Sunday, March 01, 2009

No ticket for a corpse

Below is a feature story about Papua New Guineans going  all the way across the Torrest Strait to Mabaduwan and Saibai on the Australian side to seek health services because the Papua New Guinea government doesn’t give a damn about them! You feel so much for these people who cross the sea border at the risk of their lives because the PNG government has forgotten about them.I feel an affinity for these people as my late wife was from Irupi, just about 20 minutes by dinghy from Saibai, and her people go all the way across the Torrest Strait to Mabaduwan and Saibai to seek health services because the PNG government doesn’t give a damn about them!So much for 33 years of ‘independence’ from Australia!


By John S Whitehall in the The Medical Journal of Australia 2008


Saibai Island is the closest part of Australia to another country. Lying in the Torres Strait, off the tip of Cape York Peninsula, Queensland, the mangrove-rimmed mudflat is only 4 km from Papua New Guinea (PNG) — a mere 20 minutes in an outboard dinghy, but a journey from poverty to plenty in terms of health care for residents of the palm-thatched village of Mabaduwan, PNG, north of Saibai. Mothers bring their sick children to the primary health care centre in Saibai, and who can blame them? Once a dinghy beaches, a Rolls-Royce service is triggered.

One mother recently brought her one-month-old daughter to Saibai because she was sleepy and not feeding well. The carer in Saibai noted a full fontanelle and telephoned the administrative centre in Thursday Island, about 120 km away, at the tip of the Cape. A helicopter was sent to retrieve the mother and infant to Thursday Island, where hydrocephalus was suspected and advice was sought from the regional centre for neonatal care in north Queensland, in Townsville, about 1500 km south.

 The centre dispatched a retrieval team of doctor, nurse, incubator, ventilator and backpack of medicines to Thursday Island in a twin-engine King Air of the Royal Flying Doctor Service (RFDS). Thursday Island, however, is too small for a landing strip, so fixed-wing planes must land on nearby Horn Island, where passengers catch a bus to a jetty and then a barge across a fast-flowing strip of water to Thursday Island. Medical evacuations are facilitated by a small helicopter, which is based on Horn Island and hops back and forth.

The retrieval team left Townsville as night fell, were helicoptered back and forth from Horn Island in the middle of the night and returned to Townsville just before dawn. They had confirmed the large fontanelle, floppiness, an unreactive left pupil, and a sluggish right pupil, and initiated ventilation for respiratory failure.

In Townsville, ultrasonography revealed a massive lesion in the left cerebral hemisphere, which was confirmed by magnetic resonance imaging to be a tumour.

Meanwhile, the mother, who spoke very little English and whose life to that day had been spent in rural simplicity, was plunged into the luxuries of our modern Parents’ Unit next to our busy intensive care ward: lamp-lit hut with split bamboo floor was exchanged for electric lights and carpet; wood cooking fire for microwave; sleeping mat for huge, sprung, blanketed mattress; tropical heat for refrigerated “comfort”; nocturnal silence for the cut, thrust and whistles of intensive care battle; and family and friends for armies of strangers contending at all hours. Worse, the trees near the beach had been replaced by a strange contraption, more like a well, and there was no sea water with which to clean herself.

We wondered why she had chosen to sleep with the lights on until we realised she did not know how to turn them off. Why did she sleep on top of the bed, or was she sleeping on the carpet?

We soon learned that she had no idea how to use the microwave and stove and, in any case, had no coins to turn them on so we, of course, provided food. Why did she devour the fruit and leave everything else? We learned she was ravenous for sweet potato and cassava and perhaps a piece of fish.

We thought she might like to go outside, but she was terrified to leave the ward. The acres of parked cars and the traffic on roads running in all directions contrasted with the carless, unpaved pathways between huts in Mabaduwan.

Not surprisingly, her mental health began to disintegrate, and she became so fearful she would not even go to the toilet unless accompanied by a nurse.

We needed to talk to her — to explain things and get permission for the surgery —but were confounded by her dialect. Late on the Friday afternoon of her admission, we rang our translating service, the health clinic at Mabaduwan, the Saibai clinic, people who allegedly knew her husband on Saibai, her embassy, and various consulates to no avail, but as luck would have it, someone discovered a distant “cousin” who had a boy in our paediatric ward who had worked his way to Townsville from Mabaduwan in a similar manner. The cousin spoke English.

Conversation about the apparent diagnosis, the remote chance for surgery, the risks of anaesthesia, and so on, was tricky and took quite a while, supplemented as it was with such basic information as how to use the bathroom, and reassurances that we were bringing a change of clothing. In the end, we convinced ourselves that the mother understood matters and agreed to surgery.

Surgery revealed a fleshy mass infiltrating the brain, with necrosis and haemorrhage. Frozen section showed malignant glioblastoma. As much tumour as possible was removed, the wound closed and the baby returned to the ward, still ventilated.

After the surgery was completed, conversation became even trickier as we tried to discuss the contending kindnesses of continuation or withdrawal of high-tech support. There was no doubt about mother’s continued retreat into herself.

Ultimately, it was widely agreed to withdraw high-tech support and “let nature take its course” and, while the cousin was rallying a few friends to support the mother, we began to explore the ways of transporting mother and the baby’s corpse back to her village. She was adamant that she did not want to be separated from her daughter’s body, and we were keen to preserve what remained of her stability. It was clear that mother and daughter should travel together — one should not go with the luggage.

Problems accumulated with each phone call. No commercial airline would even think of transporting a mother with a corpse in her arms. Discreetly wrapped? No way! How about in a small crib? Not on your life, mate. I tell you, we can’t sell a ticket to a corpse.

Well then, how about doing us a favour and transporting the corpse free of charge in the luggage if we really have to do it that way? No chance — it is all tied up with regulations and corpses can only travel with the assistance of a qualified undertaker and in a proper casket.

A funeral director was asked how much it would cost to transfer one small corpse to Saibai. At least $3000, was the reply which, we figured, was probably about 3000 times the mother’s accumulated wealth.

Was there any chance the RFDS would take mother and corpse on a back load to Thursday Island? Its King Air is the only plane based in Townsville, and constant demands from the living relegate those of the dead to the bottom of the list. Moreover, there were certain rules about transporting corpses.

What if we kept the baby alive, to be extubated on Thursday Island? Would the commercial airlines consider carrying a baby being discretely hand-ventilated by a nurse? It was not as if we were asking for room for our whole transport team and equipment. After all, that equipment is all we have and it, too, needed to be on call in Townsville for the needs of the living.

At least the airlines considered this question, but later phoned to express regrets that other passengers in the small regional plane might be challenged by the phenomenon.

Sensing it might be easier to transport the living than the dead, we postponed the extubation, which took a bit of explaining. Mother seemed to follow the logic, and phone calls to Saibai and Mabaduwan began to prepare for the possibility but, as night fell on the second day of fruitless organisation, there was no apparent answer to the problem. We hoped something would “turn up” in the morning. It did.

The RFDS plane had been dispatched to pick up two adult patients in Cairns and bring them back to Townsville. Cairns is about halfway between Townsville and Thursday Island, and there was time to put in a “mercy” diversion to Thursday Island. The old problem of transporting corpses remained and it was very good the baby was still alive.

We still did not want to be separated from our transport incubator for the journey, which was likely to take about 10 hours, and sent one of our experienced nurses to ventilate the baby by hand. It was not clear how we would get the baby from Thursday Island to Saibai but wondered if she could go with one of the regular field trips to those islands. On the other hand, perhaps the baby could be extubated on Thursday Island and mother and corpse could return to Saibai in some kind of unofficial way, for which the Torres Strait is renowned.

 As our time was limited, medical staff on Thursday Island agreed to meet our team on Horn Island from where the baby would be helicoptered to the hospital for extubation. This would be very helpful, but would involve four hops of the helicopter: to pick up a doctor or nurse from Thursday to meet the patient on Horn, to take her to the hospital and then return to base.

Off flew our little group — up the coast over the Great Barrier Reef, then over the flat scrub of the Cape with its single four-wheel-drive track, determinedly heading for the tip where it would join the shore of the Gulf of Carpentaria, which had been receding from the west. Almost three hours after take-off, mother, baby and ventilating nurse alighted on red-soiled, sparsely treed Horn Island in the azure flows of the Torres Strait, to breathe the heavy, hot, watery air of the tropics. Mother was instantly at home. Nurse began instantly to perspire. Oddly, mother sighed “trees”. Did you not see any in Townsville, the nurse asked? Not one, said the mother, though the hospital is surrounded by them.

Meanwhile, concerns had risen in the staff at Thursday Island when it was learned the child was returning for extubation at that hospital while her father and other family members were gathering on Saibai to see her before she died and to be with her when she did. It seemed heartless to pass a corpse on to the family and budget constraints joined the meltdown. A helicopter would be employed to return the baby and her mother from Horn to Saibai, and a nurse and experienced paramedic would go with her to continue hand ventilation.

That helicopter was waiting on the airfield when our team arrived and in the hot haze of Horn, the child was passed from nurse to nurse and continued the journey home. Our team returned to Cairns.

At about 4 pm, father was reunited with daughter but, taking her up, would not pass her on to anyone. He appeared to have been consumed by an isolating grief that excluded and even blamed his wife. Everyone was alarmed and no one really knew what to do, but time was passing and the helicopter needed to return before dark.

With the sun low, the family gathered around the child and the tube was removed in expectant hush . . . but death did not follow. Stillness was punctuated by weak gasps that strengthened, quickened, and went on and on, all night, and into the morning when the family wondered if it would be all right to head off for Mabaduwan so the girl could see her grandparents.

Something did expire that night — the bitterness of the father. In a transformation judged by the night nurse to be the most moving she had ever witnessed, father, mother and family were reunited. It was “the proudest moment” of the nurse’s career.

At about 10am, the dinghies were fired up and the family returned home, but I knew nothing of these latter events when, two days later, I took a call from the primary health care worker in the village in PNG. In broken English he explained the baby was now crying loudly, waving its arms and demanding food, and wondered if I had further advice? My English broke in reply.

In retrospect, this medical venture had involved multiple sea trips, six helicopter flights, two ambulances, two long-haul plane retrievals with special staff on overtime, several days of life-supporting intensive care, neurosurgery, anaesthesia, medicines, laboratory investigations, social-work support, interminable phone calls, accommodation, meals, and changes of clothing . . . all for free. In return, a small girl lived for six months.


Author details:  John S Whitehall, FRACP, MRCP (UK), DCH, Director

Department of Neonatology, Townsville Hospital, Townsville, QLD.




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