The mother of all……..

In September 1994, the East New Britain town of Rabaul, nestled on the edge of a deep harbour that is a volcano caldera, was changed forever. The vulcanologists have been monitoring the floor of the harbour, reassuring the locals that it was still safe to stay in town. Technology would have failed the local community had it not been for the wisdom of nature. The migration of birds large and small, and the scampering of underfed usually sleeping dogs as they anxiously ran from the volcano, encouraged everyone to get out in time. Property was damaged, the landscape became a moonscape, but virtually no-one was injured.

One outcome of the volcanic eruption was the decimation of the airport, which was then located close to town and the harbour; the volcano caldera. Now, to get into Rabaul, you have to drive from Kokopo where the new airport is located, which I did in a four-wheel drive, on a journey that takes an hour. The hour-long trip drives past the newly forested Vulcan, the larger of the two vents that exploded during the 1994 eruption, past the village that was upwind of the plumes of ash, and therefore was unscathed, along the harbour-side road, past some of the second world war Japanese tunnels, then into Rabaul, but not before weaver erratically past crater-like potholes and driving over long segments of rough, muddy, sometimes impassable dirt road, created by flooding rains that had long ago buried the bitumen.

Rabaul used to be a pretty town, with a large market filled with colour, noise and dark skinned people all with curly hair; some with orange-red hair that identifies their “arse-place” as it is called in Pidgin English – meaning the place in which they were born. The origin of others being indicated by the darkness of their skin, the facial shape, their clothes, height or headgear, or a combination.

Beyond Rabaul, the Toyota took me past wider, deeper, interconnected potholes, past container warehouses on the right with large ships just behind them; a strong arm could throw a stone toward the water and it would reach the sea.

As the end of the harbour turns toward the smaller of the two 1994 vents, named Tu’vuvur … now a popular tourist destination with hot water springs that heat guineafowl eggs, cooked in the bubbling brine and eaten by visitors who bath in the nearby heated seawater. On the left is the Hamamas Hotel, or so it was known before the volcano – the word is Pidgin for “happy”. It still lives up to its name in atmosphere, but the buildings are now more down at heel than happy.

The concrete fence at the front hides a wrought iron structure, but only partly; some of it being uncovered by virtue of the degraded cement, a process that has not only affected the front fence. When it rains, which is does both heavily and often, the water flows down the path to the rooms at the back of the property, collecting first in large quantities on a slab under a storage building. The water creates a second obstacle to reaching the room, with beautiful green, variegated and purple head-high bushes crowding the path, traversed with the need to take care not to step on geckos, frogs and stag beetles.

The room is comfortable enough, provided you note the “eventually” hot-water tap in the shower is on the right … and has a label that is hard to read. As the shower water temperature rises, so does the hint of sulphur from the nearby volcano; don’t mind the ants as you settle into the comfortable bed to the tune of the fortunately functioning, truck-noise air conditioner.

In the morning hurry up and wait, or expect to get a call well before you were due to be picked up. “Your driver is here”. Foolishly, I indicate that he was not due to arrive yet. The chauffeur was usually a beetle-nut chewing red-teeth quiet man, each knowing the potholes like the back of his hand. Driving back through town then up the hill to Nonga Hospital was the morning ritual, seeing usually only a stray dog or two; too early for the mainly pedestrian traffic.

The district general hospital is a series of long, low tin sheds connected to either side of a concrete walkway that heads down to the water’s edge, a long way down the hill. Nonga, as it is affectionately known, was badly damaged by the ash and sulphur after the main volcanic eruption, and further corroded by the oft repeated, similar, less spectacular displays of nature that have occurred over the years.

Getting to Rabaul from Port Moresby had been spectacularly easy, not so the departure back to Melbourne, which was a look-a-like to the previous trip in 2016.

Boarding the plane, in Melbourne, without a visa; noting I was on a plane running late for a connection that may not have been made. Incredibly, the plane arrived in PNG and within an hour I was on my way to Rabaul, when I found myself sitting next to a member of parliament, with two bags of surgical equipment having been successfully loaded, with my visa … and expected to be collected at the Rabaul airport.

The return trip to Melbourne … enabled me to write this story because of the 6 hours delay of the flight from Rabaul back to PNG’s capital Port Moresby, missing the connection to the Milne Bay town of Alotau, for the second time in two visits to PNG.

Getting to Nonga hospital after arriving in Rabaul was also easy, then things became difficult.

Despite Easter, patients had come from the middle of New Britain and from the capital of West New Britain, Kimbe, enabling us to review a total of 15 children, 11 of whom had surgery during the five days in East New Britain. The days were long and the cases complex, with little or no radiology services, no easy access to ultrasound, and no sign of the consultant anaesthetist. Many of the kids had problems because of an anomaly of the bowel that needs surgery. The stand-out case was a boy with what became known as “the mother of all rectums”, a term that was adopted from the contemporaneous bombing of Afghanistan by America. The boy, a seven-year-old, through his misadventure reveals much about medical care in PNG and developing countries in general.

Prior to the Kind Cuts for Kids visit, he had four operations. The first was as a baby; he was born without and anus (lik lik pikinini no gut arse in Pidgin English) – for which he had a colostomy that relieved the obstruction. Then the trouble started. Within two months he had undergone surgery to connect his bowel to his bottom, but by a surgeon who has seen the operation, but who had not been trained adequately. With the state of service development in 2000, it was not necessary for such a major elective operation to be done, let alone to be performed in a less than 3-month-old. Bad turned to worse when the colostomy was closed by the time he was 12 weeks old, leaving the boy to have a life of misery by literally “shitting through the eye of a needle”. As if that wasn’t enough medical assault, in 2015, a hospital ship came to Rabaul and patients were encouraged to come for review. Picture …. a boy who, two years later, had the equivalent of a newborn baby removed from his abdomen; in 2015 he had an operation that was like putting a bandaid on a broken leg. The part of the abdomen that had been closed at the time of the colostomy closure had stayed together only at the level of the skin; he had an incisional hernia. The additional repair of the muscle and skin had been negligently inappropriate.

So, for two more years the mass in his abdomen grew. More rice, more chicken, more abdominal distension – obviously the ingested food had not maintained its originally form – no imagination needed!

A thin boy, with a very large abdomen, and his mother, greeted me when his name was called. His abdomen akin to that of a full-term pregnant woman. How anything was coming out of his anus was an anatomic and functional mystery. What was needed was uncertain prior to the investigation under anaesthetic known as a laparotomy; the process of opening the abdomen to gain information, intending that solutions will be found. Reformation of the colostomy was a likely intermediate solution. “Bloody-hell” expletives were heard more than once as the enormous size of his rectum became apparent, it looking more like a pregnant uterus than a thin conduit of faeces.

Normally when you open a child’s abdomen after previous surgery you expect to find some of the bowel stuck together by gelatinous, stringy slime-like material called adhesions that are often easy to divide, revealing quasi normal bowel. This boy initially seemed to have NO cavity in his belly, with the expected loops of vermiculating large and small bowel, at least not until an even wider incision allowed for the delivered, as if lifting a baby through a woman’s abdomen during a caesarean section. Tommy, a surgical trainee, exclaimed, “that is the mother of all rectum’s”, which was a reference to a President Trump expression about the largest non-nuclear bomb that America has ever dropped. There seemed no other adequate way to describe the unbelievably large size of this boy’s abnormal anatomy.

The thick walled, one case in a lifetime, bowel was ultrawide all the way into the pelvis, thus precluding simply pulling a piece of the bowel up to the skin to form a colostomy to by-pass the problem, and the connection of the bowel at the anus clearly needed to be redone. Shitting through the eye of a needle is not a life-long option. Taking most of the mass out meant taking nearly all of it; if you deliver the baby you also deliver the placenta; we had to take the metaphorical placenta. To remove the mass and reconnect the bowel to the neo-anus seemed reasonable, but was likely to take a number of hours, so we repeatedly questioned how stable the boy was with the in-experienced anaesthetic staff to make sure the decision to proceed was correct from a number of perspectives. The surgeons had the go-ahead from others, but carried the responsibility for the decision to do so.

Six hours later the boy’s rectum and contents tipped the scale at 3.1 Kg, with still the part of his bowel near his anus to be removed, with a total of 3.5 Kg in all; the same weight as a good sized newborn baby. The abdominal operation done, the calculations for drugs given on a per kilogram dose adjusted for the shift from 22 Kg to less than 19 Kg, the boy was placed in position to enable the connection of his faecal effluent to the normal position. And, that part of the operation went well. The drapes were removed, the boy placed on his back and the process of reversing the anaesthetic commenced.

Documentation of such an important case is vital, so the many photos were to be labelled and the database of PNG Paediatric surgery needed to be updated; reversing an anaesthetic is usually not the role of the surgeon, albeit it is a team effort to care for the patient and no part of an operation and anaesthetic occurs in isolation. After finishing the operation, the boy seemed to have been in the theatre much longer than expected, much longer.

Stepping back into the theatre after completion of documentation of the operation, the boy was not moving and was only being given oxygen with air; no paralysing drugs, no drugs to keep him asleep. He wasn’t moving, he wasn’t breathing and his breathing wasn’t being supported; he was still had an airway into his trachea, but was recording a low blood pressure and very poor blood oxygen levels via the probe on his cold, blue right thumb. Little urine was coming from the catheter into his bladder. His lips were pink, his heart rate was high, then his blood pressure started fluctuating wildly.

The relatively inexperienced, relatively untrained anaesthetist was out of his depth, and in terms of managing the anaesthetic crisis, so was I.

More oxygen, more fluids, then some blood, then some plasma. Where is the senior anaesthetist who has been missing all day? “I have sent him a text” came the response as the pulse again became hard to feel, the blood pressure fluctuated with each of the two different blood pressure cuffs that were being blamed for the poor readings, readings that were consistent with the poor peripheral pulse. Thank God he is starting to breath; his oxygen levels stayed low if his breathing was not assisted by the anaesthetist pumping away on the bag on the end of the endotracheal tube; oxygen in, carbon dioxide out. Again, his blood pressure dipped again, while his abdomen seemed to distend with gas outside the bowel, a supposition concurred with because the nasogastric tube was able to deflate his bloating abdomen. What the hell!

Death seemed to be the only likely outcome, taking me back to a situation that happened on my fist visit to Russia in 1989, after which I was never quite the same. The death of that girl would have been the responsibility of others. This time the death was going to be because of a decision I had made … the decision was mine and mine alone: in Russia I was a junior bystander. He is going to died, I thought; I feared.

The blood, saline and plasma kicked in, he warmed up with the application of hands and blankets; his oxygenation improved when the anaesthetic staff were made to stop trying to have him breath on his own until his blood pressure was normal, plus, and unfortunately, significantly when a surgical trainee with emergency department resuscitation experience was given the task of pushing the bag attached to the airway to force oxygen into his lungs. Ultimately, the boy survived, and so did the team’s cohesion.

The next day, the parents of the boy politely insisted that the boy say “thank you” to the surgeon who had changed his life: the operation had been lifechanging for more than just the boy and his family: the surgical team had an invaluable lesson in taking responsibility; the anaesthetist technical officer was seen to lack some of the skills necessary to manage difficult cases, for which training is to be organised; the absent-without-leave anaesthetist was recognised as categorically being absent, for which he was to be counselled, and the role of surgery in isolation and surgery without adequate experience brought again into focus.

Had the boy died, I am not sure I would have coped, and I am only his surgeon.