my accent or unaccustomed to speaking to a white man. All the patients and their families watch me examine all the others and all would have seen what had happened to the lady.

I found myself struck by the apparent cheerfullness of the father but I think here people are hardened to death and, especially to pain. I would not go so far as to say that life here is cheap but its weight is certainly carefully measured: the length of mourning is prescribed by the head of the clan, based on the perceived importance of the deceased. Pain, however, is given little currency. The Papua New Guineans have an incredible pain tolerance and their invariable response to questioning about the severity of pain is that it is merely liklik (little). Furthermore if a patient, even a child, cries out in pain whilst I am examining them the relatives will almost invariably scold them soundly, often raising their hands as if to smack them.

I remember one of the first patients I saw with a fracture. He was an old man, at least 70, who had fallen out of a tree whilst trying to collect mustard to chew with his betel nut. He was sedated with ketamine for the fracture reduction. The sedation was light and the patient moaned lightly whilst manipulated his arm. Despite the light sedation I noticed that the oxygen levels in his blood were dropping. I adjusted the position of his head and put my fingers under his chin to pull it upwards and open up the airways to his lungs. This worked well and the oxygen saturations quickly came back to normal. The reduction was time-consuming and inevitably the ketamine started wearing off before we were finished causing the patient to howl. I was focussed on pulling the arm and so it was some time before I noticed the patient’s son pushing his father’s mouth closed. He’d obviously mistaken my intentions when I was performing the chin lift and thought that I was trying to shut the patient up.

The insensitivity to pain seems to extend to the staff, who do not seem perturbed when their anaesthetics wear off mid-procedure. I think part of this partly comes from helplessness. When you don’t know how do things better you just accept the unacceptable. I’ve noticed that even I have become less sensitive to screams of pain during my time here. Neverthless I try to ensure that patients who I’m involved with get good anaesthesia. The problem is that I don’t know very much myself and the books I have are frustratingly opaque on many details. My inadequacies in this area were clearly displayed on Thursday when we had a patient in theatre scheduled for an investigative laparotomy, an operation where you cut open the abdomen to see if you can determine the cause of someone’s pain or fever.

We have no ventilator so all conventional general anaesthetics are impossible. Instead we use a technique called spinal anaesthesia. For every bone in your back there is a set of nerves that leaves the spinal cord supplying sensation and muscle control to structures in the general vicinity. Spinal anaesthesia is where anaesthetic is injected into the space around the spinal cord resulting in a numbing of the nerves which it comes in contact with. It is quite simple to do if you know how to do a lumbar puncture, which I have done plenty of times. I had already given one patient a successful ’spinal’ on Tuesday and, flushed with success, I was keen to do this one too.

We had to wait for an hour or so before I could do it because the patient came into theatre with a low blood pressure (80/40) and needed lots of intravenous fluids to get it up but after 3 litres she was starting to improve and so I went ahead. (Note to medics: the normal resting BP here is about 90/60 anyway, because everyone is so fit.) The procedure itself went smoothly but whilst I was explaining the principles to a nursing student I had a sudden panic. The previous spinals I’d seen were done with the patient sitting up straight and on Tuesday I’d also the patient sitting upright. This time, however, I’d done the procedure with the lady lying on her side. If the anaesthetic floated up too high then it would reach the nerves supplying the diaphragm and paralyse them, at which point the patient would stop breathing and die. Maybe that’s why Sophie had done this others with the patient sitting.

“Quickly, sit her!” up I said and the nurses and I supported the patient for a minute or so. The problem was, in my panic I hadn’t stopped to think about where I had injected the anaesthetic. You inject the anaesthetic quite low so you actually want it to float upwards a bit because the nerves that supply sensation to the abdomen are above the injection site, not below it. Whilst avoiding diaphragmatic paralysis was certainly important sitting the patient up for so long was the wrong thing to do as the anaesthetic fell with gravity and I ended up anaesthetising her legs, not her belly.

Dr Antoine, who will be the medical chief from Monday onwards, kept pinching the lady’s abdomen distractedly until I asked him to stop. The anaesthetic clearly wasn’t going to work.
“Can we give more spinal anaesthetic or could we use ketamine” he asked Phillip, the theatre/anaesthetic nurse.
“We’ve given 4ml of anaesthetic and the maximum is 5ml so we can’t do another spinal now and no, you can’t do a laparotomy under ketamine, it’s not good enough. Anyway, I’m only prepared to give a half dose now that we’ve done a spinal.”
The news that ketamine was inadequate seemed a bit funny to me. I remembered lectures on how it was used all the time and after all we’d done that horrible caesarian under ketamine. At the time I’d put the pain down to inadequate dosing of the ketamine but maybe all ketamine operations were all like that and Phillip, like me, hated to see the patients in pain during operations. That would make him unusual but then he seemed a bit more together than a lot of the staff.
Dr Antoine hesitated and pinched the lady with his forceps a few more times, causing her to cry out.
“How long does the ketamine last?”
“About half an hour,” replied Philllip.
“If it is appendicitis I could do it in half an hour.”
Having seen Dr Antoine operate, I sincerely doubted that. Every case I’d assisted with him had been punctuated by him tutting and muttering, “A very difficult case. Very difficult.” However, I remained silent.
Dr Antoine made up his mind.”OK, give the ketamine.”
Phillip duly did as he was instructed and the lady slept, unresponsive to further pinches. Dr Antoine seemed satisfied. “It’s working,” he pronounced.
I could contain myself no longer. “This is totally illogical. If full dose ketamine isn’t good enough then half dose certainly won’t be adequate. Ketamine doesn’t interact with the spinal so you’ll be safe to give the full dose. But what if this isn’t a simple case? What if you need more time, what will you do then? Can we not wait until this evening and just redo the spinal?”
Dr Antoine didn’t answer directly. “I could just cut here,” he said tracing lines across the abdomen, “If it is appendicitis I could do it in half an hour.”
“Well OK but what if there are complications, what will you do then? Do you need to do this operation now? You need to decide soon because time is ticking by whilst we wait.”
Dr Antoine’s only reply was to ask about the blood pressure, which had previously been low but would now be artificially boosted by the ketamine and then to lapse into silence. As no further information was forthcoming I took that as a sign that he wanted to continue.
“Give the rest of the ketamine then, Phillip,” I said with a resigned sigh.

We stood there all gowned up, the patient draped in sterile drapes and all the instruments shining under the theatre light. It would cost the hospital a fair amount of money if it was wasted which we could ill-afford to do, given that we are now at the stage of resterilising plastic syringes for reuse because stocks are low. As we stood there I reflected the cost but also on how wrong this all was: I was not going to help put another patient through a lot of pain unnecessarily. I needed an answer to my question. Dr Antoine moved for the scalpel.
“Stop.” I said putting my hands over the abdomen. “Do we need to do this operation now or can it wait until the evening?”
“Are you saying that you want me to postpone the operation?” Dr Antoine bleated.
“I’m not a surgeon and I’m not an anaesthetist. I don’t know. The patient looks to me like she could wait another six hours but I don’t know. All I’m saying is that if she can wait then why not do the operation with a proper anaesthetic and then you’ll have all the time you need to do a proper job.”
“Well, OK, if you want to do the operation at six then we’ll do it at six.”

So the operation was cancelled. I was happy that I’d ultimately done the right thing but felt wretched because it was also my mistake that had caused the problems in the first place and my weakness that had meant that we’d given all that ketamine before I’d really put up a strong fight. I immediately went to the textbooks to find out what I should have done but whilst they described the needle insertion technique and drug doses they were silent about potential complications and how to avoid them. My only solace came from learning that you can safely do the procedure with the patient lying on their side. I had to wait for Sophie to return from her trip away to ask her. She told me that you simply keep checking the level of the anaesthesia and put a pillow under the patient if it is getting too high. Furthermore she had done loads of laparotomies with Phillip, both under ketamine and under combined ketamine plus spinal, so he had been lying in the operating theatre. She muttered something about him getting big ideas but didn’t care to elaborate.

In the end we didn’t do the operation. The abdominal pain, though not the fever, had subsided by 6pm so Dr Antoine felt that an operation was unnecessary. We will see.

The whole episode served to illustrate a number of things: a) how little I know and how much is being asked of me; b) when I go out on a limb in the UK I’m merely going out on one of the branches sprouting from the trunk and so there’s a bit of excitement with no real danger, here the limbs I’m out on are distinctly twig-like and it’s not fun at all; c) I, along with the whole hospital, are really going to miss Sophie. When she goes I’m going to feel like no-one’s got my back anymore, an unpleasant prospect.

Thursday also had the distinction of being my first day being on-call so the evening brought further challenges, further revealing how much I need to learn and what a poor substitute textbooks are for experience. I was so glad to be going to the mainland on Friday.

That is where I am now; I am sitting in a hotel bar, cooled by a sea breeze, taking delight in the simple things, like 24-hour electricity and water. I spent yesterday at the Madang Show, a festival of traditional dancing which was a beautiful demonstration of the ingenuity of the Papua New Guineans and how they can take the things from the forest around them and weave them into the most elaborate and wonderful things. These people really are incredible.

In the afternoon I wandered along to the sea front. I just wanted some peace and respite from the insects bedevilling my attempts to read in the open air. I carefully negotiated across the cruelly jagged boulders to get right up close to the water. Few people come out to this part of the shore, preferring to go to a beach where you can stand barefoot without being cut and swim in a sea that is not so rough. I stood in silent appreciation of the waves hurling themselves against the rocks, sending up giant plumes of spray: just me and the rawness of Mother Nature – what painters of Turner’s generation would have called ‘the Sublime’.

I became aware of a person coming towards me. A young man wearing a knitted hat, despite the blazing sun. He came right up to me.
“Do you want to hear some good news, brother?” he said handing me a damp magazine. I looked at it dumbly and ran over the Pidgin title a few times in my mind, attempting to translate it. Wastaua. Wastaua? Watchtower.

Jehovah’s Witnesses! They get you wherever you are!

“I’m leaving for Madagascar on Friday and I don’t know when I’ll be coming back. Whilst I’m away you’ll be in charge of the hospital.”

I would like to say that I remained undaunted in the face of this news from Dr Antoine, delivered in an casual manner at the start of the week, but, whilst a small fantasist part of me was excited, the majority was quite worried by the prospect. Reading the autobiographies of doctors who have boldly gone before, you get the impression that occasionally things were a bit hairy but in the main they were mostly having good clean fun, heroically saving lives, with the occasional adventure to spice things up. What they tend to gloss over is the initial feeling of bewilderment and insecurity that comes with being adrift in a new culture and trying to communicate in a new language with people who may or may not share your underlying concepts of how the world is. And that’s before you consider whether you are operating within your medical comfort zone.

Maybe the tropical doctors that write autobiographies were operating largely within their comfort zone or maybe they just don’t mention that initial steep learning curve. Almost everyday at some point I find myself thinking that a patient in front of me would be better served by one of my friends: Jenny, the Accident and Emergency registrar, would be right at home resetting broken bones, suturing up gashes and generally taking on all comers; Helen, the radiologist, would be able to use the ultrasound machine to actually diagnose things rather than saying, “Hmmm, I can’t really see much, what’s that blob?”; Kate, the obstetrician, would not be viewing the antenatal and postnatal wards with the extreme trepidation that assails me every time I poke my head around the door; and all my friends who have trained in General Practice would be far, far better suited to working in this environment, where you need to know a little bit about everything and treat your patients with virtually no investigations whatsoever.

After hearing Dr Antoine’s news, these thoughts came more frequently than ever and I had to content myself with the thought that the girls, at least, wouldn’t be able to stick it out here because they wouldn’t get on with my sometime flatmates, a small mouse, a pair of geckos and a spider the size of a dinner plate. At the end of the day I would have to be good enough, because in Dr Antoine’s absence the patients would just have me and a junior doctor from PNG, Scholastica (or Scholar for short). If things got really tough I could always ask Sophie for advice, though she was officially off duty. However, I wouldn’t have her support for long as she was leaving for Germany four days after Dr Antoine’s departure.

The week wore on and Dr Antoine was none the wiser as to when he might come back: my anxiety levels rose steadily. They were not helped by Sophie’s mischievous suggestion that accompanying his supposedly sick (but mostly hypochondriacal) wife back to Madagascar might be a ploy to escape from Eichel for good. Friday came and, even as he left to catch his plane to the mainland, Dr Antoine did not know his return date. As I watched him disappear off into the unknown, I could feel the set of master keys hanging round my neck threatening to become a millstone.

After morning devotion I gave my first ever toksave (announcement), a little pep talk about how it was business as usual even though Dr Antoine had gone, with the exception of elective surgery. I felt doubly justified in doing this when we went across to the handover room to discover that the night staff were nowhere to be found. As I had feared, they had taken advantage of the absence of the boss to go home early and not do their job properly.

My feelings towards the staff here fluctuate between sympathy, admiration and sheer frustration. One the one hand they are often working at the level of a junior doctor and I have learnt a lot from some of them. Some staff more than others are called upon to do a lot of work: the lab technician and X-ray technician, for instance, are theoretically on call every single day. I say theoretically because this untenable state of affairs has lead to a state where they come and go largely as they please. Today, for instance, we had no X-ray service because the X-ray technician had decided to go to his village so anyone coming in with broken bones would just have to wait until the following day to have the fractures properly reduced.

Even if the staff are here, they can vary from active and interested to a state of stubborn passivity. For instance I found a patient today had not been receiving the prescribed treatment. When I asked why not, I was told because they didn’t have the drug on the ward. The pharmacy is less than 100 metres away and the nurses know that it is their responsibility to get drugs from the pharmacy. However, I often find that if I do not specifically tell them to get the drug from pharmacy they will happily go for many days without administering the prescribed medicine. All patients should routinely have a White Cell Count and Malaria Screen done before surgery but almost every single time you schedule a patient for emergency surgery, you have to make a point of reminding the nurses that they have to take the blood straightaway and the results need to be collected on the same day. It’s not that the staff don’t know these things, they are all very much routine. I must confess that I find it incredibly irritating to have to continually check that they are doing what you’ve asked them to do.

One thing that I have seen with crystal clarity whilst I have been here, is that all behaviours, however strange they may seem, almost always have an understandable rationale underlying them when you look closely enough. For instance, time and again people bemoan the fact that villagers in the developing world will not take simple precautions to improve their health, such as wearing long trouser, sleeping under mosquito nets, not going barefoot and so on. Well, I can tell you that I wear shorts and T-shirts without fail and walk barefoot most of the time that I am off duty, despite having open cuts and blisters on my feet, because when it is hot the less you wear the better and walking barefoot feels nice. All in all, I do pretty much everything that the public health people have spent decades telling people not to do. My only concessions to health are sleeping under a mosquito net, taking malaria prophylaxis and not sleeping with the locals.

In the same vein, I am sure that the nurses have very understandable reasons for the way they behave and so I try not to lapse into criticism, either internally or externally. I don’t feel that I have got to the crux of the matter but I have some preliminary theories. The obvious reason, inadequate numbers of staff, doesn’t fully explain things. During the daytime there are two nurses per ward and they don’t appear to be overburdened with work. I think some of their attitudes can be explained by them having a different conception of what a nurse should be. The nurses seem to see themselves more as guardians of the thermometer and drug trolley than people responsible for the wellbeing of the patient. The doctor is responsible for the medical wellbeing of the patient and the family is responsible for everything else. So, for instance, I never bother prescribing pain killers to be given only when needed because it is very rare that the nurses will enquire whether the patient has any pain. Likewise, we have many semiconscious patients who are inadequately fed by their relatives. I am thinking of doing a little talk on nutrition for the staff but I get the impression it will fall on deaf ears because I do not think the nurses see it as their responsibility to keep an eye on things like nutrition, even in the case of severely malnourished patients.

We have a heartbreaking case of an adopted baby who was brought in with severe dehydration and malnutrition. He looks like a newborn rat, all pink and tiny with eyes that are barely open and covered in downy lanugo hair. He weighed 2.1kg on admission but has continued to lose weight in hospital, remaining terribly dehydrated for days because the adopted mother kept pulling out the feeding tubes (to be fair they did make the baby cry). It didn’t help matters that the nurses wouldn’t check that the iv fluid drip kept running. Eventually I changed how the iv fluids were going through and corrected the worst of the dehydration but even so the mother would only give the child 100ml of milk per day. Every day I explain to her that the child will not put on weight if he is inadequately fed and she must try giving the child small amounts of milk little and often. However, every time I come back I find that very little has changed because the adopting mother obviously feels that she knows best and so gives the child two big feeds a day, stopping when he vomits. It would be nice if the nurses would help reinforce the message but, as far as I can see, that’s not in their conception of what they do. If the baby doesn’t gain weight that is the fault of the mother and the doctor and nothing to do with them.

I wonder if some of this comes from the fact that when you get used to things being suboptimal – drugs not being on stock, investigations not being available, and so on – it is very hard to maintain within yourself a desire to see things through to a high standard. At night time there are only two nurses with kerosene lamps for nine wards so it’s impossible to maintain close scrutiny of all the patients, maybe that rubs off after some time and you feel that if you can’t do a perfect job at night then why try by day? I also have to remind myself that for them this is everyday life, they are not on some special mission, they are just doing their normal job. I think back to UK hospitals where at least once a week a nurse who is meant to be on duty calls in sick at the last moment and all work stops whilst the remaining nurses frantically try to find a substitute. I wonder if we drastically reduced the number of nurses on the wards in a British hospital whether the nurses might not start behaving in a similar way, frustrated by the demands made upon them.

However explicable the nurses’ behaviour might be, now that I was nominally responsible for the hospital I found their truancy on the first day quite dispiriting. I was going to have enough to contend with with all the surgical, paediatric and obstetric emergencies without having the staff run amok. However I knew that I had to keep my fears supressed because things really deteriorate on a ward when the nurse doesn’t have confidence in the doctor.

Mindful of this I put on my bravest face and went out to do the routine ward rounds. Scholar took the obstetric and surgical wards whilst I covered paediatrics and medicine. The paediatrics ward took a long time as most of the patients were new to me but by the end of the day I felt happy that I’d done a reasonable job with everybody. In the evening someone came in with a gash in their leg and blood spurting from several small arteries. I must confess to being rather agitated by the rate of blood loss but Scholar took it all in her stride and we fixed the patient up together. I found myself thinking that maybe this week alone wasn’t going to be so bad after all!

Saturday was different.

It started with a young woman admitted with severe abdominal pain and no periods for the past five months. I thought might have an ectopic pregnancy or perforated bowel. I duly requested a pregnancy test but also thought I should get some X-rays to check for distended bowel. Thankfully only a few moments before the X-ray technician arrived Scholar appeared with the ultrasound machine and diagnosed a living foetus. Ordering the X-ray before getting the pregnancy test result was a fairly basic mistake and it set the tone for a day where almost everything I did went wrong. Even simple things like catheterisation and placing nasogastric tubes, things which I would expect a nursing student to be able to do, became epic trials, usually ending in failure. Almost every severely ill admission required me to go and ask Sophie for advice. If this was to continue what would happen when she left? (To be fair every patient that I asked her about ended up being transferred out to the mainland but she was able to ultrasound them and advance the diagnosis a bit.)

The day drew to a close and I wanted to go home and crawl under the covers but I had one more error to make and this one was the biggest of them all. In an effort to wind down a bit I started to ask Scholar and a nearby visitor a few questions about PNG customs and culture. Unfortunately, due to a combination of a poor choice of words and the apparent difficulty that people have here with the hypothetical, I manage to offend both of them, though I did not realise this at the time. Just when Scholar was starting to tell me that I had to be careful how I spoke to patients I got called away to see someone in pain.

Subsequently, it became abundantly clear from the way that she deliberately avoided any contact that Scholar was very cross with me. I couldn’t even get close enough to her to ask her what I had done to upset her and so I was left racking my brains to think of some patient that I might have not taken time over but could think of none. It didn’t occur to me that questions about the value of land and electricity and my statement that I would love to see what changes in PNG over the next 30 years would be seen as critical of their culture. (In retrospect I can see how that might be misinterpreted but I do think there was also a misunderstanding of what I was actually saying.) All I knew was that without Scholar’s help I would be totally unable to manage any patient with fractures or obstetric problems. I didn’t feel that I could ask Sophie about every little thing as she had plenty on her plate and was clearly getting stressed by the major undertaking of packing up her house after four years of living here.

I think it’s fair to say that I have never felt so lonely or miserable as I did on that Sunday. I was both upset that I had offended Scholar and upset that I could resolve it because she did not want to talk. In addition, I felt that I had made a fool out of myself in front of the nurses by not being able to do simple procedures or diagnose patients without help and now they were probably even less inclined to listen to me. All this at a time when I had any number of potential disasters heading my way.

The dark mood that descended made me suspicious of everybody, fearing they either disliked or distrusted me, and took the pleasure out of everything. So much so that when a young boy came in with massive flaps of skin torn off his scalp and blood everywhere I barely noticed the significance of the fact that, with the able assistance of one of the nurses, I managed to suture all the skin back, immobilised his fractured arm in a cast and spotted the blood pooling in his ear to make the diagnosis of a base of skull fracture. I only needed to call Sophie to arrange a helicopter to transfer the boy to the mainland.

Now I’m not going to pretend that this was the world’s most difficult case. I’m sure anyone who has spent any time working in an Accident and Emergency department would have done all this and more but I have never done an A&E stint and probably even the day before I would have panicked and called the cavalry. However, on this occasion I had had the chance to observe Scholar calmly tying off the bleeding vessels so I knew what I had to do and I just got on with it. In terms of personal milestones it was a significant one but I was feeling too awful to notice it.

If Saturday was about the descent into despair, Monday was about redemption. I finally managed to corner Scholar long enough to find out what I had done and after repeated assurances that I had intended no criticism and an extensive apology we moved on. Dr Antoine also called to say that he would be returning on Tuesday, the day that Sophie would be leaving, so in the end there would be no period where I was without senior support. With these two pieces of news my world started to brighten once again and the filters, which distorted everything I saw, started to fall from my eyes.

If you had set out to deliberately construct an exercise to show me just how little I know without actually every putting me in harm’s way, you could not have done better than that long weekend. Throughout my time here I have constantly been asking myself what my role is here and as a tropical doctor. The latter has not been answered definitively, though at times I am tempted to say “very little” but as far as my role here goes, I have come to some conclusion. At the time I organised this trip I imagined that I was coming mostly to help but also to learn, now I realise that I am here mostly to learn but also to help. I may have fancy letters bracketing my name but in this environment I am very much starting afresh. There are undoubtedly many skills that I already possess and am using here on a daily basis but for each of these there are a multitude of skills that still I need to acquire. This does not come as a surprise but it is easy to get fired up with passion, especially after the Tropical Medicine course and reading those heroic doctor autobiographies. The skills and knowledge that I need will come with time, I am sure. In the meanwhile, when the going gets tough and I feel that I am floundering there is always family and there is always poetry.

When despair grows in me and I wake in the middle of the night at the least sound in fear of what my life and my children’s lives may be, I go and lie down where the wood drake rests in his beauty on the water, and the great heron feeds. I come into the peace of wild things who do not tax their lives with forethought of grief. I come into the presence of still water. And I feel above me the day-blind stars waiting for their light. For a time I rest in the grace of the world, and am free.

— Wendell Berry

I was awoken on Saturday morning by the sounds of people chattering and emerged blinking into the morning sun to find a large pig lying outside my house, its four legs trussed up around a tall stake driven into the ground. I went over to examine it and it looked back at me with an eye that seemed almost human and an expression that seemed to suggest that it had come to an acceptance of whatever vicissitudes life might throw at it. I might have been surprised that it was still alive and tied up in such a manner were it not for the fact that I’d read about this exact ritual in a book written by a missionary who lived on Silsil in the early 1900s. A feast was being prepared.

The occasion was the departure of the Klein family, after four years of working at Eichel. The departure of anyone merits a farewell kaikai (food/dinner) but only very special occasions merit the roasting of a pig. For this farewell there would be not one but two pigs. Cooking a pig takes quite a while so the day before is spent digging the mumu pit and collecting firewood, vegetation and big stones. On the day of the feast itself, the pit is lines with stones, a fire is started and the pig slaughtered. Having killed the pig, boiling water is poured over it to scald the skin, aiding its removal. Then, once the offal has been removed, the pig is lowered into the pit of hot stones accompanied by vegetables wrapped in banana leaves. Finally, the pit is covered with more leaves and vegetation to form the lid of the oven and the food slowly cooks over the course of the day.

Sadly I did not have the time to watch every stage of the process as I was on call, having the weekend that I described in last week’s post, but by 4:30pm on Sunday I was back at my house, watching the benches and trestles being laid out in a big square around the edge of the compound’s central lawn. Huge pots of food started to appear one by one, covered with large, glossy leaves, and before long the bare tables had been transformed into a river of green, guarded by a few of the male nurses, languidly waving leaf-fans to keep the flies away.

The farewell ceremony was a typical PNG affair. It started with some prayers and a sermon from the pastor and concluded with long speeches from anyone deemed to be of importance. The PNG style of oration generally involves shouting at the audience and making the same point five different ways before moving onto the next one. We had nine speakers and they all made the same points more or less, so even with my imperfect grasp of Pidgin I was able to get an impression of how much Sophie and Rudi have meant to this community. The speeches were concluded by the Chairman of the hospital board who gravely thanked Sophie for her hard work before joking that she was contributing to the island’s population crisis through her work in saving the lives of all the children.

Dinner was eaten during the speeches. I’d like to say that it was delicious but I’m afraid that I ended up slipping half of it surreptitiously to the mangy dog who likes to sleep in the chair on my verandah. I think it suffered rather from the cooling down whilst the pastor got fired up. What I was delighted to see was dessert, ice-cream, which was spooned into each guest’s cup from a large plastic-lined cardboard box. This was followed by buai (betel nut) and daka (mustard stick) being given to all the guests. Interestingly lime, which is made by burning crushed coral and is the third ingredient necessary to chew the betel nut, was not doled out. I believe this is because lime is considered more personal and not shared out in the same way that the other two are.

Finally, after all the food and speeches were finished, the choir sang a song they had composed for Sophie and then the family were invited to make speeches and receive gifts. One by one staff came and hung bilums (traditional PNG bags) across the forehead of Sophie and Rudi. Some also gave presents to the three children, Ida, Julia and Tom. Before long Sophie was festooned with so many bilums that they had to be removed to make way for more. Most touching of all were the final set, one from the patients on every ward of the hospital, each presented by an inpatient of that ward. Folliowing the gifts, Sophie her husband, Rudi, made short speeches and then everbody dispersed into the night.

Two days later came the time for the final goodbyes. I was given a whirlwind tour of their house with explanations of how to charge the solar batteries from the mains, regulate the water supply to the house and shown the office, which contained more keys than there are doors in the hospital. Finally with the parting gifts of the more keys and a clasp knife, I was bequeathed the house. I use the word bequeathed advisedly because their departure was more akin to a funeral than anything else. Staff and other women streamed across the compound, wailing openly. They reached out and clasped the children as if they would never let them go and then fell into the arms of Sophie, weeping ever more volubly. I was so absorbed by the scenes of grief that I was almost surprised when Sophie came to say goodbye. It seemed quite unreal in some way that she should be going and so our parting was done with all the weight of two friends who will see each other the next day, belying the immense contribution that all the Kleins have made to my time here. Later, when all the off-duty nurses had piled into a truck to accompany the Kleins to the airstrip, I moved all my possessions into the Klein’s house, feeling strangely like an interloper.

The funereal atmosphere was finally heightened by the appearance of the two haus girls at the end of the day. Eliza and Wanette came to the door and knocked shyly just after dark. I invited them in and they proceeded to wander slowly round the house, stroking the walls and curling round the doorframes like cats, crying all the time. “I’ve lost my mother and father,” wailed Wanette. “My own parents have died but at least I had Dr Sophie and Papa Rudi. Now they are gone I have nobody.” I could think of no appropriate response and so I sat there dumbly watching her and Eliza until they calmed down. After a while Wanette brightened, “When I see you here, I feel that the father of the house is still here” and with that I was adopted. Since then Eliza has come round every day to tidy up, do the laundry and generally look after the place. Rudight, the night of my 30th birthday, she is even cooking for me. (She’s about 50 years old, before you get any bright ideas.)

If you’d asked me a year ago what I might like for my 30th birthday I would probably have listed a whole string of gadgets. Little would I have expected to be delighted by what I have got in actuality. To date my treasure trove includes: the use of this palatial house, with its solar backup battery (so I am not entirely at the mercy of the generator) and phone line (for internet); a silk sheet sleeping bag given to me by my friend Tom before my departure; a large birthday card from Kath; a good trawl of lovely emails; the hot water system unexpectedly bursting into life this morning so I could have the first hot shower that I’ve had in ages; and, best of all, all the food left behind by the Kleins. There’s meat in the freezer, several jams, a large block of cheese, tins of vegetables, canned tuna, spices, three huge buches of bananas (about 30 bananas per bunch), a selection of cereals and even a small tin of London tea, just to mention a few of the highlights. I feel like I’m living like a king (irrespective of the fact that the water smells of rotting vegetation sometimes).

All this largesse from the Kleins comes at a price, the price being their departure. They have been the unsung heroes of my trip, welcoming me into their family and providing both support, advice and entertainment. Rudi, a machinist by trade, is one of those people who would make you feel completely inadequate as a man were it not for the fact that he is such a warm person that you could not imagine any criticism crossing his mind. He is the sort of person you could imagine wrestling crocodiles before breakfast, before building a jeep from bits of metal in the back of his shed and then driving said jeep over the world’s toughest terrain to find a mountain river catch a fish for dinner using little more than his bare hands.

My evening ritual would be to go round to the Kleins on some feeble pretext at which point Rudi would be sure to say, “Tzso! (So! with a Polish accent) You will stay for dinner(?)” I was never quite sure if it was a statement or a question but I always readily acquiesced because Rudi has built up a wide-ranging and inventive repertoire of dishes, all of which are delicious and belie the fact that half of their ingredients originate from a can or packet. I would make some attempt to help but he always had everything under control so quite quickly I relegated myself to the position of setter of the dinner table and childrens’ entertainer.

Interestingly, during my time I here, I have often felt much more comfortable in the company of children than adults. I think this is largely because, no matter what culture you are from, children behave in much the same way. Even right at the beginning, with hardly any words of Pidgin at my disposal, I was able to teach the local kids how to play tag, piggy-in-the-middle and one-touch football. I find it quite easy to enter into their world, so much so that one day, when I was playing with the Klein’s 6 year-old, Tom, Rudi was motivated to ask, in a surprised tone, “You know the rules?” In fact there were no rules. We were playing with a pie-shaped piece of plastic, some thread, a few pieces of card and a couple of boxes. Without much discussion Tom and I had instinctively turned this into an Indiana-Jones style rescue mission to open the boxes and release the bit of fluff resting inside. Being in a situation where you understand all the rules is strangely comforting and playing with the children, both the Kleins and the locals, has been a valuable way of winding down at the end of the day.

Another important source of solace has been Sophie, of course, with whom I could discuss medical problems or cultural issues intersecting with our work in the hospital. She was also a living example of a tropical doctor and thus a role-model of sorts. It is very easy to get fired up and blindly dogmatic about what roles doctors from the West should play in the developing world, when sitting in a lecture theatre or pub back home. The idea most fashionable at the moment is that, outside of humanitarian emergencies, doctors should mostly be involved in roles where they set up sustainable projects, with the aim that when they leave their role will be filled by someone native to the country that they are working in. The idea of sustainability and ‘health-system strengthening’ (supporting the projects of the goverment’s health department) are so in vogue that I’ve even heard lecturers deride the work of surgeons who “parachute in” to do specialist operations for a short while before leaving again, almost to the point of denying that their intervention brings any benefit whatsoever.

Sophie’s post here would fall into the derided category. Her post has been filled by another expat, Dr Antoine, and apart from the TB treatment program that she set up, there will be little evidence in the hospital that she ever worked here. Indeed, even the TB programme may slowly run down in the same way as her predecessor’s Pap smear project (checking women for cervical cancer/pre-cancer) has suffered from Sophie’s lack of active interest. Yet, listening to the speeches, and watching the presents mount up and hearing the wailing of the staff when she left, there can be little doubt how much her work has been appreciated by the local community. The Lutheran Church Health Service, though run by Papua New Guineans, recruits all its senior doctors from abroad and seems to have little intention of changing this, at least in the short term. They are trying to recruit more indigenous junior doctors but as their hospitals tend to be quite remote and the pay is no better (and in some cases worse) than the government hospitals, there is little incentive for junior doctors to come and work in these places, making the Lutheran hospitals more dependent than ever on foreign doctors.

Over the past month I have I thought long and hard about what role a tropical doctor should play. I have grappled with the complexities of trying to consider the work not only terms of his sphere of influence, from the individual patient at the smallest, to the health of the nation at the largest, but also the longevity of the effect of his work. Quite quickly I came to see that any lasting change on a large scale would necessitate changing the underlying behaviours and beliefs of the people which is not only difficult, but in some cases ethically dubious. For example, the tendency of people to leave paid jobs and go back to a self-subsistence lifestyle, growing the food they need in their gardens, is probably bad for the country’s economy and in all likelihood also makes the individuals financially poorer. This poverty will in turn lead to lower levels of health and education. As a doctor should I try and stop people living this way, with the idea that the richer they are the healthier they will be? Should I encourage them to give up a life where they are beholden to no man, except their clan members, for one where they are wage slaves? I think not. Leaving aside the question of whether my shaky thesis that having reliable employees would indeed lead to more businesses, a bigger economy and a generally higher level of wealth for the populace, is it the place of an outsider, however well-intentioned, to start trying to get people to change their lifestyles en masse? Interestingly most people here seem to regard town life as harder and resent the idea that everything has to be paid for, in contrast to the village, where most things are free. It doesn’t seem to bother them in the slightest that they don’t even have the option of electricity in the village.

I wrestled with these ideas but, hydra-like, as soon as I had answered one question two sprang up in its place. Watching Sophie’s farewell ceremony I realised that the question as to the role of the tropical doctor is unanswerable because there is not one single role to be filled. Any solution to the health needs of a developing nation will involve doctors working on all levels with different aims. Some will come to help the health minister devise long term goals and projects whilst others, like Sophie, will come to fill a post where a doctor is needed to serve a small community. Is Sophie’s work here any less valuable than that of a public health advisor in Port Moresby (the capital)? I would contend not. In the end the most valuable question to ask one’s self is, “What am I going to do as a tropical doctor. What will my role be in this place and at this time?” Even this is not readily answerable because the instant temptation is to change the question into, “How can I do the most good?” which quickly gets you back to considering the role of the archetypal tropical doctor.

Yesterday, fed up with living inside my head, I grabbed my snorkel and went down to the beach. Previous explorations had allowed me to find a channel of deep water and dead coral so that my unique swimming style, which I have christened ’shark bait’, did not result in me cutting my feet. I swam out round the first reef and headed into the blue haze for the second reef. Halfway there the ocean floor dropped away so that it was barely visible and it felt for a while like I was floating in space. Fragments of poem my father sent me drifted through my mind:

…when we lie in silent contemplation of the void
they say we feel it contemplating us…
There is something vast and distant and enthroned
staring through your mind, staring and staring,
like a black sun, constant, silent, radiant,
with neither love nor hate nor apathy
as we have no human name for its regard.

Part of the value of this trip, on a personal level, is to be stripped of as many support structures as possible – physical, emotional, psychological – and hang there in the unblinking regard of the void which watches how I respond. It’s not always easy and it’s not always pleasant but it is certainly illuminating. Now, with the Kleins gone, another crutch has been kicked away. How will I respond?

The other day a gecko ran up the leg of one of the nurses during morning devotion. He reached down to brush it away causing the startled reptile to shed its tail and scamper away. I was amazed on two counts: firstly by the fact that the tail detached instantaneously, with no tearing or tension needed, and secondly, after the tail had fallen off it continued to thrash around on the floor in a most energetic fashion for well over a minute, presumably to give the impression of being alive. I can’t help thinking that Eichel Hospital is now like the tail of the gecko, apparently alive but really operating in a headless fashion.

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?