Vanuatu Elective

Advice for medical students!

Here’s some general information for anyone interested in heading over to Vanuatu for their elective.

BUDGET

Spending not including flights, accommodation or diving was almost $3,000 for myself and Angus together for five weeks – pretty good considering we did every activity we planned to do. It’s definitely doable with the OS-HELP loan.

For those wondering, we got our flights for around $1100 return each though STA Travel. Accommodation was around $770 in total for our unit (with three beds, so can split the cost). Visas are free for most Commonwealth citizens for a max stay of a month. We had to extend ours for our extra three days, costing 6,000 vatu each (around $72). If you need to extend it, bring passport photos or get 6 for about $6 at Aore Art Café, next to immigration. Open water diving course was 48,000vt each (small discount for baby docs) and definitely worth doing.

Would recommend bringing a heap of cash over and exchanging it in Vanuatu – pretty much the same rate at the airport currency exchange/banks here, and no commission. There are ATMs here but there are additional charges to getting money out ($20 with Commonwealth).

MALARIA PROPHYLAXIS

I didn’t see any malaria in Santo, but am glad we had prophylaxis. P. vivax is increasingly common in Vanuatu, and poses a large problem in eradication due to its hepatic stage in the life cycle.

WHAT TO BRING

Hospital attire is casual, mostly I wore scrubs and Birkenstocks. You’ll get sweaty, so bring lightweight fabrics! In general, women have their shoulders and to their knees covered. In saying that, outside of hospital time I didn’t have particularly conservative clothing, I just avoided wearing anything that showed too much skin. Bathers etc are fine at the beach/pool – the locals wear clothes swimming though.

In terms of non-hospital stuff, definitely take at least a litre of sunscreen per person. You can buy aeroguard/toiletries at the shops. Ideal to take a couple of old beach towels, sarong, snorkel/fins, dry bag, own pillow, power board, hand sanitiser, staminade/powerade, lots of recreational activities (podcasts, books, puzzles all good options, as you’ll have hours of downtime when it’s raining). Don’t bring white clothes as they will definitely get stained, and there’s a risk of everything getting a bit gross! Make sure you have a good first aid kit too, gastro-stop/anti-emetics are good as there is a small risk of getting sick. I didn’t get too crook while we were there, and the food/tap water is generally safe, but it’s different and can take a few days to get used to.

From my observations, here’s a list of things that the hospital could do with. This is my own list, not what the hospital has provided me with – just a suggestion of things to consider for future students coming to NPH. Lester can help coordinate. I would definitely get in contact with LINCS/other donation organisation for basic supplies if you can!

Litmus paper (for NGT insertion)
NGT stickers/cannula dressings/cannula boards for the special care nursery
Adhesive removal spray
Sucrose for neonates
EMLA for paeds
Neonatal stethoscopes for the SCN
12 lead ECG machine
Manual/automated blood pressure machines
Tubigrip/compression stockings
Portable otoscopes and covers
POC troponin / blood gas testing (ubiquitous in remote clinics in Australia, not a single one in NPH)
Alcohol swabs & tuffi wipes
Butterfly needles
Blueys
Vomit bags
Tourniquets (only a handful of ‘single-use’ ones in the hospital, all quite old)
Pregnancy wheels
Hand sanitiser (are bottles of liquid alcohol but they could definitely do with more)
Gloves (especially if you have small/large hands)
Adult cannula dressings/cannulation packs
Dressing packs
LUSCS dressings
Textbooks/AMH/other books that may be useful
Spacer devices

CONTACTING NPH

You can contact any of these, it will all have the same effect! Don’t forget you’ll need to pay ~$400 to secure your spot.

Dr Lawrence Boe (Medical) sere47@gmail.com

Dr Basil Leodoro (Surgical) bleodoro@gmail.com

Lester Dingley (in admin, very organised) ldevans2014@gmail.com

NPH Medical ELectives Brochure

BISLAMA

Some resources passed on to me by Lester;

Babydoc Bislama

VU_Bislama_Language_Lessons

Bislama

Week 5: Paediatrics

The paediatric ward is run by a paediatrician, an intern and nurses. Dr Thyna was the paediatrician on the ward during that week, and she has an incredible amount of knowledge. She made sure any ‘learning issues’ we had each day were distributed to each of us to talk about for a few minutes at ward round the next day.

The ward seems to always be reasonably busy with 10-15 patients plus nursery babies. The bible for paediatrics in Vanuatu is the WHO Hospital Care for Children. Dehydration is a huge problem, with diarrhoeal illnesses being really common, so a lot of care centred around that. On the other end of the spectrum, I learnt about overhydration – signs to look out for if the child has gotten too much fluid. This isn’t something I have ever really thought about, but important in this setting because of the severity of dehydration seen, malnutrition as a confounding factor, and the resource limitation.

Some of the cases on ward included; diarrhoeal illness/gastro, TB, meningitis, neonatal sepsis, malnutrition/growth faltering, pneumonia, congenital heart disease and epilepsy. It was a bit heartbreaking seeing some children who had poor prognoses because they lived in Vanuatu and couldn’t get suitable treatment. It was also sad to hear about how many babies and children died recently, but the team really learn from each and every case and improve their practice based on their experience. We really are lucky in Australia to have resources for sick children, as well as good public health resources – not just education programmes, but things for post-natal mums and their newborns, screening programmes and availability of healthy food and a varied diet.

Special care nursery

Sisters

Traditional Ni-Van meal

Paeds team!

Info sheet in Bislama

Week 4: General Medicine

The ward is mostly run by a medical registrar, Dr Lawrence, and a Chinese physician as well as an intern. Dr Lawrence is seriously impressive, examines patients extremely thoroughly and has incredible clinical reasoning skills. There is a ward round in the morning, and following the round there is a 5-6 patient clinic for recently discharged patients, cardiac patients and the like. There is also an outpatient clinic area that runs clinics throughout the day.

The extent of psychiatry in Vanuatu

The pharmacy

On the ward I found out that most if not all of the patients that were admitted from ED while I was there ended up dying. It was probably a combination between their physical state/comorbidities, lack of resources at the hospital, and the late stage of presentation. This was pretty shocking, as I feel they may have lived if they had have received care in Australia or New Zealand. One patient, who did survive their admission, had a STEMI. Usually they use streptokinase as a thrombolytic agent, however they had run short – so she was given some aspirin and left in a bed for a few days to recover.

There are plenty of ‘asthma’ patients on the ward, and inhaler therapy occurs on ward round. From what I saw, most patients had terrible technique before education – the aerosol spray snuck out through nostrils and the corner of mouths. There aren’t a lot of spacers going around, and improvised ones made of water bottles worked very well. The education was done by the medical team and the head nurse.

The devastating burden of cardiovascular and cerebrovascular disease was really evident during this week. Patients in their 30s and 40s were having strokes and heart attacks, and without gold standard therapy or rehabilitation, it has a huge impact on their lives. There is also a lot of rheumatic heart disease, but no public outreach as far as I saw. There isn’t an echo probe in Santo for monitoring of these patients, and certainly valve repairs cannot be done in Santo. Many people live rurally, so primary health care is not utilised as much as it is in Australia. Many people do not attend school, so education and health literacy is lower than that in Australia. It’s really sad, and makes me think about how public health campaigns and education make a huge difference in populations. It is also really sad to think that these conditions, seen in a developing world, often affect Australian Indigenous populations despite living in a wealthy country with programs and funding in place.

What really struck me during this week was the juxtaposition between doctors’ knowledge and the treatments available. The docs in Vanuatu are fantastic and are up to date in terms of evidence based medicine and best practice, but are so limited in their capacity to treat patients. Some things are never available in Vanuatu, but it seems much of the time supplies have just run out and they are awaiting more to arrive at some predetermined date. It’s interesting to think about how care would fluctuate depending on supply level, and outcomes would fluctuate accordingly.

A few of us did a half-day fishing charter this week, and we got very lucky. It was the very end of the fishing season, so we were lucky to catch one rainbow runner which we cooked up for dinner. We also did some snorkelling, and saw two adult and one baby dugong. This was through Santo Island Fishing, run by the husband of the lady running Santo Horse Riding. We got quite a local insight from Fabrice who runs it, who was born and raised in the area. His opinion is that things have really gone downhill in Vanuatu after independence from France, as the government now is corrupt and poor. Again, part of the fee went towards projects in the local community.

Week 3: Maternity ward/O&G

The maternity ward sees around 1500 births a year, with plenty of grand multis rocking up and many women having had zero antenatal care. The ward consists of a birth suite with three beds, an antenatal room for incoming labouring women with six beds, a couple of rooms for women post-Caesar, and a nine-bed room for post-natal women (no curtains and no ceiling fans here). Women having their first baby generally stay on the ward for 48 hours, and those with other children usually hang around for about 24 hours. The post-Caesar women usually are given morphine, and they try to get the IDC out and mobilisation happening 6 hours later. I’m used to the nice honeycomb dressings our women get – here it’s iodine-soaked gauze covered by Elastoplast which seems to do the job.

The birth suite is one of the few places in the hospital with air conditioning, and has three beds with stirrups, a resuscitaire and a strong metallic smell of blood. It’s quite an intimidating room – very far removed from the comforts of birth suites in Australia – and women are not offered any analgesia during labour. Lucky the women here are stoic!

The Special Care Nursery has a few incubators, a couple of phototherapy lights and a no-shoes policy. There are no ventilators here or anywhere else in the hospital besides theatre. The inpatients of the SCN were mostly premature babies (one born at only 900g – and was only around 1.5kg 50 days later) or those who needed some respiratory support. They seem to mostly use high-flow oxygen although there is CPAP equipment in the cupboard. There is no regular screening e.g. Guthrie testing here, but babies do get Hep B and Vit K jabs.

I spent most of my time during maternity on ward rounds and in clinic, as the hospital was overrun with midwifery students. The hospital also decided in mid-January that medical students were no longer allowed to get hands-on during deliveries. Clinic was held every day in clinic rooms at the end of the building. The team consists of two obstetrician/gynaecologists from the Pacific, one Chinese obstetrician/gynaecologist who can speak a few words of English and none of Bislama, and a few midwives. Family planning isn’t much like Australia – they still use female condoms as well as male condoms, and other options include the pill, copper IUDs, progesterone rods similar to Implanon (except 2 rods are inserted every time), and tubal ligation. Typically, the woman continues to have children until she has the desired number, then gets a tubal ligation when her husband is satisfied. Husbands have to give consent for sterilisation surgery.

Gynae clinic is pretty similar to that in Australia, except without the colposcope. Pap smears/cytology are done but the public health program isn’t as established as Australia’s. Antenatal clinic is reasonably similar – screening questions for pre-eclampsia, palpating the abdomen, measuring fundal height etc… except no one asks about mental health (it isn’t discussed here at all), nor smoking or alcohol use. I am told that chlamydia is present in about 25% of the population, and every woman and their partner get azithromycin as a ‘presumptive’ measure. Booking bloods consist of a full blood count and hepatitis B/syphilis serology, and those women who are concerning for pre-eclampsia get urine MC&S and UECs. There is no OGTT or routine screening for gestational diabetes. The only post-natal depression information I saw the entire placement was a poster in the doctor’s meeting room. There is one ultrasound machine for use, and a few dopplers which are hit and miss – so mostly the foetal heart is heard with a Pinard horn. I didn’t believe it would work until I listened to a few women’s bellies on my own and actually heard the FHR loud and clear! As you can see, antenatal care is not as thorough as it is in Australia and this is probably reflected in maternal and foetal mortality rates.

During this week we also went horse-riding at Santo Horse Riding, run by a lady from NZ who rescues horses from all over Vanuatu. It was a great experience – riding along the beach, through the water, into a mangrove tunnel and through bush. Part of her income from the horses goes back into the local village for building schools and other important projects.

Angus and I also started our PADI open water diving course, diving the SS Coolidge and the various military equipment at Million Dollar Point. It was the highlight of the trip, an amazing experience and would recommend it to anyone! We did it through Allan Power Diving.

Birthing suite

Post-natal ward

Waiting for clinic

Pinard Horn

Week 2 – Emergency Department

Every day at the hospital starts with a 15 minute walk up a reasonably steep hill. By the time you arrive at the hospital you’re soaked with sweat and your glasses are foggy, no matter what the weather is like! The local Ni-Van people are notoriously friendly, so you can expect to say hello or wave to every single person you walk past, as well as receive friendly beeps and waves from cars passing by. Often there are utes with their trays stacked with people, all smiling and waving! The hospital has a few different areas; ED, medical ward, surgical ward, maternity ward, paediatrics ward, TB ward, outpatients area, theatre, radiology and pathology.

I began my elective in ED on my own, welcomed by the lovely head nurse Claudine. The nurses there wear white dress uniforms, and the head nurse is recognised by red patches on their shoulders. Claudine taught me some basic Bislama, the local pidgin language, so that I could communicate with patients and get a basic history. The ED there has three beds plus one resus bay, with curtains dividing the adjoining bays. The room has louvres for windows, which are pretty much always open no matter what is happening inside the bays. This didn’t seem to bother the Ni-Vans who came in for treatment, as modesty wasn’t a big concern in general. This in itself was strange for me, coming from Australian hospitals where there is a painstaking effort to maintain modesty for all patients.

As far as I could tell, there wasn’t a triage system in place. Patients who would be Cat 4 or 5 in Australia went to the Outpatient area, which among specialist clinics seemed to operate as a GP service. It was a bit confusing for me being in ED, as I wasn’t sure which patients were supposed to be getting seen and which were to be sent away. Quite a few patients came through for salbutamol nebulisers (an alarming amount, given it’s not something done particularly often at home), and some for IM penicillin jabs. The IM penicillin was something I was used to seeing being administered in Broome for skin sores, and it seemed to serve the same purpose here as rheumatic heart disease is prevalent here, too. Only certain medications are in stock, so sometimes things need to be crushed and mixed with some fluid to be given as a syrup rather than a tablet for someone who can’t swallow well. Luckily, they have a rock for crushing medicines on hand.

The big difference I noticed between procedures – besides using salbutamol nebs for a variety of patients, including a kid who probably had bronchiolitis – is that everything is reused. The masks are reused for the nebs, and a syringe sits on the bench for drawing up saline and salbutamol – both of which remain on the bench to be used up over the course of the day/week. The vials of penicillin for IM injection were also used for as many patients as they could, to save equipment. When cannulas were put in, blood was dripped into tubes instead of using a syringe to draw blood out. ECG dots were reused, even when they were covered in someone else’s chest hair. This made me realise how lucky we are in Australia to have so many disposable items at our fingertips, and that we have plentiful resources so that hardly anything is reused. Where I used to be shocked at the amount of wastage in hospitals in Australia, I was now shocked at how little was wasted here.

Other things I had taken for granted in Australia; alcohol wipes, paper towels, alcohol hand rub, liquid soap, lancets for BSLs, computers, lab reagents, vomit bags, blueys, IVC dressings, bleach… things are quite basic here. When something runs out, everyone has to wait. For example, the lab has run out of reagents for UEC and LFT tests – so only pregnant women with possible pre-eclampsia get UECs. Sometimes they don’t have the right equipment for Hep B serology, so routine screening for pregnant women is disrupted. Currently the only tests you can order routinely are; FBC, ESR and malarial parasites (plus the standard microbiology tests). If you do someone’s BSL, you find a small needle and quickly stab them in the manner of a lancet. Luckily there are glucometers and test strips, as diabetes is a big problem here. If someone is getting cannulated, you need to find a cotton ball and squirt some alcohol onto it to serve as a wipe. To wash your hands, there is running water and a bar of soap, and if you’re lucky there might be a towel hanging there to dry your hands with, although often not. And if someone vomits on the floor, currently there’s a bleach shortage so it just gets mopped up with some water.

As for imaging, X-Ray is available, and there are lightboxes for you to be able to see the plain film. There isn’t a radiologist to report on them though, so you just have to find the best person to double check it for you. Ultrasound is available, however the reports are usually a few sentences at best, recorded on the small piece of paper that serves as the request, and you hardly ever get any images. The shortest report I saw was ‘RPOC’ – retained products of conception. Much snappier than the reports we get in Australia – they really do get straight to the point here.

So seeing patients in ED, with very limited investigations at my fingertips, it really is about a good history and clinical examination. Unfortunately, the people of Vanuatu are among the most stoic I have ever come across, and those coming to ED who are sick are usually incredibly sick. All records are handwritten, and not many have files as thick as our Australian patients. It amazes me how the medical records team find anyone’s file – it’s all hand-written, most people I’ve come across don’t know their date of birth (and their age they admit to seems to change their birth year every time they attend the hospital), so the additional information they ask for are parents’ names and island of origin. If they do find the folder, you are left with a stack of pages which are not necessarily dated, in time order, signed or legible. Often there are no record of medications on discharge or regular meds. It’s a challenge, and all you can do is your best!

Some of the interesting cases we had included;

A young girl of 11 who came in with sudden onset paralysis of both legs and one arm. She’d had a couple of weeks of pain in her legs, then the day prior had collapsed in the kitchen. She had been otherwise well. On examination, she had decreased tone, power 1/5 both legs and left arm, power 3/5 in right arm, absent deep tendon reflexes, and grossly normal sensation. Cranial nerves were normal. It was later found she had dislocated her femoral head when she fell down, although she didn’t admit to any pain. One day later, the paralysis had started to encroach on her respiratory muscles, and she was in distress. As NPH only has a ventilator in theatre, she was sent to Vila. Her doctors were thinking maybe Guilliame-Barre Syndrome or spinal TB. I later found out that she died from respiratory failure before she made it onto a ventilator, and the working diagnosis was still GBS despite the rapid onset.
A woman with incomplete miscarriage who arrived to ED on a blood-soaked tarp on the back of a ute, moaning and shocked. It had been a long and bumpy journey. She ended up going for a D&C in theatre, which was performed under ketamine and propofol, with just an oxygen mask to manage her airway. She was discharged a day later.

In terms of out-of-hospital activities, we went to Nanda Blue Hole for a traditional lunch and to see how kava is made, as well as doing Millenium Cave and going to the private island Ratua for a day of swimming, snorkelling, SUPing and eating. Nanda is absolutely amazing, the bluest of the holes and wonderful to swim in. Millenium Cave was a huge day – it involves 1.5 hours of hiking, 45 minutes of caving, 45 minutes of canyoning and 45 minutes floating down a gorge river past waterfalls and hanging vines. The canyoning was the highlight – climbing over rocks, upright wooden ladders, crossing fast flowing streams holding on a rope all while it steadily rained. Ratua was worth doing, especially for the Sunday buffet and the snorkelling!

ED bays

medicine-crushing rock

standard hospital attire

Week 1: Getting our bearings

I have been fortunate enough to come to Espiritu Santo, Vanuatu to do my elective at Northern Provincial Hospital, the second largest hospital in Vanuatu behind Vila Central Hospital. I am joined at the hospital by a number of other medical students, from UWA, UQ, Sydney and Adelaide.

I arrived a week early, taking advantage of the once weekly direct flight to Santo from Brisbane, which left plenty of time to do some exploring and touristing. Three girls from UWA were already here, and helped orientate me to life in Luganville. It’s really hard to figure out what to do in Vanuatu from the internet, but it’s pretty easy to book things once you’re here!

We all stayed at the Hibiscus Motel, the most popular choice for medical students. It’s easy to see why – it’s extremely affordable – around AUD$770 for a three-bed self contained unit cleaned daily for five weeks! It’s also fairly basic – foam mattresses, thin pillows, a ceiling fan, and a small two-burner camping stove. The owner, Marie, is one of the loveliest and most accommodating people I have ever met. She made the entire stay really special and I wouldn’t have wanted to stay anywhere else!

Some of the things Angus and I got up to in the first week included a visit to Aore, a trip up the east coast to Port Olry and some local exploring. We figured out the food situation, visited some local resorts, and went shopping for some cheaper food after experiencing Australian prices at the restaurants!

The local market is a real highlight of Luganville. It’s a covered area filled with stalls with local produce – hundreds of bananas, pineapples, papayas and many things I have never seen before in my life. It is essentially open 24/7 except for Saturday evenings and Sunday mornings! The people selling the goods often span a few generations, with mothers often sleeping and nursing their youngest underneath the tables. There are banana leaves protecting the food from the floor, and hand-woven baskets hold all sorts of goodies. Cooked peanuts in their shells are a popular item for sale, and are absolutely delicious! Most things cost 50-300 vatu, depending on the item. A bag of about 30 chillies, or 8-10 pieces of ginger 10cm long, or a bag of limes cost around 100 vatu – or $1.20. It’s extraordinarily cheap to buy from the markets, and as a result we have eaten a lot of stir-fries! Across the road from the market there is a butcher. Santo beef is famous for being organic, delicious – and cheap! Sirloin steak goes for about $15/kilo, and diced beef for our stir-fries is about $10/kilo. Among various cuts of beef, you can also buy chicken, pork, tuna, offal and dog. Needless to say, we didn’t buy any dog meat!

Next to the markets, there are local stalls where you can buy a meal for 500 vatu, or around $6. For that price, you get snacks (either peanuts, banana chips or marioc chips), a meal with rice (stew, steak or curry), fruit and the local speciality, lime juice, which is like a lemonade.

The local supermarket, LCM, sells everything else available. They have a lot of imported food which parallels Aussie prices – Tim Tams, Cadbury chocolate, Nutella and Lays chips. There is also a lot of tinned goods, sauces and a lot of usual stuff you’d find at your regular shop. They don’t have much fresh stuff – usually there are onions and garlic, and occasionally you can buy apples, carrots and cabbages too. There are a range of ice creams, cheeses and meats available too, but expect to pay about $12 for 500g of cheese! There’s no fresh milk, so UHT milk is the only option. The bread in Santo is fantastic, reflecting the long French history here. You can also buy alcohol from LCM, again at Australian prices – and there are a few bottles of mostly Australian wine which are all over $20, and don’t expect to see many (if any) familiar labels!

Aore Island (or ‘Little Australia’) is a small island across the channel which has a resort, plantation and apparently a large population of Australian ex-pats. As with most of the resorts here, buying some food or drink allows you use of the facilities/pool/WiFi etc. There is a free ferry that goes to Aore daily, leaving at 11.30am and returning at 4pm. There’s a great restaurant, lovely shady beach and decent snorkelling metres from the shore. The fish there are pretty bold – expect some nibbles or some confrontational fish swimming full tilt into your goggles.

The east coast was lovely – we stayed the night at Port Olry and did some exploring in between. The girls had a treehouse and we had a bungalow, just a hundred metres from the beach. Highlights of the trip included Champagne Beach (apparently a must-do while here), Riri Blue Hole (two rope swings!), Hala Blue Hole (local one, not signposted) and local lobster for dinner. We were pretty lucky with the weather, making our photos even more spectacular.