My last patient at Eichel was dead when I first met him. A man in his mid-forties, he had been brought into the hospital with severe breathlessness and, in the short time that it had taken for the nurse to cross the corridor from the minor theatre-cum-emergency room to the main theatre, both his heart and his breathing had stopped altogether. I started resuscitation, running round the body demonstrating to the staff how to massage the heart and blow air into his lungs with an Ambu-Bag, whilst trying to give further instructions to the nurses and discover from the family what had lead up to this. It is quite hard to try to juggle all these things at the same time and our efforts were not aided by the fact that the seal around the oxygen mask was broken so most of the gas was escaping around the side of the mask rather than going into the patient’s lungs. Consequently, by the time we had got a drip needle sited and given the first milligram of adrenaline the patient’s face had developed the bluish tinge of hypoxia. It all looked pretty hopeless. I decided that after the statutory two minutes of CPR required to give the adrenaline a chance to work we would stop. Without the proper equipment to monitor the heart rhythm and administer electric shocks, if needed, the whole affair seemed somewhat farcical. I was entirely unsurprised when there was no pulse to be felt two minutes later.

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

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

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

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

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

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

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

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

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

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

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

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

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

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