PIOA Supervision visit to Nonga Hospital, Rabaul

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

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

PIOA supervision visit to Nonga, PNG

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.

Report on Module 1, 2018 – Trauma module / Research module

 

 

Module 1 was held at the Modilon Hospital and the Madang Lodge Conference room in Madang, Papua New Guinea(PNG) from January 29th to February 16th, 2018. This was the first time we combined two courses in one module over 3 weeks and the first time we have held the Research module There were 14 trainees in the Trauma module and 20 trainees attended the first ever Research module. They are Dr. Shaun Mauiliu and Areta Samuelu from Apia in Samoa, Dr. Kabiri Itaka from Kiribati, Dr. Stephen Kodovaru, Dr. Alex Munamua, Dr. James Tewa’ani and Dr. Clay Siosi from Solomon Islands, Dr. Pita Sovanivalu and Dr Mark Rokobuli from Fiji, Dr. Johnny Hedson from Pohnpei, Federated States of Micronesia, Dr. Naseri Aiotato from American Samoa  and Dr. Alois Mouemuem, Dr. Jimmy Yakea and Dr. Petrus Opum from Popondetta, Dr. Thomas Kiele from Kavieng, Dr. Raymond Saulep 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. Nik Friederich, Dr. Jochen Ruckstuhl, Dr. Gerold Lusser (all from Switzerland) Dr. David Bartle from New Zealand, Dr. Stephen Kodovaru from Solomon Islands Dr Sara Coll and Dr. Des Soares from Australia.

In this module, the students were taught a systematic approach to diagnosis and management of trauma. This included clinical history taking and a thorough clinical examination with emphasis on a systematic approach to the management of trauma including 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 trauma affecting the long bones of the limbs.

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 bone and joint infection and trauma – both of which are common conditions throughout the Pacific and are often poorly managed. PNG has a large volume of severe trauma due to bush knife (machete) and gunshot wounds. The students were assessed with a written examination on the final day of the Trauma course.

In the Research module students were taught critical appraisal skills, biostatistics and research methods. The goal is for our students to be able to identify areas of research they can successfully perform and publish to improve the outcomes not just for their patients but for patients throughout the developing world. Every student left the module with a written and team reviewed research proposal to implement.

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 Paediatric orthopaedics and Orthopaedic Tumours to be held in Apia Samoa, commencing on 29 July 2018.

Our thanks to the staff and patients of the Modilon Hospital, Madang and the Madang Lodge 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 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..

Brief course review – Stevens James from Lae, PNG

It has been a pleasure in the last almost three weeks of statistically drilling/screwing the gospel vibes of PIOA across the corridors of the Pacific.
Although tiring, it’s an opportunity not to be missed for some of us and the most exciting aspects of Orthopedic care.

Moulded cast application – Kabiri Itaka (Kiribati) applying a short arm cast to Stevens James (Lae, LNG) under the supervision of Prof Nik Friederich (Basle, Switzerland)

To our teachers/mentors, you have been sent from heaven, thanks a million times.
To our colleagues in the Pacific, our haematological bondage has grown thicker to strum the orthopedic vibes more closer and enjoyablly.
Happy sharing/gaining skills and knowledge, farewell! Special thanks givings to Prof Nik Friederich and Our none other than the man himself, Des
Cheers! !!!

Stevens James, Lae, Papua New Guinea

Trauma module in Madang, PNG Week 1

The Trauma module commenced at Modilon Hospital, Madang and at the Madang lodge.

David Bartle (NZ) teaching Jimmy Yakea (PNG) with Thomas Kiele (PNG) as patient

We do ward rounds and practice clinical examinations each day at the hospital and then use the Madang Lodge conference room for lectures and practical exercises.

Learning the SIGN nail system. From L to R – Thomas Kiele, Jimmy Yakea, Anthony Nasai, Alois Mouemuem and Stevens James (all from PNG)

 

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