It's been almost two months since I left the Solomon Islands, and I decided I should be writing 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 in which 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.
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 try to explain why many an hour was wasted in clinic trying to figure out if the pharmacy had a particular drug before we could consider 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 of all this 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?
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:
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.