From Elective Reviews - Zambia - St Francis' Hospital - Jessica Haslam
This summer I had the privilege of spending my elective at St Francis Hospital (SFH), Katete in the eastern province of Zambia. This proved to be a truly life-changing time for me in both my personal and professional development. SFH is a church administered hospital serving both the local population of 200,000 as well as taking specialist referrals from the eastern province (1.5 million people). Primarily run by over 400 Zambian staff, it also relies on volunteer doctors from overseas.
When planning my elective I intended to spend time in most of SFH's departments, but on arrival I quickly realised that given the cultural and language differences and to get the most out of my time, it was better to fully integrate myself into one department. Since I intend to specialize in Obstetrics and Gynaecology I elected to work in the rather wonderfully named department “Bethlehem”. The department is the busiest in the hospital and consists of a labour ward, a maternity ward, a basic special care baby unit and a gynaecology ward, which is currently shared with the female surgical ward.
Whilst working in the department both my knowledge and clinical skills were vastly developed. I learnt the most practical skills during my afternoons and night shifts working closely with the midwives on labour ward. Not only did I acquire the skills to make a bed out of three chairs and a cushion, I am now competent in managing labour from the moment a patient walks through the door to delivery and post partum monitoring. Due to the limited resources in this third world setting, monitoring was stripped back to basics. I learnt how to monitor fetal heart rate using a fetoscope, time contractions, vaginally examine the patient, plot all of the necessary information onto a partograph and interpret the observations to determine whether labour was progressing satisfactorily or whether expert review was required. I am now able to deliver both a baby and the placenta, rub up a contraction whilst removing any retained products and monitoring both mother and baby post delivery, including neonatal resuscitation. Since these skills are no longer taught on the undergraduate syllabus the experience I gained whilst at St Francis will be hugely beneficial as a baseline to my future career.
The department had recently received a donation of a CTG machine. Difficulties in obtaining paper for the machine meant that its use was strictly reserved for those with a strong indication for its use. The majority of patients giving birth at St Francis are referred from rural clinics and due to problems in the first stage of labour, many of them required additional monitoring. This meant that I repeatedly applied a CTG and developed skills in the five steps of interpretation, knowing when it is necessary to call for help. Attending many emergency C-sections, I became proficient in assisting at this procedure. Emergency C-sections carry the highest risk of occupational transmission of HIV and in Zambia 1 in 6 people are HIV positive. It was therefore essential to be able to competently assist without putting the surgeon or myself at risk. Although not directly applicable back home, I intend to return to Africa and volunteer in the future and so I believe developing this awareness of working with high-risk patients safely is particularly important to my learning.
The introduction of the CTG machine to the hospital also gave me the opportunity to observe cross-cultural education and think about how this can be approached. Most of the Zambian doctors had never used CTG before and were therefore reluctant and preferred to rely on their well-practiced skills. Looking around the wards it soon became clear that although overseas donation of equipment is extremely valuable, donation alone is not sufficient. Many items of useful equipment lay idle in the wards because staff does not know how to operate them. Dr Irene, a Dutch doctor in the department, was determined that this wouldn't happen with the CTG. She held multiple educational sessions for the midwives and doctors about the indications for CTG and how to interpret the recording. I learnt two important lessons from observing Irene teaching. Firstly it fundamentally highlighted the importance of education. This is transferable to my studies back home. I must endeavor to learn fully about technologies available to me so that I can most appropriately and effectively use them in my future career. Secondly, Irene had excellent communication skills. Teaching peers without appearing condescending is not always easy. From Irene I have acquired several approaches in my tool kit that I can use both now when working with my peers and also with colleagues in the future.
On Labour ward, one of the most striking differences to me was the fact that women give birth with only the midwives and no loved ones with them: they wait on a bench outside. The midwives were all extremely experienced and very good at what they did but the approach to management of childbirth is very much 'tough love'. The same was reflected in the treatment of all patients in the hospital. Patients were not involved in their care and it was extremely rare for a full history to be taken. Whatever treatment the doctor decided was given without explanation to the patient of what was wrong with them or what treatment was needed. Coming from a working environment where patient autonomy is so well respected this was particularly hard for me. Although the doctors were much quicker in their work and patients accepted the situation, as this is the local culture I couldn't help but feel that care could have been improved with more patient involvement and communication. It wasn't uncommon for patients to be frustrated or upset because they didn't understand, had unanswered questions or worse still were being given a treatment they didn't want. This reinforced to me the importance of the extensive communication skills teaching in HYMS and how valuable communicating with the patient and involving them in their own care is to patient outcomes.
As with any third world setting, to me one of the most interesting lessons from SFH is the way they cope with scarce resources. I used some of the bursary money I received from the Beit Trust to purchase supplies that the hospitals are regularly short of. On arrival it was apparent that this was just a 'drop in the ocean'. SFH lacks resources not only due to poor funds but also because of poor availability within Zambia. For example, simple things that we take for granted like KY Jelly, normal saline as well as many drugs were unavailable the whole time I was at the hospital. I was astonished on many occasions with the innovative way that the hospital combatted short supplies. Some examples include using old fluid bags as catheter bags, suction tubes as temporary catheters, old sterilized mosquito netting for hernia mesh, scrubbing with a bar of soap in theatre etc. not to mention the fact that there was no running water in the hospital 50% of the time and the power was regularly off ;I became extremely skilled in the art of lighting a theatre using multiple torches. Despite this, patient care was rarely compromised. There were, of course, a couple of occasions that really hit home the implications of a resource scarce environment and how lucky we are to be so resources rich in our work in the UK. One example was a patient 36 weeks pregnant with a Deep Vein Thrombosis (DVT). We had no Warfarin or Heparin and therefore the only treatment we had available for her was Aspirin. Fortunately the patient's DVT resolved but the alternative consequences could have been devastating. Influencing my future practice, I hope that now I will think when using resources whether they are necessary in order for me to make my diagnosis, treat the patient etc. and avoid the wasteful use that so easily happens in our disposable society.
In Zambia the patient's ability to get to the hospital has huge implications on outcomes. At St Francis it was commonplace to see patients presenting with late stage disease because they were unable to spare the money to travel sooner. Travel related problems were also present in the maternity department. I was involved in the care of four cases of eclampsia. I have never witnessed a seizure in the UK and although this afforded me the opportunity to manage both the emergency situation of a seizure and later the eclampsia I found the sight of a heavily pregnant women fitting particularly distressing. Eclampsia is now fortunately rare in the UK due to antenatal care picking up and treating pre-eclampsia. In three of the four cases the patients had not had any antenatal care because of geographical difficulties accessing it. The hospital attempts to overcome this problem and other complications of pregnancy by having a building known as “Waiters”, which is a room with mattresses on the floor. Although basic, women from far away with bad obstetric histories who may struggle to get to a clinic or the hospital quickly can come and stay at the hospital for the last few months of their pregnancy. The most interesting element of this service is not only that it provides the women with medical reassurance but also the opportunity to bond with women similar to themselves. In Zambia, repeatedly having miscarriages and/or stillbirths (of which these women had often had three or four) can result in a woman being socially outcast. Giving birth to a healthy child is therefore their whole world and spending time speaking to the patients in Waiters was an explicit example of how medical care of any patient not only affects them physically but also socially and culturally and therefore how far reaching the consequences of our care can be.
Whilst at St Francis I was lucky enough to have the opportunity to work with visiting surgeon Dr Tom Raassen of the “Operation Fistula” charity. Dr. Tom is a world-renowned specialist in vesiculo-vaginal fistula (VVF) repair who operates at the hospital twice yearly. Though now rare in the UK, VVF's are commonplace in Africa due to both poor obstetric care and prolonged labour before intervention. Women travel from as far as Mozambique for the repair surgery. Whilst part of “the VVF team” I learnt about the causes of VVF's and how they can be avoided, to assess patients presenting with “leaking” through history taking and examination with a dye test, assisted in seventeen repair operations, became proficient in the postoperative care of these patients, learnt how to suture an episiotomy but most importantly of all learnt about the impact living with a VVF has on these patients. Often these women had been outcast as a result of their leaking, divorced by their husbands, not to mention the issues of living with incontinence when you have no sanitary supplies whatsoever. By repairing these fistulas the women were given another chance at life. The charity supports the women in finding employment and rebuilding their lives. Just how important this change is for these women was highlighted to me one day when I was walking through the hospital on my way to theatre. I had got to know all of the VVF ladies well through the assessments, operations and daily ward rounds. One VVF patients on her way home to Mozambique, ran up to me in tears, hugged me and repeatedly thanked me. That fortnight with the VVF team not only taught me a great deal about a condition rare to the UK, but also inspired me and confirmed my desire to take time to give back to these people so in need as part of my career. I am now intending to go back to Africa following my F2 year and will make use of this valuable contact to find a volunteer post where I can help people in a similar way.
I had a truly amazing elective period and I am so grateful both to the Beit trust for assisting me in taking up the opportunity to visit SFH and to all the wonderful people there for making me so welcome, allowing me to experience their culture and teaching so many lessons valuable to me both personally and professionally.