Rarotonga

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• Destination website: none available

First impressions
I knew things were going to be very different here, as I stepped off the plane & into the hut that was Rarotonga International Airport, to be greeted by a man playing a ukulele in the immigration hall. Having forgotten to get a document out of my bag, immigration informed me that it was not necessary to retrieve it, and that they would "just trust [me]" when I said I had it!

The hospital
This very much set the tone for my stay, with everything operating on 'Cook Islands Time': that is to say, things happen when they happen. This extended to the hospital, a 60-bed rather run-down affair sitting on top of one of the few inhabited hills on the island. Ward rounds might happen at 7am, 9am, or not at all. This made life as a student (especially one not living on site, and cycling up the hill every morning!) very frustrating. Equally frustrating was the lack of utilisation of medical students - despite the 6 medical students at the hospital all being final year students in their respective countries, and despite the hospital being chronically understaffed, medical students were relegated to little more than observers, only occasionally being asked even to clerk patients. This was in stark contrast to colleagues on Aitutaki (another Cook Island), who were effectively junior doctors during their attachment.

I ventured this to the new clinical director at the hospital, a motivated New Zealand woman, who asked me to help set up a more fruitful & worthwhile elective programme for students. Thus, by the time I left Rarotonga, the wheels had been set in motion to ensure future students will be better informed and more involved. I continue to be in email contact to this day, being consulted on potential changes.

How I spent my time in the hospital
On the clinical side, 2 weeks were spent on General Medicine, and 1 week on General Surgery. Medicine dealt almost exclusively with the complications of the islanders' poor lifestyles & endemic obesity - diabetes, gout & hypertension. However, more unusual diseases were encountered, such as ciguatera, a transient dysfunctional disease of the central nervous system caused by ingestion of the neurotoxin unpredictably carried by some reef fish. Patients present with abdominal pain, intense pruritus (creating lacerations in an attempt to ease the itch) & limb weakness/paralysis. There is no treatment (other than supportive measures), and recovery (which may not be full) can take up to 6 months. Mornings were spent on the ward, with afternoons in outpatients' clinic with the attending Burmese physician, which acted as a hybrid between a typical outpatients' clinic, and a GP surgery.

Surgery was a little more hands-on. Mornings were spent on the ward and in clinic, with afternoons generally free. Two days a week, there was an operating list. Surgery was highly variable, ranging from cholecystectomy (gall bladder removal) to repair of a slipped upper femoral epiphysis (a bone problem seen in children), and was done by an ageing Maori, or a young Fijian, surgeon. I was able to assist in a number of operations, and in some clinics my opinion was actively sought & followed - the latest guidelines from the UK do not reach the Cook Islands quickly, so my post-finals knowledge was considered very useful.

In both medicine & surgery, emphasis was on clinical signs & the history - the hospital had only a few basic blood tests available, and imaging was limited to x-ray and ultrasound (which were non-operational for a week, as the hospitals only sonographer was on sick leave!). Any complex diseases, or requiring more advanced investigations (such as CT), were flown to New Zealand, at the government's expense. Given the cashflow problems in the Cook Islands (the islands being heavily dependent on New Zealand for aid), this decision was not taken lightly, either by the doctor or the patient - in chronic disease (such as renal failure requiring dialysis), this was in effect a permanent emigration to Auckland, leaving family behind. Thus many patients refused to be treated, as it would mean leaving the Islands.

Time to say goodbye...
Having finally got myself onto 'Cook Islands time' (to the point of stopping wearing a watch at one point), it was time to leave again & head home. I was able to move my flight forwards by a few days, allowing me to spend a few days in New Zealand. Despite initially struggling with the heat (30-36 degrees every day) & humidity (due to the island's rainforest), & the constant war against mosquitoes (Dengue Fever having been a real problem on the island in the past), I had developed an appreciation for a people who have (just about) moved into the 21st century (only 2 of the 15 islands have mobile coverage, from a single network started 3 years ago, and the entire island uses a single server for internet access), whilst maintaining a perspective on what's important in life - time to enjoy life, and family & friends.