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REPORT

PRIMARY TRAUMA CARE (PTC) COURSES

Luganville, Santo, Vanuatu

30 November – 5 December 2011

Executive Summary 1. What is the problem?

Trauma is a major cause of death and disability in many developing countries, including Vanuatu. The Primary Trauma Care course was developed to train health care workers to effectively and systematically manage trauma patients. The first PTC course was run in Port Vila (central Vanuatu) in 2009, and a decision by the Vanuatu Government and MOH was to run the next course at the Northern District Hospital on Santo, in the north of the country.

2. What did we do?

A 2-day PTC course and one-day PTC Instructor Course was held in Luganville, Santo. These courses were immediately followed by a second 2-day course organised and taught by the newly trained local instructors. 22 people attended the first 2-day course, 12 attended the instructor course, and 40 attended the second 2-day course. The aim of these courses was to teach trauma management knowledge and skills to course participants and also to train and develop the skills of local PTC instructors.

3. What happens next?

There is now a strong group of local PTC instructors who have the equipment, knowledge and skills to run future PTC courses in Vanuatu. The core group of senior instructors is based in Port Vila at the Vila Central Hospital, and there is now a second group of instructors based in the North, at the Northern District Hospital

4. What help will be needed?

Both AusAID (through the Pacific Islands Project) and the Ministry of Health were very generous in their support of these courses. PTC courses are relatively cheap to run but the future sustainability of PTC in Vanuatu will depend on the enthusiasm of the local instructors and the ongoing support of the Ministry of Health. In addition, PIP / AusAID can help by providing targeted assistance, eg, printing costs, equipment costs if required, some travel costs.

Introduction Vanuatu is situated in the southwest Pacific and comprises a chain of 83 islands spread over a large area of ocean. It has a population of about 220,000. The capital is Port Vila, population 40,000. The country’s main hospital is Vila Central Hospital in Port Vila, with the Northern District Hospital on Santo servicing the population in the north.

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Statistics are unavailable but most trauma deaths and disability in Vanuatu are caused by road traffic crashes and burns. Factors contributing to car crash injuries are alcohol use, lack of seatbelt use, vehicle overcrowding and poor vehicle maintenance. Burns are caused by open cooking fires. The Primary Trauma Care course was developed with the backing of the WHO to train health care providers to prioritise and treat severely injured patients quickly and systematically, thereby reducing death and disability. The course is specifically designed for health care providers working in developing countries and takes into account the resource shortages in these countries. The very first PTC course was run in Fiji in 1997 with the backing of the Australian Society of Anaesthetists, but PTC is now being taught in many parts of the world, including many countries in Africa, South America and Asia. Apart from teaching a system for managing trauma patients, PTC has a number of other benefits:

• PTC principles can be applied to non-trauma patients. • The course teaches teamwork and communication between doctors, nurses

and other healthcare workers. • The course develops teaching skills and encourages ownership by local

healthcare workers. Local Organisers Dr Willie Tokon, an instructor on the 2009 Port Vila course and Medical Services Manager of Vila Central Hospital, played a vital role with initial central course coordination, including selection of Santo as the venue and liaison with the Ministry of Health. Unfortunately Dr Tokon was overseas whilst the courses were conducted. Dr Basil Leodoro and Dr Andy Ilo also assisted with pre-course organisation and played leading roles during the courses. They both acted as local course coordinators, arranging the venue, catering, printing and selection of course candidates. Dr Leodoro was asked by the Vanuatu MOH to conduct some basic trauma management training for the nursing students in Port Vila prior to the PTC courses in Santo, which he did with considerable expertise. Dr Leodoro devised and taught a shortened trauma course based on the PTC model that received very positive feedback. Unlike the first PTC course in Vanuatu, which had a strong overseas presence in the instructor group, these courses were primarily organised and taught by Ni-Vanuatu PTC Instructors, with only one overseas Instructor present. This is very much to the credit of the PTC process and the capabilities of the Ni-Vanuatu Instructors. Course Instructors for First 2-Day Course (and Instructor Course*)

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Dr Andy Ilo* (Local organiser) Anaesthetist, VCH

Dr Basil Leodoro* (Local organiser) Senior Surgical Registrar Fiji School of Medicine, Suva, Fiji

Dr Chris Bowden* (Overseas organiser) Anaesthetist and Senior Lecturer Fiji School of Medicine, Suva, Fiji Dr Tildena Mandavah* Senior Anaesthesia Registrar Fiji School of Medicine, Suva, Fiji

Dr Samuel Kemuel* Surgical Registrar, VCH

Instructors for Second 2-Day Course

Dr Andy Ilo (Course Coordinator) Anaesthetist, VCH Dr Basil Leodoro Senior Surgical Registrar Fiji School of Medicine, Suva, Fiji

Dr Tildena Mandavah Senior Anaesthetic Registrar Fiji School of Medicine, Suva, Fiji Dr Samuel Kemuel Surgical Registrar, VCH Dr Wilma Luan Paediatrics, NDH Tousei Lestour Nurse Anaesthetist, NDH Ray Williams Nurse A&E, NDH Marieleah Alguet Nurse Eye Clinic, NDH Nadia Ala Nurse Practitioner, North Pentecost

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Dr Julianne Tevi Dentist, NDH Claudine Bani Nurse , A&E Elianne Metak Nurse, Medical Ward, NDH

Course Participants See Appendices 1-2 (Unfortunately I have misplaced the course attendance list for the second 2 day course). 22 people attended both days of the first course. All came from Northern Vanuatu. The group included 17 nurses, 2 doctors, 1 dentist, 1 physiotherapist and 1 hospital driver. 14 people attended the instructor course – unfortunately the 2 nurse anaesthetists had to leave early in the day for a hospital function and could not complete the course, leaving a group of 12 new instructors. 40 people attended the second 2-day course. This was thanks to the hard work of Dr Andy Ilo, who together with the Medical Services Manager (Northern District Hospital) Dr Thomas Sala Vurobaravo arranged for 26 nurse aid students and staff from the Vanuatu Police Force (VMF), Fire Services and Luganville Airport Services. Course Programmes See Appendices 3-5. The courses all started on time, ran well to time and were efficiently managed by Drs Ilo, Leodoro and Mandavah. The local instructors coped exceptionally well with the large numbers attending the second course, improvising well with available resources. Most importantly all courses were conducted in Bislama, with the instructors translating the PTC slides for all lectures. This lead to clear communication and much better understanding of the PTC message by all participants.

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Venue, Presentation, Catering All courses were held at the Northern District Hospital Nursing School Seminar Room. This was an excellent venue with fan cooling and air conditioning and outside covered areas. It was a little cramped for 40 participants and 10 instructors for the final 2 day course, but local planning coped admirably with most scenario and skill training sessions held outdoors. The Nursing School provided a lap top computer and data projector, which worked very well. Catering was arranged by Dr Ilo, and provided by families of the nursing staff at the NDH. The catering was very good, and certainly appropriate for the participants. Teaching Materials Unfortunately teaching materials were not printed in Port Vila prior to the courses commencing, and sourcing suitable printing in Luganville proved a little challenging. However with the help of Dr Leodoro the course manual, instructor manual and all certificates were printed and available by the second day. The manuals were good quality, and costs were met by PIP. The slides developed during the regional meeting in Lautoka in 2009 and used in Port Vila were used for the 2 day courses. I discussed the feasibility of translating the course slides into Bislama with Dr Leodoro; we both think this would be relatively straight forward to do, and would be extremely useful to future courses in Vanuatu. I will raise this possibility on my return to Melbourne. Copies of all teaching materials, manuals and other documents were copied and given to all new instructors. MCQs MCQs were asked at the beginning and end of each course. The MCQ’s were simplified and translated into Bislama by Dr Leodaro, and proved to be an entertaining way of assessing learning and development by the group. Scores improved markedly by the end of the second day.

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Publicity / Liaison The Medical Services Manager (Northern District Hospital) Dr Thomas Sala Vurobaravo and the Acting Director – Northern Healthcare Group, Ms Gerrolyn Tagaro were invited to the certificate presentations of the 3 courses. Participant Feedback Feedback from the 3 courses was universally positive. Many expressed appreciation for the opportunity to develop basic trauma management skills, especially the nurse aids, who staff the health centres in remote areas, and as such are true ‘first responders’. Financial The courses were very generously supported by AusAID through the Pacific Island Project (PIP), and the Vanuatu Ministry of Health. PIP met the costs of the overseas instructor, travel costs of the FSM trainees between Nadi and Port Vila, printing, catering, venue and an instructor course dinner. The Instructor Course dinner was held on the evening of the course, and was an outstanding success, allowing the new instructors an opportunity to socialise and network with the senior instructor team. The Ministry of Health provided funding for all local expenses for the local course instructors. Success and Relevance of the Visit The main objectives of the visit were:

• To teach PTC concepts and skills to relevant health providers • To give a group of local instructors the knowledge and skills to run more PTC

courses in the future. We were able to teach PTC concepts and skills to relevant health providers in both 2-day courses. There was a good mix of healthcare providers during both 2-day courses. The first 2 day course participants were hand selected as the best available from the staff at NDH. They came from different clinical (and non-clinical) backgrounds. The second 2 day course participants were all true ‘first responders’ in the Vanuatu MOH structure, and as such were most suitable. The instructor course and subsequent 2-day course were very successful. The newly trained instructors were extremely well organised, very enthusiastic and were very effective teachers. Under the guidance of the local senior instructor group they ran the second 2 day course with very little assistance. I am very confident that the Vanuatu PTC instructors can now run a 2 day PTC course with very little external support.

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Plans for the Future There are two main challenges:

• For PTC instructors and participants to apply PTC principles to the management of patients on a day-to-day basis.

• For PTC instructors to run more PTC courses. To do this, they will need ongoing support from senior clinicians, the Ministry of Health and possibly targeted assistance from the Pacific Island Project. The PTC Committee formed in 2009 was discussed during the instructor course debrief, and it was decided that Tousei Lesteour would be appointed to the committee as the NDH representative. In Dr Richard Leona’s absence (working in Australia) it was also decided that Dr Andy Ilo would be the chairman of the Vanuatu PTC committee, supported by Dr Tildena Mandavah. Drs Samual Kemuel and Basil Leodoro will continue surgical training in Fiji and New Zealand respectively. Acknowledgements Special thanks to Dr Andy Ilo and Basil Leodoro for doing all the groundwork, and to Dr Tildena Mandavah and Samuel Kemuel and the rest of the team of new instructors for doing such a great job. Thank you also to Dr Willie Tokon for his continuing support for PTC in Vanuatu. Thanks to the Vanuatu Ministry of Health for its support. Thanks also to Lito de Silva and the team at the Royal Australasian College of Surgeons, and to AusAID for its continuing financial support for PTC in the Pacific region. Dr Chris Bowden PTC Vanuatu Course Coordinator 6 December 2011

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Graduates of first 2 day PTC Course, Luganville, Santo.

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Appendix 1: Participants, First 2-Day Course 1. Claudine Bani Nurse, A&E, NDH 2. Nathan Warale Radiology, NDH 3. Ezekiel Danmelip Nurse, Medical Ward, NDH 4. Elianne Metak Nurse, Medical Ward, NDH 5. Romeo Leyrou Nurse, Surgical Ward, NDH 6. Marieleah Alguet Nurse, Eye Clinic, NDH 7. Leisale Ronette Nurse, ENT, NDH 8. Laisale Thomas Nurse, Maternity Ward, NDH 9. Dr Julianne Devi Dentist, NDH 10. Ray Williams Theatre nurse, NDH 11. Jerome Metteck NDH Hospital Driver 12. Rex Usi Physiotherapist, NDH 13. John Bore Nurse, A&E, NDH 14. Hendry Wetul Nurse, A&E, NDH 15. Meltenoven Theophile Nurse, Paediatrics, NDH 16. Yellie Metak Nurse Anaesthetist, NDH 17. Keimol Rock Nurse Anaesthetist, NDH 18. Dr John Kasso Ophthalmologist, NDH 19. Tousei Kasso Nurse Anaesthetist, NDH 20. Nadia Ala Nurse Practitioner, Pentecost 21. Alvine Bule Nurse, Paediatrics, NDH 22. Anthony Mermer Nurse, NDH

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Appendix 2: Participants, Instructor Course (* Instructor Course 2) 1. Dr Wilma Luan* MO, Northern District Hospital 2. Dr Robert Vocor MO, Northern District Hospital 3. Albert Kaipam* Physiotherapist, VCH 4. Claudine Bani* Nurse, NDH 5. Tousei Kasso* Nurse Anaesthetist, NDH 6. Ray Williams* Nurse, NDH 7. Marieleah Alguet* Nurse, NDH 8. Romeo Leyrou Nurse, NDH 9. Leisale Rovette Nurse, NDH 10. Nadia Ala* Nurse Practitioner, Pentecost 11. Elianne,Metak* Nurse, NDH 12. Dr Julianne Devi* Dentist, NDH

Dr Andy Ilo teaching a scenario

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Appendix 3: PTC 2-Day Course, Luganville,Santo , Vanuatu 30 November, 1 December 2011 DAY 1 0900-1000 Introduction Chris Local Trauma Perspective Basil MCQs 1000-1030 ABCDE, Primary Survey Andy 1030-1100 Morning tea 1100-1130 Airway and Breathing Tildena 1130-1200 Circulation Samuel 1200-1300 Skill Stations Airway 1 Andy Airway 2 Tildena Cervical Spine Chris Chest Drain Basil 1300-1345 LUNCH 1345-1415 Demonstration Scenarios All 1415-1530 Scenarios (four) All 1530-1545 Afternoon Tea 1545-1615 Secondary survey Tildena 1615-1645 Chest Trauma Basil 1645-1700 Day 1 Summary Chris DAY 2 0830-0900 Abdominal and Pelvic Injuries Samuel 0900-0930 Head and Spinal Injuries Andy 0930-1000 Paediatric and Obstetric Trauma Tildena 1000-1030 Morning Tea 1030-1100 Burns Basil 1100-1215 Workshops Analgesia Tildena Transportation Andy Paediatrics Chris Neuro assessment Basil/Samuel 1215-1300 LUNCH 1300-1400 Disaster Management Basil/andy 1400-1515 Scenarios All 1515-1530 Afternoon tea 1530-1615 MCQs and discussion Andy 1615-1630 Feedback, close Chris

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Appendix 4: PTC Instructors' Course, Luganville, Santo, Vanuatu 2 December 2011 Session 1: Introduction and Teaching Basics 0830-0840 10 mins Introduction Chris 0840-0855 15 mins PTC in Fiji Samuel 0855-0910 15 mins How adults learn Basil 0910-0925 15 mins Asking questions Tildena 0925-0945 20 mins Feedback Andy 0945-1015 Break Session 2: How to Give Presentations and Workshops 1015-1035 20 mins General introduction Chris 1035-1055 20 mins Giving a lecture Samuel 1055-1115 20 mins Running a discussion group Tildena 1115-1215 60 mins Workshops

• Lecture • Discussion group

Divide into two groups, 30 mins each workshop 1215-1315 Lunch Session 3: How to Give Presentations and Workshops 1315-1335 20 mins Teaching a skill Andy 1335-1400 25 mins Running a scenario Basil 1400-1500 60 mins Workshops

• Skill • Scenario

1500-1530 Break Session 4: How to Run a PTC Course 1530-1700 90 mins Discussion of issues All

• Language • Personnel • Equipment • Paperwork

Planning for 2-day course The future of PTC in Vanuatu Course evaluation

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Appendix 5: PTC 2-Day Course, Luganville, Santo, Vanuatu December 3,5 2011 DAY 1 0900-1000 Introduction Andy Local Trauma Perspective Samuel MCQs 1000-1030 ABCDE, Primary Survey Tousei 1030-1100 Morning tea 1100-1130 Airway and Breathing Marieleah 1130-1200 Circulation Robert 1200-1300 Skill Stations Airway 1 Wilma/Andy Airway 2 Ray/ Tildena Cervical Spine Claudine/Samuel Chest Drain Nadia/Basil 1300-1345 LUNCH 1345-1415 Demonstration Scenarios Andy/Tildena/Sam/Robert 1415-1530 Scenarios (four) All 1530-1545 Afternoon Tea 1545-1615 Secondary survey Julie 1615-1645 Chest Trauma Elianne 1645-1700 Day 1 Summary Andy DAY 2 0830-0900 Abdominal and Pelvic Injuries Romeo 0900-0930 Head and Spinal Injuries Wilma 0930-1000 Paediatric and Obstetric Trauma Claudine 1000-1030 Morning Tea 1030-1100 Burns Nadia 1100-1215 Workshops Analgesia Ray/Tildena Transportation Claudine/Andy Paediatrics Wilma/Elianne Neuro assessment Samuel/Julie 1215-1300 LUNCH 1300-1400 Disaster Management Julie/Romeo 1400-1515 Scenarios All 1515-1530 Afternoon tea 1530-1615 MCQs and discussion Samuel 1615-1630 Feedback, close Andy

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Dr Samuel Kemuel demonstrating ICC insertion – skill station

Dr Tildena Mandavah lecturing – Instructor Course

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Dr Wilma Tuen running a clinical scenario outdoors.