Always learning

By Rob Mitchell

22 September 2017

I made mistakes last time. Perhaps that's inevitable, but I wish it wasn't the case.

After 15 years of medical training, I thought it would be easy to translate my skills to a new environment. It's not as if human physiology changes when you cross a border.

As it turns out, scientific principles may not differ, but plenty of other things do. When I undertook my previous volunteer assignment – as Visiting Clinical Lecturer in Emergency Medicine at Divine Word University in Madang, Papua New Guinea (PNG) – I spent a portion of my time supervising students and junior staff in the Emergency Department (ED) of Modilon General Hospital. I learned that what works in Australia doesn't necessarily work in PNG.

I vividly remember one patient, Ben *. He presented with a descending paralysis nearly 24 hours after being bitten by a snake. His airway was compromised and his respiratory effort poor.

There was no functional intensive care unit in Madang, and only in rare and specific circumstances would patients be intubated – a process that involves inserting a breathing tube into the trachea to facilitate oxygen delivery to the lungs. Patients would then be supported in the operating theatre's recovery suite or ‘private ward', a wing usually reserved for VIP patients. The local emergency physician and I quickly decided that Ben needed this level of attention.

The intubation went smoothly. He received anti-venom because it was in stock that week. Basic monitoring was implemented. Care was handed over to the inpatient team. We updated his family members.

Ben died a few hours later. We only found out when we enquired about his progress.

It wasn't the news we expected to hear. Ben's emergency care had been timely and effective, despite the Department's extremely limited resources. His presentation even provided an opportunity for teaching; we'd demonstrated the intubation process, and discussed snakebite treatment.

I was never able to find out exactly why he died. There are many potential explanations, but fundamentally, the environment wasn't equipped to support someone in such a vulnerable state.

I've thought about Ben a lot since then. What could and should we have done differently?

I've learned that, in these challenging and resource-constrained environments, less is often more. Rather than a plastic breathing tube, Ben may have been better served by the lateral recovery position and an oxygen mask. That approach would have had significant risks, but it might have limited his exposure to iatrogenic injury. One of medicine's guiding maxims is ‘first, do no harm'.

I've also realised the importance of systems of care. Hospitals are complicated pieces of machinery, and all the parts are interconnected. There is little value in developing components in isolation.

Although clinical care was not the focus of my work in PNG, Ben's case is illustrative of the challenges of practising and developing capacity in an under-resourced environment. Those of us who visit from outside need to think deeply about what strategies will be safe and effective.

When I got back to Australia, I experienced a sense of guilt that I'd benefited more from my assignment than I was able to contribute. I only hope that, during my brief time in Madang, I was able to have some small impact on the health students I was teaching. They will play a critical role in improving healthcare delivery in the most remote corners of PNG.

Fast forward three years, and I'm sitting in a balcony hammock overlooking Iron Bottom Sound. My (now) wife and I have returned to the Pacific for another volunteer assignment with the Australian Volunteers for International Development program. This time we're in Honiara, contributing to the Solomon Islands Graduate Intern Support and Supervision Project (SIGISSP). Our first task? Learning how to pronounce the acronym.


Australian volunteer Dr Rob Mitchell (l) and Emergency Nurse Rita Suvi (r) at the National Referral Hospital, Solomon Islands. Photo by Nick Sas.

Similar to PNG, the central focus of our work is teaching and training. This time we're helping to develop and implement a transition-to-practice program for Solomon Islanders who have completed their undergraduate medical studies in Cuba. The current group of trainees have returned to Honiara after six months of Spanish language training and six years of medical education.

It's an exciting time to be at the National Referral Hospital. There are more interns than ever before, and there is a palpable sense of possibility. Our challenge is to help convert the Cuban investment in undergraduate education into an effective medical workforce for Solomon Islands. There are very few doctors outside Honiara, but that stands to change.


Intern Dr Phillip Notere (l) and Australian volunteer Dr Rob Mitchell (r) at the National Referral Hospital, Solomon Islands. Photo by Nick Sas.

The first cohort of Cuban returnees are about to complete their internships. The two junior doctors currently working in the ED have been posted to isolated island communities that have not had a doctor for many years, if ever. Tony is destined for Tulagi, the country's former capital that was decimated during World War II, and Edwin is heading to Renbel (a portmanteau of Polynesian Islands Rennell and Bellona). Heading to a province as a sole doctor must be incredibly daunting, but I am confident that both of them will have a positive and enduring impact on these communities.

In my work here, I consciously try to apply the lessons I learned in Madang but there are still plenty of challenges. My responsibilities are much more varied than they are at home, and again I find myself learning new skills. In the ED, I supervise interns, but I also contribute to a whole raft of quality improvement activities, including departmental teaching, guideline writing and policy development.

Last week, the ED implemented the Solomon Islands Triage Scale. Based on a South African model, it's been adapted for the setting by an Australian volunteer nurse advisor who's also based in the ED. It's a major milestone on the road to improved emergency care.

On the SIGISSP front, our team of Australian volunteer doctors, along with the volunteer Intern Training Program Supervisor and local colleagues, are assisting with the development of the hospital's training programs. We've been formalising guidelines, developing a syllabus and writing examinations. These are not tasks in which we are particularly experienced, but we're drawing on our experience and networks to do the best job we can.


Bridging interns Dr Culwick Sigoto, Dr John Geseni and Dr Adam Wyndam with Australian volunteer Senior Registrar (Paediatrics) Dr Rami Subhi (L-R) at the National Referral Hospital, Solomon Islands. Photo by Rob Mitchell.

We hope we're doing the right thing, and worry that our colleagues are too polite to tell us if we're not. Solomon Islanders are not only extremely resilient, they are incredibly forgiving.

I've been told on many occasions that international assignments come with their ups and downs. I anticipated that prior to my first volunteer deployment, but I didn't appreciate that the amplitude would be so extreme.

Working in a clinical environment, the lows seem all too regular. Death and despair are common in the ED, and sometimes the demands are overwhelming. But there are plenty of reasons to keep coming back. For one, the director of my department is an exceptional leader. Having only finished her specialty training 18 months ago, she is one of the most positive and influential role models I have ever worked with. She is leading a range of reforms that will have a marked impact on the quality of emergency care, as well as teaching and supervision, within the ED.

There have been many mistakes and there will be many more. I do a lot more reflecting here than I do at home, and it's probably still not enough. My job title here is the same as it is in Australia, but the content and the context are very different. That comes with challenges, but it also rewards in abundance.

I learnt a lot from Ben's death, and I think my local colleagues did too. I hope there will come a time in PNG and Solomon Islands when that sort of system failure is a distant memory. It's a long way off, but I hope that the Australian volunteer presence is bringing it a little closer.

I strongly encourage you to become part of the effort.

*Ben is a pseudonym used to protect the privacy of the patient and his family.


Rob's volunteering assignments are part of the Australian Volunteers for International Development (AVID) program, an Australian Government initiative.



Last Updated: 22 September 2017
Australian volunteer Dr Rob Mitchell (l) and Emergency Nurse Rita Suvi (r) at the National Referral Hospital, Solomon Islands. Photo by Nick Sas.