PIOA represented at Asia Pacific Orthopaedic Association (APOA Sports meeting 2019) conference in Kuala Lumpur

From L to R Dr. Jashint Maharaj and Dr. Reshwin Rajan (Solomon Islands)

PIOA first year trainee, Dr. Reshwin Rajan, from Solomon Islands presented a poster at the Asia Pacific Orthopaedic Association (APOA) Sports meeting 2019 conference in Kuala Lumur. He is the first trainee to represent PIOA at APOA. His paper was on the “Epidemiology of Soccer related fractures in Solomon Islands“. Pictured with him is Dr. Jashint Maharaj, an associate member of PIOA, previously of Fiji but now living in Brisbane, who also presented at the same conference.

Graduation ceremony for Dr. Stephen Kodovaru – Master of Surgery (Orthopaedics) at National University of Samoa (Apia)

Today marks the culmination of a 7 plus year journey for Dr. Stephen Kodovaru from Solomon Islands. Stephen received a Master of Surgery in Orthopaedics from the National University of Samoa in Apia. He is the first graduate of the Pacific Islands Orthopaedic Association training program. He is also the current President of PIOA.

You can read more at
https://www.samoaobserver.ws/category/samoa/39922

Report on Module 1, 2019 – Introductory module / Upper limb module

New trainees from L to R: Viola Kokiva (Kavieng, PNG), Bohu Urakoko (Kundiawa, PNG), Haynes Rasin (Buka, AR Bougainville, PNG), Reshwin Rajan (Honiara, Solomon Islands) and Juvencio Dias (Dili, Timor Leste)

Module 1 was held at the Modilon Hospital and the Madang Lodge Conference room in Madang, Papua New Guinea(PNG) from February 4th to February 22nd, 2019. There were 14 trainees in the Introductory module and 17 trainees attended the Upper limb module. They are Dr. Shaun Mauiliu  from Apia in Samoa, Dr. Alex Munamua, Dr. Reshwin Rajan and Dr. Clay Siosi from Solomon Islands, Dr. Pita Sovanivalu from Fiji, Dr. Johnny Hedson from Pohnpei, Federated States of Micronesia, Dr. Naseri Aiotato from American Samoa, Dr. Juvencio Dias our first trainee from Timor Leste and Dr. Haynes Rasin from Buka (autonomous region of Bougainville), Dr. Jimmy Yakea from Popondetta, Dr. Viola Kokiva, our first female trainee, from Kavieng, Dr. Raymond Saulep and Dr. Bohu Urakoko from Kundiawa, Dr. Felix Diaku and Dr Kevin Lapu from Rabaul, Dr. Stevens James from Lae and Dr. Anthony Nasai from Wabag (all from PNG). The lectures were delivered by Dr. Bruno Fries from Switzerland, Dr. David Bartle, Dr. Vaughan Poutawera and Dr Roy Craig from New Zealand, Dr. Stephen Kodovaru from Solomon Islands, Dr Sara Coll, Dr. Ian Incoll, Dr Paul Hitchen, Dr. Stephen Quain, Dr. Matthew Sharland, Dr. John Stephen, Dr. Graham Gumley, Dr. Keat Choong (Infectious diseases) and Dr. Des Soares from Australia.

In the Introductory module students were taught a systematic approach to history taking, clinical examination and investigation with a focus on trauma and common orthopaedic conditions. In the first week the practical sessions were aimed at common trauma management options including external fixation and basic internal fixation.

In the upper limb module, the students were taught a systematic approach to diagnosis and management of Upper limb conditions. This included clinical history taking and a thorough clinical examination with emphasis on a systematic approach to the management of conditions affecting the shoulder, arm, elbow, forearm, wrist and hand. This included the management of the soft tissues and the management of closed and open fractures. In addition, there were focussed lectures and practicals on the management of hand trauma with the first ever microsurgery course over 4 days.

Lectures were supplemented with practical demonstrations. Each morning we commenced with a ward round seeing two or three patients and getting the students to present the history and clinical signs of the patients. Their management was then discussed and suggestions for improvement were made. This was a useful exercise as we were able to improve clinical skills. It was also helpful to try and elucidate clinical reasoning and decision making and help with developing these skills. The students enjoyed having expert advice on the management of elective conditions and trauma affecting the upper limb PNG has a large volume of severe trauma due to bush knife (machete) and gunshot wounds.

The highlight of the course was the 4 day microsurgery workshop each afternoon. Our students went from complete novices to being able to do a nerve repair using a “chicken Maryland” model in 15 minutes. The chicken sciatic nerve is the same diameter as a human digital nerve in a finger. PIOA is very grateful to Dr. Graham Gumley for leading this part of the course. The students were assessed with a written examination on the final day of the course.

Overall the 3-week module was intense, and it was obvious the students were stimulated to learn. The students are now already reading ahead to prepare for the next module on Knee and Foot and ankle to be held in Kundiawa, PNG, commencing on 29 July 2018.

Our thanks to the staff and patients of the Modilon Hospital, Madang and the Madang Lodge Hotel for the use of the Conference room and for allowing us to conduct the course there. Our special thanks to the staff of Madang Lodge Hotel who provided nutritious food for the duration of the course and made us feel at home. Finally, this module would not have been possible without the generous financial support from Wyss Medical Foundation, AO Alliance Foundation and South Pacific Projects.


Staff and students at the end of week 1
Front row L to R: Keat Choong (AUS),Bruno Fries (Switzerland), Vaughan Poutawera (NZ), John Stephen(AUS), Stephen Kdovaru (SI – President PIOA) David Bartle (NZ), Ian Incoll (AUS)
Staff and students at the end of week 2
Front row L to R: Bruno Fries (Switzerland), Susan Hitchen, Paul Hitchen, Sarah Coll , Stephen Quain, Matthew Sharland, Des Soares (all Australia)
Staff and students at end of week 3
Front row L to R: Bruno Fries (SUI), Des Soares (AUS), Roy Craig (NZ), Graham Gumley (AUS), Shaun Mauiliu (Samoa – Director of Training designate)

PIOA welcomes Dr. Juvencio Dias our first trainee from Timor Leste

From L to R Dr. Juvencio Dias (Timor Leste) and Dr. Shaun Mauiliu (Samoa) learning microsurgery skills while practicing on a rubber glove.

PIOA is pleased to welcome Dr. Juvencio Dias from Timor Leste. He is our first trainee from Timor and is based in Dili. Juvencio is fluent in 6 languages (English, Spanish, Portuguese, Bahasa, Tetun and his local language. He is a quiet but very hardworking student.

PIOA will faciliate supervision visits by Dr. Matthew Sharland who is based close by in Darwin.

PIOA welcomes Dr. Haynes Rasin our first trainee from Bougainville

From L to R – Dr. Anthony Nasai(Wabag), Dr. Haynes Rasin (Buka, Bougainville) and Dr. Des Soares

PIOA is pleased to welcome Dr. Haynes Rasin our first trainee from the autonomous region of Bougainville in PNG. Haynes is an experienced general surgeon who has worked in Bougainville for many years. Patients with trauma make up a large part of his surgical workload. He was very pleased to be able to take a supply of implants back with him after the course.

PIOA facilitates the provision of high quality, low cost implants from India and China and encourages hospitals to purchase these implants in order to develop local systems that are self reliant rather than relying on constant donors.

PIOA will facilitate a supervisory visit to Haynes after the August module. Dr. Nik Friederich from Switzerland will visit Haynes and help advise him on how he can further develop the orthopaedic service in Buka.

PIOA welcomes Dr. Viola Kokiva our first female trainee

Viola proudly demonstrating the ex-fix technique of bar-bar-handle

PIOA welcomes Dr. Viola Kokiva from Kavieng in the Islands region of Papua New Guinea(PNG). Viola is our first female trainee. She has recently completed her Part 1 exam in Port Moresby. Viola said she found the first week of the course very hard. By the end of the third week she was glad she persevered and was proud of the new skills she had gained. This included learning microsurgery skills in nerve and artery repair.

Viola being instructed in microsurgery by Dr. Roy Craig from New Zealand. Dr. Steven James from Lae concentrating on his repair on the left of the photograph.

Viola was also the recipient of a generous grant from medical students from the UK who have provided her hospital with funding for orthopaedic implants. PIOA facilitates the provision of high quality, low cost implants from India and China and encourages hospitals to purchase these implants in order to develop local systems that are self reliant rather than relying on constant donors. Viola will pay for half the cost of her implants and the grant from Aruni Mathyalakan and her friends in the UK will cover the other half. PIOA is grateful for their generous gift.

Viola with her new implants and instruments to take back to Kavieng

Congratulations to Dr. Raymond Saulep PIOA trainee at Kundiawa

Dr.Raymond Saulep presenting at the GSA / PISA meeting on “Surgical management of spinal TB”

Congratulations to Dr. Raymond Saulep, PIOA trainee at Kundiawa for the best surgical paper at the recent combined General Surgeons Australia (GSA) and Pacific Islands Surgeons Association (PISA) conference held in Fiji. The paper is the culmination of many years work by Raymond’s mentor Fr. Jan Jaworski.

Raymond being presented his award by Dr. Trevor Collinson, President of GSA.

Report on visit of Swiss surgical teams to Nonga, Rabaul, PNG

Report PIOA Visitation  in Nonga Hospital, Rabaul

16.06.2018 – 23.06.2018

Dr. med. M. Walliser, Dr. med. Philipp Stillhard

Dr. Kevin Lapu is a general surgeon undergoing orthopaedic / traumatologiy specialization. One additional consultant, 2 registrars and 3 residents are completing the team. The orthopaedic ward has a capacity of around 60 beds. One major and a minor theatre is available. Staff on the ward and in OT, as well as the doctors are motivated and working in a structured and reliable way under the leadership of Dr. Lapu.

As in Lae, our daily work on the wards, in the clinics and in OT was the most important part of our visit. Due to a prior visit of Dr. Philipp Stillhard last April and the previous preparation of several cases for surgery by Dr. Lapu, we could efficiently start with our planned tasks immediately after arriving.

Main surgical activities:

There seems to occur an incredible amount of forearm fractures in the Rabaul area. This was the main topic in OT and we could operate on several forearm fractures, emphasizing surgical approaches, anatomical particularities and special injury types (as Galeazzi and Monteggia fractures).

Due to lack of intraoperative imaging, ORIF  with standard 3.5mm LC-DCP plates was the standard procedure.

 

 

 

Conclusions

Due to good preparation of our visit, we could work efficiently and successfully with a very motivated surgical team, even if our visit was only short. Further visits in this kind would help to further promote decision making, case prioritization and surgical capabilities. Further support in procurement of equipment and implants will help to improve trauma care in the future.

Supervision visits for PIOA trainees in the future

Several hospitals in PNG have been visited during the last two years. We were working out several conditions, which should be satisfied for this kind of direct teaching. It is ideal, if the PIOA candidate is HOD or at least consultant and is also following the PIOA guidelines and principles of fracture treatment. This dedication ensures a high acceptance and full application of our principles by all team members involved during the whole length of the process of treatment. Good leadership and team abilities as well as communicative skills should be present in order to solve organizational problems in OT (especially essential cooperation with anesthesia and scrub nurse teams).

Visits in one hospital should not be too short, ideally around two to three weeks. Though we could show that very efficient visits can be done even during short stays of one week with previous preparation and organization. The overall duration of a mission with European doctors should be at least three to four weeks in order to limit travel expenses and ecological impact.

Certain issues concerning travel conditions, security and accommodation should also be considered.

Two visiting doctors as a team can incredibly increase the efficiency of a visit, whereas principally one doctor can also achieve a lot. As we are planning to split teams from next year on, introducing new trauma surgeons into the project, we will continue with teams of two over the next years. The process of evaluation and selection of capable trauma surgeons is under way as well as the planning of our next mission. PNG will most certainly be the main focus of our clinical work during the next years, but if there are valuable PIOA candidates meeting our conditions in other south pacific countries there are always possibilities to visit other countries as well.

 

Financial Support by the SST (Swiss Surgical Teams)

The 2018 visits were again supported financially by the SST. Travel expenses, especially the flights to, from and within PNG, are a substantial part of the project costs. Living costs in PNG are as well astounding, if the Hospitals don’t provide accommodation for foreign doctors. This is especially true in the Highlands, where accommodation costs even for very basic rooms exceed 100 USD per person per night by far.

The SIGN Set, which was introduced in Lae, was funded by the Swiss association “South Pacific Medical Projects”. This represents also a substantial amount of money, invested for a better trauma-care in the South Pacific.

Report on visit of Swiss surgical teams to Lae in PNG

Report PIOA Visitation in Lae, Angau Memorial General Hospital 

05.06.2018 – 15.06.2018

Dr. med. M. Walliser, Dr. med. Philipp Stillhard

Aims and outlines of the project:

Two program participants of the PIOA trauma program in PNG have been selected for a supervisory visit. Both participants are acting as HOD of the trauma departments in their hospitals, in this way ensuring a certain continuity in leadership and position. Both of them are qualified and experienced surgeons with good communication skills and reliability.

Dr. Steven James, head of the surgical department of AMGH and participant of the PIOA program since the Madang module in February 2018, was selected for the first time. The SIGN nail should be introduced and instructed in this hospital.

Dr. Kevin Lapu, also HOD of surgery in Nunga Hospital, Rabaul, has already been visited in April 2018 (Dr. med. Philipp Stillhard), this visit was planned as continued training especially in the field of plate osteosynthesis and external fixators.

Angau Memorial General Hospital (AMGH) in Lae, 05.-15.06.2018:

Dr. Steven James is a general surgeon, undergoing orthopaedic / traumatologic specialization. Two additional consultants, 4 registrars and 4 residents are completing the team. The orthopaedic ward has a capacity of 80 beds. There are 4 operating theatres, three actually in use. Instruments and implants for trauma surgery are available (good array of basic instruments, reduction clamps, small and large fragment sets, K-wires, external fixator, air-drive, C-arm and most recently a SIGN set for intramedullary nailing).

Daily ward rounds and clinics (bed-side teaching, case discussions, OP planning) and operations were parts of the daily routine.

Main surgical activities:

As common in PNG, most patients are presenting late after open fractures (the most common reason for admissions to the trauma ward), resulting in soft tissue and bone infections as well as soft tissue defects. Debridement, soft tissue management and temporary fixation is the most important surgical procedure in order to prepare definitive fixation.

The introduction of the SIGN intramedullary nailing system was the most important goal of this mission. We were able to operate on several tibial and femoral fractures.

The standard approach in displaced simple fractures: Open reduction, standard antegrade nailing and distal interlocking with the aiming device. During the first independent phase, Steven will start with simple tibial fractures.

 

 

Several elective cases of mal-unions and non-unions as well as complications were operated during our stay. Due to a wide array of instruments and implants, various possibilities of problem-solving and internal fixation could be demonstrated. 

Equipment in OT was very good compared to PNG standards. An almost new and perfectly working C-arm was available, enabling a much higher standard of safety, especially in nailing procedures on the femur. Working with intraoperative imaging has to be instructed in regard to radiation protection, sterility and technique.

The main problem we were facing was the inability to get patients – even with relatively urgent indications – into OT. The cancellation rate as well as the resulting waiting time was very high, even due to inacceptable reasons. Due to this limited OT capacity, it seems to be very hard for the surgical team to provide a sufficient basic trauma care. Admitted patients often wait for days and weeks, until initial operative treatment is carried out.

Conclusions:

The introduction of the SIGN system can be considered successful, even though the number of treated patients could have been much higher. The future will tell if a sufficient number of SIGN cases will be reported in order to sustain the program.

Various other cases were operated on during our stay, but the overall efficiency of our visitation was restricted due to limited time in OT.

Several suggestions to optimize workflows in clinics and OT were made. Full use of available resources, guidelines to standardize trauma care (including use of antibiotics) would lead to a more efficient trauma service, shorter length of stay in hospital, less complications and better functional results. Angau Hospital in Lae, serving a very large population and dealing with a heavy burden of trauma, would be a very important place for future educational projects within PIOA. A future visit for further evaluation and continuing education will be planned.