From Elective Reviews - Zambia - Kalene Mission Hospital, Zambia, 2011 - Mark Lethby
I spent my elective at the Kalene Mission Hospital in the remote north-western corner of Zambia, around 15 miles from the borders of Angola and Democratic Republic of Congo (known as Congo to the locals). Kalene is distinctly a Christian hospital. The vast majority of staff are Christians, and it is part of the daily routine for the nurses to hold a short bible study in the ward offices each morning. There is often contemporary Christian music and sermons playing on the wards. Chaplains regularly circulate to pray with patients. Major theatre cases are commenced by the team (including the surgeon) praying with the patient for God's blessing over the operation. As a Christian myself, I was particularly keen to experience work in such an environment. However students who are not Christian may struggle with this.
The hospital has four wards. Male, female and children's wards each hold around 40 patients. There is also the maternity unit which accommodates 30 women split between the antenatal and postnatal rooms and the labouring beds. There was also an outpatients unit, run by a team of nurses, and several rural health clinics that I had chance to visit during my stay.
Surgery and post-operative care is a major part of the work at Kalene. The hospital has 2 relatively well-stocked operating theatres (one far superior to the other - the second just being used for minor cases); however many of the things we take for granted in the UK simply weren't there. There was no nice positive-pressure air-conditioning system. Scrubbing was done in cold water using Imperial Leather bar soap. Gowns were sterilised and reused. The oxygen nasal prongs were probably used and cleaned a number of times before being replaced! You really recognise how much wastage there is back at home. A lot of the equipment was "hand me downs" from overseas, especially the UK and Canada. Sunderland NHS Trust seemed to have provided quite a lot of surgical scrubs!
Kalene is a fantastic place to learn - both in terms of encountering pathology you simply would not see at home (or at least not presenting so late - a common problem!) and in learning how to be a doctor and manage your time. I found it extremely flexible how much I "got my hands dirty". The first few weeks I spent shadowing the 4 doctors on ward rounds or in clinic as I learnt the ropes. I would also attend theatre and help out where needed - sometimes scrubbed as an assistant, other times just finding the correct suture material mid-operation or manically running to and from the lab to get blood for an exsanguinating patient. I also got chance to do some spinal anaesthetics and lumbar punctures under supervision from Phil, and also to undertake a normal vaginal delivery with Emma's help - things that were so much harder to try at home, but that could still be done in a supportive way.
After a few weeks I took a few tentative steps forward and offered to become the 'house officer' on the female ward. This was an amazing opportunity to practice my future role immediately after qualifying. I wrote in the notes on ward rounds, constructed job lists, requested and chased bloods and imaging (limited though they were!), and clerked in any new patients onto the ward. I was allowed to prescribe, and over the weeks got used to the main drug dosages and regimens. I also had the chance to act as the consulting doctor in the outpatient's clinic on a few occasions, with telephone support from one of the doctors when needed. Most outpatients were not seen by a doctor, but if the nurses did not feel equipped to deal with the presenting complaint they would send them to wait outside the doctor's consulting room. One of the greatest challenges was not simply making a diagnosis, but also to have the confidence to make major decisions - in particular to admit a patient or, harder still, to send someone home reassuring them their problem was not serious.
My final three weeks were a very different experience. The three registrars all left so I was therefore asked by John, the consultant, to take over the running of children's ward (the other two students had yet to do paediatrics). He would come down a few times a week to see review patients I was concerned about, and would always be contactable if I had acutely unwell children I did not feel capable of dealing with. This responsibility initially seemed immense but I realised that the skills I had developed over the previous 5 weeks had suitable prepared me. It felt like I had progressed from medical student to house officer to SHO in just over a month! At medical school I have always felt apprehensive about going beyond my comfort zone, but I realised that in this case my seemingly limited skills were worryingly in demand, and what I could do as a somewhat incompetent student was often better than would have happened if I hadn't been there!
I also was given the chance to undertake some on-call work during my time at Kalene. This involved a home-based out of hours shift overnight from 4pm-8am. I would do the first on call and then call one of the doctors in if there was anything I couldn't handle. This was where you really had chance to put your diagnostic skills into practice as well as dealing with deteriorating patients. It was really useful to handover patients in the morning and to get feedback on what you did right and also what you could have done differently.
Less than 10% of patients however could speak English, so all patient encounters had to be translated by one of the nurses, which was at times frustrating as you always had to pair up. But you do pick up a few words as you go... I was able to ask about pain, vomiting and vaginal discharge amongst other things by the time I left, as well as knowing simple greetings.
There were three fixed engagements every week for all the westerners at the hospital/on the mission - a prayer meeting on Tuesday evenings for all the western missionaries/hospital staff at someone's house, church on Sunday mornings, and a bible study again for the westerners on Sunday evenings. Otherwise there was always something going on in the evening - either a dinner at someone's house or some people getting together to watch a film. I would normally spend 4 or 5 nights a week out at someone's house. I spent Christmas at Kalene and it was great fun - it felt like a real little community! Once the other students arrived we all lived together and would always cook together, watch movies in the evenings etc. There was also a small getaway house at the edge of the mission by the airstrip that you could rent for $10 each per night that had a pool, BBQ etc. (it felt like a holiday destination!) - me and the other two students had a great weekend there eating antelope steak and watching Lord of the Rings on a massive screen we devised from collapsible tables and bed sheets!
One of the best pieces of advice I was given whilst there was by a visiting orthopaedics consultant from the UK, who advised me to "get out and look around whenever you can". It was great advice. I went on every available visit to the rural health clinics, and always tried to link this in with doing something else e.g. an hour-long excursion into Angola!
Going alone also meant that I got invitations that you may find harder to get if you go with a group of students - I joined Chris, Emma, Phil and Tess on a weekend to stay with a Mel and Ross and their children, a white Zambian family who have lived in the area for 4 generations (Mel's great grandfather was Dr Walter Fisher, who founded the hospital!). It was a fantastic weekend away. You don't get hospitality like that at home!
There were plenty of nice walks around the local countryside and villages. It is completely safe but I would always suggest going with someone as it can be quite intimidating as everyone recognises you as a foreigner. The only tourist attraction nearby is the source of the Zambezi, which I visited with Mike and Ben (the two other students) for a daytrip, which also included crossing the border into Congo excitingly! We also called in at the local orphanage (run by Mel), which was great fun!
We had a full day to explore the Livingstone area. We went on an early morning game drive in the Mosi-oa-Tunya national park and then spent the entire afternoon at the falls. The scale of it is indescribable. It was fantastic to go to the start and end of the Zambezi in Zambia within a week!
On my final day I explored the capital, Lusaka, a bustling African city which is perfectly safe so long as you don't flash your money around and look like you know where you're going. An afternoon is sufficient though - a walk down the Cairo Road and a trip to the museum and you've seen all there is to see! There's some great shops in the market to get all your stereotypically African souvenirs!
I can't recommend an elective in Kalene highly enough. It's great insight into how many doctors worldwide have to practice, in difficult situations with poor resources. You also see some amazing pathology and get to try out the responsibilities you'll be expected to take on a few months later in a safe supportive environment. It's also a beautiful country and home to some amazingly friendly people, and I know that for me it was a real privilege to have been able to go. I hope I've inspired you!