First PIOA module in PNG

In 2 weeks we will hold the first ever PIOA module in Madang, PNG. The module will be held from 29 January to 15 February 2018 and will cover Trauma and Research.

PNG has the largest population among the Pacific Island countries with approximately 7 million people most of whom live in remote areas with limited clinical services. PIOA hopes to train enough PNG doctors over the next few years to have orthopaedically trained surgeons in at least 18 centres around PNG. We already have trainees in 4 centres.

Name tags with flags of the trainees who will be attending this module.

 

Kavieng visit

PIOA Supervision visit in  Kavieng, Papua New Guinea (PNG) November 2017

 Dr. med. Philipp F. Stillhard, General- and Trauma Surgeon, incl. Orthopaedic Trauma

Kavieng

Kavieng is the capital of Papua New Guinean province of New Ireland and the largest town on the island of the same name. The town is located at Balgai Bay, on the northern tip of the island and it is both a trading and a tourist destination. The Kavieng Hospital is responsible for over 200.000 people in New Ireland Province. My accommodation is on a small island, called Lissenung Island, a 20 minutes’ boat-ride from the hospital.

 

Dr. Thomas Kiele, a PIOA trainee, is working in a small team of three, a fellow resident a consultant and himself. The ward buildings are old and some of them would need some renovations. Energy and water supply seems more or less sufficient. Unfortunately, the new operation tract, opened one year ago, has still some unsolved problems and only one of two OTs can be used. The OT-team is motivated and highly trained, clinical nurses provide an anaesthetic service and the surgeons are responsible for regional anaesthesia. However, the actual main problem is the modern digital x-ray machine. Sometimes it works, sometimes not and even when it works there are no printed films and x-rays can only be looked at one computer in the x-ray department leading to a difficult situation for daily work, especially in clinics and OT. An intraoperative C-arm is on its way, hopefully it will arrive at the end of this year.

A small fragment set, a donation from New Zealand, is available with screws, DCPs, 1/3 tubular plates, some Recon- and T-plates as well as its reposition clamps and K-wires. A power drill just arrived some days ago, unfortunately without quick coupling and the key for the Jacobs chuck is missing as well. I realized that Thomas and his team has no idea what amount of osteosynthesis material they have in stock. Finally, we went on to count all the plates, screws and reposition clamps and wrote it down in an Excel file, which I got kindly from Alois from Popondetta.

My first day at Kavieng Hospital, we did an extensive ward-round, discussed all the orthopaedic cases for its non-operative or operative treatment. We have been recruited patients from the surgical ward and from the out-patient clinic, especially with non- and mal-unions around the forearm and some cases of osteomyelitis. Just some cases to mention:

 

Case 1: A young lady with a history of broken left forearm 3 years ago. Initial treatment was done by a rush pin. Healed in a malposition. After removal, a second fall followed and the forearm was treated non-operatively. Finally, a non-union was the result. We discussed the different approaches for the forearm, treatments for non-and mal-unions and of course how to use the new power-drill. Unfortunately, getting a new x-ray was not possible because of the faulty x-ray machine. But clinically it was obviously a non-union.

 This was the first time a power-drill was used up here and I did some training with Thomas and his team including the OT-team how to prepare and sterilize.

Case 2: A 12 years old girl with an old dislocated radial head fracture leading to a huge extension and flexion deficit as well as no pronation and supination movement anymore. After explaining the operation and avascular necrosis risk to the patient we decided to go for an operation over a lateral approach, exposed the dislocated radial head followed by an osteotomy and reduction and fixed it with percutaneous K-wires.

Unfortunately, there are no postoperative x-rays available for all these cases we did because of the broken x-ray machine.

Next to all the operations and teaching in the OT, we discussed fracture management around the humerus, femur and tibia and its different approaches as well as intraoperative use of the C-arm in orthopaedic trauma care because of the arriving C-arm at the end of this year. I also got the possibility to talk about the idea behind PIOA in a morning discussion with all members from the hospital medical board. Hopefully, they got my message about supporting Thomas for his PIOA training as well as financial support for further osteosynthesis material.

 

After all this work, Thomas showed me how life is going on up in Kavieng. He showed me the market and took me out to a boat ride with his friends

Future ideas

More supervision missions should be organised for the Kavieng Hospital. Dr. Thomas is motivated to learn but the support he gets from the local surgeon is quite low because of leaking knowledge in osteosynthesis. Furthermore, a large fragment set should be the next investment or donation because right now the only treatment for long bone fractures is ExFix. With the arriving of the C-arm, there also should be some instructions how to use it in daily practise and protection overalls are absolute necessary. The hospital should realize that it must support Dr. Thomas with buying some implants and screws. To mention only one deficiency, shorter sizes of screws in the small fragment set already run out and so do plate soon.

Furthermore, Thomas will regularly update his PIOA database and implant register.

 

Philipp F. Stillhard, Kavieng 03/12/2017

Popondetta visit

PIOA Supervision Trip in Popondetta,  Papua New Guinea (PNG) November 2017

Dr. med. Philipp F. Stillhard, General- and Trauma Surgeon, incl. Orthopaedic Trauma

Popondetta

Popondetta is the capitol of Oro (Northern) Province in PNG and is not far from the beginning of the Kokoda Trail, made famous during World War II. Popondetta Hospital is responsible for over 300.000 people in this area. The town is small, some shops and one hotel, which has a simple infrastructure but it has everything what you need up here and it is special secured by a high fence around the property and a security guard is doing his rounds at night.

 

PIOA trainee Dr. Alois Mouemuem is working in a small team with a fellow resident, Jimmy, and a consultant, Dr. Opom. The buildings are several decades old but well maintained. The surgical ward accommodates general surgical patients and orthopaedic trauma patients. Energy and water supply seems more or less sufficient. Right now, 2 ORs are running with a small sterilisation and packing unit. Clinical nurses provide an anaesthetic service which is working quite well and efficient. Basic instruments and reposition clamps are available as well as a hand-drill. Recent orders, such as a small and large fragment set is available as well. Basic procedures such as external fixations, pin tractions and uncomplicated small- and large-fragment cases can be done safely. For more complex cases or just for simple K-wire usage, a power drill should be purchased, better with a quick coupling than a Jacobs chuck. Unfortunately, there is no intraoperative imaging available right now.

The OR team is working very thoroughly and clean. Some ideas how the material and especially the different reposition clamps should be packed and stored should be discussed as well as a screw rack would be helpful to get a screw overview during the operation.

An amazing new building in high quality standard is built on the hospital’s property, including 2 new ORs with a C-arm and a casting room with its own x-ray machine, a sterilisation and packing room and a huge recovery room, including 2 ventilation places for patients who need some artificial respiration. Hopefully, it will be opened soon early next year 2018.

During my stay in Popondetta, my main aim was to supervise Alois, as a PIOA trainee and to evaluate the hospital for future supervising visits because working together with the trainees in their environment and with their equipment and possibilities will be an important mean of teaching and transferring knowledge in the future (Walliser M.: SST Mission PIOA Module Apia, Samoa and Kokopo / Kavieng, Papua New Guinea June-July 2017).

A warm welcome was organized at my first day with everybody important from the hospital, followed by lunch. We have been recruited patients from the surgical ward and from the out-patient clinic. Just some cases to mention:

Case 1: Around 60 years old lady with a delayed-union at the right proximal humerus. Because of pain and dysfunctional movements, the right upper extremity is useless. The aim of this case was that this old lady can use her arm again. From the side of teaching aspect, there are three main goals. First, it is important to know the difference between delayed-union and non-union because the treatment is or could be different. Secondly, there is the issue of the different possible approaches around the humerus. After discussing the benefits and drawbacks, we have decided to go for an anterolateral approach which was never done before by Alois. Finally, there are the AO-principles, which should be respected when we go for an operative treatment. In this case, we reached the stability by drilling eccentric during using a large fragment DCP.

Case 2: Old lady, hit by a grass-knife at the right elbow. The x-ray showed an olecranon fracture. We discussed the different treatment possibilities and came up that tension band wiring, especially this technique is unknown in Popondetta, is a great and cheap option for fixing olecranon fractures.

 

Case 3: However, there are a lot of dislocated forearm fractures in this area. Most of them reach the hospital after some weeks, already nearly healed in a mal-position. This case shows a 4 weeks old right distal radius shaft fracture. The patient can’t hardly do any pronation or supination.

Next to these cases, we did a lateral approach for a distal femur fracture, some tendon repairs and a lot of children fractures for open and closed reductions.

But not only operating was a main issue. We had some good discussions with the hole group about x-rays, reposition techniques, non-operative versus operative fracture treatment, different approaches to the femur, radius and humerus, principles of osteosynthesis, and influence of the patient factors and the injury.

And of course, free-time was also there. I learnt from the “hospital gang” how to play dart and billiards and they showed me places around Popondetta.

I am grateful for this effort.

Future ideas

For sure, more supervision missions should be organised for the Popondetta Hospital. There will be new options with the opening of the new theatre in 2018 meaning that better conditions such as a C-arm could be used for procedures. Furthermore, Sign-Nails should be organised and introduced to the guys up here. Dr. Alois is motivated, has the power, cleverness and knowledge, that he could deal with the Sign-Nails after some supervision.

The hospital should keep going on with buying some implants and screws. To mention only one deficiency, shorter sizes of screws in the large fragment set already run out. In my opinion, a power drill should be purchased, better with a quick coupling than a Jacobs chuck.

Another issue to mention is, that there is a need of teaching the OR-nurses how to use orthopaedic instruments and how they should maintain these instruments because these instruments are quite a new topic in the hospital and of course dealing with it is not easy and has to be learnt.

I am pretty sure, also the anaesthetic team would profit from some supervisor visits and beginning in time in the morning is one important thing next to the different techniques in anaesthesia.

Philipp F. Stillhard, Kavieng 03/12/2017

 

 

Pohnpei visit

Dr. Des Soares, Dr. Vernon Moo (anaesthetist) and Nurse practitioner Lisa Yang visited Pohnpei in the Federated States of Micronesia from  11 to 19th November 2017. The visit was aimed at supporting PIOA trainee Dr. Johnny Hedson who has worked as one fo two surgeons on Pohnpei for many years.

The team dealt with a number of trauma cases that had malunions and chronic elbow dislocations. They also did 4 hip hemiarthroplasties. Below is one  38 year old lady who had a nonunion f a subcapital fracture for the past year and who had not been able to weight bear.

On the last day Dr Johnny took the team to visit the World Heritage Nan Madol area and deep sea fishing.

 

AOA ASM, 9 October 2017, Adelaide

PIOA trainee Felxi Diaku (PNG) presented a scientific paper at the Australian Orthopaedic Association Annual Scientific Meeting in Adelaide on 9-13 October 2017. Dr. Paul Hitchen, President PIOA presented  on Chop injuries in PNG and Dr Des Soares, Director of Training for PIOA  presented on the progress in the PIOA training program.
A special presentation was made to Dr. Stephen Kodovaru on his graduation from the program. Photos of some of the AOA fellows who have helped PIOA during training modules.
From L to R: Kate Stannage, Nicole Williams, Peter Cundy, Des Soares, Stephen Kodovaru, Paul Hitchen, Bruce Caldwell, John North, John Tuffley

Module 3, September 2017, Hip

Front row: L to R. Andy Vane (NZ), Vaughan Poutawera(NZ), Johnny Hedson (FSM), Sud Rao (NZ)

Back row: L to R. Naseri Aiotato, Areta Samuelu, Mark Rokobuli, Alois Mouemuem, James Tewa’ani, Felix Diaku, Thomas Kiele, Kabiri Itaka, Pita Sovanivalu, Raymond Saulep.

The “Hip” module was held at the National Referral Hospital, Honiara, Solomon Islands, from 18 to 29 September 2016. This module covered history taking, clinical examination, and management of  orthopaedic conditions affecting the hip including traum .. You can read  the  Module 3 2017 report here.

PIOA congratulates first graduate Dr. Stephen Kodovaru

PIOA is delighted to announce the graduation of our first student, Stephen Kodovaru from Solomon Islands who has successfully completed his training and passed the final exit exams. The independent external examiners were Dr. Richard Lander from New Zealand and Dr. John North from Australia. Stephen will play a central role in further developing the PIOA program.

PIOA students singing to celebrate the graduation of Stephen Kodovaru (click link to view)

PIOA meet with Prime Minister of Samoa

Dr. Des Soares, PIOA Director of Training,  met with  the Honorable Prime Minister Tuila’epa Sa’ilele Malielegaoi of Samoa on 13 June 2017,
 to discuss the PIOA training program. The Prime Minister was very interested in our model of training doctors in orthopaedics,
 using a module approach that minimised the time away from their hospitals and home countries.

Module 1, February 2017 , Introduction to orthopaedics

The Introductory module was held at the Lautoka Hospital, Fiji from 30 January to 8 February 2017.
We welcomed 7 new trainees (Raymond Saulep, Thomas Kiele, Alois Mouemuem, Henao Asa from PNG, Alfredo Adams from Samoa, Pita Sovanivalu from Fiji and Johnny Hedson from FSM). PIOA now has 18 trainees in 8 countries. You can read the Module 1 2017 report here.
From L to R: Front row: Stephen Kodovaru (Solomon Islands), Des Soares (Australia), Roy Craig (New Zealand), David Bartle (New Zealand), Tim Gregg (New Zealand), Mark Rokobuli (Fiji)
Back row: Raymond Saulep (PNG), Pita Sovanivalu (Fiji), Thomas Kiele (PNG), Naseri Aitaoto (Am. Samoa), Alfredo Adams (Samoa), Henao Asa (PNG), Alois Mouemuem (PNG), Johnny Hedson (Federated states of Micronesia).