MAF medevacs man to hospital after house collapses on top of him
It’s a miracle Nepo is alive. Whilst working under his house on 19th August in the remote PNG village of Pyarulama, the stilts holding up his home suddenly gave way on top of him. The weight of the building nearly killed him, but a swift MAF medevac to Kompiam Hospital saved his life. Dr Diana Zwijnenburg has been overseeing Nepo’s recovery…
Houses in rural Papua New Guinea are traditionally built on two-metre stilts to avoid flooding, improve ventilation and to keep out vermin.
The area underneath the house also offers much needed respite from the sun – a place in the shade to work on various projects. Unfortunately, Nepo – in his late forties – was
working under such a house when it suddenly collapsed on top of him.
Large fireplace stones from the floor above fell onto his chest and a wooden beam has crushed his leg.
Screaming in pain, he’s pulled from the debris. Mathew Panglas, the local health worker, gives him some morphine and calls for a MAF medevac.
Pilot Mathias Glass medevacks Nepo from Pyarulama to Kompiam Hospital. This mere twelve-minute flight saves his friends from carrying him in a makeshift stretcher over rugged terrain for two days.
A&E in the middle of nowhere
Nepo is admitted to Kompiam Hospital just before 5pm. Dr Diana Zwijnenburg, a volunteer doctor from Holland, gets to work on him straight away:
‘He’s badly injured and not very responsive. Although barely conscious, he’s breathing ok. I’m concerned about a possible skull fracture because there’s blood coming from his ear. His right upper leg is broken and there’s a nasty graze and bruising across his chest.’
Unfortunately, the x-ray machine is broken and they’re still waiting for replacement parts:
‘We have an ultrasound machine instead - a real blessing in this situation. Fortunately, there are no collapsed lungs or blood in his abdomen or pelvis, so I’m reasonably confident that there’s no major pelvic fracture.’
In the West, it’s standard practice to protect the neck in all trauma cases, but for doctors like Diana in the middle of the bush with limited resources, there isn’t that luxury:
‘His head has been wobbling around unprotected from the time of the accident. Should I put him in an ill-fitting collar, which might increase the pressure in his head and make a potential skull fracture worse? I decide that is probably worse, so I leave the neck, assuming it’s uninjured.’
Then there’s the other matter of his leg:
‘Under a lot of local anaesthetic, I insert a traction pin into his lower leg and hang some weights on it. This instantly makes his broken leg look a lot straighter.’
Nepo takes a turn for the worse
Although Nepo looks better the next day and is fully conscious, bruising on his lungs from the falling stones start to cause breathing problems. Diana is worried:
‘Stones falling from a height of two metres are bound to cause significant damage. I examine him again but can’t find any broken ribs. His condition worsens - by morning he needs nasal prongs to give him oxygen and over the next 24 hours he deteriorates further. By Monday he’s on dual oxygen.’
Nepo urgently needs a ventilator to survive:
‘We need to intubate him (a breathing tube inserted into the airway) and put him on a ventilator until his lungs have healed enough for him to breathe again on his own.'
This would be an easy decision in the West, but here in the middle of nowhere with few resources, staff have never seen, let alone looked after an intubated patient.
Dr Diana Zwijnenburg, Kompiam Hospital
His family consent to him being put onto a ventilator. Diana has to work fast:
‘I get some stuff together - a simple oxygen powered ventilator, intubation equipment, the suction machine from the labour ward, and various drugs.
‘Two very competent junior doctors and a health care worker are willing to help even though they’re completely outside of their comfort zone. By now, Nepo is on his last few breaths, bathed in sweat from his effort to breathe.’
Divine intervention required!
Diana and the team pray for a miracle:
‘We pray for the God of heaven and earth, the creator and sustainer of life to help. We pray for peace for the family and for a smooth intubation. We pray for this man to live - for God to give him a second chance, so that he can glorify God’s holy name.’
After doing all they can, they leave the rest to God. Nepo stabilises, but needs 24-hour care – a concept lost on the nurses of rural Papua New Guinea says Diana:
‘I discuss the importance of one nurse being with Nepo at all times. Regardless of lunchtime, breaks or other jobs, he needs to be watched. I realise that most of them have no clue what to watch out for or what to do in case of a problem.
‘Then we discuss suctioning - every hour his tube needs to be suctioned. More blank faces! Then there’s the matter of regularly turning him, feeding tubes, alarms, the pump and when to get a doctor. The staff have never experienced this before, yet in normal Melanesian fashion, they all nod and say “yes”, indicating their willingness, but I know I will have to show them first.’
With every changeover of staff, Diana patiently explains how to care for Nepo over and over again.
Everything is harder in the bush
As if broken equipment and inexperienced medical staff weren’t enough to contend with, there’s also the matter of out-of-date drugs, scarce medical supplies and blocked roads caused by election violence says Diana:
‘In a western Intensive Care Unit (ICU), drugs are administered through different syringes and pumps, which are adjusted to the patient’s needs. Here, we have one pump, so it all goes into one syringe.
‘Next, we realise that we’re going to run out of oxygen bottles before the weekend. Normally we get new supplies, but the road to the provincial capital is blocked due to election violence. Kompiam drivers are not keen to risk it.
‘We’re also running out of bandages, gauzes, and other medications. After much procrastinating, two drivers finally pick up some supplies. When they return safely, everyone is so relieved.’
In the meantime, Diana is having issues with the contents of Nepo’s syringe and the quality of ICU care:
‘I need to change the contents of his syringe constantly due to some drugs not working properly. Most of our drugs are either 5 to10 years out of date or out of stock altogether.
‘The continuous supervision of his care has also become very tiring. One night I found both night nurses fast asleep with nobody watching Nepo. It didn’t happen again!
‘He has also developed some pressure sores because he hasn’t been turned every two hours. We dress all his wounds and turn him to prevent deterioration.’
All this time, Nepo’s family are keeping their distance. Diana learns why:
‘They are terrified. They’re convinced that a bad spirit is to blame - the spirit of Nepo’s wife’s first husband. They blame this spirit for the house collapse and are afraid of more trouble. They also don’t know what’s happened to Nepo’s spirit.
‘The amount of fear is heart-breaking. Our local pastor visits and speaks to them in their own language. Then we pray - God is so much bigger than all these spirits and fears.’
Slow road to recovery
On day five, it appears that Nepo may be able to breathe by himself without a ventilator. Diana is pleased with his progress:
‘His airway pressure has been quite reasonable, and his numbers are looking good. There’s also a lot less debris when suctioning. We get all our equipment ready and stop the sedation. We wait for about three hours but not much happens. Nepo starts to breathe again, but not enough to support himself.
‘The unpredictable effects of the drugs are not helpful. On top of this, the people in PNG seem more sensitive to some of the drugs. I admit defeat and put him back on the ventilator with a different sedative.’
A simple ventilator out in the bush is a lot less sophisticated than ventilators in the West:
‘A good ventilator synchronises with the patient’s breathing pattern. A patient is then weaned off the ventilator and their breathing tube removed after their medication is reduced.
‘Our little ventilator is unable to synchronise at an advanced level – it’s all or nothing so I have to keep Nepo in a much deeper state of sleep so he can tolerate the ventilator.'
The disadvantage of this particular sedative is that it runs out much quicker than the previous one explains Diane:
‘Every four hours - day or night - his syringe needs to be changed. After two days, we try again to wean him off the ventilator. We pray again, leaving it all in God’s hands.
‘We stop the syringe and I suction all the debris that he coughs up. Nepo starts to breathe. We stop the ventilator and connect oxygen to the end of his breathing tube.'
Nepo’s breathing is shaky at first, but gradually it improves:
‘Eventually, I take the breathing tube out – he’s on his own. We give him double oxygen and make sure he sits up as much as he can tolerate. We wait - the next hour is crucial.
‘Will he have the energy to sustain his breathing? His lungs are still very stiff and will take effort to overcome the trauma.
‘Two hours later Nepo opens his eyes after a family member calls his name. He improves quickly. Initially confused, Nepo manages to stand on his good leg wondering why his other leg is tied up. He’s reminded that his leg is broken and in traction.
‘We remove his feeding tube and he’s able to eat and drink. Success! God has done it!’
On 25th October, Nepo was discharged from Kompiam Hospital and flown back to his village, Pyarulama, by MAF:
Thanks to MAF airlifting me and the work of the staff at the hospital, I am finally leaving this place. I am now well again. May God bless their hands.
Nepo, a MAF medevac patient
Without MAF’s initial medevac, the ending to this story could have been very different.