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.
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..
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.
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
Stevens James, Lae, Papua New Guinea
The Trauma module commenced at Modilon Hospital, Madang and at the Madang lodge.
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.
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.