The Electives Network Newsletter: Obstetrics in the Tropics

April 2017

Over the past couple of weeks we’ve seen two very important dates in the healthcare calendar. April 25th was World Malaria Day, which raises awareness and funds to fight the tropical disease across the world. May 5th was International Midwives Day, when we celebrated the work and dedication of midwives everywhere. To mark these two events, we’re bringing you a special edition of our newsletter featuring two obstetrics electives in tropical destinations. Both students chose to head to an island paradise for their electives, with one placement in the Caribbean and another in Oceania.
First, we bring you Seren Peters’ account of an elective where she was able to try out three different specialities at the Milton Cato Hospital on the island of St. Vincent.
Our special report is an in-depth account of an elective at Kavieng General Hospital in Papua New Guinea, written by Austrian student Martin Heidinger.
We’ve also put together some special reports on World Malaria Day and International Midwives Day to give you more information about both dates.
This month’s featured article is a Q&A with Johana and Lukaš from the European Center for Career Education, who talk to us about placement opportunities in Prague.

Featured hospital

Featured hospital

Gizo Hospital is a main referral hospital serving a population of 60,000 in the Solomon Islands. It is a relatively remote hospital and is therefore a good choice for students interested in remote, island care, who also want to see a range of cases. » read more

Featured country

Featured country

The Maldives is made up of a chain of nearly 1,200 islands, most of them uninhabited, which lie off the Indian sub-continent. There are many beautiful lagoons and amazing coral reefs with exceptional underwater wildlife such as butterfly fish and bluestr » read more

Q&A with Johana and Lukaš from the European Centre for Career Education

Can you tell us a little about why the ECCE was started?
Being recent graduates ourselves, we realized how demanding the professional industries have become with recruiting young professionals. We live in a world where a university degree does not guarantee graduates a placement and success. Good knowledge of your field is essential, but you have to be able to apply your knowledge in practice. Our vision is to provide ECCE Summer Program graduates with an extra advantage among their colleagues; to stand out from the crowd in order to have a future advantage on the job market.

What can students who attend the summer program expect to learn?
Students on our summer program learn from the industries international experts about various aspects of medicine. We concentrate on scientific innovations in but also on topics which aren’t given very much attention at most medical schools, but are very important, such a palliative care. We also try to give students advice in areas which could be challenging for them such as stress and productivity. We are also trying to get a financial adviser for students to speak to.

Can you tell us about a typical day on the program?
The lectures are usually in two blocks during the day with 2 hours long lunch break and minor coffee breaks during the program. Lectures start approximately at 8:00 AM and end at about 6:00 PM. The students must attend the classes and be focused and active in order to get the most out of their participation and to have a better chance to get the best elective. There will be organised trips not only within Prague itself but also cities of interest in the whole Czech Republic and close abroad. Karaokes, laser games or simply nights out popular local places are possible as well. There are many options such as beer tasting, night thematic sightseeing of Prague full of fun facts, even cruises or of some of many Prague museums are possible. We also organise panel discussions for our students. So that there will be balance between fun and work.

What is the benefit of joining you on the summer program?
The biggest benefit for our potential students is the opportunity to learn about modern topics trending in medicine combined with the practical experience during electives at local hospitals, private clinics or pharmaceutical companies. Where possible we try to tailor make the elective according to student wishes. We believe that this combination will give them a significant competitive advantage on the job market compared to their peers. Further the summer program is designed to give students possibilities of networking with potential employers, among themselves and to form long lasting friendships.

What are the social aspects about the program?
The students will have a chance to make long lasting friendships during the course of the two months. Further they will interact with the lecturers, professionals during their electives and the ECCE staff. At the Grand Reception they will also have a chance to form bonds with professionals not only from the medical field but also across various industries (business, law, politics, etc.).

Who will be giving lectures?
It is very difficult to choose only a few lecturers to mention. We worked extremely hard to have the best possible local and international experts to give lectures for our students, such as highly rated medical doctors, university professors and experienced and renowned international speakers. We are very happy to say that for example professor Dan Burke, a leading expert on Salvestrols research in cancer; MUDr. Kahleova will lecture on novel treatments of diabetes, or Dr. Nupur Kohli, who is one of the most sought-after speakers in the world; MUDr. Šebek will share his experience from his many travels from Doctors without Borders, including his last mission to Sudan; we will also have Prof. Dr. Paolo Biffignandi, MD, PhD, FTOPRA, FRSM, EU QPPV a past CEO of pharma associations and companies and past president of Topra to come and lecture on the pharma industry, and many more.

Do students leave with any qualifications?
Students will leave with a deeper and novel knowledge of the industry, including hand on experience. At the moment we are at the final stages of negotiation with Charle’s University in Prague to obtain accreditation for students who graduate from our program. We are optimistic and keeping our fingers crossed.

Where is the program based and what language are lectures taught in?
The program is based in the beautiful capital city of Czech Republic – Prague. This means that students will have an opportunity to live for two months in the joys and bohemian life this city has to offer as well as discover rich local culture and history. The summer program includes a couple of trips around Czech Republic to a richer experience. Most of our experts will speak directly in English but there are one or two local lecturers who prefer to use an interpreter.

What are the costs involved?
The application fee is €2500. This amount covers 3 weeks’ worth of lectures and also the subsequent elective placement.

Special Elective Report: Martin Heidinger's in-depth account of his placement at Kavieng General Hospital in Papua New Guinea

Introduction
Kavieng is a town of approximately 40.000 people, the capital of the New Ireland Province and located on the West-end of New Ireland Island north of mainland Papua New Guinea.
Since 1884, the island of New Ireland, together with New Britain, Manus and Bougainville were part of German New-Guinea, whilst mainland Papua New Guinea fell under British control. During the first World War, Australian forces overtook New Ireland and Kavieng, which was thereafter mandated to Australian care. During World War II, Japanese forces invaded Kavieng and were only defeated in September 1945. Most of the infrastructure however was completely destroyed due to constant bombing. After the war, mainland Papua and the Island provinces were combined to the country of Papua New Guinea (PNG).
Currently about 6.5 million people inhabit PNG on a landmass of 500.000 km2 where over 800 different indigenous languages are still spoken. The official language is Tok Pisin.
People from New Ireland are Melanesian and speak around 19 local languages. The three main cultures persisting in New Ireland are Malagan culture in the north, the Kabai culture in central New Ireland and the Tumbuan Culture in the south. However, as with each island/village speaking its own language, also cultural specifications occur from village to village.
Clinical Setting
Kavieng General Hospital (KGH) is a provincial hospital located in the town of Kavieng and serves the urban area of Kavieng as well as rural areas of the whole province. Services provided are a General Surgery Ward, an Obstetrics and Gynaecology Unit, Pediatric Services, and an Emergency Care Unit. Furthermore, there are basic services for Internal Medicine, Radiology and Dental Health. The team consists of doctors, Health Extension Officers (HEOs – with an University education of 4 years), nurses, midwives and technical staff. Altogether, the hospital counts just over 100 patient beds, outpatient settings for around 350 consultancies per day and a new operational theatre, which opened just as I arrived. During the first week I spent at KGH, executive staff from the federal ministry of health came to confirm the opening of the newly erected surgical theatre, which would allow two operations at a time and give space due to the takedown of improvised surgical theatres, which were serving the different services up to that point. Furthermore, a new x-ray machine was put in place to provide services to the clinicians.
Organising a placement here
The best way to get in touch with KGH is to connect via their Facebook page – Kavieng General Hospital Volunteers. Ange, who organizes internships for medical students is also married to Dietmar a diving instructor from Mödling, Austria and the two of them run an idyllic dive resort on Lissenung Island just 20 mins by boat south-west of Kavieng. Ange provides you with up-to-date information, available dates and information packages concerning your internship and stay in Kavieng. Most of the interns also find their lodging opportunity via her connections and just about all of them enjoy at least one weekend on Lissenung relaxing, swimming, snorkeling, diving or just eating incredible seafood.
Personal Medical Preparation
Concerning malaria, the country is a high-risk country. I brought my own impregnated mosquito-net and mosquito-spray, however both are also available in the shops here, whereas I’m not sure which sprays are exactly being sold. On arrival I took Malarone for one week and switched to stand-by mode thereafter. Continuous treatment is discouraged by doctors here, because of the possible false-negative diagnostic it can cause. Additionally, I brought some Arthemeter-Tea, which tastes good and is supposed to help with just one cup a day (at least it definitely does no harm). With the common prophylactic measures, I was fine throughout my stay and even if something happens to you, testing and treatment is available at the hospital.
What I found more dangerous were ‘reef cuts’, as I was left with an infected foot for a whole week. Always wear reef shoes (available in stores here) when going for a swim.

Martin's Placement

The Placement
During my 8 week internship, I served 3 weeks in the Obstetrics and Gynaecology department, 2 weeks in the Surgery department and 3 weeks in the Outpatient and Emergency service.
The KGH is used to international students as there have been so many from Australia, the UK and the USA. Marika and Stephanie from Leeds University spent their summer break here with me. It was great being able to exchange experiences and stories. Together with expats working for Australian Doctors International (ADI), the Red Cross and the WWF we also had Friday night get-togethers to exchange views from various ”western” minds.
The hospital in general and the staff are very professionally organized, with team meetings each Monday, Paper Club meetings once a week, oral presentations by the registrars once a week and a Grand Round Staff Meeting each Friday morning.
What is lacking are diagnostic facilities (limited lab tests, one ECG, two Ultrasound machines, one x-ray, for the whole hospital) as well as treatment options (at times no oxygen for weeks, no chemotherapeutics, no intraoperative x-ray). However, I want to stress that coming from a European setting, where everything is possible at all times and one really needs to filter which options are really necessary, it was a wonderful experience to work with limited resources and get trained to diagnose with only that equipment you’re naturally given – eyes, ears, and hands.
Obstetrics & Gynaecology
At KGH, 21 inpatient beds and three labour ward beds are managed by a team of two specialists, one registrar, six midwives and a dozen nurses. On average, three babies are delivered each day. Wednesday and Friday are Theatre days, where treatments range from Tubal Ligation for family completion, through Total Hysterectomy in malignancies, to explorative laparotomies in emergencies.
In the four weeks I spent on this ward I learned a lot, from general gynaecological examinations, to delivering babies, assisting in various operations and leading ward rounds. It was a very hands-on and pleasant work setting.
Surgery
The surgical department consists of two specialists and two registrars who together with nurses manage around 40 beds (20 for each sex) for both emergency as well as elective procedures. During my internship I got to see a variety of Inguinal Hernia Raphing, Orchyectomy, Emergency Laparatomy, Hemi-Thyroidectomy, etc. I was surprised by the high quantity of paraplegics due to trauma, tuberculosis and neuronal degeneration, as well as by the numbers of diabetic feet that are treated here.

Off-placement

Kavieng offers lots of possibilities for outdoorsy people, especially those who are interested in diving and water sports. Being on the shore of the Pacific Ocean, swimming, snorkelling, diving, surfing and fishing are all on the doorstep. Generally, one has to have some kind of tourism provider to obtain gear, transport and expertise, but everything is provided by local operators. However, one of the downsides of Papua New Guinea in recent years has been skyrocketing prices, especially compared with other developing countries, which are often cheaper getaways.
Seasonwise, December to February is rainy season, and the area becomes a surfer’s paradise, with people coming from all over the world for the famous waves. At the same time, this means that it’s not recommended to plan any voyages in small dinghies or canoes!
How to get there
The cheapest route I researched starting in Vienna was the one going via Brisbane to Port Moresby and Kavieng. However, especially as Air Niugini is intensifying its services to places like HongKong and Singapore those routes might be ones of choice in the upcoming years.
Flight providers in Papua New Guinea are basically Air Niugini (www.airniugini.com) as well as PNG Air (www.pngair.com.pg). It’s worth checking both airlines for fares, as PNG Air is especially good at providing low fares on domestic flights. Air Niugini covers Sydney, Brisbane and Cairns in Australia, HongKong, Singapore and Tokyo in (South)-East Asia.
Visas can be obtained at the PNG Embassy in Belgium, but pay attention to the possible admission-time of up to 5 months. Tourist Visas can be obtained for free at Port Moresby Airport.
Accommodation
There are several hotels in Kavieng, and your best shot to get information on the most recent developments is to have a look into the newest version of the Lonely Planet’s Guide to Papua New Guinea and the Solomon Islands. Most of them are quite expensive and are no real option for long-term stays. As mentioned above it’s best to talk to Ange about lodging opportunities for volunteers.
Kavieng
Kavieng town is a stretched out along the coastline, with the hospital being on the southern most tip, the airport marking the north-eastern end, the ocean on the west and the Boluminsky Highway running to the north and all the way to Namantanai.However, the whole north-south stretch is not more than 5km and since bikes are provided for students by the ADI Service for the duration of the stay (for a 50 Kina fee), it’s easily coverable. Attractions are the marketplace, where local goods are sold from Tuesday to Sunday, Nusa Island, with the Nusa Island Resort, which makes another good weekend destination – the small island where the resort is on can be walked around in about 1 hour, and the bigger island can be reached via a reef-bridge at low tide. Downtown, you can find well-stocked grocery stores, a post office, a handful of hotels and eating-places and a golf-club which is quite flexible concerning foreigners wanting to play. However, I never saw anyone play during my stay, and the fairways reminded me more of links than easy-to-play holes!
People
New Irelanders are proud to say that they see themselves as the most relaxed of all Papua New Guineans. Generally, people are very friendly, curious about white people visiting their society, and thankful once one picks up some everyday phrases in Tok Pisin – the local language. Many people chew buai (betelnut), which is why they are spitting red saliva, and roads tend to be covered in this colour. People on the streets are often poor, and see white people as rich, which is why one should always be cautious not show-off by throwing money around or openly carrying cameras, laptops, etc. – stay discrete and keep valuables with you.
Melanesian culture is centred around community, which is why for people here it’s sometimes irritating seeing someone walk alone – usually people of one tribe do things together. Especially during night time I wouldn’t recommend wandering around just by yourself, firstly because it’s culturally atypical and secondly because it can be dangerous for a foreigner to roam the streets at night, especially when people are out partying. In summary, I always had the feeling to be living in a safe place, but I did take certain measures to make myself feel comfortable without disturbing anyone or giving them any silly ideas.
Small Issues
Two (or three) aspects that make life here just a bit more difficult in regards to travel, communication and living are that…
1) AirNiugini as well as Air PNG are ranging their flights in a price scheme which is almost mind-blowing considering cheap European airlines,
2) telecommunication is extremely expensive and I had months where I spent around 50€ on data-bundles to surf the internet or skype with home, but at the same time connection is bad and I never had longer conversations than 25 minutes without disruption,
3) there are no coffee-shops in town. Luckily I brought a small espresso-machine to soothe my addiction!
Destinations
From Kavieng it’s very easy to get to:

  • Nusa Island (call the resort and get picked up at the Malagan Lodge or the wharf)
  • Lissenung Island (call the resort and get picked up at the Malagan Lodge or the wharf)
  • Namatanai (buses run there and back on a regular basis)
  • You can bike the Boluminski Highway easily in around 5 days
  • You can also organize trips to Lavongai, Mussau, New Hanover, and Manus

Summary
For anyone with an open mind, a flexible character and the heart to get to the other side of the world, I can only recommend taking the chance to get to know a place which is very different, and people who are very interesting and grateful for the interest you take in them. It’s really been a glorious experience and I’m grateful for everything I’ve seen, everyone I got to know and all the lessons I have learned, medically, socially, culturally, historically and personally.
Thank you to everyone who was part of this experience.

Going with the flow: Seren Peters’ account of exploring different specialities and different places on a Caribbean elective

Seren Peters reports on her experiences both in the hospital and in her free time during an elective at Milton Cato Hospital in Kingstown, on the island of St Vincent.

My motivation for carrying out my elective in St Vincent was to explore a different culture, and experience medicine in a place completely different to the UK. St Vincent and the Grenadines is a country in the Caribbean with a very low GDP, and consequently has quite a different health care to the system where I come from in the United Kingdom. There are certain medications and procedures that are free, but many investigations need to be paid for. This makes it a hybrid health system that combines both public and private care, and the whole structure operates in a combination of public hospitals, private hospitals, and outpatient clinics. I felt this was a good opportunity to see how a different healthcare system functions, whilst also being able to communicate with healthcare practitioners and patients effectively, thanks to it being an English-speaking country.

There is also a different caseload to be seen in the hospitals in St Vincent, due to the high rates of obesity and diabetes in the Caribbean, as well as infectious diseases. This is something I was interested in getting experience in, as obesity and diabetes are growing concerns in the UK, and therefore this experience is clinically relevant to my practice back home.

I felt at the time of organising my elective that I wanted to pursue a career in Obstetrics & Gynaecology, so I decided this would be a good opportunity to get more experience of the speciality. Seeing the differences between the Caribbean and the UK in how obstetrics and gynaecology are practised was a motivation for me choosing this speciality as one of my rotations during my elective. I thought I could take away an improved understanding of both good and bad practice, by seeing the differences between both countries. As it turns out, some of the staff in the obstetric department turned out to be particularly unfriendly to UK students, and on a couple of occasions tried to embarrass me in front of the staff in the unit, including one occasion on my second day there, when she called on me at the end of the ward round to present to the whole team (doctors, students & midwives) what I had read about the night before, expecting that I hadn’t read anything. I had read up on a small topic luckily, but she had given me no warning that she was going to do this, though she always gave the local students a warning a day or two before they were expected to present. For these reasons, unless you’re particularly keen to spend every evening revising a topic and preparing to be asked to present without notice, and be okay with regularly being put down in front of the local students, I wouldn’t really recommend doing this speciality at this hospital on your elective.

Surgery has always been an interest of mine and for reasons similar to those I mentioned for choosing obstetrics and gynaecology, I chose to also do a surgical rotation. I originally chose to do the second half of my elective in general surgery, but when I got there I became aware that general surgery had a very large number of trainees and students attached to it as a rotation, and therefore learning opportunities were limited, as you often had to fight to get to the front of the ward round group if you wanted to hear what the consultant was saying! The same applied to the theatre sessions for this speciality – there were so many students that more often than not, most students in the theatre for general surgery couldn’t see what was happening or hear what was being said. For these reasons, I changed the second half of my elective to study paediatric surgery instead of general surgery. I had heard that the teaching was very thorough and useful on paediatric surgery, so I felt it would stand me in good stead for final year to get some teaching during my elective on the subject. The surgery component of the rotation also offered more opportunity to be involved in the surgery, as well as gain anatomy teaching during these sessions with few enough students for one to be able to hear and actively participate in teaching. The teaching turned out to be very good, usually only two or three students to a consultant, and I was glad that I had switched to paediatric surgery from general surgery.

Overall, I had a good time at the hospital, particularly in paediatric surgery. From what I gathered, both from my experience and from what my friends who were with me on elective but doing different specialities, told me, it seems there is huge variation between departments in terms of what you will experience on your elective. Some expect you in all day and some weekend days (general surgery), and others barely acknowledged you and told you to go home at 10AM (paediatrics – i.e. not paediatric surgery which I thought was a great balance between expecting you in, expecting something from you, and not being expected to be in constantly when you also kind of wanted to have a bit of fun on your elective!)

In terms of general teaching, pretty much every speciality delivered teaching to some extent or another, as the local students learn primarily on the wards and reading during their own time, with very little lecture-based learning, as far as I could gather. The hospital is very much used to having students around so they are prepared to take you on and show you where to go.

The hospital was undergoing refurbishment whilst we were there so the operating theatres had temporarily moved in to the delivery suite. The paediatric department had already been refurbished and was very clean and modern, which was a stark contrast to the surgical wards, which were still very colonial, with wooden shutters and antiquated furniture.

When I wasn’t in the hospital, Kingstown was a pretty fun place to be, and there’s more than enough to keep you entertained. There are quite a few beaches which are a bus ride away (bus being a loose term – they could more accurately be described as a minivan which has been given the Pimp My Ride treatment, usually fitted with an extra row of seats and a set of bass-heavy speakers turned up to full volume). The bus rides could be a little precarious, as there were no seatbelts and they would go pretty fast, but the majority of the time they were a fun experience.

The beaches themselves were hit and miss – some really nice ones, some a bit busy and noisy, but ask around and explore and you’ll find a good one! Indian Bay was our favourite. A lot of the nice beaches have hotels that open on to them, and many of these are nice places to eat and drink. There was also a good lunch spot in town called “Chill’n”, which served the only good iced coffee I could find anywhere in Kingstown! For evening BBQs and drinks I recommend “Chillspot” – it’s further away from town than the beaches, ask the bus driver to tell you where to get off. The food is good and very cheap, and it’s close to Tree House Bar which is worth a visit if you fancy a Caribbean clubbing experience (Friday night) or a place to chill and play pool during the day.

You can also visit the neighbouring islands quite easily by booking a ferry at the terminal (just next to town), Bequia is very close and cheap to get to, and has absolutely beautiful beaches. I highly recommend the “Scaramouche” for a full day touring round Tobago Cays leaving from Union Island, swimming and snorkelling with turtles, and cooked lunch and drinks included!

One of our weekends, we travelled to St Lucia which was a great experience if you get the chance. You can go to the Hotel Chocolat plantation / restaurant and climb Gros Piton!

Overall, I would recommend St Vincent as an elective destination, and looking back I feel that it has provided me with valuable experiences that I will take in to practice. It has shown me what is possible in terms of healthcare, with a limited budget, and conversely made me immensely grateful for the facilities we have back home.

World Malaria Day

April 25th was World Malaria Day, an annual occasion to highlight the need for continued investment and sustained political commitment for malaria prevention and control. Malaria is a disease which continues to cause around 400,000 deaths every year, and is widespread across sub-Saharan Africa and the tropics.

World Malaria Day has been organised since 2007 by the World Health Organisation (WHO), and the day grew out of an earlier annual event called Africa Malaria Day, celebrated in various African countries since 2001.

This year’s global theme for World Malaria Day is “End Malaria for Good”. Find out more about the day on the WHO website.

International Day of the Midwife

On May 5th we celebrated the International Day of the Midwife, a day for the world to focus on the role of midwives and to celebrate the work they do.

This year marks the 25th anniversary of the first International Day of the Midwife, which has been organised annually by the International Confederation of Midwives since 1992. The day has been officially observed in over 50 countries around the world, and that number is expected to be even higher this year.

The theme for 2017’s celebrations is “Women and Newborns: The Heart of Midwifery”. To find out more about the International Day of the Midwife, including information and photos from the day, visit the ICM’s website, Facebook or Twitter.