Medical Elective Experiences: Impactful Journeys in the Solomon Islands and the Philippines
The University of Nottingham was recently awarded a grant of £10,000 by The Hospital Saturday Fund to support their Medical Electives program. This initiative provides funding to medical students in order to facilitate their elective placements. Making decisions is an important part of being a doctor so choosing an elective is a good opportunity to test themselves. The elective gives them the chance to find out more about themselves and what they want to do in the future. It allows them to explore a particular area of medicine or something different, such as research or teaching.
Below are personal updates from some of the students who benefited from the Awards by completing their electives this year.
Emily Teagle: Providing Care in the Solomon Islands
The Solomon Islands is east of Papa New Guinea and is made up of 906 islands. I travelled to Gizo, the capital of the Western Province. It is the third-largest town in the Solomon Islands and has a population of approximately 7,000 people. Gizo Hospital was built in 2007 following an earthquake and tsunami that devastated much of Gizo and the old hospital. The hospital consists of an emergency department, clinics (there is no primary care system so patients go directly to the hospital), a male ward, a female ward, a labour ward, a children’s ward and a theatre. The hospital is run by its sole consultant and medical director, Dr Michael Buin. There are only three other doctors supporting the hospital and together this team of 4 work around the clock to provide the best care they possibly can. Gizo receives patients from all islands within the Western Province and during my time there we were met with a huge range of clinical presentations from penetrating wounds, shark bites, Dengue, Malaria, and complications from poorly controlled diabetes.
Resources and equipment are incredibly scarce in Gizo. Most clinical investigations are unavailable (only a full blood count, ultrasound scan and basic X-ray are to hand). This is a direct result of the COVID-19 pandemic which almost entirely stopped the supply of materials to Gizo. Sadly, this has not been reinstated to a sufficient level. In addition, medications such as antibiotics often run out. Therefore, a patient’s condition is mostly assessed from clinical impression and treatments have to adapt depending on what is available. Emergency care is limited due to the lack of a trained anaesthetist at the hospital. The doctors are limited to using Ketamine and spinal anaesthesia for emergency surgery and patients unable to maintain their airway must persevere with only a pharyngeal airway until they reach Honiara. Sadly, morbidity and mortality rates are high for such patients.
Due to a combination of limited access to treatment, poor health education and the time and money it takes to reach Gizo, chronic conditions such as diabetes and heart disease are poorly controlled. This leads to a lot of very late and advanced presentations, often secondary to complications which could have been prevented in the UK.
Life In the Hospital
Life in Gizo Hospital is busy. With so few doctors any extra help is welcomed with open arms and the regular doctors are used to being called back into the hospital at any hour as emergencies present themselves.
In order to optimise their time and ensure all patients are seen regularly Mondays, Wednesdays and Fridays are ward round days. During these days we would go to each of the wards, review each patient and complete any jobs that were required. Much of the work was similar to that in the NHS: speaking to and examining patients, reviewing drug charts and writing discharge summaries. I felt instantly useful being quickly put to work to help complete these tasks. Meeting so many patients with a huge range of problems, in such a short space of time, meant I had to quickly find ways around the language barrier. Although many people in Gizo speak English, Pidgin is the language most commonly spoken across the Solomon Islands and was the sole language spoken by patients from the more remote islands. The nursing team were incredibly helpful, acting as translators and also teaching me some common medical phrases. Once the ward round was finished, we would then head down to the emergency department, or clinics, to help tackle the tide of patients that came through the doors each day.
Tuesdays were surgery days. The most common operations were amputations of digits (due to diabetic foot infections) and C-sections. I was able to scrub in and assist with multiple C-sections. The birth rate in the Solomon Islands is high and sadly death during labour is one of the commonest causes of death. This is due in part to many women not seeking out antenatal support from the rural clinics, with complications such as Placenta Previa going undetected until the expectant mother presents in antepartum haemorrhage. It is also due to a lack of a blood bank (the hospital relies on ambulance boats to bring a relative with the patient who can be used as a blood source) and a lack of medications such as tranexamic acid which can be lifesaving in such situations.
Another procedure I commonly saw was abscess drainages. Many patients would attend months after receiving a penetrating wound. Having not been treated acutely, these wounds would become contaminated with dirt or by foreign bodies and would become infected. One such patient was a 5-year-old child who presented systemically unwell with an abscess on his wrist. He had fallen from a tree and cut himself with a knife (many children climb trees to cut down fruit and betel nuts which can then be sold at the market). Under ketamine sedation, I assisted to drain the abscess and wash out the wound.
Working with DASI
Due to the lack of specialist doctors and resources within the Solomon Islands, Gizo Hospital relies heavily on international aid from organisations such as UNICEF, Japan Aid, Australian Aid and DASI (Doctors of Australia working in the Solomon Islands). Maintaining this supply of aid and ensuring patients have the best opportunities possible is a never-ending job for Dr Buin who works tirelessly to arrange for such organisations to come to Gizo. I was lucky enough to encounter the work of the DASI organisation in the form of a urology mission. Due to the lack of a urology specialist in the country, many patients have very advanced prostate cancer, BPH and Urethral strictures which can only be treated with a long-term catheter. The DASI mission treated as many of these patients as possible and provided training to the local doctors. I observed and assisted with TURPs, cystoscopies and the removal of many bladder stones and cancers. Thanks to the presence of an anaesthetist within the team, the local doctors were also able to perform operations that they otherwise could not without GA. I learnt much about the administration of anaesthetics in rural medicine and assisted with airway securing and maintenance as well as the administration of spinal and ankle blocks.
Life Outside of the Hospital
Outside of our hours at the hospital, my elective partner and I made the most of exploring the town. We frequented the market which is the town’s source of fresh fruit, vegetables and fish; we ventured into the shops, and we took the opportunity to dive and snorkel around the surrounding islands. The locals were keen to show us the pristine coral reefs, something they are incredibly proud of. They also taught us about the history of the Solomon Islands and its involvement with WW2, showing us Kennedy Island and the Japanese shipwreck Toa Maru.
The islanders are incredibly proud of the diversity of fish they have available in their lagoons. Protected from the effects of industrial-scale fishing and pollution, the quantity of marine life surrounding the islands is vast and hugely diverse. Many of the locals enjoy spending their free time fishing. One of our friends caught a coconut crab and showed us how to cook and eat it. Green coconuts are another incredibly popular food.
During our time in Gizo, we stayed at The Naqua Motel which is located just behind the hospital. Amos the owner was incredibly accommodating, helping set up transfers from Nusatupe (the landing strip), setting up SIM cards, showing us around the town and organising fishing trips and BBQs at the weekends.
Poverty is greatly apparent throughout the Solomon Islands. This does not, however, impact the cast iron sense of community within Gizo. Everyone knows everyone and to not say hello or do what you can to help your neighbour is just not the Gizo way. Come rain or shine the people of Gizo have a positivity that is as sunny as the climate. Family and community are of the utmost importance, with many of the patients admitted to the hospital surrounded by their entire family. That family will stay with their loved one, camping on the ward floor and helping care for their loved one in any way they can until they are discharged. We only experienced a snapshot of this community but the generosity and warmth we received within that time was second to none.
Thank You
I feel incredibly fortunate to have had the opportunity to work in such an incredible country, with some truly incredible people. The Solomon Islands is such a remote country, in such a far away and seemingly forgotten part of the world and to have completed my elective here has truly been a once-in-a-lifetime opportunity for me. My time in Gizo has not only sharpened my clinical knowledge but has also taught me a lot about myself. It has highlighted both my weaknesses and my strengths in new and strange situations and has brought out a love for rural medicine which I had not realised prior to this trip. The skill, knowledge and tireless dedication that is required to be able to treat patients with any condition, both minor and life-threatening, young and old, medical and surgical with limited resources is truly remarkable. I can safely say that the doctors at Gizo Hospital are some of the most selfless and dedicated people I have ever met.
I would like to thank the Hospital Saturday Fund and the University of Nottingham for awarding it to me. The money you provided not only aided my journey to the Solomon Islands but also enabled me to bring much-needed resources in the form of medical scrubs, urinalysis sticks and pregnancy tests to the hospital. It has made a significant difference to my development as a doctor and aided me to not only experience a healthcare system outside of the NHS but also to experience life in a community that could not be more different to the communities in which I reside at home. My experiences from this trip will stay with me for many years to come and I hope will help to mould the type of doctor I hope to be in my future career.
Jess Gill: Learning and Giving Back in Cebu City
I would like to begin this report by offering my gratitude to the Hospital Saturday Fund for their immense generosity in providing a bursary to help fund my medical elective and subsequent further learning. Without this donation, I would have been unable to afford this once-in-a-lifetime opportunity and missed out on the many life lessons and experiences I’ve achieved here.
My first attachment was Emergency Medicine at Cebu Doctors University Hospital. I was able to clerk and become involved in ED, and also become an active member of internal medicine ward rounds in respiratory, Cardiology and Nephrology. This meant that I was exposed to a range of conditions and infectious diseases which are common in this part of the world. This included TB, systemic lupus, dengue fever and SIADH. Under the supervision of a 3rd year Resident (4 years postgraduate), I was able to shadow them throughout their day.
Tasks included morning ward rounds, teaching sessions and attending resident and student conferences. The conferences held were grand ward rounds where residents would present cases from the previous week to a panel of senior consultants. This was a unique experience; I was able to understand the relationship between staff and the hierarchical structure within the hospital both in job title and respect. Some instances were quite brutal: the direct questioning from the seniors posed many challenges for the junior doctors. Upon reflection, although harsh, residents were able to clinically reason their decisions or further action plans which highlights areas of improvement in my own skills that need to be worked on.
On ward rounds, I gained a grasp of how healthcare in the Philippines is dependent on your financial state as much as the severity of your illness. An example of such was when I saw a patient on a ventilator in a general medicine ward rather than in ICU. In the UK, only in ICU will you see a patient on a ventilator. Here, because the patient could not afford ICU, they were still given treatment but in far less suitable settings. It costs $10 for one night on a general medicine ward: in order to be admitted into ICU this can cost upwards of $120 a night. For severely affected patients this can lead to weeks or months of hospitalisation where ICU is just not affordable. These kinds of situations are sad, and you feel a sense of guilt towards these patients as you know there is more that could be done. I guess that’s just how the system is run, it has made me feel a great sense of gratitude towards the NHS and how important public healthcare is to a sustainable community.
One of the more fascinating cases I witnessed and was an active member of was admitting a female patient aged 45 who presented with severe epistaxis. Her nose had bled a large volume of blood and she appeared to have an excruciating headache when admitted to ER. After taking a history, with the resident, it was decided that the patient required surgery and was admitted to the OR. I was lucky enough to be invited and scrub into the removal of nasal polyps from the patient; this was a very interesting procedure. In the UK nasal polyps are removed via endoscopic resection through the nostrils, in this procedure it entails making a passage through the roof of the mouth and the nasal floor. This is the first time I was part of a surgery which I followed from admission. I feel privileged to have been present during this time. Following this, I developed a relationship with the surgical team.
My first 2 weeks at the Hospital introduced me to a contrast in healthcare compared to the UK. I worked with an open mind and tried to absorb as much knowledge and understanding as I could from the doctors, but also the patients who could speak a little English. I am appreciative that I got this opportunity but was very much ready to join the community team to gain experience of medicine not confined within the walls of the hospital.
As part of the community medicine team I was able to fulfil many desires I had prior to my elective: for example, aiding patients in disadvantaged situations and providing teaching to local members of the community about preventative medicine and healthy lifestyle choices. The community team primarily act as an open clinic to the public, much like a GP back home. This clinic was situated 45 minutes outside Cebu City, surrounded by mountains, acres of vegetation and underdeveloped settlements. The clinics offer support seven days a week for neighbouring communities. A small team of a consultant, several physiotherapists and five or six medical students work within the clinic. Medical students have a very prominent role in providing care. Initially I had my doubts about whether medical students could provide adequate care, yet they seemed well-versed in common conditions that patients in the community are exposed to. If ever in doubt there is fluent communication between them and seniors. They were also able to prescribe medication, which bewildered me.
Common conditions were mainly paediatric, as worried mothers in the community were able to walk to the clinic compared to getting a long expensive journey into the city’s nearest hospital. These included: bronchiolitis, otitis media and general poor feeding. A few cases stood out to me, and I was excited to be involved in. A man presented to the clinic with dizziness and headache, upon taking a history we were able to decipher that the gentleman has had numerous road traffic accidents with his moped in the past. He admitted to having hit his head several times, but as the bruises healed he believed them to be treated. Unfortunately, the examination findings were positive for cerebellar injury e.g. nystagmus and dysdiadochokinesis present. Although the language barrier posed some obstacles, with assistance from the accompanying medical student, I was able to examine thoroughly and the patient was referred for transport to the main emergency department in Cebu.
In addition to this, I was able to travel to patients who were unable to get to the clinic. I was exposed to a variety of living conditions and makeshift homes for families throughout the neighbouring communities. One of the more shocking experiences was visiting a sixty-nine-year-old man with a known spinal fracture after falling from his motorcycle. His previous employment was transporting barrels of water to communities, thus upon his accident, a large amount of weight contributed to such extensive damage to his spine. My role, along with the physiotherapists, was to deal with any general complaints of the patient. This included examining the rashes on his lower leg which could be managed conservatively with emollient cream. I noticed on further inspection that he had several pressure ulcers forming on his buttocks and torso. Unfortunately, his disability meant he was unable to move himself and his only carer is his son who now has to work double time to cover the job of his father. This meant for the majority of the day the patient was in one position lying on a plank of wood for a bed, with a whole cut near his buttocks for defecating. If this wasn’t ill-fated enough, the patient’s home was situated within a landfill site. Surrounded by the city’s waste, unsanitary water and swarms of flies and mosquitoes, this experience was my first exposure to the major difference in poverty within the Philippines. Following this, I didn’t really know how to feel. I’ve always been protected as a medical student within the hospital. Witnessing such a scene opened my eyes to the importance of programmes such as community medicine in providing healthcare to everyone who needs it, even within the depths of poverty. It also opened my heart to the many Filipino residents who face similar circumstances and have to deal with them as part of daily life.
One aspect that is often overlooked in community medicine is its role in medical education in underdeveloped communities. Cebu Doctors Hospital outreach programme initiated a project called COPAR which is a community participation project aiming to provide teaching and awareness about community health in an attempt for communities to use this new insight and spread the message to neighbouring communities. There is a great sense of wholesome togetherness when participating in meetings and events. I was introduced to a cohort of 15 women from the Cacao community who had been part of this initiative for almost a year. Topics that were discussed included smoking, dengue fever and child safety within the household. The end goal was for each community to formulate a presentation of any kind e.g. songs, posters or dance routines to express what they have learned and hopefully pass insight to others.
Having attended the final graduation and presentation, I experienced a great community spirit, with everyone willing to learn and share. The community team offered great encouragement and seemed to have built strong relationships of trust with the community. I felt proud to have been able to experience this. A great initiative in my opinion, is optimal when there are so many different communities surrounded in poverty which require increased awareness about social health and lifestyle factors. I was able to also help create posters within the community to present as part of a teaching session on child safety.
While the majority of my time was spent learning new skills and out in the community, I had enough time on the weekends to explore Cebu and spend time at its beautiful beaches. Whether it was snorkelling with sardines or trying scuba diving for the first time – none of this would be possible without help from the Fund. I was able to spend my own money on achieving a PADI level 2 certificate meaning I can now scuba anywhere in the world. Although I was quite fearful of attempting this, having now completed it I have confirmed that it is one of the most exhilarating things I’ve ever done, allowing me to learn so much more about my capabilities.
I could never have imagined going to Southeast Asia for 4 weeks, this is the furthest and longest I’ve ever travelled. I have learnt new things about myself, also other cultures – their formalities and healthcare systems. Much of which I have taken for granted in the UK. I’ve met people from all walks of life and poverty, and I’ve laughed and shared memories that I’ll have for a lifetime. This is all thanks to the Hospital Saturday Fund. Thank you for the unbelievable support you offer for aspiring medics to develop and improve their understanding of healthcare worldwide. I am forever indebted to the Fund. This was an eye-opening experience I’ll have with me throughout my medical journey. I believe this experience has made me a more empathetic medic. Thank you dearly.
Joseph Norvill: Surgical Exposure and Medical Outreach in Cebu
I would first like to begin by thanking the Hospital Saturday Fund for providing me with this very generous bursary. Your contribution to my elective facilitated me in organising an elective in the General Surgery Department at Cebu Doctor’s University Hospital, Cebu City, Philippines.
Cebu is an island located in the central Visayas region of the Philippines with a population just short of one million. Cebu Doctor’s University Hospital is a 300-bed capacity, tertiary private hospital in Cebu City. The Department of Surgery has eight operating rooms and on average, treats 513 patients each month. I was fortunate to gain exposure to a wide variety of procedures, both major and minor, in the community and hospital.
From day one I was able to scrub in and assist in major operations. My colleagues were very enthusiastic about teaching and keen to get me involved. I was able to shadow and gain exposure in all surgical specialities.
Notably, I was able to assist in numerous thyroidectomies of patients with significantly large goitres. With iodine supplementation not commonplace in the Philippines, goitres remain a common presentation. I was shocked to learn this. Nevertheless, during the procedures I was in awe of the surgeon’s skill as he carefully dissected the thyroid, being sure to avoid the recurrent laryngeal nerve.
Furthermore, I was able to assist in a suboccipital craniotomy and ventricular tube insertion, in a 59-year-old male, to remove a suspected hemangioblastoma. In other cases, I was able to make an incision and use the ETHICON Harmonic under the careful guidance of the resident and attending surgeon. Gaining these skills in a structured, teaching-focused environment is what drew me to Cebu in the first place. I am very happy to have gained such hands-on experience in a wide variety of cases. Other cases included a hemicolectomy with colonoscopy, total mastectomies, proctosigmoidoscopy with fistulectomy, removal of squamous cell carcinoma of the cheek, transurethral resection of the prostate, total hip replacement, hernia repairs and laparoscopic cholecystectomies. Asides from theatres, I was also keen to gain research experience. As a result, I am now collaborating with one of the surgical residents and his consultant, a plastic surgeon, to write a case report. The case is regarding a 68-year-old female who underwent pedicled flap reconstruction for a large perineal defect. I expect to finish this in the next few months and submit it for publication afterwards.
Unfortunately, healthcare in the Philippines is expensive and government-subsidised treatment is not always adequate. Learning this helped explain why patients often presented late and those from lower socioeconomic backgrounds may choose to avoid expensive treatment (e.g. ICU) or avoid treatment completely. In light of this, I was delighted to accompany Dr Chua, Justice Geraldine and their team on a medical mission to the island north of Cebu, Malapascua. A diving hotspot known for its Thresher sharks, Malapascua is nothing short of paradise. However, despite such successes in tourism, healthcare on the island is of a very low standard. From chatting to locals I was surprised to learn there is only one clinic and one full-time midwife. Asides from scheduled visits from physicians, locals must travel to the mainland for the majority of their healthcare. The mission, therefore, aimed to address these inequalities and supplement the poor service provision currently available.
In total, 134 consultations, 84 dental procedures, 235 optometry consults, 32 minor operations, 73 circumcisions and 36 pterygium removals were performed in the local basketball court in one day! I was honoured to be invited and support the team in carrying out their great work. This experience is something I have certainly taken home and will carry closely as I pursue a career in surgery. Asides from assisting in theatres, I was able to attend the weekly endorsements where interns (final-year medical students) and residents gave case presentations and answered questions from the consultants. To say they received a ‘grilling’ would be an understatement. Of course, this was understandably exacerbated by their tiredness as they were all coming close to finishing a 36-hour shift! The long hours worked by my Filipino colleagues did indeed concern me.
Nevertheless, the interns and residents did get a chance to relax and enjoy themselves occasionally. On a few of such occasions, we were delighted to join them for weekly meals and learn more about Filipino culture which much to my delight, includes karaoke! Indeed, the welcoming and accommodating nature of the Filipinos made me feel very comfortable during my time here in Cebu. I did not expect to be treated so kindly and attentively by my colleagues. I have promised to return the favour should they decide to visit the UK in the future.
I would again like to thank the Hospital Saturday Fund for their generous support which allowed me to undertake this elective. In short, my time there was a once-in-a-lifetime experience. Learning how healthcare functions in a less developed country compared with the UK has been very insightful and led to much reflection.
These personal accounts showcase the diverse experiences and profound learnings gained from medical electives in resource-constrained settings. The Hospital Saturday Fund’s support enabled these aspiring healthcare professionals to expand their horizons, develop new skills, and gain a deeper understanding of the global healthcare landscape.
About us
In 2023 The Hospital Saturday Fund will give £2.3m/€2.5m in donations and grants to medical charities for care and research, hospices and hospitals across Ireland and the UK Assistance will also be given to individuals whose illness or disability has caused financial difficulties.
For further details please contact Dee Wright, Charity Manager – dee.wright@hsf.eu.com
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