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.
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.
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 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.
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.
PIOA today signed an MOU with the National University of Samoa. It was signed by Professor Fui Le’apai Tu’ua , ‘Ῑlaoa Asofou So’o , Vice Chancelor of the National University of Samoa and Dr. Desmond Soares, Director of Training for PIOA.
PIOA in conjunction with NUS will provide a post-graduate training program in Orthopaedic surgery including trauma care. The programme will train medical practitioners in orthopaedic surgery to the standard of a specialist orthopaedic surgeon within the context of Samoa and the Pacific Island countries. PIOA currently has 18 students from 7 Pacific Island countries (Samoa, Solomon Islands, Kiribati, Fiji, American Samoa, Papua New Guinea, and Micronesia.)The MOU and formal letter confirming that PIOA graduates will be granted a Master of Surgery (Orthoapedics) was signed today. This marks a new phase in the co-operation agreed between PIOA and NUS.
PIOA is running the Paediatric module with trainees from Samoa, Fiji, PNG, Micronesia and Solomon Islands. Lecturers include Peter Cundy and Andrew Morris from Australia, Sud Rao and Koen de Ridder from New Zealand, Stephen Kodovaru from Solomon Islands and Des Soares from Australia.
Through a generous donation from Dr. Herman Oberli and South Pacific Projects, PIOA has been able to introduce the SIGN nail system to ANGAU Hospital, Lae in Papua New Guinea. Lae is the second largest city in PNG with a busy trauma load. Dr. Steven James is a general surgeon there who has commenced the PIOA program in 2018. PIOA is grateful to Dr. Philipp Stillhard and Dr. Martin Walliser from Switzerland who are visiting Lae to help introduce the SIGN system.
The first case of SIGN Nailing here at ANGAU hospital, Lae, Thank you PIOA!!!! Dr. Steven James, LAE
PIOA Supervision Mission in Rabaul, East New Britain Province, Papua New Guinea (PNG) April 2018
Dr. med. Philipp F. Stillhard, General- and Trauma Surgeon, incl. Orthopaedic Trauma
Rabaul is a town in the East New Britain Province, on the Island of New Britain. Until the huge volcanic eruption in 1994, Rabaul was the province capital. During the eruption, a rain of ash destroyed 80% of the buildings. Rabaul’s history is exciting. Before World War I, the city was under German New Guinea administration followed by The British Empire and later on became the capital of the Australian mandated Territory of New Guinea. During World War II, Rabaul was captured by the Japanese and in 1942 it became the main base of Japanese military in the South Pacific. Military installations from this time can still be seen. After the Second World War, the area returned to Australian administration until independence in 1975 (modified from Wikipedia)
The Nonga General Hospital is the main hospital in East New Britain Province and is responsible for over 350’000 people in the area, some patients even come by boat from New Ireland Province. The hospital was recently renovated, and the wards and OT are in quite a good condition. Next to several departments, such as surgery, internal medicine, radiology, accident and emergency, gynaecology, laboratory and so on, there is an ICU as well as an Intermediate Care.
My accommodation is a simple hotel, called Rabaul Hotel only 10 minutes from the Hospital by car. The daily transfer is organized from the hospital.
The Head of Surgery and PIOA trainee Dr. Kevin Lapu, is a highly experienced surgeon with a brilliant surgical hand and huge empathy, he is working in a team of six, one consultant, 2 registrars, 2 residents and himself. The buildings have been recently renovated and look nice. On closer examination, you realize that certain things are not working properly. The surgical ward is divided in three rooms: the first room accommodates general surgical patients, the second, orthopaedic trauma patients and the third, infected and diabetic surgical problems. Energy and water supply seems sufficient, and they have their own generator available for emergency reasons. Right now, 2 ORs are running with a sterilisation and packing unit. A minor theatre was recently renovated and will open soon for wound debridement. One consultant and clinical nurses provide an anaesthetic service, which is working more or less efficiently. Basic instruments and reduction clamps are available as well as a recently ordered power-drill, unfortunately they are without a quick coupling and oscillating saw. A full small and large fragment set with screw rack, wire and external fixator set are available. Basic procedures such as external fixations, pin tractions and uncomplicated small and large fragment cases can be done safely. For more complex cases the team needs more training. Unfortunately, there is no intraoperative imaging available right now.
The OT team is working very thoroughly but without a lot of experience in orthopaedic trauma surgery. The topic, aseptic workplace should be discussed with infectiologists. The management of plates and screws stock should be taught by an experienced OT-nurse. Finally, I went on to count all plates and screws and wrote it down in an Excel file, which I kindly received from Dr. Alois Mouemuem under the note: “helping PIOA trainees is caring for them”.
My first day at Nonga General Hospital, a Sunday, we did an extensive ward-round, discussed all the orthopaedic cases for its non-operative or operative treatment. We have reviewed patients from the surgical ward and from the out-patient clinic, especially with non-unions and mal- unions around the upper extremity and some cases of infected osteosynthesis and acute and chronic osteomyelitis.
During my first days, I met everybody important from the administration, the medical officer, supervisor and CEO included.
The following are just some cases we discussed and operated on together during my stay in Rabaul:
A 40 year old man with a history of left femur fracture. ORIF was done with a K-Nail and cerclage wires more than a year ago and got infected. The clinical examination shows a 20° externally rotated left leg with a sinus around the old approach with some pus and a gluteal decubital ulcer. Actual XRay findings: osteolytic lesion around the nail and an avital fragment, clearly a postoperative infection. The reason for the decubitus is identified, the nail juts out of the greater trochanter, much more than it should.
After discussing the problems of rotational instability using K-Nails without locking bolts, the management of infected osteosynthesis and the problem nails sticking out of the greater trochanter, we planned a revision surgery for the patient. First of all, we excised the decubital ulcer and removed the nail from there. Secondly, we excised the old scar with its sinus. After removing the cerclage wires, we tested the bone fragments with the “Cocker Test”, removed all necrotic bone, applied pins to the distal fragment in 20° external rotation and to the proximal fragment straight laterally. Finally, we rotated the distal fragment by 20° and applied an unilateral external fixator.
Another case was a lady presenting with a humeral shaft fracture treated with a POP over 4 weeks. The clinical examination and the x-ray XRay findings motivated us to proceed with ORIF.
From the teaching aspect, there are different goals to mention. To begin with, there is the topic “different approaches to the humerus”. After discussing the benefits and drawbacks of the different approaches, we have decided to go for an anterolateral approach which was never done before by Dr. Kevin Lapu. The second point was the issue “AO-principles” and how can we get compression to a transverse fracture.
The last case to mention was a lady in her thirties who presented with a displaced R forearm fracture. Initially the fracture was treated conservatively during 4 weeks. The indication for ORIF was to correct the displacement by anatomical reduction and therefore avoid a poor functional outcome.
We chose the Thompson approach to the radius and a straight approach to the ulna, removed the callus, achieved anatomical reduction. The radius was fixed by a 7-hole DCP and the ulna by 6-hole 1/3 tubular plate.
Next to all the operations and teaching in the OT, we discussed fracture management for open fractures, paediatric fractures and fractures around the humerus. Another, non-surgicaI topic, I tried to cover, was the use of hand disinfectant and gloves during the ward round and change of dressings. Furthermore, I got the chance to talk about the idea behind PIOA and general aspects in paediatric fracture management during a grand-round meeting with some members of the hospital medical board. Hopefully, they got my message about supporting Dr Kevin Lapu for his PIOA training as well as financial support for further instruments and implants for operative fracture management.
Early Sunday morning, we walked up to the top of the volcano. Just amazing and I am grateful for this hike.
Future ideas:For sure, more supervision missions should be organised for the Nonga General Hospital. Furthermore, a C-arm would be helpful as well as an oscillating saw.
The hospital should keep going on with buying some implants and screws. The shorter sizes of screws in the small fragment set have already run out. Also, some small reduction clamps (pointed forceps (2x) and crab-claw clamp (1x), new external fixator bars and Schanz screws should be organized. There is also a need to teach ORP about use and maintenance of orthopaedic equipment, as well as stock-keeping and ordering replacements in time.
“…the ward is our library, patients our books we are learning from…”
Dr. Kevin Lapu
Philipp F. Stillhard, April 2018
We are delighted that Dr. Philipp Stillhard from Switzerland is able to visit some of our new PNG trainees in their own hospitals.
First stop is Nonga Hospital near Rabaul in PNG. Here, Dr. Kevin Lapu has been trying to look after trauma with limited training and equipment. Through PIOA, he has been able to source implants and a battery surgical drill.
This is Kevin using his new drill under direct supervision of Philipp, for the very first time. Over the next 3 years as Kevin gains new skills he will be able to provide quality surgical orthopaedic care for the people of his community who come to Nonga Hospital.
Philipp’s travel costs are met by generous donors who cover airfares and his accommodation in PNG. All of his time is a free donation to improve the care of patients in the Pacific.
You can read Dr. Kevin Lapu’s report on the visit here.