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Elective Report, Saint Francis' Hospital,2015 - Toby Hoskins

After I'd settled into my accommodation my first experience of medicine in Zambia was the Tuesday morning clinical meeting. A long list of medications was read out followed by the words 'are out of stock'. The list included a number of drugs that I would have regarded as fairly basic: amoxicillin, nifedipine, even ibuprofen. Whilst I always knew there were going to be difficulties, this was my first glimpse of some of the challenges facing doctors and hospital staff at Saint Francis' Hospital (SFH).

I was then introduced to Professor Bleichrodt and his surgical team with whom I would be spending the next 9 weeks. With a keen interest in surgery I had been looking forward to my elective since I organised it a year and a half ago as it would be the longest surgical attachment during my medical school career. The reason I chose to go here was that I knew I would get a very hands-on experience and see a wider range of surgical cases than you wouldn't see at overly specialised centres. I wasc ertainly not disappointed.

I had not really been sure what to expect in terms of facilities but at first glance the operating theatres looked very much like those back home just a bit less new and shiny. On closer inspection there were some noticeable differences. There was no hot water to scrub up with, no disposable equipment - everything was cleaned to be reused - and what suture was used to close a wound depended on what was available rather than surgeon choice. Despite these differences there was a large range of equipment available including diathermy, orthopaedic drills and a mesher for skin grafting. What equipment was lacking was made up for by ingenuity; instead of the expensive synthetic meshes used to repair hernias in the UK a small piece of sterilised mosquito net was used that only cost pennies. Recovery was a tiny room, not much more than a corridor, where one often had to play Tetris with the beds to fit everyone in. Then there were two surgical wards, one male and one female, each containing 47 beds but the actual capacity seemed to be endless. Mattresses were forever being placed in the treatment room or side ward to create space for more patients.They were all looked after by two nurses who covered the whole ward, with only one nurse present at night.

A lot of time was spent dealing with orthopaedic cases; Zambian football is ubiquitous and is particularly physical with the ground being particularly hard. Whilst I recognised many treatment sfrom my previous placements, an ankle ORIF looks like an ankle ORIF wherever it's done, there were some big differences. There was no X-ray in theatre so all manipulations of fractures had to be done by feel alone and then the patient would go for a check-X-ray after they had woken up. This often meant that patients would have to return to theatre once, sometimes twice, to ensure a good reduction of the break. Another difference was that patients with femur fractures would be treated by putting them in traction for about 6 to 8 weeks. This meant that at any one time there were around 6 or 7 patients laid in bed with weights attached to their leg. I often thought how incredibly boring this must be for the patient but as these were normally young men I wondered what impact it would have on the rest of the family, particularly those from the villages whose livelihood depended on farming.

The rest of the workload was hugely varied and included most specialties. I saw patients with prostate problems, head injuries and those undergoing thyroidectomy; the youngest patient I saw was 6 weeks and the oldest 87 years. However, the cases I found particularly interesting were the acute abdomen presentations. With no CT scanner the importance of a good history and examination was amplified and gave me the opportunity to hone these skills. As well as no CT, bloodtests were limited to HIV, haemoglobin, malaria, hepatitis B and there was certainly no diagnostic endoscopy or laparoscopy. Whilst this lack of equipment presented a diagnostic challenge it meant the surgeons had to rely on their clinical acumen more and in the vast majority of cases were making a correct and timely diagnosis.

One thing I hadn't expected was the high number of burns cases. Given that it was the cold (by Zambian standards) season people tended to come in with burns as a result of sleeping too close to the fire. I hadn't had much experience previously in this field and at first found these patients quite daunting. It was difficult to come to terms with the fact that when the patients came in they were in pain and burnt but other than that seemed quite well, able to talk, eat and walk about. Then, if the burns were significant they would often deteriorate, with many trips to theatre along the way forwound debridement or skins grafts. With burns over 20% the end point was often the same, death.A case that particularly affected me was two chemistry teachers who had been demonstrating an experiment which had exploded, setting fire to their clothes. They came in with about 32% burns each but were talking and aware of what was going on. After initial dressing of their wounds they were cared for on the ward and seemed well until later that night one of them went into respiratory distress and passed away. After several trips to theatre to clean his wounds the second patient also succumbed to his injuries a few days afterwards. It is tricky to put my finger on why these deaths affected me so much. I think it was partly due to the fact that I had been with them from the start of their care right through to the end and as they both spoke English I was able to find out more about them and their background. It was also partly due to the circumstances, an accident like that should never happen and then to have to watch your colleague die knowing that it could be a predictor of your own fate is particularly harrowing. For me this case really exemplified some of the challenges of practicing medicine in Zambia, although everything possible was done to help there were just simply not the resources available to deal with the situation.

During my time at SFH I was encouraged to get heavily involved and always had excellent supervision. By the end of the placement I was able to see my own patients on ward rounds and formulate management plans for them. Whilst much of the management is different in the UK and even some of the pathology, what I learnt the most was confidence in my own ability as well as knowing when I needed to get help. I was also given the opportunity to assist in many operations and even performed several small procedure smyself. Whilst I have always spent as much extra time in theatre as I can in the UK and practice my knot-tying and suturing skills at home on a regular basis this was a whole new experience. When doing procedures myself, always under supervision, I understood the complexity of operating.Not only do you have to have good technical abilities but also be able to problem solve on your feet and maintain oversight of what you are trying to achieve. These nontechnical skills are something you take for granted when you watch an experienced surgeon operate.But what I learnt from doing an elective in Africa goes beyond the clinical aspects of surgery. I saw how surgery could be delivered with limited resources and that the versatility of a surgeon can makeup for the lack of equipment often seen as essential.

When I wasn't on the ward or in theatre the rest of my time was spent in the surgical outpatient department. On clinic days patients would begin to queue up from about 06.00 with their green cards that contained a summary of all their previous medical encounters. The patients would then wait patiently to be seen and could often be waiting most of the day. All patients were seen in the same room and although there were separate, curtained-off areas to examine patients privacy was minimal. Clinic would last from the end of the ward round until 16.00 but would often overrun, lasting 6 or 7 hours. In that time the three doctors on duty could see anywhere from 60 to 100 patients between them, alongside being called away to deal with emergencies. On one of the three monthly visits of the specialised plastic surgeon he saw 58 patients on his own in a day long clinic before starting his operating list that evening. Whilst the outpatient department seemed absolutely manic at times with an overwhelming number of patients it was incredible to see how the doctor sjust got on with it, giving the same high care to the first patient as to the last.

With 72 languages in Zambia most of the trained medical staff speak English but many of the local population only speak Chichewa. Whilst I was able to pick up enough to take a basic history, for some of the more complex cases a nurse would assist me with translating. Even with the assistance,taking a history became a lot more challenging. Not only will I have missed out on some of the subtle nuances of what the patient was trying to say but also I did not fully understand the cultural backgrounds and beliefs of the patients I saw. For example some Zambians believe that all illness is caused by someone wishing it upon them and if they can find and confront that person then they will get better. For that reason if a doctor was breaking bad news they couldn't say 'I' or 'we' in the sentence in case the patient thought it was the doctor who was wishing them harm. The doctors who had volunteered there for some time had picked up on some of these beliefs and were able to adapt to them but it was more difficult for me having only been there a short time. It did help me to understand that even if you pick up on all verbal and non-verbal communication you still need an idea of where the patient is coming from, what their beliefs and traditions are, so that you can put everything in context.

Patients' beliefs and expectations were another challenge for me. I am very used to the concept of'shared decision making' in medicine, having had it drummed into us in medical school, however the Zambian style is much more 'paternalistic'. I found this quite difficult to watch at times as I felt the patients' weren't being treated with the same empathy that they would in the UK. When I saw patients in the clinic I tried to stick to what I had been taught at medical school, offering explanations and choices to the patients but in many cases this just didn't work. Some of thepatients from the villages had little or no schooling and found it difficult to understand what was being explained or offered. Either that or they are just used to being told what to do by doctors and were therefore taken by surprise when offered a choice. On reflection it is difficult to know how to approach this, there is such a large volume of patients through outpatients that there simply isn't the time to have a lengthy discussion with each one. At the same time if a patient doesn't know why they are taking a medication then they are less likely to take it, which was certainly the case amongst many of our patients.

Outside of the clinical environment it was really interesting to talk to other doctors and find out about the transition the hospital was going through. As a mission hospital, SFH gets some money from the government but in the past had been almost entirely reliant on donations and volunteer doctors from overseas. However recent years have seen the appointment of a Zambian medical superintendent, two medical doctors, two gynaecologists and a paediatrician with news of an additional paediatrician and a surgeon on their way. The hospital seems to be moving away from this reliance upon volunteers and towards a state where they are fully self-sufficient. To me this seems like a much more sustainable way for the hospital to function with staff appointed on a more permanent basis supplemented by volunteers who are there to experience healthcare in Africa rather than run the hospital.

Working at the hospital was a great way to quickly feel embedded in the local community. Seeing patients was great but it was also fantastic to work with Zambian staff. It was interesting to see how they worked but also to bond outside of the hospital setting and find out a bit more about them and their culture. I would play basketball most evenings but would also go to parties and celebrations with some of the Zambian staff at weekends; I was even invited round to learn how to make nshima.I have since attempted to make it back home but despite only having two ingredients - maize and water - it was quite difficult! The town of Katete itself was interesting. It is a small border town and had somewhat of a 'wild west' feel to it. Regardless of the time of day a sizable proportion of the population would be in one of the many bars. The market and shops were incredible, selling all sorts of spare parts and odds and ends. I noticed that nothing in Zambia is thrown away or wasted; bikes that appeared beyond repair would be cleverly fixed by welding bits of steel to the cracked frame or wedging wood into the wheel in place of a spoke. I was fortunate enough to be able to borrow a bike during my time at SFH which was the perfect way to explore the surrounding villages at the weekends. The people here were so friendly and welcoming when they saw that I wasn't local. One family gave me lunch and turned down my offer to reimburse them for the food and I was very moved by this kindness.

Overall my elective cost £1,944, with flights costing £675, accommodation £945 (£15/day charged by the hospital including food and laundry with some going back into the hospital), vaccinations and prophylaxis £261, visa £35 and additional travel costs to and from the hospital costing £28. I would like to thank the Beit Trust for their very generous support that helped to make my time at SFH possible. I would encourage any other medical students to undertake their elective in Zambia. The hands-on experience gave me a real flavour of what it would be like to be a surgeon, helped build confidence and allowed me to see how surgery is done in a healthcare system worlds away from our own. My time in Zambia provided me with a once in a lifetime opportunity that has not only strengthened my resolve to become a surgeon but has also convinced me that taking time out of my future training to go and work abroad, whether that is Zambia or elsewhere in Africa, is something that I will do.

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