(Medical Student, Edinburgh)
extracted from his Blog:
5th-Aug-2008 02:21 pm
So, Saint Francis' Hospital. The first thing you'd have to mention in any description of it would be the red sandy dirt which coats every bit of the landscape and finds its way inside shoes, pockets and houses at any and every opportunity. There's a lot of red brick here too, usually topped by corrugated roofing, so at first glance it's not the most aesthetically pleasing environment. However, you soon get used to that as the friendliness of staff and patients alike and the ubiquitous sunlight recolour the scene.
The hospital is actually pretty well put-together and decently equipped. In brief, there are two medical wards, Saint Augustine and Saint Monica - male and female respectively - each with about 45 beds and seemingly limitless expansion capacity in the small areas of floor between them. There are likewise two sizeable surgical wards, Kizito and Mukasa - I'm afraid I can't provide translations - a large paediatric ward, Mbusa, and Bethlehem: you guessed it, the maternity ward. There is also St Luke's: the outpatient clinic/pandemonium central, a laboratory, excellent ophthalmological and dental clinics and a very good physiotherapy department. (The physio even turns his hand to orthopaedic surgery on occasion.) There are two theatres, only one of which has diathermy at the moment though. A small digression here, but I'm sure cautery was one of the earliest inventions in surgery, many centuries if not millenia old... Having said that there are only two theatres, anaesthetic procedures are not necessarily limited to their confines. For instance, the other day I gave a patient a pretty big shot of ketamine in the middle of the surgical ward to knock her out while we changed her dressings. The reason for the general anaesthetic became apparent when we rolled her over: she had completely lost all the layers of her skin across at least half of her back and much of her left thigh, having been knocked off her bike by a speeding car. Horrific. Even with morphine the simple procedure of changing dressings would have been tantamount to torture.
There is no ICU, or rather there is: the first 6 beds nearest the nurses' desk on each of the wards. Certainly no ICU facilities: no i.v. monitoring of vitals (and not even pulse oximetry except as a one-off test); no ECG (there is one very dodgy machine in the hospital which I have never seen function correctly) and certainly no invasive ventilation unless you're in theatre (the best we've got on the wards is 5 litres/min oxygen via face mask), dialysis, cardiac pacing etc. There's not even a single defibrillator in the whole hospital. When it comes to theatre, monitoring of patients under anaesthesia consists of a pulse-oximetry probe which provides oxygen saturations and pulse. And that's it.
We're also a bit short on the labs front: the FBC machine has been broken for most of the time I've been here so it's either just Hb or a very special request for a manual count on blood film in exceptional circumstances. (I've strategically made friends with one of the main guys in the lab for the sake of those potentially life-saving occasions.) This is something of a problem given the prevalence and variety of anaemias in the hosptial population, and potentially dangerous when e.g. deciding whether someone has a high enough white cell count to get chemotherapy for their Kaposi's sarcoma (a tumour commonly found among HIV positive patients; type it into Google images and you'll get an idea of what we're dealing with). Electrolyte levels have never been available: they did have a machine but apparently it broke down after a fortnight. This is likewise a major problem as many of our patients come in, for instance, very dehydrated and/or malnourished, and there's a lot of kidney failure going around too. Speaking of the latter, fortunately we can do urea and creatinine. (Stop press: the creatinine reagent has run out!) LFTs are available, though some of the reagents are out of date leading to results which are untrustworthy at best and at times frankly bizarre. X-rays and ultrasounds are, however, available and of decent quality, as are microscopy, culture and sensitivity of various bodily fluids (though the latter two don't usually seem to yield much!) The most frequently-ordered tests, apart from an Hb, are thick blood slide for malaria and sputum for acid fast bacilli (TB). CD4 count (an important indicator of how HIV positive patients are doing) is usually available.
Machines breaking down is a big problem here as skilled technicians are not exactly to be found around the nearest corner. For instance, the non-diathermy theatre mentioned does have one, but it's been broken for at least a couple of months. Fortunately the surgeon who operates from there is a very skilled obs/gynae consultant who manages rather well without - impressive. Drug and laboratory reagent supplies can be rather erratic too. It all really makes one appreciate the work and organisation that must go on behind the scenes back home in our NHS hospitals.
The biggest change - nothing short of a paradigm shift - since he was here has been the introduction a few years ago of free anti-retro-viral drugs (ARVs) for patients with HIV, thanks largely I think to the Americans. This has absolutely revolutionised healthcare for those with the disease, enabling people who would otherwise be dead or dying to lead active and productive lives. The term "Lazarus effect" has been used by observers as emaciated, bedridden shells are transformed into people at whom you wouldn't glance twice on the street. For instance, the fiercely energetic young manager of the outpatient department is openly HIV positive, as are a number of the nurses and other members of staff.
Over the last year I've discovered one or two other connections with the hospital. Mike Jones, an infectious diseases specialist who lectured us on the dangers of swimming in Lake Malawi (complete with gruesome pictures: Google images schistosomiasis - but not before or during dinner) and who runs the travel clinic at Edinburgh's Western General Hospital, has worked out here among other African hospitals. He was inspired to come here through his friendship with one of his patients, Sandy Logie, a Scottish physician previously of the Borders General Hospital who worked here in the early 90s. Tragically, he contracted HIV via a needlestick injury here and died back in Scotland about 10 years later, though not before returning to SFH more than once (in spite of the dangers to his fragile health) both to again serve medically and to highlight the plight of Africans denied anti-retroviral medications. I have not yet read them, but it would be worth looking up the articles he wrote for the BMJ about the experience, including that of "coming out" to the rest of the profession in Britain in 1996 - when things were much harder for HIV positive doctors even than they are now. Fittingly, the HIV clinic at the hospital is named after him, and his widow, Dorothy, herself also a medic, maintains a close association with the hospital, getting out here about once a year I think. In fact, while out here I received an email from her (Brian Magowan, obstetrician and gynaecologist at the BGH, put us in touch) in which she mentions working on proposals for Scottish Executive funding for the hospital and the agreement to a formal twinning arrangement between SFH and the BGH. Hopefully this will facilitate the exchange of plenty of staff and knowledge - in both directions - in years to come.
Well, what's it actually like being on the wards? English is the official national language of Zambia since there are so many different tribal languages (at least 70 I think - so a bit like Britain) none of which is predominant, so all the staff of the hospital speak it and children are supposed to learn it at school. Having said that, in my experience very few of the patients that we see have much English, perhaps because this a very rural area. The local language here is Nyanja, closely related to the Chichewa spoken in Malawi. I'm may be out by a few hundred years here, but the majority of the local inhabitants are descended from Bantu invaders/migrants who came to this part of Africa from further north and west about a thousand years ago. (Don't believe anyone who tells you colonialism started with the Europeans!) The language barrier is an enormous disadvantage, both in complicating the taking of a good history from patients, and because it makes establishing a personal connection so much harder - and that's the bit of medicine I enjoy the most. Having said that, people respond very warmly to an enthusiastic "Muli bwanji?" ("How are you?") and I've learnt how to make standard NHS banter along the lines of "Muvi konda vya kudya yam chipatala?" ("What do you think of the food in the hospital?" - believe me, NHS patients don't know how lucky they are..
Something I really do enjoy is the way Zambians speak English. Even those who don't speak much are often able to respond to the question, "How are you today?" However, said response will invariably be rather quirky. The accepted options are, "Just OK," which, although it sounds as though the person is barely keeping their head above water, actually means something more like, "Just hunky-dory." Then there's the wonderful, "A bit fine," which means just that: kind of OK. If they reply, "At least," that's good: it means something akin to, "At least I'm getting better." Perhaps appropriately, if they're not doing so well they can't find an English phrase to express it (after all, we Brits are incapable of answering such a question in the negative) and usually reply, "Pangono," meaning really not too good. So actually the response you get is probably more informative than that which a patient on an NHS ward would give you to the same question.
Other entertaining quirks include adding the sound "ee" to the end of words, e.g. then-ee, and-ee, abdomen-ee (in Nyanja, every syllable ends with a vowel), saying "what what" instead of etcetera/and so on, and referring to people as "this one"/"that one" rather than him/her. The word "actually" is liberally applied to the end of sentences while "so" is often stuck on the front. Put it all together and you get such gems as, "So this one-ee had an acute abdomen-ee actually so we took her to theatah what what."