It’s been almost two months since I left the Solomon Islands, and it’s about time I wrote down some of my thoughts about my medical elective there – both for posterity’s sake, and the hope that something I’ve written will be helpful to students heading out on elective to the same or similar areas and circumstances.

I spent 5 weeks in Gizo in late October/November, 2009 at the Gizo Hospital. The hospital is the referral hospital for the Western Province, and has a catchment population of somewhere between 35,000 and 60,000, depending on the source. Numerous remote nursing stations/clinics make up the remainder of the healthcare facilities available in Western Province. Most of these stations are equipped with only the most basic of supplies, but even so these clinics are very valuable for treating the more common illnesses and injuries that occur, such as malaria, non-life-threatening viral fevers and uncomplicated fractures.

Gizo Hospital manages to do a lot with very little in the way of facilities, personnel and equipment. Services offered at the hospital include Obstetrics, Radiology (X-Ray and Ultrasound), General Surgery (Tuesdays and Thursdays), and Outpatient Clinic (Mondays, Wednesdays, and Fridays). There are 4 inpatient wards (male, female, paeds, and maternity), with a total of about 60 beds.

The Gizo Urban Nursing Service (GUNS) also operates out of the hospital, and provides first-line treatment for malaria, vaccinations, and gynecological services. They might even do more than that, but I never had much contact with them while I was there. Malaria is such a routine illness in the Solomons that the doctors generally only saw the very sickest of patients, or those with complications (i.e. cerebral malaria).

St. Vincent’s Hospital in Sydney, Australia has a program where new registrars at the hospital can spend 3 months in Gizo. St. Vincent’s sends a registrar over 4 times a year, so this means that as a medical student you get the best of both worlds – excellent one-on-one training with a Western trained physician, while working in a 3rd world hospital, learning improvisation and resource management skills, as well as getting experience with tropical disease. The registrar we had supervising us while at the hospital was great, and allowed us to do as much as we felt comfortable doing.

Even though I was only a first year medical student, I got experience in administering anaethetics (Ketamine), drawing blood, inserting cannulas, taking patient histories, giving vaccinations, assisting in minor surgery, and watching a Caesarian section or two.

There are generally 3 to 5 doctors working in Gizo Hospital at any one time, with the majority of them being local doctors trained in Fiji or Papua New Guinea.

The daily schedule is generally ward rounds in the morning (either male, paeds, or female/maternity), and then either outpatients or surgery depending on the day.

Local Culture and Custom as it Pertains to Medical Treatment

Please take what I write in this section with a grain of salt, as this is only my opinion, formed from my own observations and talks with locals and ex-pats, and does not necessarily reflect reality, as I only spent a little over a month in Gizo.

There is a Pharmacy attached to the hospital, although it is rarely well-stocked, and the pharmacist (at least while I was there) wasn’t all that knowledgeable about current treatment regimens. The problem with this state of affairs soon became apparent, so let me explain why many an hour was wasted in clinic trying to figure out if the pharmacy had a particular drug before prescribing it.

The majority of the local population lives much the same way that they have for centuries, because it’s what works best for them. They get plenty of rain, so with the help of a rain tank attached to their home they have no need for a plumbed town water supply. Electricity on the island is provided by diesel generator and is subsequently quite expensive, so many make do without. Fish and seafood are so plentiful in the waters around Gizo that at times there seems to be more fish than water, and you can buy giant tuna in the market for under $7 CAD. Almost everyone it seems has a mobile phone, but otherwise they are self-sufficient. They have very close-knit families, wherein if problems arise, be they medical, legal, or otherwise, they are usually handled within the family rather than being taken to the authorities. And finally, since Gizo is the main referral hospital for the area, many of the patients that present to hospital admissions are from very remote islands with very little in the way of contact with Western civilization.

And so, getting on to my point, there are two major consequences on the healthcare provided to Islanders in Gizo: they present late in illness, when symptoms are severe and illness is often more difficult to treat; and they defer to the healthcare staff completely. Whether in general they are scared, intimidated, or otherwise, I learned that if I were to write them a prescription that they were unable to fill at the pharmacy, either due to lack of availability or ineptness on the part of the pharmacist, they would simply go home to avoid having to see me again in clinic.

The reality of patients presenting very late in illness made for some memorable times in the clinic, but also makes treatment a challenge. I can’t count the number of osteomyelitis cases we saw, especially in young children, where an old (perhaps a year or more ago) fracture had failed to heal correctly, had gotten infected, and only now when the pain is unbearable do they present to hospital for treatment, where they learn that they will need 6 weeks of IV antibiotics. That presents a real problem for some families, especially from other islands: They need to stay in Gizo for 6 weeks, so where do they live? How do they get fed?

Hospital Departments

The outpatients clinic operates on Mondays, Wednesdays and Fridays, and sees a little bit of everything. There is usually plenty of patients to see, and after ward rounds attending clinic will take up the bulk of the day. Some of the presentations I saw while in outpatients include: numerous machete wounds, usually to the left wrist or right leg; uncontrolled diabetes, along with diabetic neuropathy; hypertension, either treated or not, with a plethora of different beta blockers, ACE inhibitors, diuretics, ARBs, and Calcium channel blockers; fractures; osteomyelitis from old fractures that weren’t set properly and/or didn’t heal properly;

The surgical suite stays busy on Tuesdays and Thursdays for elective or non-emergent operations, with the occasional trauma case or emergency C-section occurring. The bulk of the elective surgical cases are made up of tubal ligations, vasectomies, Incision & Drainage of abscesses, and appendectomies, with major surgical cases being referred on to the National Hospital in Honiara. There are two theatres at the hospital, a ‘dirty’ one for minor trauma, I & D, etc., and a ‘clean’ one for internal procedures like Caesarian sections.

I never ended up spending much time in the female or maternity wards, but they were kept busy with births while I was there, with usually at least one each evening.

The male and paediatric wards are located adjacent to each other, and this is where I spent the majority of my time when not in surgery. Each morning started with ward rounds at 8:30am (give or take an hour – remember it’s ‘Solomon time’!), and we proceeded to check on each patient in turn. Although the nursing staff was friendly, a lot of the problems we faced on the wards were with drug administration – either doses were missed, or IV drugs were given orally instead, rather than taking the time to place another IV line. This became a problem when treating osteomyelitis, as in a few cases the antibiotic regimens had to be restarted from scratch. I learned a lot by following around the registrar on ward rounds, listening to her reasoning, and was even able to occasionally form a coherent thought to add to the discussion.

Pidgin English is the local language, and although the vast majority of the vocabulary comes from English, varied pronunciation combined with a strong accent render the locals mostly unintelligible when you first arrive. I would suggest picking up the Lonely Planet guide to Pidgin before arriving, and learn some basic grammar that will come in handy, such as:

• ‘blong iu’ or ‘blong me’, pronounced ‘blong you’ or ‘blong me’, which makes a noun possessive when placed after it. For example, ‘my employer’ = ‘employa blong me’.
• ‘yumi’ = ‘You and me’.
• ‘mifela’, pronounced ‘me fella’ is ‘Me and someone else, excluding you’.
• ‘wifela’, pronounced ‘we fella’ is ‘Me and you’.
• ‘iu fela’, pronounced ‘you fella’ is ‘You and someone else’.
• ‘I’ referring to yourself, is ‘me’ in pidgin.
• ‘lo’ is, as far as I could tell, an article used in many different contexts, to replace ‘the’, ‘a’, ‘an’, ‘to’, as well as ‘in’, ‘on’, etc. For example, ‘I am going to the hospital’ = ‘Me go lo hospital’.
• ‘Wantok’, pronounced ‘wahn-talk’, doesn’t have an exact translation, but roughly means ‘family, including extended family’. In order for patients from other islands to spend time in hospital in Gizo, you need to know if they have ‘wantok’ in Gizo that they can stay with. ‘Do you have family in Gizo?’ = ‘Wantok lo Gizo?’

Most of the locals you’ll see in the hospital or clinic will only speak Pidgin. The medical staff at the hospital all speak fluent English and Pidgin, so they can help translate for you, although it’s helpful if you practice your Pidgin as much as possible. Most medical terms sound the same in English and Pidgin, so as long as you can get a grasp on the basic grammar of the language, I found you can communicate effectively enough with most of the locals.

Things to Know Before You Leave

• Bring a flashlight, as there are only a few streetlights in Gizo, the roads are rough and uneven, so if you’re walking when the moon isn’t out a flashlight is a must.
• The airstrip is located on Nusatupe Island, about a 10 minute boat ride from Gizo. The Gizo Explorer is a big former cattle transport boat that belongs to the Gizo Hotel, and heads over to Nusatupe for pickup and drop-off for each Solomon Air flight. A one-way trip to Gizo or back costs $50 SBD.
• Contact Danny or Kerry Kennedy at Dive Gizo to come over to the jetty on Nusatupe Island to pick you up if you’d rather not pay the $50 SBD. The Kennedys are a very nice, welcoming couple – if you’re up for any diving while in Gizo, I highly recommend them!
• Speaking of diving, it’s worth a second mention – the diving in the Gizo area is apparently considered some of the best in the entire world, and after spending a few weekends out diving myself, and I can see why: plenty of colourful, lively coral reefs full of reef sharks, fish, and the occasional sea turtle. The visibility is outstanding all the time, the water is warm year-round, the currents vary between slow and non-existent, and there are several World War 2 wrecks within easy boating distance of Gizo. Again: I highly recommend filling up your weekends with some diving!
• There are a few cheap places to stay in Gizo, and some not so cheap ones. If you want all-out comfort, the Gizo Hotel charges about $150 AUD/night, and is the only accommodation in town up to Western standards. Cheaper options for students include Phoebe’s Resthouse and Naqua Resthouse, both of which are a short walk from the main market and the hospital. I stayed at Phoebe’s and can recommend it as a nice clean place to spend a month. $100 SBD/night for Phoebe’s, and $120 SBD/night for Naqua. Jacob is Phoebe’s son, and is the current manager of Phoebe’s – his family lives on the first floor, and the second floor has 5 rooms with 2 single beds in each. You can book most of the accommodation in Gizo through Danny Kennedy’s new website – he processes the credit card online, and then hands cash to the resthouse manager, as not very many businesses in Gizo deal in anything other than cash. I didn’t book in advance, but I got lucky – Phoebe’s is generally full and needs to be booked in advance, and I assume it is a similar situation with the other resthouses.
• As of this writing, internet was freely available at the hospital for student use, although I would recommend bringing your own mini-notebook or laptop as there is only one computer available for all the staff to use, but there is an ethernet cord available if you have your own computer.
• There is an elective fee of $100 SBD/week to be paid at the hospital office, which helps to pay for student internet use.
• If you don’t have your own computer and the hospital one is busy (it almost always is), then there are two internet “cafes” in town. Telekom is the national telecom provider, and provides (expensive!) internet access at their office on the main street of Gizo. A cheaper alternative is Solomon Internet Solutions, located on the opposite end of main street from the hospital, close to Dive Gizo, where you can get internet access for about $0.10 SBD/minute, which is cheap even by Aussie standards!

Random Facts That Didn’t Fit in Elsewhere

• “Gizo” is the town, “Ghizo” is the island.
• Fatboys Resort is located on Mbabanga Island, directly east of Ghizo Island.
• Kennedy Island is named after President John F. Kennedy of the United States, who was stranded there for a few days during World War 2.
• The town of Gizo is powered by three massive diesel generators, and so electricity is expensive on the island. Do your part and turn off lights and appliances when you’re not using them.
• The RAMSI Participating Police Force is active in Gizo, and seems to keep the place generally safe. Walking home at night was fine, although just to be on the safe side I would recommend walking in pairs.
• A major tsunami hit Gizo in 2007, and although most everything was repaired by the time I arrived, you could still see damage on other parts of the island.
• Alcohol is expensive here ($3 AUD/can in the liquor store, don’t even think about wine), but the local brew, “Solbrew”, isn’t half bad.
• Fruits and vegetables are cheap ($1 SBD/each for most vegetables) and available in the market 7 days a week. The markets are best on Monday and Friday, as that’s when producers from other islands come to Gizo to sell. Tuna and other fish is also incredibly cheap, but the good stuff is only available after 3pm when most of the fishing boats come back into shore.

Overall, I thought her presentation was just about as useful as it could be – she immediately struck me as someone who had done this presentation many times before, and spoke with measured words about the many hurdles we would have to face in coming back to Canada, while staying within the limits of PCness.

I’ve listed some of my notes from the presentation below, for those who might be interested. Anyone not in med can safely quit reading now.

• The current trend is that the gap between the number of Canadian Medical Graduates (“CMGs”) and number residency training spots will continue to increase, which is a good thing for us internationals!
• In the last 5 years, the provinces have decided to make it policy to automatically increase residency spots to the same degree that they increase spots at Canadian medical schools. Common sense thinking from the government… imagine that.
• They aim for a 40% Family Med to Everything Else ratio.
• Manitoba lost the human rights battle to keep International Medical Graduates (“IMGs”) out of the first round of the match. So your best shot for matching is Manitoba, as an IMG. Downside being, you have to live in Manitoba.
• In 2009:
  • 392 IMGs matched.
  • 2294 CMGs matched.
  • 2705 total positions available.
  • 126 unfilled spots after the second round, mostly in Quebec (which has onerous requirements for matching, hence the unfilled spots…)
  • 90% of Emerg matches were Canadians Studying Abroad (“CSAs”).
  • 52.5% of match graduated last year.
  • 39.5% of match graduated 2 years ago.
  • 84% of CSAs who matched did an elective in Canada.
  • 44% of CSAs matched.
  • 22.9% of immigrant IMGs matched.
  • 58% of Aussie CSAs matched.

The talk was given by Jeffrey Lipman from my own School of Medicine here at UQ, and I found he was a very engaging and energetic speaker.

One of the first slides he showed us in his presentation was a man with a knife with about an inch and a half wide blade, stuck through the middle of his skull from ear to ear. The amazing part wasn’t the picture itself, but that, after they decided that the best thing to do would be to just pull the knife out, the man was fine and went home the next day. Crazy!

Of course, this didn’t happen in Australia, or any first world country for that matter – the same situation here would lend itself to teems of neurosurgeons crowding around the patient, and copious amounts of radiological imaging being done before they would even attempt such a maneuver. The slide Dr. Lipman showed us was from his time working in South Africa, just outside of Johannesburg at the world’s largest hospital, Baragwanath. Baragwanath has over 2000 hospital admissions per day!

That segued into speaking to us about running the ICU at Baragwanath Hospital, and the distributive justice and resource allocation issues that he had to deal with on a daily basis. He gave us an interesting day-in-the-life-of problem, and one I assume he had to deal with often in the ICU. He talked of starting the day with 5 requests from elsewhere in the hospital for admission to the ICU. Any of these patients would certainly die without the intensive care and supervision of the ICU ward, but the problem being that he only had 3 beds available for patients that day. So from that… how do you choose which two patients will die?

All five of these patients are different ages, have different diseases, injuries, complications, lifestyles, etc., and as the doctor in charge of the ward you need to “play God”. How does one deal with limited resources, and how can we ensure that those resources are distributed as fairly as possible? He then talked about the idea of building evidence-based criteria for ranking potential ICU admissions, so as to give the best outcomes to the most patients. The guy with 5 organ system failure, on a ventilator, and 6 major surgeries in his future? Probably should rank lower on the list compared to a 5 year old male in a motor vehicle accident, two surgeries to fix shattered bones in his legs, but otherwise stable, conscious and alert, with a good prognosis.

Dr. Lipman has been practicing in Australia now since 1997, and finished up his talk by making the point that these kind of resource allocation issues will only get worse in Australia as well, although perhaps never to the same degree as what he experienced in South Africa. We as new physicians need to learn things beyond the traditional physician training, such as finance and administration, in order to know how much your resources cost, how they are being used by patients, and how best to allocate them in the future to ensure the best of patient outcomes. By resources, I mean everything that could potentially be in short supply in your practice: nursing staff, reception staff, consumables, equipment, drugs, and two of the most important ones: space, and your time!

What are your thoughts? When we inevitably face healthcare resource shortages, how best do we allocate those resources? What is the criteria we as physicians should be using to make those decisions?

I’ve also managed to open up my bank account at NAB finally, since they’re closed all weekend, but I won’t get anything in the mail from them until the end of this week apparently, and I need some mail with Barb’s address on it and my name on it from the bank before I can get my beloved iPhone (snickers from the peanut gallery, love you too family ;)). It’s awesome of Barb to have let me borrow her “disposable” phone that she picked up at the airport, so I can start making some calls about finding a place to live here.

Barb and I took the opportunity this morning to head over to the St. Lucia campus to check out where all our lectures will be. She managed to find a class schedule with room numbers on it, and apparently we’re in the same lecture theatre for the entire semester, and for the most part classes go from 8am – 5pm. Lecture attendance is mandatory I believe, so it looks like my new home away from home will be the lecture hall. Oh, and the best part of all – it’s in the new Hawken Engineering building! So I might get to meet some engineers from down under – always a pleasure since Engineers are always awesome to hang around with :)

Oh, and of course the obligatory… it’s sooooo hot down here! I’m going to love winters down here when it’s about 18C every day, but right now, it’s super humid and super hot and I’m dying! Barb’s in the same boat though, and as long as we’ve got lots of water for the road, we do just fine. Buses down here come often and have A/C, so they’re actually much more pleasurable to ride than back in Edmonton, since the A/C filters out the diesel fumes and makes the trip downright pleasant.

They also have these things down here called “busways”, which as far as I can tell are road entirely reserved for buses that mostly run underground throughout the city, and it makes getting anywhere by bus so fast! We were on one going from Fortitude Valley to Dutton Park today, and it made the trip much shorter than I thought it would otherwise be, with Monday morning rushhour traffic. Good idea from Brisbane Transit!

Two more days until Orientation, and I can’t wait!

Finally done with the flying, and writing this is the beautiful summer weather in Brisbane, Australia! Customs here at the airport took an inordinate amount of time, and it didn’t help that there were apparently quite a few planes unloading at the same time, so I got a bit nervous when the two hour mark came and went after the plane landed. I thought the UQ accommodations guy would surely have given up on me and left me, but I raced through Customs as much as possible and he was still waiting! He must be used to those kinds of delays in Brisbane… just ridiculous for an international airport of its calibre, but oh well! And then I got mighty nervous on the drive over to Barb’s place that she wouldn’t be there, but of course she was, and I really can’t thank her enough for putting me up for a few days. Not to mention feeding me and showing me some of the area around here, and lending me one of those ‘disposable’ cell phones until I get a phone of my own. Barb, I owe you big, you’re awesome!

Orientation is this coming Wednesday, and hopefully there I can meet some med students who are looking for a roomie.

It’s a beautiful 15 degrees C here in Taipei, and it’s cloudy and a bit rainy and (I think, at least) a bit smoggy as well, but the people are so friendly! From the brief bit I bothered to learn about Taiwan before I arrived, they’ve made it there national goal to be the West’s gateway to the East (and visa-versa, I suppose), making a point to be fluent in both Traditional Chinese and English. It really shows – everyone I’ve spoken to here has a least a decent grasp of English.

The airport even does free tours, which is great since I wanted to see Taipei 101 for sure while I’m waiting for my flight on to Brisbane, and apparently the Metro system doesn’t quite make it out to the airport, so I would’ve had to spring for a taxi otherwise.

And, I’ve been foiled by the phone system here – whenever I go overseas I get the Canada Direct number to allow me to call the parents back home without ridiculous international long distance fees, but the number I have for calling from Taiwan doesn’t seem to work, so my next communication will be from Brisbane I guess!

Only an 8 hour flight this time, so much nicer! Oh, and of course… Australia! I mean… what could be better?

I’m sitting here in the Edmonton Airport, after spending 15 minutes looking for one of the seldom seen and even more rarely available power outlets in the departure lounge. It occurs to me now that I really should have made finding an Australian power adapter for my laptop a priority before heading out today, since after Vancouver (and maybe Taipei, if I’m lucky) I won’t have access to any power source for my laptop.

And, a reminder to myself in the future, and to those who might not do a lot of flying – seat selection (at least on EVA Airlines) is open up to a 100 days in advance, so if you want to get one of the few “good” seats available on the plane, make sure to login to their online seat selection sooner than the day before.

All considered, only two things I could’ve arranged better, and I couldn’t be more excited about heading out for Brisbane. Halfway around the world, and I only know two people down there, and then only through Facebook. I have a 14 hour layover in Taipei, and I’m hoping to be able to take the time and head into Taipei City to see the Taipei 101, currently the world’s tallest building (apparently the Burj Dubai doesn’t count until it’s finished 6ish months from now).