Baimuru ward round
Kapuna Rural Hospital is not like a New Zealand hospital- that is obvious on so many levels. But it functions. Patients come, are assessed, treated, discharged or referred. It is a haven in this vast isolated jungle. The staff are diligent and have studied hard to gain the necessary knowledge and skills to care for their community. They are punctual and attentive. My ‘ward round’ to Baimuru showed me the other face, the much more common face, of health care in PNG.
Baimuru is a large village or station 1 hour up river by fast canoe. It has a large store, an air strip that can be used in the dry season, and has, for many years, had a school and health centre. Recently the facilities for the health centre became so run down as to be all but unusable so the decision was made to rebuild the station. A lovely new complex with running water, louver windows and intact floor and ceilings was build next to the original health centre. However, the new health centre has not yet been ‘officially opened’. I understand that despite having been competed months ago, this opening requires the presence of some dignitaries and has not yet been arranged. In the meantime health services are being provided out of the old condemned building. That, however, is not the most frustrating aspect of the Baimuru situation.
The Baimuru health centre is staffed by a number of trained nurses and community health workers. They are paid by the government and receive their pay into their bank accounts. Unfortunately, there is no cash machine in Baimuru, and no bank. As there is no way for health workers to access their pay at their place of work, they travel to Port Moreseby periodically. Many do not return for duty. For a considerable period of time the Kapuna doctor has attended Baimuru monthly to do ‘ward round’ at the health centre with a group of volunteers from Kapuna who are not technically on duty. The paid Health Centre staff have simply disappeared. The Kapuna staff are filling the gap.
We were in good spirits as we made the canoe journey up from Kapuna on the morning of the ‘ward round’. We were hoping to get through our duties quickly, hoping that some staff might show up to help with the scheduled clinic. It was a beautiful day and we could see the mountains of the highlands in the distance as we moored our boat and climbed the ladder to reach our destination. I knew the facilities were run down, but was still surprised at what I found. Floor boards were rotted out, the ceiling was sagging, mosquito net over the open windows was ripped. There was one table and a few shelves, two iron bed frames and one filthy foam mattress. Yet the drug store, while lacking any organisation, was topped up to the brim with a wide range of medicines, many still well within date. Staff had clearly come in, taken what they needed and left what they didn’t packed in opened and unopened boxes, lying here and there. The dressings were mixed in with papers and full and empty bottles. There were boxes full of rubbish and some drawing needles still poking out of antibiotic vials. The ordering schema inside me ached to put it right, to make it orderly, to banish the chaos. There is no point I was told, it won’t last, no one maintains it.
We hoped to get to the store before the patients started arriving, but it was not to be. They were already filling up the room, sitting and standing here and there as we put some supplies on a table and divided up duties. Several staff would work on vaccinating children and doing their health checks, one would offer contraception and the doctor and I would assess unwell patients. I inwardly thanked God for my years of nursing in medical wards, emergency department and, most useful of all, at Hutt Union where I did extensive assessment, diagnosis and treatment under standing orders. Armed with my copies of the PNG treatment guidelines for both adults and children I prayed for help in my overwhelming task. I had brought my medical bag with me, with all the instruments I had brought from New Zealand for use in such circumstances – there would have been none available for me otherwise and I could not imagine providing care without a stethoscope and thermometer.
My first patient was an elderly lady who looked about 80, but was probably no more than 60. She had a swollen foot and ankle pain. I was struggling with language. Was this a new injury or a long standing problem? Fortunately I was saved by a Village Volunteer Health worker – Peter who appeared at an opportune moment. He stuck with me all day translating and helping me when I got stuck. Together we treated chest infections, skin infections, handed out salbutamol pills (!) to the asthmatics who don’t think inhalers constitute medicine. We did a renewal of antihypertensives for a patient who had been started on these in a previous clinic – I was very surprised to unearth atenolol in the disordered drug store room. I frustrated a couple of mothers by prescribing recuperation for children who appeared otherwise well. We prescribed panadol for musculo-skeletal injuries of unknown origin and did simple dressings for a range of minor skin wounds, bitterly regretting the lack of running water most at that time. I was astounded that, in these conditions, a colleague undertook the minor surgery needed to replace contraceptive implants in patients’ arms. The women submitted to this with astounding strength and determination.
We saw far too many children with weight and height for age below the second standard deviation. PNGs are small by any standards but many in the Gulf many also lack protein, especially inland where fishing is more difficult. We referred one malnourished little one for TB assessment after a year with persistent cough while living with her Bubus (grandparents). I found another little girl with a significantly swollen lymph node characteristic of extra pulmonary TB and asked the doctor to look at her too. It was a unilateral swelling – ear infection more likely! Silly me. One wee baby worried me with a high fever and lethargy, not feeding properly for more than a week. She saw the doctor and came with us on the boat for better assessment at Kapuna. All through the clinic Peter, the Village Volunteer, stuck by me helping me immensely.
I was very concerned to ‘first do no harm’ and comforted myself that all the treatments we gave or plans that we made were unlikely to risk any harm. I wrote in the patient’s exercise books – their version of clinic books, or perhaps just a scrap of paper for those who didn’t have one. The task of noting presenting complaint, history, subjective and objective findings cleared my head and helped me to work through things in an orderly way to minimise the risk of missing something important.
The tide of patients finally subsided and I was well ready for lunch, I figured it was about 2pm. I was told it was more like 5pm. We had worked the whole day away. It turned out one of our patients was in fact the Chinese owner of the Baimuru store. In his gratitude he donated cold coke cans and crackers to our cause – we were more than amply rewarded in this.
The boat ride home gave me time to reflect on a system in which a new purpose-built building sits empty, while we work without water or privacy in a dilapidated building next door; a system where one group is paid and do not work and another group is not paid and yet work. Truly PNG is a land of the surprising.