World Anaesthesia onlinehttp://www.nda.ox.ac.uk/wfsa/index.htm
Vol 3 No 1 (1999) Article 17: 1-2
Anaesthesia, and Life, in Fiji
Dr Mike Pullman
Final Year Senior Registrar Grade,
Northern General Hospital, Sheffield, UK.
Introduction
For the year 1996-1997 I worked as Consultant Anaesthetist in Lautoka Hospital in western Viti Levu, which is the largest of the two main Fiji Islands in the South Pacific. This is an account of my experience which proved to be one of the most rewarding both personally and professionally in my life to date.
Background and History
The Fiji Islands in the south-west Pacific consists of 300 of the most beautiful islands in the world, of which only a hundred are inhabited. Most of the 750,000 population live on the two main islands, Viti Levu and Vanua Levu. It also has two incredibly diverse populations, the Fijians and the Indians, with a varying degree of racial tension. This tension was brought to worldwide attention in 1987 when the now Prime Minister, Sitiveni Rabuka, overthrew a democratically elected government in a bloodless coup.
Apart from the main road that runs around the island, all other roads are unsealed, rough, mountainous and dangerous. The incidence of serious road traffic accidents is increasing and is of major concern. The interior of Viti Levu contains many traditional Fijian villages, often 1-2 days horse ride from the nearest Health Centre, through tropical rainforests.
Preparation for Fiji
On completing my fellowship examination in the United Kingdom, I wrote to the senior anaesthetist in Fiji, Dr Sereima Bale, applying for a job. I was told that a consultant post was available in Lautoka Hospital in the west of Viti Levu.
I contacted many anaesthetists experienced in developing world anaesthesia, gaining invaluable advice and information. Attending the course in Oxford on "Anaesthesia for difficult circumstances" was theoretically and practically excellent. I strongly recommend this to anyone considering working in such conditions.
Prior to leaving I assembled my own anaesthetic survival kit including: some gum elastic bougies, a Sanders injector, CVP manometers, laryngoscopes, and my greatest coup, about 150 laryngeal masks. They had all been autoclaved 40 times and therefore were deemed "useless" in the UK. A laryngeal mask in Fiji costs £100. There were only about half-a-dozen on the whole of the island when I arrived.
I also contacted Dr Steve Kinnear, consultant anaesthetist from the Royal Adelaide Hospital, who was working in Suva, the capital of Fiji. He had previously spent 2 years in the Cook Islands and had extensive experience of Pacific life as an ex-pat anaesthetist with a family. He is one of the most inspiring anaesthetists I have met. His workload and enthusiasm in the development of the Diploma of Anaesthesia for the South Pacific was extraordinary. His return to Australia was a loss to anaesthesia in the Pacific although I am not sure he will be able to stay away for long.
Medical Education
The health system in Fiji is still reeling from the mass exodus of specialist Indian doctors to Australia and New Zealand following the coup. The Indians feared for their future and thousands, including many consultants, left overnight. Despite this the future of healthcare is bright and with financial and logistical aid from overseas, including the WFSA, both under- and post-graduate medical education is undergoing a complete reconstruction. All major post-graduate disciplines are beginning to offer Diplomas and Masters Degrees. The opening of the post-graduate training centre in Suva is an exciting venture, aiming to concentrate specialist training in the South Pacific. However, the universal problem of underpaid, undervalued and overworked doctors still has to be addressed. During my time in Fiji there was very little incentive to take post-graduate examinations and progress up the ladder because effectively, there is no ladder. This is the main problem with hospital careers in Fiji. There are some excellent trainee clinicians and surgeons in Fiji, but unless a consultant leaves, or dies, there is no possibility of promotion at present.
Anaesthetic Experience
Lautoka Hospital is a 400-bedded, British-built hospital of a similar design to those in sub-Saharan Africa and serves a population of 200,000. It looked impressive from the outside, with beautiful grounds, teeming with Indians and Fijians visiting friends, relatives or doctors. Inside, the hospital was equally impressive with a high standard of cleanliness.
However, the reality was brought home with my first visit to the Recovery Ward, where I found comatosed patients lying next to routine post-operative cases. There was a ventilated infant, in a coma from meningococcal septicaemia and, coming from behind a closed door marked Burns Unit , were the most chilling screams. Inside there was a beautiful, 6-year-old Fijian boy, lying in a saline bath dirtied with his excrement, with 2 nurses debriding his 70% burns with scalpels. He was in agony and his father was doing all he could to comfort him. There was no formal surgical debridement or grafting, mainly because of a lack of experience and manpower. Most major burns victims died although, despite severe facial burns, in the majority no-one succumbed from acute airway obstruction. Our resources precluded the use of elective ventilation of these patients.
I was surprised to find on arrival that I was head of the anaesthesia department, consisting of 3 Chinese registrars, one Fijian trainee and the semi-retired Fijian, Dr Goneyali, who had been running the department admirably for many years with less than skeleton service. For the first month I simply observed and learned the "system". This was the most useful piece of advice I was given prior to leaving the UK - just watch!
There were 2 main theatres, performing about 200-300 operations a month, plus one minor-ops theatre carrying out 10 or so procedures daily. On top of this there was, on average, one flying squad (by helicopter or 4-wheel drive vehicle) called per week to a distant island or village, mainly for gynae/obstetric emergencies. Once a week we would send a team to one of the smaller health centres to perform 8-12 tubal ligations, commonly under single-shot ketamine anaesthesia.
The majority of anaesthetics consisted of nitrous oxide, oxygen and halothane following a thiopentone induction. Piped oxygen was supplied. Apparently, much lower quotes had been submitted for an oxygen concentrator but, mysteriously, BOC won the contract following top level talks. Suxamethonium, pancuronium and alcuronium were available, and atracurium occasionally. Morphine, pethidine and fentanyl, plus local anaesthetics, were also regularly supplied. Anaesthesia was administered via early Boyle's machines and the theatres had a few oximeters and two capnographs. The local biomedical engineers had been well trained by the Australians and were able to maintain most of the electronic equipement. A young Fijian orderly, named Samu, was paid the equivalent of 60 pence an hour to maintain the anaesthetic machines and solve any other problems with gases around the hospital. He did a remarkable job under the circumstances and his unique skills were greatly undervalued. Ventilation was carried out with the robust, but not entirely efficient, Nuffield 200 via a circle system. Single-use Portex endotracheal tubes were used repeatedly. Spinal needles (22g and 25g) were available, as were intravenous fluids and ephedrine.
Pre-operative assessments were absolutely vital as this was often the fist time the patients had ever seen a doctor. The laboratories were efficient and reliable and we rarely had a problem with blood donors from the patients' families. Anaemia is very common. There is an extraordinarily high incidence of ischaemic heart disease, hypertension and diabetes in Fiji. We managed to rationalise the investigations performed pre-operatively by means of a simple flow chart and reduce the number of unnecessary chest X-rays for example. The language barrier was a minor problem and both Fijians and Indians tended to give the answers they felt you wanted to hear. The Fijians are remarkably stoical and become increasingly more silent as the pain of their condition increases.
Patients presented very late, often after a long boat trip or painful truck journey from the interior. There is still a strong belief in traditional Fijian medicine. One remedy, for example, used for chills and backache, involved the insertion of a mulch of hot chillies inserted on a finger per rectum.
The Fijians swore that the afflicted person would move with more purpose and energy after such a treatment. I did not doubt this enough to try out the remedy.
Despite being presented with a number of emergency patients with uncontrolled blood pressure, outcome after a balanced anaesthetic with halothane, or a spinal, was excellent. It was an education for a modern-day UK trainee, and not once did I feel I needed anything that was unavailable. It merely reinforced my impression that a common sense approach, utilizing the golden rules of anaesthesia, is all that is necessary to administer a safe anaesthetic.
Despite all this there were a number of aspects of anaesthesia that I felt could be improved and my period of observation allowed me to concentrate on the development of an ITU and the setting-up of a regular programme for the anaesthetists, nurses and doctors. I rapidly set up a 3-month Basic Anaesthetic Nurse Course for a number of the theatre nurses to enable them to help the anaesthetist with induction, emergencies and recovery. This has become an on-going programme with regular sessions being held amongst the nurses since my departure. There was previously no skilled help for the anaesthetist.
The surgical specialities were general, orthopaedic, obstetric and gynaecology, plus some ophthalmic surgery. There was no vascular surgery and little colorectal surgery. The standard of general surgery was variable and the all-day lists equally so, often consisting, for example, of a neonate for Ramsted's procedure, a couple of hernias, a gastrectomy, a thyroid-ectomy and a tonsillectomy. Orthopaedics were excellent as a result of the work of Mr Eddie McCaig, the consultant, a native Fijian who achieved the Fellowship in New Zealand and returned to establish the Orthopaedic Training Programme. He remains the shining light in the Fijian Health System. Orthopaedics consists mainly of trauma surgery on RTA casualties, plus fractured neck femurs (Jewitt's nail). A distressingly high number of amputations were performed (sometimes 15 per month) for diabetic foot sepsis. Obstetrics and gynaecology were also practiced to a very high standard. Pre-eclampsia was common and generally well managed.
I adapted a widely used protocol for management of blood pressure, fluid and seizures. I purchased a few mobile entonox delivery systems before arranging for the installation of pipeline entonox. I successfully introduced epidurals for post-operative analgesia following Wertheim's hysterectomies. With the help of the very adept Chinese registrars I reversed the ratio of GA to spinal anaesthetics for Caesarean sections and this trend has been maintained. The incidence of spinal headache was less than 5% and only two blood patches were performed in 14 months. Abortion is illegal in this deeply religious country and hence there was a distressingly high number of septic abortions developing shock and organ failure.
Intensive Care
This became my main concern and where most of my energy was directed. The pre-
existing system resulted in approximately 600 critically-ill patients being sent to the
post-op recovery ward. This is where the most monitors were situated and where
there was the greatest concentration of nurses. There were initially 3 oximeters, 1
Dinamap, 2 cardiac monitors and 10 nurses on a shift system. In the corner lay a
defunct Ciba Corning blood gas machine and a couple of American Biomed ITU
ventilators that had last been serviced 5 years previously and had no alarms. There
was an obvious need for a separate area for these patients. The initial challenge was
daunting. There seemed to be no limit on the number of patients that were allowed
into the recovery ward. Beds were moved closer together and more squeezed in. The
nurses worked under extraordinarily difficult circumstances and did a remarkable job
considering that they had no training in the management of these patients. I proposed
the development of a separate 2-bedded ITU. I was asked to submit a design and
equipment requirements with costing. Unfortunately this had not formed a major part
of my UK training. The chapter in "Care of the Critically Ill Patient in the Tropics
and sub-Tropics" by Wilson et al was vital. We purchased a new ITU ventilator, a
simple blood gas machine and CVP lines. Regular teaching sessions with the medical
team on ITU subjects and practical procedures were held.
I produced a number of protocols for the basic management of these patients.
I introduced a 4-month ITU Nurse Training Course for five nurses who were
allowed one day leave per week to attend.
The course was based on a similar course
that Steve Kinnear had set up in Suva.
Workshops on resuscitation and the use of
equipment formed an integral part of the
course.
A picture from the presentation day for the
ITU/anaesthetic nurses at Lautoka hospital
is shown on the left.
The nurses were incredibly enthusiastic throughout and the rewards in terms of
patient care and outcome were evident from the start. I still receive progress reports
including a copy of the front page of the Fiji Times revealing a woman who had
survived 28 days on the ITU! This was worth far more than any exam result.
Teaching
Being based at Lautoka in western Viti Levu, I was able to act as a satellite for the
Pacific Anaesthetic Training Programme (PATP) based in Suva on the other side of
the island. The curriculum for the 3-year Diploma and Masters course was basically
the work of Steve Kinnear. My only dilemma was that the 3 Chinese registrars
wanted to learn western anaesthetics. This was their first venture outside China and
therefore they were very keen to find out what was happening in the outside world.
The PATP had just held its inaugural examination before I arrived and it was most
successful. Recently a second group has been trained with equal success and there is
no doubt that standards of anaesthesia in the Pacific are rising rapidly.
I was asked by the Fiji School of Medicine to teach anaesthesia to a rotating group of
20 medical students. This was very enjoyable and an education for me and them. A
number of them have gone on to specialise in anaesthesia on the PATP.
The Downside
Fiji is a very long way from home. It is prone to the kind of natural disasters that can
wipe out a large population very quickly. Cyclone Gavin passed through when we
were there at about 300 kph and this was classified as only a moderate one! From
behind barricades, in our most interior room with all our supplies around us and with
the most deafening noise outside, we thought our time had come. With small children
there is always the thought that, if they become seriously ill, can one really justify
being in a developing world situation? Although New Zealand appeared near on the
map, it was in reality about 24 hours away if an urgent transfer was required.
Another downside is having to witness the urbanisation and development of perhaps
the finest proponents of self-sufficiency and survival. More and more islanders and
bushmen are leaving their villages and communal existence to come to the big towns
with their 5-8 children to live in tin shanties and earn a pittance. All this in the name
of development! Even Macdonalds has reached Fiji.
Huge commercial ventures such as copper and gold mines are wreaking havoc with
the wondrous ecosystems and the environment is taking a back seat. But perhaps the
biggest downside about working in Fiji is having to leave. It is something with which
I still have to come to terms.
I would like to thank the Association of Anaesthetists of Great Britain and Ireland
and John Cahill for their financial support. Also many thanks to Iain Wilson, Martin
Coates, Roger Eltringham and Mike Dobson for their advice and help. A special
mention also for Steve Kinnear whose work inspired me immeasurably.
Whilst in Fiji, Dr Raghwa Narayan, the consultant obstetrician and gynaecologist at
Lautoka Hospital died during a run. In a short time I became good friends with him
and his kindness to me and my family was present from the start. His death was a
great loss to Fiji and to me.
Finally, I must thank all those with whom I worked, and played, within Fiji, for
making my experience one I will never forget. For a Welshman, a country that has
perpetual sunshine and loves rugby, singing and drinking was like heaven on earth.
Thanks Eddie!
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