Final day in Goroka

It was the first day back at work after the long weekend and we were making plans for the day – the hope was to get out to a Rural Community Health Post and have a meeting with the EHPHA Executive team.

My job in the morning was to get Schola’s (Infection Control Nurse) computer working so that the Access data base that had been created for her could work and we could download the driver for her printer. She has no internet connection in her basement office, I was not able to hotspot, so the plan was to take her computer up to the IT lab and connect to the only room with Ethernet connections. Arthur is in charge of IT (he was running late). There is only one line into the hospital, so all the offices are running off the same service. This was eventually done and at the end of the day I went back to get things sorted (at 6pm) – as it turns out her computer has a file corruption, so Arthur will need reinstall the whole system – I hope that this does not take longer than a week. Then scholar should be able to input data into the data base and into a spreadsheet to share Hand Hygiene audits with the Executive.

My phone was ringing and Marie and Leslie were just beginning our meeting with the Executive; Dr. Joseph Apa, CEO (anaesthetist);  Mr. Kidron Gimiseve, EO to the CEO; Dr. Kendaura (General Physician) Director of Curative Health Services; Dr Max Manape, Director of Public Health (this includes all Rural Health). The meeting was very productive and positive. There was recognition of the important role that the Highlands Foundation has had in the hospital since 2004. The organisation is very well respected and Marie is known and very highly regarded by all levels of staff.

It is a good time to have reconnected with the area. The new hospital has been built, bringing new specialist to the area; there is a new Model of Care Policy being rolled out;  and new Community Health Posts (CHP) are being built. The executive was keen for us to reengage and felt that our resources were best suited to Public/Rural Health Services. We introduced the Health Worker Kit project and the team was very receptive.

They noted that often resources provided to the hospital and health centres went missing and it was difficult to keep an inventory of items, so if Health Workers were given their own equipment they would take pride and take ownership of that equipment. It was decided that a goal would be to equip the Community Health workers and Midwives working at the CHP. When each centre is opened, the staff would be presented with a kit. The goal is to build 72 centres with 3 staff. That would be 216 packs.

We discussed the importance of incentivising staff to take ownership of their equipment and centres. Dr. Manape thought it would be great if THF could sponsor an award program for the best performing rural hospital (there are 8) and the best performing staff member in each region. The details of this are to be clarified, but this sound like a great opportunity for THF to invest in the valuable human resources in Public Health by supporting them in their practice. This year they sponsored the team from the best performing Health centre to attend a medical symposium.

If this project is successful, the plan would be to roll it out further. The idea is that this program can be a pilot for the country. The executive understand that they will need to keep records and monitor the success of the project.

We were then into the back of a land cruiser and off for a rural visit to Jafa Community Health Post (2 hours drive down the National Hwy). The country side is beautiful; green mountains, tropical temperate forest the then clear into savannah grass lands. Villages are scattered all the way along. People are selling veggies from their small plots at roadside plots. Jafa is in Kainantu District which is next to Goroka District. The houses are a little different as are the layouts of their garden plots. We slowly climbed and as we did the air became cooler. The highway is riddled with pot holes bigger than people and areas of unsealed dust roads. People are walking along the sides of the road the whole way, children returning home from school and villagers carrying their wares. It was a long and uncomfortable journey – demonstrating the challenges of getting people to general hospitals quickly.

After a bumpy journey (navigated very well by our driver Danny) along the Highway and up a final dirt track (of a few kms) we arrived at an impressive looking building perched on the crest of a hill. The centre is currently run by two Community Health Workers from the village of Jafa, George and Lizen (husband and wife).  They live on site with two of their children, whilst the older board at school in Goroka. The location was chosen to allow for access from mainly five local villages. The walk in is still an average one to two hours, cars are dime a dozen. It is then a 30 minute drive to the Kainantu District hospital or two hours to Goroka General.

The centre is large; a delivery suit, maternity ward (3 beds), emergency room, two consult rooms and an education room. It was intended to work as a mini hospital, but it is obvious that the centre is very large to be run by two community health workers. The equipment is technical and unfortunately they do not have the skills to use much of it. Marie was able to explain/turn on the resus cot. We made attempts to set up the steriliser, but they will need to have skilled staff come to the centre and support them. This is now another project for us: to make sure that the staff who work in these centres are supported and given the technical skills to use the facilities that have been provided. If we are going to support the workers with their own Health Worker Kit, it is important that they are supported by the local system to utilise the resources that are provided.

George and Lizen are on call 24/7. They tend to see most patients in the morning, maybe 20-30 a day. They run anti-natal classes on Tuesday mornings. They have found that the women who come to classes come to birth at the centre. They have birthed 9 babies – all have been strong and none have required interventions. They encourage the fathers to attend the births to support their wives. This is then followed by family planning and parenting programs. They feel that the fathers are more receptive to family planning after they see their wives birth their children. Especially the younger fathers. This approach benefits the whole community. Lizen did say that women who come from further away villages often come alone (or with another family member) for they need someone at home to look after the farm and other children.

It was a valuable experience to visit the centre. They are still waiting for the midwife to come who will also live at the centre. They will be more senior and be able to support the CHW. They need help with keeping the centre clean – louver windows are open and dust continually comes in. there are cupboards all everywhere, but everything sits on the benches. They need support with organisation, cleaning rosters, inventory etc. This centre is such a step up from the aid posts where they have worked before, so different to any building they have seen before that the processes to run such a place simply don’t exist in their lives. This has been an obvious gap in implementation of these new facilities. They are so advanced to anything before that there is culturally no experience that can prepare them to be responsible for such a place. Even simple cleaning of surfaces that we do so naturally, is not a part of their daily routine at home, because they don’t have surfaces and very few cupboards. They are great at keeping floors clean, but dusting just doesn’t exists.

On Wednesday morning we had a very quick tour of the new hospital. It is amazingly decked at – it looks like a hospital! Sturdy new hospital beds, wards that look like our hospitals (but unfortunately open cubicles, separated by curtains, so looks more like emergency), top of the line equipment. The labour ward does have 3 private delivery rooms, with 9 open beds and a theatre for performing C-sections. It is huge compared to what they have now. It was disappointing to see that many women will still not have much private space to move around through labour, but you still cannot say it is not an improvement.

The challenge now is to get the staff in and the hospital active and have systems in place to look after the space. There is still a need to purchase consumables and set up the space.

 I write this from Port Moresby – sitting overlooking the airport and The Stanley ranges drinking delicious PNG coffee.

Show weekend

The weekend bought in the show. The town is extremely busy, the streets are full of people – walking, singing, chanting, selling and eating (lots of beetle nut!) On Saturday Marie and I went second hand clothing shopping – there are huge warehouses full of clothing from Australia and NZ, we wondered around town and then prepared to pick up Leslie (Treasurer) and Moale (Marie’s Step daughter) and join Ricky’s (Cultural Liaison) family and friends for a gathering at Ricky’s family home (a 5 minute walk from the hospital). We have been so well looked after by family and friends here;  Marie, Dr Hoffman and Dr Laurie have done a great job in interweaving The Highlands Foundation into the community here, as have volunteers following them. But the hospitality afforded by the people here is so lovely. A huge spread was put on, BBQ local vegetables . . . . . . . . .. . . .  A beautiful welcome to Goroka.

Sunday morning and we were up early to head to the Goroka show. A gathering of communities from the Eastern Highlands and further afield (Mt. Hagen, Medang, Mendi and Sepik) to compete in a Sing Sing festival. The show was started y missionaries in the 1950’s for communities to come together and show their culture proudly. There is also a market and other recognisable show features; a flower display and competition, food market, simple games (throw a Basketball into a netball ring 20m away from 1K and win 20K), and community information stalls.

The experience was quite overwhelming; the costumes, the singing and dancing, the tourist presence and the local community all coming together. A total sensory overload. I felt so privileged to be a part of such an event.

The afternoon bought some rest, a talk about infection control with Margie and how I could help with some of the tech side of improving the auditing abilities of the hospital in relation to hand hygiene. I would fix their spreadsheets and attempt to connect a printer. More challenging than it sounds with no internet connection.

Monday was independence day. I woke to make pancakes for the kids and then headed to the basement office to start helping with the computer and spreadsheets. This would take the better part of the day. There was some success – with the spreadsheets, but the computer issues included needed to take the computer up to the IT room and connect it and see what could be done.

The afternoon was spent back in the labour ward. Women had just had babies and were labouring. We gave a girl who came with nothing a Mother and Baby pack, helped to get the baby feeding (he was very small, 2.5kg). Once he attached he sucked strong for such a little boy, he was going to be OK. This was her first baby.

Another woman had also birthed a small baby, her 5th. He was sluggish. Remembering my breastfeeding classes (and the challenges I had feeding my babies) I was able to help get her baby feeding (firm push to tilt his head, nipple to nose and firmly shove!). She had very little milk supply, but was keen to get help to get things started. She was a concerned Mum who know what should be happening. He fed and then they both rested.

The experience in the labour ward is bitter sweet: The women come in and have to be very self sufficient. They go through most of their labour independently, with midwives and nurses popping their head in and taking some measurements. There is no back rubbing or taking about breathing and little reassurance. They are not offered water. They are required to bring in their own plate to receive rice when it comes around (the plates in the ward disappear. There were no containers around, so one of the mothers just missed out.)

Having babies is messy business. The labour ward is the only ward to supply linen (a sheet), many women leak amniotic fluid, on the bed and floor. They clean this up themselves. The toilets have been closed for some reason, so they pee into one of the cleaning sinks in the open ward. These women are tough and just get on with it. They move into the postnatal clinic an hour or so after birth and leave the following morning. If their baby requires the special care nursery the mothers stay in the postnatal ward, they are encouraged to spend time with their babies and to feed them by hand expressing, especially if they are very small.

Babies end up in the Special Care Nursery if they are low birth weight (under 2.5kg), premature (under 37 weeks) or have some kind of sepsis (meconium aspiration that can lead to pneumonia). But it was clear that often their dating is imprecise.

The ward has little resources to make things easier for the women, nurses and midwives; no hand soap (but alcohol hand rub was available), no towels or cloths to wipe beds for women, no light for suturing (we bought some head torches), no cups for water (we did find a couple), no pillows.

What was available were birth packs (including scissors, scalpel, cord clamp and two stainless bowls ), a dopler to hear the babies heart rate (1 for the ward), Vit K with Hep B for the babies, Syntosinon for the women, catheters, IV fluid drip and stand.

The staff are doing the best they can with the little they have, but there still seems that there could be room for a little more care and cleanliness (for example, keeping the mop bucket clean with water (I could not find any soaps to clean these). The midwives/nurses have a reputation for being hard on the women, especially out in the rural centres. I definitely didn’t experience this – the midwives on the ward were attentive, but I can see how culturally the women to not receive much positive communication through the process.

Day 2 - Catching Babies

SO, after a challenging nights sleep (dogs barking and party music all night) we were up and off to a talk given by Margret Evans – a specialist in infection control(who first came to Goroka as part of THF 11 years agao). She was talking at the Grand Rounds to doctors and nurses. Most infection control is about minimising cross contamination – hand washing, instrument washing, consciousness about patient contact and how you use instrument between patients and then keeping the wards clean. The use of simple soap is better than antiseptic (just don’t use antiseptic!) for cleaning and making sure that surfaces and spaces are clean.

This all sounds simple enough, but in a hospital where; it is difficult to find a cloth, which has unreliable water supply and other funding issues – this can all be a challenge. But an important challenge to tackle considering infection is the major cause of death in the community and within the hospital. A doctor made an interesting point - in PNG seeing is believing - so bacteria is a hard concept to understand.

We then met with Joseph Apa (Eastern Highlands Provincial Health Authority CEO) to discuss how we can continue to support the district. The EHPHA has put together a new model of care with the aim of strengthening Primary care services within communities. Their goal is to build 72 new Community Health Posts through out the 24 Local Level Government districts (3 to a district). These CHP will staff 1 nurse and 2 community health workers and doctors visiting on out reach trips. They will service as mini hospitals (including a labour ward). This is a huge task, but there seems to be money at local levels available and these facilities will be wanted by the local communities. It would seem that this is where our services could be of most benefit. We will visit one of these CHP on Monday.

After a coffee we headed to the antenatal clinic, but the day was completed. On Fridays they run couples counselling – that includes family planning, looking after the baby and family responsibilities. This is apparently a popular program and the men who come respond well.

So we headed up to the labour ward. Four women were in labour. I felt a little overwhelmed, but Marie put me to work. I rubbed backs, cleaned the beds and helped to deliver. The women were amazing – no pain relief and they worked through it.

 

Naomi, 18, having her first baby was calm. Her labour had been going for most of the day. Marie called me over to help push. She worked very hard and pushed, but the baby was in no hurry. Finally, the head came, but the chord was around his neck. Thankfully Marie was there. It took some time, and some manual . . .. . .  and resuscitation. Finally, the cry and time under the heat lamp. Within an hour he was with Mum and feeding.

Warigame, 40, having her 5th child. She went into labour yesterday in her village Aivo. Due to the baby being posterior she was sent to the hospital in the ambulance. She was in immense pain. I spent time rubbing her back, knowing how intense her back pain. She told me that she was ready to push. A doctor arrived, she moved back up to the bed and the baby came.

Anita, 17, having her fist baby was having very strong contractions. She was loud, but controlled. When she was ready to push she was ready. Once the head crowned the baby literally fell out of her. Marie caught it!

Stephanie also had had her baby – she was very relaxed following the birth. It was her third child. I talked with her. She gifted me a bilim and said she would name her baby after me – fancy that!

The women came with their own items for their babies. What they bought were all the items that we put into our Mother and Baby packs.

What a day!

The women all consented to us using their photos. They were very happy to share their story.

And we are off . . . . . . . . . to Goroka General Hospital

SO, after a very long day of travel and an unexpected nights stay in Port Moresby we are up at the crack of dawn on Thursday to (hopefully) get onto a flight to Goroka.

On our flight from Cairns to Moresby we met an Australian architect (married to a Papua New Guinean) who works on projects in both PNG and Australia – he  was very keen to find out more about what we do and very happy to assist with on ground logistics.

Finally getting a seat on the morning flight to Goroka we boarded and the. The final empty seat next to Marie was taken by the CEO of Goroka Hospital, Dr Joseph Apa. What were the chances. It was lovely for Marie to catch up and we were able to start a casual meeting.

I listened hard (over the engines of the Fokker 700) and started to get a feel for the challenges he faced in his role. Infection control is a major challenge, in the hospital and in the community. Illnesses such as HIV-aids are now well treated and stabilising, but unfortunately TB is extremely problematic at the moment.

Flying through the clouds and seeing the beauty of the green hills and villages below it felt nice to be arriving in to the Highlands. We were greeted by Mummy Sonia (Director of Nursing) and Mummy Julie (Rural Health nursing director) it was a very warm welcome and many people were very happy to see Marie back in Goroka. We toured the town. The bustling bilim market, The Trade Centre market (a huge outdoor produce and odds and ends market), the Goroka University and the main strip. The streets are full of people here for the annual Goroka Show (known to the best in PNG).

We are staying at the simple accommodation on the hospital grounds, next door to Sonia. It was an impressive sight to see the new (yet empty) hospital on the grounds over shadowing the existing site. This will house the new A&E, theatres and labour ward. The current hospital will continue to be used as the general hospital wards. There are still some teething problems with the new site and more staff are needed to run the extra space. We are hoping to have a tour and meet with the Obstetrician over seeing the transition tomorrow to see if there are any practical measures we can take whilst here to help with the transition.

Marie and I did a walk through of the hospital. It was so lovely as the nurses on the ward remembered her- it was a real homecoming. I found the experience to be unexpected, but still confronting. The simplicity of the open wards, the small amount of equipment, many family members tending to the sick and poor staff patient ratios are apparent. The hospital supplies basic meals, but patients bring their own linen and blankets. The toilet facilities are very basic and communal for the ward. We talked with the staff in the neonatal ward and have a wish list from them of items they require (which we have). The next step is to get these here with out needing to send a whole container.

The one thing that is very noticeable here and in town is the friendliness of the people and the importance of family and community. The staff at the hospital all want the best for their patients and they are doing very difficult work with very limited resources to what we have available.

We are sharing our accommodation with Margret Evans an infection control nurse specialist. She is presenting at the Grand Rounds tomorrow to the doctors and nurses to help improve infection control within the hospital, a challenge for all medical centres, but a huge ask in this environment. We have sat up this evening talking infection control, politics, process and human nature with nurses. A meeting planned for tomorrow with the CEO, a tour of the new hospital and let’s see what that brings.