Dr Gary Nou shares his story of life as an emergency medicine physician in Papua New Guinea

Dr Gary Nou is a Specialist Medical Officer at Gerehu General Hospital (GGH) in Port Moresby, Papua New Guinea and President of the Papua New Guinea Society for Emergency Medicine (PNGSEM). Dr Nou plays a critical role in the advancement of emergency medical care and systems across Papua New Guinea as well as a clinical lead in the national COVID-19 response.

How have you and your team been going through this challenging time of COVID-19?
It’s been hectic, stress and early burnout signs have been noted, but I get a lot of support from my team. As well as myself I have two other Emergency Physicians involved in the rollout across our province. We have been lucky so far and have escaped a major outbreak, but this gives us more time to prepare as best we can for the worst.

I’m the incident manager for the national capital for COVID-19. For COVID-19 we adopted an emergency care plan and implemented that as a COVID-19 response aligned with directions from the National Department around Surveillance, IPC, Points of Entry, Health Awareness (risk communication) and Clinical Care. We outlined our care plan from when we saw patients in the community, ambulance transport, when we received patients, within the facility when we are treating patients right through to the final disposition of COVID-19 patients. This became our Emergency Response Plan. By taking this approach it was easier for us to them implement a system that worked for us and not leave out any of the crucial elements of the planning.

Last week we had a little spike – around 3 positive cases. Whereas before that we were having sporadic cases or one case. We were up to eight cases and then suddenly got one case and then another three which were not in direct contact. So at the moment in Port Moresby we’re looking at community transmission. But surprisingly, with our transmission rates and the rates of the severely ill, we’re not seeing the numbers presenting to hospitals as we expected to. Right now we’re ramping up our testing across the city and getting our ward prepared for a surge that may come in a few weeks time. This means a lot more work from my team as we try to expand and implement MoH directives.

What are the main emergency medicine challenges that you face in Papua New Guinea?
One issue is having 1 doctor to 17,000 people in the population. The challenges with this are already apparent and then you look at emergency physicians and the ratio is extremely low. Then trying to get those emergency physicians out across the country is another challenge we face. We’ve got more emergency medicine physicians completing their training but still the demand is high. We do loose some to Private facilities and Mines for better pay. So with this we need to expand training to other cadres of workers to spread the understanding of emergency medicine concepts. For example, a simple effective triage, a safe ambulance service, first responder training in communities, Primary Trauma Care and more.

Further education for emergency medicine for Nurses, Health Extension Officers and Community Health Workers is a challenge. With limited (Nurses – acute care) to none available for most. Currently the UPNG does offer a diploma in EM, this is for doctors that don’t want to do the full 4 year masters program, but we are reliant on short courses to build capacity in Emergency Departments across the country. As much as we can we try to do as many as we can but are limited by funding and in recent times travel restrictions.

Other challenges include equipment, and we’d like to do telemedicine and virtual lectures but the internet connection is an ongoing challenge. Not enough equipment, not enough training and we can’t even get the training out even if we’re trying to be innovative with electronic platforms because the internet doesn’t work. We have 22 provinces, so you can look at it is as having 22 little pacific islands which brings with it other unique political and geographical challenges as well as the language and cultural diversity across these provinces. Often you’re sent to work somewhere different to where you grew up and live so you also need to spend time understanding the local politics and culture. There are 800 languages across PNG. Linguistic barriers are very real.

Another challenge is often the physician is taking on management and administration roles. These physicians are trained as clinicians, but have undergone limited training for management and administrative parts of their roles. So these are skill-sets that need to be learned. Understanding our Public service general orders, doing staff appraisals and handling staff morale and discipline are some administrative issues we get landed in. It became so apparent to me that doing a month’s roster for a department is not a simple task and needs a system.

I guess the greatest challenge to face is improving our current systems, monitoring their effectiveness and implementing timely change.

What has been your greatest emergency medicine achievement?
The setting up of the isolation facility as the COIVD-19 response. This facility is a repurposed indoor netball court made into a field hospital. Previous to the set up to the facility we had a total of 8 beds available for COVID-19 patients in PMGH. We needed more space in case of a surge. In my opening address to health workers at the facility I mentioned that I am an emergency physician but here I am a creator of space. A space for the initial surge here and expansion, if we need it. The Netball courts is connected by road and in the same perimeter fence with 7 other sporting ovals, all with water power and sanitation.

We set up a separate field hospital in the city to cater for a surge of COVID-19 patients. The first in the country, to declutter the hospitals as much as we can. This field hospital also differs from our normal hospital structures as we have given prominence to IPC and OHS. Both given an elevated role from the DNS and corporate services and involvement in planning meetings.

What are you hoping to achieve over the next few years?
As the President of the PNG Emergency Medicine Society I’d really like to see the completion of our standard treatment guideline in the next year and also the endorsement of our training program. One of my passions is disaster medicine so I would like to see major incident management courses run locally, as well as all the other emergency courses we do. So a push for more training to be done and a broadening of our training categories. As well as emergency medicine training for our health extension officers and other community health workers.

Why did you become an emergency medicine physician?
When we go to the villages people don’t know if we’re a paediatrician, physician or obstetrician. We’re expected to go and attend to a sick patient if there is one, so as I was going through training I wanted to be able to be a jack of all trades, and at least be able to assist to some degree with everything I came across. Plus emergency medicine was new and exciting at the time. As soon as I finished my residency, I went into emergency medicine and I’ve never looked back.

What is the best thing about being an emergency medicine physician?
I think the excitement of it, its not the same thing all the time. Every time you walk into the emergency department you don’t know what’s coming.  Opportunities to do more outside of the ED.

What is the best way IFEM can assist the advancement of global emergency medicine?
I think the platform you have for accessing resources is really good but if we could have databases based in societies, or something that would work better for countries that struggle with internet. There is a group that provides a flash drive with resources that is updated annually which helps address internet issues. Everyone has a laptop but not everyone has consistent access to the internet. Plus we’re not strong at checking emails. So its really about providing platforms with resources that are more accessible and more relevant to low and middle resourced countries.