ALTERNATIVES * OPTIONS
Barefoot in the OR
Elvira Stahl
In 1988 Dr. Sylvia Uhthoff Munro, an Ottawa general practitioner, and her husband Martin Munro, a professional engineer, spent a year at a small hospital in Ialibu, in the Southern Highlands of Papua New Guinea. The way medicine is practised there may be primitive by Canadian standards, she learned, but the country also proved to be a valuable classroom, one where the lessons came very quickly.
er for her than her husband. "I could start general practice after my return, while Martin was giving up a steady position." However, he finally decided that a change of scenery would be worth while, and they began making inquiries. Uhthoff Munro had thought the well-educated couple would be snapped up by an aid agency, but she received a surprise. "We thought it would be a lot easier than it turned out to be. W Here were a professional engineer hen Uhthoff Sylvia x r Munro graduated from and a young physician - what a the University of Otta- great combination to help somewa in 1986, she was ready to where in the developing world. establish a general practice in Ot- But most organizations want you tawa, where her husband was em- to commit yourself for 2 to 3
ployed by the federal government. But even though they liked Ottawa and were near family and friends - her father, Dr. Hans Uhthoff, is head of orthopedic surgery at Ottawa General Hospital and her mother, Dr. Annegret Uhthoff, is an anesthetist - they decided to leave their comfortable life behind for a stint in isolated and underdeveloped Papua New Guinea (PNG). Uhthoff Munro says the decision wasn't difficult. "I had always wanted to work in an underdeveloped country", she says, adding that the decision was easiElvira Stahl is a writer-editor living in Montreal. 1292
CANMEDASSOCJ 1990: 142(11)
years and many have long waiting lists. One Canadian agency told us they had no use for our skills or abilities at that time." She says their reason for going to Papua New Guinea is simple - it was the first place that made an offer. After accepting, they dealt directly with the provincial government in the country's Southern Highlands. She has a message for physicians comtemplating a similar venture. "We now realize that there would have been many advantages if we had been sent by a Canadian organization", she warns. "They pay the airfare and look after your health care, mak-
'Ton
Uhthoff Munro's hospital in Ialibu, PNG
ing sure you get the proper medical attention if required. In retrospect, we were rather naive. If we go somewhere on a similar mission we will certainly check the political climate carefully." And they'll get their gamma globulin shots earlier, too. They were forgotten until the last minute and the results were rather uncomfortable seats on the flight to Vancouver. After a few days in Port Moresby, the capital of PNG, a small plane took them to Mendi, the capital of the Southern Highlands. They spent about 6 weeks there while Uhthoff Munro was being introduced to local hospital life and medical care. She was part of the health care team at a 200-bed hospital that served about 100 000 people, and learned the surgical procedures she would need at her highlands hospital. The one in Mendi had five physicians, including a Canadian and American, and all performed surgery. "Although I had done some surgery during my internship, you don't learn that type of surgery at home", she recalls. "I started by assisting and then gradually operated -on my own. None of the other physicians was a qualified surgeon either - they were general practitioners like myself." Her training completed, the couple had a "shake and bake" drive to her hospital on extremely rough roads, and although they were pleased with the house that was supplied, Uhthoff Munro admits that her first impression of the new hospital "was a bit frightening". She was confronted immediately with both her practice and administrative tasks - patients were waiting when she arrived. "Dr. Sylvia", as she became known, found herself the administrative head of a 70-bed hospital with a staff of 30 that served about 87 000 people. "You learn fast", she says of her role as ad-
ministrator-coordinator-physician-
Anesthetist Annegret Uhthoff (right) assists as her daughter performs a tubal ligation.
surgeon. Two years out of medical school, she had to "learn to deal with the personnel, all natives, or nationals, as they want to be called, to attend to patients, and to assure that we had at least some urgently needed supplies at our disposal. "The greatest temptation was to change everything at once my way. But that wouldn't have worked. I had to adapt to their mentality to assure their cooperation. If you can't accept that you'd be a very unhappy physician there. You can't expect to have it as you're used to at home, so I forced myself to assume the attitude that I may be the boss but it's their hospital, their system, and their people. So you had to put up with slowness and disorga-
nization. "No matter how often I recommended that we order penicillin as soon as the stocks started getting low, this would happen every time - 'Oh, we've run out of penicillin. Let's order some at once.' Of course, it took a week for it to arrive. One day the cook came to my office and announced that he couldn't prepare meals because he'd run out of wood for the stove. I asked him, 'Why didn't you tell me yesterday so we
could have ordered a new supply?' He replied, 'But yesterday I still had some wood.'" Uhthoff Munro found the absence of consultants frustrating. Instead of calling a gynecologist or her orthopedic surgeon father for advice, she had to thumb through 20-year-old texts "or simply figure out myself what to do". She also learned not to mourn a lack of resources that meant it was often impossible to save lives that could have been saved at home. "What I missed most were surgical instruments and anticancer drugs, but considering the meagre resources we did extremely well in most cases. I did treat some patients with chemotherapy but not very successfully - they wouldn't stay long enough. They wanted to go back home to die." Save for hepatomas, Uhthoff Munro says the incidence of cancer is no higher than in Canada. She says there are two theories why hepatomas are prevalent. One is that hepatitis is common because of unhygienic conditions and therefore the liver is already damaged. The second is that natives eat a lot of raw peanuts that are believed to contain a hepatogenic toxin. "These hepatomas often ocCAN MED ASSOC J 1990; 142 ( 11)
1293
0
curred in young men in their mid-20s", recalls Uhthoff Munro, "'and we couldn't do anything for them. Since it is such a painful condition, all we could do was send them home with a supply of ASA. We had Demerol but it could only be given in the hospital." She performed numerous tubal ligations, which she recommended to women who had had their fourth child. The situation was much different than in Canada because a woman had to have her husband's permission to have the procedure. "That was difficult", says Uhthoff Munro. "They were in hospital having their fourth baby while the husbands were somewhere in the bush. So the women had to wait until they returned home to get their husbands' Xs on the paper we gave them." She didn't perform any major surgery, mainly because there wasn't any anesthetic equipment. Instead, she employed intravenous anesthetics or nitrous oxide, a balancing act that was difficult because she had to monitor patients, inject more anesthetic as needed, and keep operating. She sent patients needing major procedures to the hospital in Mendi.
Her most unusual procedure? "Pulling a spear out of a man's chest, the result of a tribal war. There was no time for transport to Mendi. Fortunately, it had not pierced the lung - a shot of penicillin was the end of the episode.," Many of her duties were administrative, from checking on drug supplies to reminding staff to wash floors and walls. The water supply - rain water gathered in large holding tanks - was usually adequate, although it sometimes ran out. "Many of the patients had never seen a tap, so they would open one and keep the water running", Uhthoff Munro says. "They just didn't realize that one had to turn the water off. If we didn't notice it, some taps would keep on running and, suddenly, no more water. The patients were surprised and we were dismayed." She witnessed some ludicrous incidents. For example, the Asian Development Bank had given the PNG government money to build a laundry in the hospital and a huge washing machine, water extractor and driers were acquired. There was only one thing wrong: there were no bedsheets and only a few towels to wash. Patients lay
Uhthoff Munro removes a spear as victim's relatives look on. 1296
(
\N ME) ASSOCJ 1990; 142 (I 1)
on bare cots or brought their own sheets and blankets if they had any. If the hospital supplied them, she says, they'd be stolen in minutes.
Uhthoff Munro says her year abroad made her realize how wasteful wealthy countries like Canada are. And how different attitudes are. "Death is much more part of life there. Here it is a disaster when somebody dies, even though we know it will happen to all of us. Over there, it is accepted with equanimity. If a mother loses a child, she cries for a day and that's the end of itshe has 6 other children to keep her occupied. When older people die, they say, 'Well, they've had their life and it's over now. That's it.' " She had to visit outlying clinics, trips that often meant frequent stops because news spread quickly that "Dr. Sylvia" was in the neighbourhood and she would be led to huts to attend to the sick. At the clinics, patients would be waiting when she arrived. The medical problems she encountered ranged from "terrible pneumonias" to malnutrition, osteomyelitis and burns. "In the hospital as well as in the bush clinics I saw a lot of anemia", she recalls. "There was no routine blood or other lab testing, so I looked inside their eyes for a diagnosis. Most are iron deficiency anemias and anemias caused by chronic malaria, but I must admit that I often didn't know what I was treating - I just prayed that my diagnosis was right and the iron supplement would do the trick. It did surprisingly often, and shows again how important clinical observations and intuition are. You learn to observe with a third eye and listen with a third ear.," She also performed several murder-related autopsies. "I had a few cases where the women had been hit by their husbands and had died. We have lots of abused
women in shelters in Canada, but there it was accepted that husbands beat their wives. Moreover, it is a polygamous society and women fight each other due to jealousies - they can hurt each other badly." When her parents visited, she made sure both worked hard she had 25 orthopedic patients for her father to operate on with help from her anesthetist mother. "When Mother anesthetized patients while Dad reduced forearm fractures, she used a blood pressure cuff as a tourniquet. It worked. The natives were such stoics - they accepted pain and discomfort and even wanted to watch what the surgeon was doing. And there is always some member of the family sitting nearby watching as well. "Of course, both my parents had to get used to working in the OR barefoot, since this is the natives' way of keeping the OR clean." Despite many hardships and
Removing a cast from a child's clubfoot
ing physical hardships, then don't dare it. It's not for everybody. Some people can't live without TV, the movies, theatre, family, and friends, and you might be really miserable. "I got used to the place quite fast and finally had everything
trained for, felt that he was helping people a lot more than he does here, no matter how high he eventually climbs on the executive ladder. They appreciate life more and they appreciate what we did for
them so much more. "Perhaps it is selfish to want to be needed", she says, "but my greatest satisfaction is the knowledge that I made a difference. I see so many functional diseases here, back troubles and psychoso"We heard from our friends in the Catholic matic diseases. In Papua New mission that they haven't been able to find a Guinea I saw so many more disphysician to replace me. And that makes me tressing and difficult diseases that could have been prevented by very sad." teaching and proper care. Helping people to help themselves and Dr. Sylvia Uhthoff Munro teaching them how to help themselves is most rewarding. "Apart from the rewarding medical aspects in my case, we frustrations, Uhthoff Munro says organized and running smoothly. both feel that we've become so she would like to have stayed for But I would have liked to do much more appreciative and conanother year, but her husband's much more. And I could have scious of what really matters in work in PNG, although reward- accomplished a lot more in anoth- life." Uhthoff Munro has also reing, was not fulfilling enough to er year." Uhthoff Munro and her hus- ceived some bad news since her prolong their stay. "Since our return home, I've often been asked band hope to eventually repeat return to Canada. "We heard to advise other young physicians their experience for 2 or 3 years, from our friends in the Catholic or surgeons whether to undertake even though "Canada is the best Mission that they haven't been such a trip", she says. "I say this. country to call home. We want to able to find a physician to replace If you feel uncomfortable not hav- experience again a place where life me. "And that makes me very ing a bathtub, operating in your has so much more meaning. Even he's what sad."do not did who isolated and bearMartin, bare feet, being CAN MED ASSOC J 1990; 142 ( 11)
1297
Barefoot in the OR
Elvira Stahl
In 1988 Dr. Sylvia Uhthoff Munro, an Ottawa general practitioner, and her husband Martin Munro, a professional engineer, spent a year at a small hospital in Ialibu, in the Southern Highlands of Papua New Guinea. The way medicine is practised there may be primitive by Canadian standards, she learned, but the country also proved to be a valuable classroom, one where the lessons came very quickly.
er for her than her husband. "I could start general practice after my return, while Martin was giving up a steady position." However, he finally decided that a change of scenery would be worth while, and they began making inquiries. Uhthoff Munro had thought the well-educated couple would be snapped up by an aid agency, but she received a surprise. "We thought it would be a lot easier than it turned out to be. W Here were a professional engineer hen Uhthoff Sylvia x r Munro graduated from and a young physician - what a the University of Otta- great combination to help somewa in 1986, she was ready to where in the developing world. establish a general practice in Ot- But most organizations want you tawa, where her husband was em- to commit yourself for 2 to 3
ployed by the federal government. But even though they liked Ottawa and were near family and friends - her father, Dr. Hans Uhthoff, is head of orthopedic surgery at Ottawa General Hospital and her mother, Dr. Annegret Uhthoff, is an anesthetist - they decided to leave their comfortable life behind for a stint in isolated and underdeveloped Papua New Guinea (PNG). Uhthoff Munro says the decision wasn't difficult. "I had always wanted to work in an underdeveloped country", she says, adding that the decision was easiElvira Stahl is a writer-editor living in Montreal. 1292
CANMEDASSOCJ 1990: 142(11)
years and many have long waiting lists. One Canadian agency told us they had no use for our skills or abilities at that time." She says their reason for going to Papua New Guinea is simple - it was the first place that made an offer. After accepting, they dealt directly with the provincial government in the country's Southern Highlands. She has a message for physicians comtemplating a similar venture. "We now realize that there would have been many advantages if we had been sent by a Canadian organization", she warns. "They pay the airfare and look after your health care, mak-
'Ton
Uhthoff Munro's hospital in Ialibu, PNG
ing sure you get the proper medical attention if required. In retrospect, we were rather naive. If we go somewhere on a similar mission we will certainly check the political climate carefully." And they'll get their gamma globulin shots earlier, too. They were forgotten until the last minute and the results were rather uncomfortable seats on the flight to Vancouver. After a few days in Port Moresby, the capital of PNG, a small plane took them to Mendi, the capital of the Southern Highlands. They spent about 6 weeks there while Uhthoff Munro was being introduced to local hospital life and medical care. She was part of the health care team at a 200-bed hospital that served about 100 000 people, and learned the surgical procedures she would need at her highlands hospital. The one in Mendi had five physicians, including a Canadian and American, and all performed surgery. "Although I had done some surgery during my internship, you don't learn that type of surgery at home", she recalls. "I started by assisting and then gradually operated -on my own. None of the other physicians was a qualified surgeon either - they were general practitioners like myself." Her training completed, the couple had a "shake and bake" drive to her hospital on extremely rough roads, and although they were pleased with the house that was supplied, Uhthoff Munro admits that her first impression of the new hospital "was a bit frightening". She was confronted immediately with both her practice and administrative tasks - patients were waiting when she arrived. "Dr. Sylvia", as she became known, found herself the administrative head of a 70-bed hospital with a staff of 30 that served about 87 000 people. "You learn fast", she says of her role as ad-
ministrator-coordinator-physician-
Anesthetist Annegret Uhthoff (right) assists as her daughter performs a tubal ligation.
surgeon. Two years out of medical school, she had to "learn to deal with the personnel, all natives, or nationals, as they want to be called, to attend to patients, and to assure that we had at least some urgently needed supplies at our disposal. "The greatest temptation was to change everything at once my way. But that wouldn't have worked. I had to adapt to their mentality to assure their cooperation. If you can't accept that you'd be a very unhappy physician there. You can't expect to have it as you're used to at home, so I forced myself to assume the attitude that I may be the boss but it's their hospital, their system, and their people. So you had to put up with slowness and disorga-
nization. "No matter how often I recommended that we order penicillin as soon as the stocks started getting low, this would happen every time - 'Oh, we've run out of penicillin. Let's order some at once.' Of course, it took a week for it to arrive. One day the cook came to my office and announced that he couldn't prepare meals because he'd run out of wood for the stove. I asked him, 'Why didn't you tell me yesterday so we
could have ordered a new supply?' He replied, 'But yesterday I still had some wood.'" Uhthoff Munro found the absence of consultants frustrating. Instead of calling a gynecologist or her orthopedic surgeon father for advice, she had to thumb through 20-year-old texts "or simply figure out myself what to do". She also learned not to mourn a lack of resources that meant it was often impossible to save lives that could have been saved at home. "What I missed most were surgical instruments and anticancer drugs, but considering the meagre resources we did extremely well in most cases. I did treat some patients with chemotherapy but not very successfully - they wouldn't stay long enough. They wanted to go back home to die." Save for hepatomas, Uhthoff Munro says the incidence of cancer is no higher than in Canada. She says there are two theories why hepatomas are prevalent. One is that hepatitis is common because of unhygienic conditions and therefore the liver is already damaged. The second is that natives eat a lot of raw peanuts that are believed to contain a hepatogenic toxin. "These hepatomas often ocCAN MED ASSOC J 1990; 142 ( 11)
1293
0
curred in young men in their mid-20s", recalls Uhthoff Munro, "'and we couldn't do anything for them. Since it is such a painful condition, all we could do was send them home with a supply of ASA. We had Demerol but it could only be given in the hospital." She performed numerous tubal ligations, which she recommended to women who had had their fourth child. The situation was much different than in Canada because a woman had to have her husband's permission to have the procedure. "That was difficult", says Uhthoff Munro. "They were in hospital having their fourth baby while the husbands were somewhere in the bush. So the women had to wait until they returned home to get their husbands' Xs on the paper we gave them." She didn't perform any major surgery, mainly because there wasn't any anesthetic equipment. Instead, she employed intravenous anesthetics or nitrous oxide, a balancing act that was difficult because she had to monitor patients, inject more anesthetic as needed, and keep operating. She sent patients needing major procedures to the hospital in Mendi.
Her most unusual procedure? "Pulling a spear out of a man's chest, the result of a tribal war. There was no time for transport to Mendi. Fortunately, it had not pierced the lung - a shot of penicillin was the end of the episode.," Many of her duties were administrative, from checking on drug supplies to reminding staff to wash floors and walls. The water supply - rain water gathered in large holding tanks - was usually adequate, although it sometimes ran out. "Many of the patients had never seen a tap, so they would open one and keep the water running", Uhthoff Munro says. "They just didn't realize that one had to turn the water off. If we didn't notice it, some taps would keep on running and, suddenly, no more water. The patients were surprised and we were dismayed." She witnessed some ludicrous incidents. For example, the Asian Development Bank had given the PNG government money to build a laundry in the hospital and a huge washing machine, water extractor and driers were acquired. There was only one thing wrong: there were no bedsheets and only a few towels to wash. Patients lay
Uhthoff Munro removes a spear as victim's relatives look on. 1296
(
\N ME) ASSOCJ 1990; 142 (I 1)
on bare cots or brought their own sheets and blankets if they had any. If the hospital supplied them, she says, they'd be stolen in minutes.
Uhthoff Munro says her year abroad made her realize how wasteful wealthy countries like Canada are. And how different attitudes are. "Death is much more part of life there. Here it is a disaster when somebody dies, even though we know it will happen to all of us. Over there, it is accepted with equanimity. If a mother loses a child, she cries for a day and that's the end of itshe has 6 other children to keep her occupied. When older people die, they say, 'Well, they've had their life and it's over now. That's it.' " She had to visit outlying clinics, trips that often meant frequent stops because news spread quickly that "Dr. Sylvia" was in the neighbourhood and she would be led to huts to attend to the sick. At the clinics, patients would be waiting when she arrived. The medical problems she encountered ranged from "terrible pneumonias" to malnutrition, osteomyelitis and burns. "In the hospital as well as in the bush clinics I saw a lot of anemia", she recalls. "There was no routine blood or other lab testing, so I looked inside their eyes for a diagnosis. Most are iron deficiency anemias and anemias caused by chronic malaria, but I must admit that I often didn't know what I was treating - I just prayed that my diagnosis was right and the iron supplement would do the trick. It did surprisingly often, and shows again how important clinical observations and intuition are. You learn to observe with a third eye and listen with a third ear.," She also performed several murder-related autopsies. "I had a few cases where the women had been hit by their husbands and had died. We have lots of abused
women in shelters in Canada, but there it was accepted that husbands beat their wives. Moreover, it is a polygamous society and women fight each other due to jealousies - they can hurt each other badly." When her parents visited, she made sure both worked hard she had 25 orthopedic patients for her father to operate on with help from her anesthetist mother. "When Mother anesthetized patients while Dad reduced forearm fractures, she used a blood pressure cuff as a tourniquet. It worked. The natives were such stoics - they accepted pain and discomfort and even wanted to watch what the surgeon was doing. And there is always some member of the family sitting nearby watching as well. "Of course, both my parents had to get used to working in the OR barefoot, since this is the natives' way of keeping the OR clean." Despite many hardships and
Removing a cast from a child's clubfoot
ing physical hardships, then don't dare it. It's not for everybody. Some people can't live without TV, the movies, theatre, family, and friends, and you might be really miserable. "I got used to the place quite fast and finally had everything
trained for, felt that he was helping people a lot more than he does here, no matter how high he eventually climbs on the executive ladder. They appreciate life more and they appreciate what we did for
them so much more. "Perhaps it is selfish to want to be needed", she says, "but my greatest satisfaction is the knowledge that I made a difference. I see so many functional diseases here, back troubles and psychoso"We heard from our friends in the Catholic matic diseases. In Papua New mission that they haven't been able to find a Guinea I saw so many more disphysician to replace me. And that makes me tressing and difficult diseases that could have been prevented by very sad." teaching and proper care. Helping people to help themselves and Dr. Sylvia Uhthoff Munro teaching them how to help themselves is most rewarding. "Apart from the rewarding medical aspects in my case, we frustrations, Uhthoff Munro says organized and running smoothly. both feel that we've become so she would like to have stayed for But I would have liked to do much more appreciative and conanother year, but her husband's much more. And I could have scious of what really matters in work in PNG, although reward- accomplished a lot more in anoth- life." Uhthoff Munro has also reing, was not fulfilling enough to er year." Uhthoff Munro and her hus- ceived some bad news since her prolong their stay. "Since our return home, I've often been asked band hope to eventually repeat return to Canada. "We heard to advise other young physicians their experience for 2 or 3 years, from our friends in the Catholic or surgeons whether to undertake even though "Canada is the best Mission that they haven't been such a trip", she says. "I say this. country to call home. We want to able to find a physician to replace If you feel uncomfortable not hav- experience again a place where life me. "And that makes me very ing a bathtub, operating in your has so much more meaning. Even he's what sad."do not did who isolated and bearMartin, bare feet, being CAN MED ASSOC J 1990; 142 ( 11)
1297
