Thursday, October 24, 2013

Rugby? Yes, but I wont be mentioning the Yachting.

"Grog" = Kava; Very important in Fiji - but I prefer the Icecream
Working at the Hospital in Lautoka was fascinating, challenging and rewarding. In Fiji everyone is incredibly friendly and there is an openness and warmth thats inclusive, and welcoming. When you experince it at the airport or in your holiday resort you might be tempted to think they are making a special effort for Tourists, but no, everyone really is like that, everywhere you go. So I was working in a  very warm and supportive environment with hardworking and fun loving people. The clinical cases were interesting, and I was given the specific task of beginning to develop, support and strengthen the relationship between the Base hospital and the five peripheral subdivisional hospitals. This meant I got to travel about and visit them all, meet the staff, inspect the facilities, conduct training and teaching sessions there, and then provide feedback and make suggestions about where improvements could be made. I also assisted the Regsitrars prepare for their exams by going to their teaching sessions and helping with Mock Exams. This was all quite different to the clinical work I was used to doing, but I did plenty of that as well.

One evening at 8pm when I was on call we received an urgent call from the subdivisional hospital at Sigatoka. A woman had been brought in from a distant barely accessible inland village in shock. It was thought she had a ruptured ectopic pregnancy, a complication of early pregnancy feared for this very reason, that women can suddenly collapse with massive internal bleeding, and die.  She needed urgent surgery, but was too unstable to transfer to Base, and  unfortunately there was no surgeon in Sigatoka. Years ago these little hospitals were staffed by clever old fashioned General Practitioners who could  do that sort of emergency surgery as well as  appendixes and caesareans,  and a few other basic surgical things. Unfortunately however, after a couple of Military Coups there was a massive depletion of trained medical personnel, many of whom were Indo-Fijians  fearing the worst left for Australia and New Zealand. Health services everywhere but especially in the districts took a massive backward step as a result, and they are still trying to recover from it. But the little operating theatres in each hospital are still there, though hardly ever used. The local solution to this awful dilemma is to activate "The Flying Squad". We didn't actually Fly to Sigatoka, we drove, so I suppose it should be called The Driving Squad but that doesn't sound anywhere near as glamorous or exciting.

The Flying Squad  consists of a couple of Theatre nurses, an anaesthetist and a surgeon - in this case, me - who are rapidly assembled and speed off in an Ambulance with lights flashing and siren blaring, taking with them a full set of sterilised theater instruments to the hospital where the patient is. We were supposed to also take blood but I hadnt known then that the subdivisional hospitals have only two or three units and expect us to bring more. Fortunately someone asked me about it as we headed south, but instead of going back we radioed ahead to Nadi Hospital, called in there on the way through and picked up the extra units. It was quite a scary ride, because the road is poorly lit and narrow, cattle and horses are often seen wandering across it, not to mention people and dogs and goats, but we made good time, and maybe ten minutes after arrival we began the surgery, and gave her the extra blood. The ectopic was the worst kind - cornual - but wasnt hard to deal with. We brought her back to Lautoka, arriving at about 2am, and a couple of days later she went home. There have been three deaths from Ectopic pregnancy in this district in the  last year, and about 7000 births - by comparison, in Australia over the three years 2003-2005 there were nearly 750,000 births but only one death from ectopic pregnancy.
The Course Participants at Sigatoka Traing Sessions
Clearly Ectopic pregnancy seems to be a particular problem in Fiji, with a mortality over three hundred times what it is in Australia. Its related to tubal damage from sexually transmitted infections, which occur at very high rates here, but this is not the cause of the excess mortality. The cause relates to what the WHO calls "The Four Delays" - delays in recognising theres a problem, delays in deciding to do something, delays in reaching a healthcare facility, and delays in receiving the correct care.The Four Delays apply to all causes of maternal death. In Australia every woman of reproductive age - say 12 to 50 - who comes to an Emergency Room, gets a Pregnancy test, no matter what the reason for her being there is, and there are usually prominent notices reminding nurses and doctors to do them. The nett result is pregnancies get picked up earlier, ectopic pregnancies are recognised before they have ruptured, and simple laparoscopic surgery usually means they can be cured and go home the next day.

The problem for Fiji is firstly the lack of education about the danger signs - this leads to delays in recognition and in deciding to seek help. The remoteness of many fijian villages contributes to delays in reaching help, and sadly the medical profession here is not as vigilant as it ought to be, so there are additional delays in receiving the correct care. Pregnancy tests are often not done, and thats often because they are not available. The Health budget, indeed the economy generally is not robust enough to supply the thousands of pregnancy test kits that would be needed - so overseas charities have often provided them, but on an inconsistent basis. I suggested to the subdivisional hospitals that they buy a few from the local chemist and recover the cost of each one directly from the patient , but they told me that would contradict the policy of care being free - but will do it anyway! The retail cost is $3.95 but they could get them for a lot less if they bought in bulk from a supplier.

This scenario is repeated at every level throughout the health service in Fiji, and made me realise anew what a massively expensive undertaking it is to develop and maintain a modern health system. There are liquid soap dispensers above many sinks - but they are empty, and so are the paper towel dispensers. Many lab tests become unavailable once the budgeted supply of reagents has been used up,  the recommended tests for diabetes cant be done because the special glucose drinks have all been used up, CTG monitoring paper is in short supply so the midwives run it for ten minutes at a time instead of at least 20, many of the hospital buildings are in need of basic maintenance and in the operating theatre disposable caps and masks are in short supply. We did three laparoscopic cases and then they ran out of the special cleaning fluid for the instruments so couldnt do any more. There isnt the money to run a proper cervical cancer screening program, so I have seen more cervical cancer in six weeks here than I ever saw in all my working life in New Zealand and Australia.  If these women need radiotherapy, its not available in Fiji. No doubt similar budgetary constraints apply in paediatrics and general surgery and medicine.

Anyone coming here from a developed country would probably be shocked - but having worked in Ethiopia and South Sudan I see the glass here as half full, not half empty ( or too big as an engineer once said)  In South Sudan and Ethiopia  most of these tests are NEVER available,  you can't diagnose cervical cancer let alone treat it because there are hardly any doctors, there is NO pathology service, and most of these women would never get to hospital because there are so few roads and so few hospitals.

There is therefore much to admire in what has already been achieved in Fiji. The Doctors and med students and nurses are really hard working, eager to learn and on the lookout for any extra bit of help they can get, but there is still much to be done.
Watching Rugby - very popular here. 

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