PTC REPORT PRIMARY TRAUMA CARE (PTC) COURSE Tikura Community Hall: 4th – 5th November 2015, ,

Executive Summary

What is the problem? Trauma is a major cause of death and disability in many developing countries. The main causes of injury in the Cook Islands are car and motorbike crashes, and falls. The Primary Trauma Care course was developed to train health care workers to effectively and systematically manage trauma patients. Trauma management and exercises have been held in the Cook Islands for the last 10 years on the island of , , and recently, Mangaia. Our next target audience group will be on the island of or .

What did we do? A project and funding proposal to implement the Primary Trauma Care Course (PTC) training on the island of Mangaia was sent to World Federation of Societies of Anaesthesiologists and the PTC Foundation through AusAID -Pacific Island Project (PIP) and World Health Organisation to source funding and approval for the programme in early 2015. Approval to carry out the PTC training was requested through the (then) residential doctor in charge Dr Tune Win, (now) Dr Frank Obeda and the Mangaia Island Mayor- Mr Teremanea Atariki, to enable us to deliver the PTC on Mangaia. Once the approval from Mangaia was received, the PTC program, aims and objectives were presented to the Secretary of Health Mrs Elizabeth Iro (PTC Instructor) for approval. Another letter of request for approval for all PTC Instructors to carry out the training on Mangaia was sent out to all Directors, Chief Medical and Chief Nursing Officers. The local instructors consisting of Rangi Tairi (and Coordinator of the Programme), Nga Manea and Charlie Numanga were supported by our colleague Howard Tangimetua (as IT) who was just completing his implementation of the Global School Health and Global Youth Tobacco Surveys in Mangaia. This year we were fortunate to have our very own Surgeon Dr Deacon Teapa, who is also recognised as an International Certified PTC Instructor, assisted the group of instructors who were locally trained as PTC instructors in 2010. A locum cover for Dr Deacon Teapa for a three days period was also sourced. The training on Mangaia was adapted to a 1 ½ day programme with a field Moch exercise on the last day.

Preparation for accommodation, participants, venue, sound system, catering and transportation were planned and discussed with Mataiti and Clara in Mangaia via telephone calls and emails. Printing of certificates, pre and post-tests, programmes and programme evaluation were made ready before our travel to Mangaia. The PTC team of four instructors

PTC FINAL REPORT 1 from Rarotonga arrived in Mangaia on Wednesday 4th November 2015 and the team departed for Rarotonga on Friday 6th November 2015.

The mission of Primary Trauma Care is “To promote and enable the training of medical professionals to manage and treat severely injured patients in low & middle income countries. The desired outcome is that lives are saved and disabilities are avoided”. In Mangaia’s case we had to include other non-health participants to make up the numbers so that delivery of the training is successful.

The objectives of the Primary Trauma Care course: For the candidate to understand the clinical priorities in trauma management and be competent to undertake a rapid systematic assessment and to resuscitate and stabilise trauma patients in environments of limited resource.

A total of 30 participants for Mangaia were assisted and registered from the Ministry of Health-Mangaia by Charge Nurse Manager – Mataiti Matamaki and Snr Public Health Nurse Clara Ngametuatoe.

What happens next? The Cook Islands has an enthusiastic group of PTC instructors; it is important that we continue to use our knowledge and skills to improve trauma management in the Cook Islands. In order to reinforce knowledge and maintain skills, it will be important to run at least yearly courses. The plan for next year is to move the PTC training to either Mitiaro or Mauke (Pa Enua -outer islands).

Introduction The Cook Islands is a self-governing nation situated in the south Pacific about 4 hours flight northwest of New Zealand. It comprises 15 islands spread over a very large area of ocean. The population is 17,791. (2011 Census). The main island, Rarotonga, has a population of 13,097. Most injuries in the Cook Islands are caused by car or motorbike crashes. Contributing factors are drunk driving, and low rates of seatbelt and helmet use. The Primary Trauma Care course was developed with the support of World Health Organization and Pacific Island Projects through AusAID World Federation of Societies of Anaesthesiologists and the PTC Foundation, 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 low income countries and takes into account the resource shortages in these countries. The very first PTC course was implemented in in 1997 and is now being taught in many parts of the world, including many countries in Africa, South America and Asia and other Pacific Island countries. PTC was first introduced in the Cook Islands in 2001 by Australian doctor colleagues, but this did not really take off as no one took ownership to coordinate the programme locally. In 2004 PTC was reintroduced by Dr Teariki Maoate (NZ), Professor McKegg (FNU), Dr Waqa (Fiji) and Dr James Hamill (NZ) to coincide with the Ministry of Health Conference, PTC was maintained, strengthened and coordinated locally since 2006 alongside with the Ministry of Health conferences annually, until it was decided by the PTC team of instructors to implement this training to other Pa Enua’s so that they benefit also.

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. Trauma management exercises involving first responders and health workers have been held annually in the Cook Islands for the last eleven years. This was the 10th time the local instructors took the lead in organising and preparing for the training and were grateful for the support of Dr Lito De Silva, World Health Organisation (WHO), and Clinical advisor Mr Teariki Maoate of New Zealand. On Mangaia we were able to train a mixture of medical professionals, Cook Islands Red Cross, Police, government and non-government organisation enthusiastic participants. The theory and practical sessions were challenging because of the diverse group of participants we had. The instructors were able to deliver the training confidently and efficiently. The team was also fortunate to have Howard Tangimetua for his Information Technology expert in assisting the PTC team. There was also another workshop delivered from Monday 2nd – Thurs 5th November by Ministry of Agriculture personnel from Rarotonga.

PTC FINAL REPORT 2 Local coordinator/Instructors

N0 NAMES GENDER DIVISION Directorate 1 Dr Deacon Teapa M Operation Theatre/Surgical Ward/Clinic Hospital Health Services 2 Rangi Tairi (and Coordinator) F Acting Manager Public Health Nurse Community Health Services (CHS) 3 Charlie Numanga M Manager Ambulance Officer Hospital Health Services 4 Nga Manea F Manager Accident & Emergency Hospital Health Services 5 Dr Frank Obeda (Mangaia) M Medical Officer In Charge - Mangaia Hospital Health Services

Howard Tangimetua M Health Promotion/ICT/Camera man CHS

Participants- Mangaia: NO NAMES ORGANIZATIONS 1 JAKI HERMAN Mangaia school student 2 MATA HERMAN Public Utility 3 TANGI MOEAURI Public Utility 4 TEREMOANA ATARIKI Mangaia Island Mayor 5 MAKITANGI TOKO Infra Dept 6 NOOROA SAMUELA Infra Dept 7 FAITH TAOKIA AOG Youth 8 TANGI METUAKORE Disability 9 AKERURU TANGATAKINO Disability 10 TAATA TANGATAKINO Retired 11 POROA AROKAPITI Internal Officer 12 WESLEY KAREROA Air Raro Agents (MP) 13 LEANNE TAOKIA Red Cross 14 NGATUNGANE AERERUA Oneroa CICC Youth 15 MAKIANU TUMUTOA Mangaia Child Welfare 16 TUAKANA TUPOU Oneroa CICC Youth 17 JULIE PUKEITI Red Cross 18 TERENCE NGAMETUA LDS Youth 19 TEINA NGAMTUATOE Public Health Inspector 20 CLARA TEINA Public Health Nurse, Midwife 21 TEREAPII TAOKIA Enrolled Nurse 22 MATA MATAMAKI In-Charge Nurse 23 JIM MATAMAKI Health Groundsman 24 TAI MAKIITI Enrolled Nurse 25 MUMMY HERMAN Hospital Maid 26 MAMATIARE GEORGE Nurse, Midwife 27 REV TOKO ONGOUA CICC Oneora Ekalesia 28 TAOI NOOROA Tourism Officer 29 TEAROA MAINE Police Officer 30 FRANK OBEDA Resident Medical Officer 31 DOREEN MOEKAPITI Mangaia Child Welfare (Secretary)

PTC FINAL REPORT 3 Course Programmes Mangaia: Day 1: Wed 4th Nov 2015 11: 00 – 11:05 Welcome MC: Clara Ngametuatoe/Rangi 11: 05 – 11:10 Opening Prayer Rev Ongoua 11:10 - 11:20 Speech AUSAID-PIP Rep Dr Deacon Teapa 11:20 – 11:25 Welcome/Opening Mangaia Mayor-Teremanea Atariki 11: 25 – 11:30 Group Photo Howard/Rangi 12:00 – 12:50 MCQs Pre Test Rangi/Nga 12:50 – 1:10 Principals of PTC Dr Deacon Teapa 1:10 – 1:25 Primary Survey/ABCDE Rangi Tairi 1 :25 – 1 :45 Airway and Breathing Dr Deacon Teapa

AFTERNOON TEA

1:45 – 2 :05 Circulation & Shock Dr Deacon Teapa 2 :05 – 2 :25 Secondary Survey Nga Manea

2 :25 – 2 :45 Video session Rangi Tairi

- Chest tube (3. 38 sec) - E Tube insertion (1.6 sec) - Ventilation with bag mask (1. 18 sec) - Insertion of Oropharyngeal- Adult (43 sec) - Insertion of Oropharyngeal- Child (27 sec) - Oral Tracheal insertion (2.25 sec) 2: 45 – 3:05 Chest Trauma Dr Frank Obeda Practical Skills Stations - Airway - Cervical Spine - Intubation

3 :05 – 3 :30 Abdominal/Pelvic Trauma Dr Deacon Teapa

4:00pm LATE LUNCH

DAY 2 Thursday 5th Nov 2015

8.45 – 9.10 Limbs Trauma Dr Deacon Teapa

9.10-9.30 Disaster Management Charlie Numanga

9.30-10.00 Trauma in Children Dr Deacon Teapa

10.00-10.30 Morning Tea

10.30 -10.50 Burns Dr Frank Obeda

10.50 – 11.05 Group Workshop: 10 mins each Analgesia Dr Frank Obeda

Disaster Preparedness Charlie/Clara

Practical Skills Stations - All

PTC FINAL REPORT 4 Skill station was divided into 4 sections:  Basic Airway/Log Roll  Intubation  Analgesia  C-Spine and Transportation

11.05 - 1.30 Group Field Moch Exercise – All Instructors

1.30 – 2.30 Group work/Discussion & Feedback/Recommendations

2.30 – 3.00 MCQS Post Test/Evaluation Nga/Rangi

MCQ review with participants Dr Deacon Teapa

Presentation of Certificates by: MP for Mangaia Hon Wesley Kareroa, and Island Mayor Mr Teremanea Atariki.

Closing speech PTC Rep Dr Deacon Teapa

Official closing ceremony of PTC Mayor

Closing Prayer

4.00 END OF DAY - KAIKAI

The time table was readapted so that Dr Frank Obeda and other health staff could participate with delivering some of the program. Overall, the timetables worked really well.

Venue, Presentation, Catering The training was held in the Tikura Community Hall. The venue was excellent with spacious room for the different skill stations and catering the large number of interested participants. The outside venue was also spacious and was a good spot to deliver our moch exercise.

A data projector, a white sheet for screening and laptop were provided by the MOH. Catering was excellent with plenty of fruits, nu (coconut drink) and plain water.

Teaching Materials Each participant was provided with the training materials, these were printed and collected locally. Equipment were supplied from Rarotonga, from previous training sessions and Mangaia hospital. The Mangaia new ambulance was used for training – i.e. – how to use the scoop, how to unfold and fold stretcher from ambulance to transport patients to hospital. Manager Ambulance Officer- Charlie Numanga demonstrated how to use the equipment’s in the new ambulance effectively and efficiently.

PTC FINAL REPORT 5 Airway Management Trainer: funded by the World Federation of Societies of Anaesthesiologists and the PTC Foundation.

Mangaia Practical Skills Station

Skill station was divided into 4 sections:  Basic Airway/Log Roll  Intubation  Analgesia  C-Spine and Transportation

Each section takes 15minutes to allow each group to hands on at each station skills. As our evidence shows, the Skills Station was highlighted by the participants as a turning point for them and how this links to all the presentations provide by the facilitators. I saw their need wanting to capture as much of these skills in a short time as it explains so much through both days facilitations.

Field Mock Exercise: Purpose of Mock Exercise:  Is to allow the participants and PTC managements an opportunity to evaluate and assess the teaching and delivery mechanism of the program objectives and whether the participants clearly understood its theory and practical terminology status with satisfactory  For the participants to be able to demonstrate their knowledge and skills gained following 1 ½ day PTC workshop and  To encourage participants and other parties to lead and share these skills to the surrounding environment of their family and community  For participants to feedbacks on what went well, and what needs to improve for the future delivery program references that will improve and better meet the PTC goal

Scenario:

The PTC team agreed to conduct a Motor Vehicle Accident scenario which involves 2 x motor vehicles and a total of six (6) people to act as patients. The scenario was setup using half of the main coastal road to the entrance of the village, Oneroa coming back from the islands only airport and wharf.

The six actors were tasked to provide near to real life style believe scenario playing the following roles; 1. A 62 year old male driving a one ton flat back tray that is travelling with his son. Driver has a Cardiac Arrest which causes truck to wheel off onto the opposite side of the road colliding into an on-coming motor cycle at 60kms and the force of impact rests both vehicles into a giant rock (3.5 x 5 x 4m) located on side of road. He was not wearing a seat belt therefore lays on the steering wheel with horn sounding and engine still running and shows no signs of movement. PTC FINAL REPORT 6 2. A 24 year old male (son of 62yr driver) who before impact was standing on the back tray of the truck but finished off on impact to the rock falling over the truck roof hitting head onto the giant rock and laying motionless on the ground next to a bystander. 3. A 40year old father travelling in the opposite direction with daughter ends up jammed to his cycle and truck at resting point sustaining a femur fracture to his right leg and abrasion to his body. He is continuously screaming to the pain sustain and has no recollection of his daughter. 4. 17 year old female the daughter of the motor cycle driver also hits her head to the truck and again to the road. She has little movement and fear of communicating to responds. 5. A 12 year old female student walking home from school manage to avoid full impact from both vehicle is shaken from the near accident after witnessing the entire impact the continuous screaming on the ground by the cycle driver 6. Home owner who did not see the accident but rather came out to investigate following the big bang and screaming who initially raise the alarm and calling for help.

Participants were briefed of the scenario prior to its activation and asked to discuss, organise amongst themselves two teams to handle and manage the impact of this situation both on scene and at the Mangaia Hospital.

The three main key elements we were looking for in this exercise;

 Communication – How did the entire communication system at the accident site, the transportation system and hospital go during this period?  Coordination – Did anyone stepped forward and took the leadership to manage and over see this operation?  Control/Command – The manner of controlling the whole situation at all four corner of the, calling for helps, managing the transportation of the injuries per priority and the treatment at both sites.  Management of Trauma Patients- Primary Survey ABCDE, Secondary Survey

What went well;

 There was alot of talking amongst the responders at both the scene and hospital site

 The management actions at the accident site attended by the teams met the objective of the exercise

 Transportation at scene and to hospital when according to their create plans

 Hospital control accommodated for the numbers fine

What did not go well;

 Time management of appropriate treatment per casualty a bit slow

 Crowding at one casualty rather appropriate distribution and sharing of casualties

 Back to front handling practises and working individual at times and not da team approach (eg:Ambulance going without a nurse)

 Monitoring system of the casualties/patient at both site right to the stand down call

Recommendation;

 To conduct a second PTC in Mangaia to sustain competent of capacity and this time identify potential participants from the village/community of Ivirua and Tamarua who is a distance from hospital. Aim for them to assist nurses who are station in them before main team from hospital arrives.

 Would also like to look at a Air Rarotonga plane crash and how would they handle the situation

Video Sessions Video sessions on Improper Handling of Initial Assessment and Management of a trauma patient (in-correct procedure), Proper Handling on Initial Assessment and management of a trauma patient (correct procedure), Chest tube insertion, Oral tracheal insertion and E Tube insertion was shown during day 1 training. PTC FINAL REPORT 7 Motor Vehicle A hired truck was provided to pick up the instructors from airport and back, transport to take instructors and equipment’s to training venue and back to accommodation.

MCQs MCQs were asked at the beginning and end of the course and there was significant improvement on the post test.

Financial The courses were very generously supported by AusAID through the Pacific Island Project (PIP), World Health Organisation and the Cook Islands Ministry of Health.

Recommendations 1. Regular courses It is important that courses are run at least annually to maintain the knowledge and skills of both instructors and participants. PTC courses are cheap to run but some financial support will be required from the Ministry of Health (e.g. transport, laptops and data projector, printing and catering costs). AusAID & PIP and WHO to continue to assist funding for Rarotonga and Pa Enua (Outer Islands) PTC as well. 2. Course content The instructors discussed and agreed to continue a two-day format for Rarotonga and a 1 or 2 day format for any of the Pa Enua (Outer Islands) pending on the flights. We felt it was appropriate to concentrate on Primary Survey topics in the morning with scenario teaching and disaster planning in the afternoon. 3. Airway management trainer An airway trainer was provided in December 2010 sponsored by the PTC Foundation and AusAID, This has allowed advanced airway management training for PTC participants as well as for our OPD/Emergency Department staff, and doctors.

4. Liaison The local instructors have the knowledge and skills to run regular courses; it will be helpful though to have the input of an overseas instructor.

5. Instructors Course An Instructor’s course to be carried out next year or the following year pending on the budget.

PTC FINAL REPORT 8 Analysis of Participant Feedback: Mangaia PTC: 33 forms were received.

What went well? 1. The majority of the participants commented that it was an honour to have the Mayor as a participant and also officially opened and closing of the PTC in Mangaia. 2. Very useful training, (several comments) to keep up with up-skilling in emergency preparedness and response annually. 3. There were several comments ++++++++++, the best part of the course was Primary Survey – ABCDE, practical skills and moch exercises. Hands on was very effective. 4. Practical sessions was very useful (comments by health workers). 5. Provision of notes and PTC Manuals, and power-point presentations and Airway Management Manikin was a +++ several comments 6. Well prepared practical skill stations excellent demonstrations by instructors, it was a +++++because everyone got a chance to do hands on practice really appreciate it. 7. Majority really enjoyed the Pre & Post-test but they enjoyed the post-test more because it showed how their knowledge and skills has improved or not. 8. Although I didn’t know anything about PTC in the beginning, (several comments) I managed to get a good mark after the post test. I know I have learned a lot! I hope to practice these skills one day and help our health care workers. 9. Excellent Venue, very spacious for theory and practical skill stations. 10. All Health personnel were able to attend all of the sessions. 11. Several comments from participants, Instructors presented very well, excellent training, it was clear, understandable and very informative. 12. Majority of presenters have a sense of humour, clear and straight to the point. 13. The integration of our Maori language into the training is a +++ so that the participants will understand more. 14. Instructors were well prepared with their teaching and practical skills station. 15. Several comments on to involve outer islands so that we are in the same boat. 16. Several comments said thank you to Rangi Tairi for organising an excellent PTC training Programme. 17. Several participants commented it’s a +++++++ to always have a Cook Island doctor to assist local instructors, because when it’s difficult to speak in English they can always switch in Cook Islands Maori language. 18. Nearly all participants commented and thanked Dr Deacon and the rest of the instructors for ensuring that they (participants) understands or have increased knowledge at the end of each sessions. 19. Summarising and recapping of sessions were a plus +++++ 20. Several participants commented that it was a +++ especially non health, for them, they were fortunate enough to be participants to the PTC and to hopefully assist in any way they can. 21. Several commented they have learned more after practical skill stations and after moch exercise, you get to do things hands on, very thoughtful way of learning. 22. Abbreviations and Medical terms were explained with extra notes provided. 23. This is good we get to have a certificate +++++ at the end of the training to prove that we have done the training.

What didn’t go so well? 1. Not enough time (2 comments) needed more time during skills station. 2. Last minute informing 3. Two workshop trainings running at the same time on the island.

What would you Change? 1. More time but majority did not want to change anything. 2. More practical time. 3. If able to for Aitutaki to start planning own Course Program using the PTC format given. 4. Nearly all evaluation received said don’t change anything, 2 good!!!

Other Comments? 1. “Was an eye opener and being exposed to this course made me appreciate the importance of continued education in relation to my profession?” 2. Awesome course! It was good to see our own doctor –Dr Frank Obeda present with the other instructors. 3. One commented to include leaders in the community so that they are able to assist with any Trauma, maybe because of the other workshop. PTC FINAL REPORT 9 4. PTC –need regular ongoing training and exercises (several comments) please don’t STOP! 5. PTC training to be introduced to other outer islands and not based on Rarotonga only. 6. Have funding available to run another instructors course. 7. Several first timers to PTC programme recommended that this PTC be provided to others 8. “Please can we have more of these workshops in the future”? 9. Several comments on congratulated Rangi Tairi for a very successful and well organised workshop and please to continue organising more PTC training. 10. Thank you AusAID/PIP for funding the Airway Management Manikin for training- awesome. 11. Instructors (some) to come to Mangaia once or twice a year to train nurses and ambulance officer so that they are capable of dealing any trauma and for up-skilling too. 12. All of the 32 evaluation forms received requested if PTC can be trained again in Mangaia. 13. This course must be followed up in the future to ensure what is taught is actually followed.

Acknowledgements: Mangaia 1. Special thank you to Dr Lito De Silva and Dr Teariki Maoate for their support towards the local instructors in delivering this year’s PTC training in Mangaia. 2. Many thanks to the Cook Islands Ministry of Health for its support and to the Minister of Health – Hon Nandi Glassie and Secretary of Health Mrs. Elizabeth Iro for their continuous support towards this training. 3. Meitaki Ngao to the Mangaia Island Mayor -Mr Teremanea Atariki for the delivering the official opening and closing of this year’s PTC Training. 4. World Federation of Societies of Anaesthesiologists and the PTC Foundation. AusAID through the Pacific Island Project (PIP), PTC (Primary Trauma Care) Foundation. 5. World Health Organisation for assisting with funds for Mangaia PTC training 6. Local instructors – Rangi Tairi (and Coordinator of the Programme), Nga Manea, Charlie Numanga, and Dr Deacon Teapa who also represented as PTC representative. Howard Tangimetua for assisting with printing of certificates and for his IT expertise while on Mangaia. 7. Vainetini in Mangaia for their excellent catering, Mr Poroa Arokapiti for his sound system which made things easier to hear. 8. Ministry of Health staff on Mangaia for assisting with preparation of venues for PTC 9. Charge Nurse Manager for Mangaia Hospital Mrs Mata Matamaki and Snr PHN Clare Teina for their patience, assistance and support towards the Mangaia PTC. 10. All participants on Mangaia for their participation and enthusiasm in the training.

PTC FINAL REPORT 10