There are some experiences in medicine that are hard to forget. Mine took place in my second year of residency (between November 1998 and January 1999) during my rural medicine block on the volcanic island of Karkar, in Madang, a maritime province of Papua New Guinea (PNG). The Gaubin Rural Hospital, run by the Lutheran Church, serves the island’s population of over 50 000 people.

Karkar volcano (reproduced with permission of Hervé Sthioul).

I was a relatively junior resident, having graduated from the Medical Faculty at the University of PNG in 1996 and spent 23 months training at the Goroka Base Hospital in the Eastern Highlands Province. One fateful afternoon, a health centre referred a pregnant nulliparous woman with prolonged labour and splenomegaly. She was in shock, her abdomen was tense and distended, and there was a distinct non-tender mass occupying the left lower and upper quadrants — was this the spleen? The central abdomen was tender, and no fetal heart sounds were heard. Pelvic examination revealed that the woman had severe cephalopelvic disproportion, which was not unexpected, as she was only 1.5 m tall. She had a minimal pelvic bleed.

I resuscitated her and whisked her into the operating theatre to do an emergency caesarean section. I administered spinal anesthesia (there are no anaesthetists or general anaesthesia in rural PNG), then scrubbed and put on surgical shoes. The parietal peritoneum was tainted blue, heralding the presence of haemoperitoneum, and, sure enough, the peritoneal space was bubbling with blood — heaps of it. Certain that she had a ruptured uterus, I immediately felt for the uterus to examine the site and severity of the rupture, but, to my amazement, the fundus was small and well contracted and there was no fetus in the uterine body. There was, however, a huge, nasty, transverse wound on the uterine body. I was perplexed — where could the baby be? I tried to feel for the spleen and got the shock of my life when I felt the legs of the baby! The spleen wasn’t enlarged at all.

The dead 3 kg fetus was removed. The uterus was sutured and a tubal ligation was performed. During recovery the outcome of the surgery was explained to her and she accepted the fact that she would no longer be able to conceive. Seven days later she was discharged.

The health of women and children in rural PNG is still a significant problem that consumes most of a rural doctor’s day-to-day practice. A major issue for the training of doctors in PNG is the need for senior doctors to guide and assist resident medical officers with practical on-the-job training in patient management. This practice should be continued, encouraged and strengthened.