From Elective Reviews - Zambia - Elective report from Chikankata Hospital
From September 3rd 2012 I spent seven weeks working and studying at Chikankata hospitalin the South of Zambia. I was helped considerably in paying for this trip by the Beit Trust, who I amextremely grateful to for their help.
Chikankata is a small hospital situated between Lusaka and Mazabuka. Leading up to the hospital there is a stretch of around seven km of reasonable quality paved road, but to get to this it is necessary to drive over 25km of bumpy dirt track riddled with pot holes from the main road to Mazabuka. The hospital has a large catchment area, with a population of around 70,000. Dotted around the surrounding countryside there are small health centres stocking a supply of drugs and providing basic medical services. Part of the service Chikankata provides is travelling once a week to one of these health centres to run what were inevitably manically busy clinics for the locals.
The hospital is funded partly by the Salvation Army and partly by the Zambian government. I am not sure of the intricacies of this arrangement, but I believe the charity are responsible for the buildings and equipment, while the government pay the wages of the staff and give a nominal quantity of drugs and medical supplies every month.
The staff do amazingly well considering the resources they have available. There were frequent shortages of important drugs and equipment and there was a distinct lack of investigative capabilities. X-rays and ultrasounds could be performed but the radiologist was notoriously unreliable and this could often take several days. To get a CT or other more advanced investigations the patient would have to be transferred to Lusaka, a three hour journey over the previously mentioned very bumpy road! Basic blood tests could be performed, but not always reliably, and some tests which are done routinely in the UK were not available. I only saw a blood test looking at Urea and electrolyes, done in England on nearly every patient coming into the hospital, about three times due to the expense of the reagent needed to perform the test. Many of the patients in the hospital were on diuretics to remove fluid from their body, this can cause a low potassium which is potentially fatal so would normally be closely monitored by doing this blood test. To remedy the situation every patient on diuretics would take oral potassium and their levels would not be monitored – defensible given the lack of resources available but definitely not advisable medical practice.
The hospital itself is made up of eight wards, the largest holding over 30 patients. There is a maternity ward, with a new neonatal intensive care unit, male and female medical and surgical wards, a basic intensive care unit with space for five patients, a children's ward and a ward solely for patients with tuberculosis in order to control the spread of infection. All together the hospital has space for around 170 in-patients. As well as this there are two operating theatres, an HIV clinic, the OPD which serves as something equivalent to a GP surgery, an eye clinic and an out patients clinic for more complicated cases. This clinic, originally room B is referred to universally as room eight due to the miss reading of the name on the door. There is a high school, nursing school and biomedical college on the same site, and the staff and students of all of these institutions live together in the Chikankata compound. Just outside there is a small town called Chipanga with basic shops and a few disreputable drinking establishments.
As well as the doctors there were several clinical officers who ran the OPD and in many situations would take more prominent roles in the management of patients due to the lack ofdoctors. One member of staff, Mr Mangombe had taken further exams and held the position of medical licentiate, he was solely responsible for the running of Bethany ward – for TB patients, andacted as the tuberculosis specialist at the hospital with many years of experience under his belt.
I met three other medical students performing electives at the hospital. Andrew, from Scotland was there for the first few weeks, he was very knowledgeable and good to have around.The whole time I was there and for a further month afterwards there were also two Danish medical students. Although very nice they were unfortunately not too aware of their limitations, frequently putting themselves in positions which in my opinion they were not equipped to properly handle,pushing to run ward rounds and room 8. This led to friction early on in the trip with me and Andrew and the administrators from the UK, Simon and Lyndsey, who were managing the hospital. It seemed to pose less of an issue for the African doctors, suggesting that it was not uncommon for Western medical students to perform roles such as these.
In the theatre at Chikankata, from left to right on the back row is Dr Michelo, secondly the theatre assistant who performed some minor procedures, thirdly Mr Hamonge the anaesthetist and a clinical officer, fourthly a student from the biomedical college and finally Mr Mangombe. In the front row there is Martin and Rosa the English doctors, me, Sarah one of the Danish medical students and Gift the very entertaining theatre manager.
My trip began in Ethiopia where I spent time with two friends, anaesthetist registrars who are working in Gondar hospital. I spent two weeks travelling there before flying down to Dar es Salaam in Tanzania where I spent the next two weeks, mostly relaxing on the beaches of Zanzibar before heading to start work. I travelled to Zambia by train on the Tazara railway from Dar to Kapiri Moshi just North of Lusaka. Here I was picked up by Lyndsey, the administrator from the hospital and I began my elective! After my time at the hospital I spent just under a week in Livingstone where I spent time in the national park and saw Victoria Falls.
I wanted to go to a rural hospital in Africa for my elective for several reasons. First of all Iwanted to experience a practice of medicine which was dictated less by clear algorithms and investigation and treatment pathways. Obviously these are incredibly useful but I felt by working in a hospital with less resources and less clearly dictated courses of action I would have more opportunity to think in greater depth about the pathologies and how the treatments work. Secondly I wanted to gain more experience with different practical procedures, as there is not a great chance to do this at medical school in the UK. Thirdly I wanted to see some different diseases and pathologies which are not common in this country. And finally I entered medical school originally aiming to work in a hospital such as this, and hoped that the elective would give me some relevant experience. All of these aims were definitely achieved, as well as this I had a great deal of exposure to difficult situations challenging my communication skills and my emotional responses. What follows is a brief description of how I feel I achieved each of these objectives.
1. My medical practice: Every day at Chikankata would begin with morning report, a meeting ofall of the doctors and senior nurses at the hospital to discuss the night's events. This would be followed by morning ward rounds, when I would accompany one of the doctors or Mr Mangombe. I think I was performing some of the functions that an FY1 would in England. I would write the notes for the doctor, and sometimes be given tasks to perform later in the day, such as coming to see a patient and doing a thorough neurological exam which nobody else had time to do. This was a great feeling as it is not very often as a medical student in the UK that you feel you are actually doing something to contribute to the diagnosis or treatment of a patient. Once, when the hospital was particularly understaffed I performed a quick ward round alone, checking that there were no major problems with any of the patients. In the afternoon I would take one of the rooms in the OPD clinic, sit in room 8 with one of the doctors or help with tasks around the hospital. To begin with I did not feel particularly comfortable running one of the OPD clinics, but this feeling was allayed after observing the other clinics. The clinical officers would have to work through the patients so fast that I felt by taking a thorough history and doing a thorough examination of the patients I saw I could achieve a standard at least comparable to theirs, whilst obviously getting through far fewer patients. There was always someone close at hand to offer advice if a complicated patient came in. This was fantastic experience in developing my diagnostic skills. In the evenings I would sometimes accompany the doctor who was doing a night round to see any of the sicker patients who needed attention.
2. Practical procedures: Every Thursday was a theatre day at the hospital; there were also various emergency procedures during the day and night, often C-sections and one memorable case of appendicitis. All of the doctors would do a quick ward round before heading to theatre to perform the operations of the day. During my seven weeks at the hospital I assisted with around 20 operations, in about half of these cases I was the one to close the patient up afterwards, and in some procedures I made the incisions and did some of the dissection. I helped to perform minor procedures from room 8, stitching up small wounds and removing debris from injuries. I witnessed many other procedures, including the nonchalant amputation of a girl's finger which she had split down the middle with a blow from a hatchet. On the ward I put in cannulas, catheters and chest drains. I was able to practice my examination skills a great deal whilst in clinic and on the wards. There were several patients with complicated neurological presentations, the doctors at the hospital did not have time to do a thorough assessment so this job was handed down to me. One of the most exciting opportunities I had whilst at the hospital was in meeting a plastic surgeon based in Lusaka – Dr Goran. As well as being an impressively capable surgeon he is also a qualified pilot. He runs a charity flying out to isolated hospitals to perform procedures such as cleft palate repair and skin grafts. I travelled with him by plane to Macha hospital, also in Zambia, and assisted in five or six procedures here. I had never seen this type of surgery before so it was a great experience, and Dr Goran was a very interesting man.
3. The pathologies at Chikankata: I quickly realised at Chikankata that unlike in the UK nearly every presentation, no matter how unusual was nearly always caused by infection. There was a massive amount of HIV and TB and infections related to the patients reduced immune systems. I saw several patients with Pott's disease of the spine and Cauda Equina syndrome,where the patient loses control of their bowels and the use of their lower limbs due totuberculosis pressing on the spine. Another patient had Cryptococcal meningitis secondary to HIV infection and presented with confusion and hearing loss due to the build-up of an infectious mass in his brain. A child came into the hospital who had been provisionally diagnosed with cardiomyopathy, a rare and ambitious diagnosis, it was later discovered that he had had undiagnosed HIV infection from birth and repeated bouts of pneumonia and other infections. Other HIV related infections witnessed included herpes simplex, herpeszoster ophthalmicus, fungal pneumonias, abscesses and (very) advanced cases of cervical cancer. Other unusual infections I saw included leprosy and advanced sexually transmitted diseases – several patients with syphilis and many women with pelvic inflammatory disease caused by chlamydia or gonorrhoea infections which had been left untreated for far too long. One such patient had developed Fitz-Hugh-Curtis syndrome when the infection rises and causes damage to the liver and other organs, this led to her having to have an operation. There were also many horrific trauma cases, apart from the hatchet finger injury– lots of burns and ox-cart mishaps. Patients would arrive remarkably stoical and later multiple fractures and serious injuries would be discovered.
4. Experience in this type of hospital: My time at Chikankata only concreted my ambition to work as a doctor in hospitals and areas such as this. I loved how the doctors had to perform as generalists in the truest sense of the word. The lack of specialists meant that they would have to deal with anything that came through the front door, only referring patients to other centres in Lusaka or elsewhere if the necessary treatments were not available at Chikankata, such as renal dialysis or neurological or cardiac surgery. My experience has also affected thec areer route I want to pursue. Previously I never considered surgery an option, but I enjoyed the surgical experience enormously. It seemed that maybe it would be more useful to be a surgeon that could also perform some medicine than a medic that couldn't do any surgery in understaffed hospitals such as Chikankata.
The accommodation at the hospital was infinitely nicer than I expected! It was possible to go to a nearby hot shower (a pleasant surprise!), there were mosquito nets in the rooms and a reasonably well equipped kitchen next door. The only issues were the frequent power cuts and water shortages. In some weeks there would be power cuts over four or five evenings, resulting in me eating an unfortunate amount of bread, peanut butter and cold baked beans.
Time not spent in the hospital was spent having bonfires, jogging in the surrounding countryside, relaxing by the nearby lake and occasionally sneakily going to a bar in a nearby town with Dr Michelo and some of the other staff from the hospital that drink alcohol. The Salvation Army maintains a strict no drinking policy so the members of the community who were not part of this church would have to travel to indulge in their vice as to not be frowned upon too severely.
Apart from being in the hospital I was helped by Lyndsey and Simon to help out in other ways in the community and around the hospital. I was travelling with a guitar and was put in touch with a local volunteer teacher who had had a guitar donated to his school. We didn't have long but I was able to teach him some basics to play for the children. Every week on a Friday I would help outwith a children's club that Lyndsey and Simon organise to keep the local children occupied, playing games and in one instance using a projector to make a cinema for them – this proved incredibly exciting for the kids. Along with the other medical students I helped one of the locals, Matros, who was responsible for looking after our accommodation in building a new house for his family. There were also various opportunities to help giving out clothes in the surrounding communities which had been donated, and helping in the transport of a large shipment of wheelchairs that had been given to the hospital.
On the weekends I went on trips to surrounding attractions, climbing a nearby mountain(maybe mountain sounds too impressive... more of a large hill), going to Siavonga on the border with Zimbabwe to see the huge hydroelectric dam and going on trips back and forth to Lusaka to get food and other supplies.
There was obviously a strong religious component to life at the hospital, the nurses hadchurch services every morning and there was a large service for everyone in the compound once aweek. I am not myself religious but went along to one of the services to be welcomed to thecommunity. Our accommodation was just next to the church and I loosely got involved with anotherservice when on hearing a commotion outside I came out to see the church being smothered in thicksmoke from a quickly spreading fire in the fields opposite. I got involved with the fire fighting effortsattempting to stop it spreading to Mr Mangombe's house next door, garbed in swimming gogglesand a theatre mask running back and forward with buckets of water. Obviously this was hilarious tomany of the locals but nonetheless they appreciated my efforts and hopefully it helped them toforgive me for not regularly attending the church services! Also we managed to save MrMangombe's house so I think he was pleased!
I had a fantastic experience on my elective, and I hope this report has illustrated some of the reasons why. I would like to thank the Beit Trust for helping me considerably in being able o go on such a trip as this, and for helping others to do the same.