A Young Surgeon in Africa
(medical voluteer & UK Surgical Registrar)
As an inexperienced general surgeon, I left England in early September 2005 with little idea of what was before me, apart from James Cairns’ advice that the work was unremitting. Laura, my girlfriend at the time (who became fiancée and then wife in Zambia), and I were accommodated and then spent a week being shown round and becoming acquainted with the hospital.
My first problem was getting to grips with obstetrics. I had (excepting a few weeks, as a student) no obstetric experience. As a surgeon at St Francis you cover all surgical and obstetric emergences, so I had to quickly learn a basic system for managing pregnant women, including Caesarean Section and vacuum extraction. I was guided by Dr Ziche Makukula MRCOG (Specialist Obstetrician and Gynaecologist), and was lucky that in the first month there were other surgeons around and so I did not need to go on the on-call rota alone.
However, as is often the case at St Francis people leave (for holidays, or return to work in Lusaka) and suddenly it was just Dr Makukula and myself on the on-call rota, with Jaap Van Bruggen, a general surgeon helping out. I learned fast, every other night (and most weekends) I would find myself in labour ward or in theatre desperately trying to save the baby and occasionally the mother as well. During this period the operating theatres in the neighbouring hospitals of Petauke (80km away) and Nyimba (160km away) were closed and all women in obstructed labour east of the Luangwa River were transferred to St Francis. While I could now manage the operative side I was far from being a competent obstetrician. Laura, by now my fiancée, had done 6 months of obstetrics and gynaecology in the UK and so I often sought her advice. One night the watchman came to the house to tell me a lady had just gone into labour, with the foetus lying transversely. Not knowing the danger of this condition I went back to bed; Laura asked what the problem was and when I told her she pointed out that I should be doing a C-section at once, so I climbed out of bed and went to the theatre.
During the day I would be in theatre, on the wards or occasionally (to the medics chagrin) doing a clinic. Elective theatre lists are every Monday, Wednesday, and Friday. We would start with clean procedures; hernias, prostates, the endless fractures, and progress to abscesses and debridements in the separate theatre in the afternoons. Emergencies had to go theatre almost every day. The surgical staffing varied throughout the year. Initially there were Medical Licentiate trainees (Zambian, doing a four year medical course), who looked after the wards and helped in theatre. They left by mid October and the ward work fell to me. Two 50 bedded wards soon occupied my time outside theatre. In addition there were three Zambian Surgical Registrars on rotation from Lusaka, who each came for three months and were universally excellent and very helpful. The consultant cover was provided by Dr Jaap Van Bruggen and Dr Yotam Phiri, who were around for most of the time and did grand rounds on Tuesday and Thursday mornings.
As the season changed, so did the nature of operations and injuries. A large proportion of the fractures were related to fruit gathering. Before the rains came (in November) we had the mango season and these trees seem to be particularly dangerous (worse than guava trees, which came later) and we would have a steady stream of young kids who had fallen and suffered, often appalling, supra-condylar fractures of their elbows. Although Jaap disagrees, I think that there was no doubt that just as the maize harvest was coming in there was a significant increase in the amount of sigmoid volvulus we were seeing. My theory is that after relative starvation the villagers would eat the green maize before it was ready. This was relatively indigestible and filled their sigmoid colon with fibre, and the overloaded colon was much more likely to twist and cut off its blood supply.
The rains came and the nightly trudge to theatre became damper and many umbrellas were left on wards, as the heavy downpours stopped as quickly as they started. The erratic electric supply suffered more in the rainy season and provided additional excitement in theatre. One early morning whilst completing a C-section the generator failed (we had no mains power in the evenings and nights that week), and the rest of the operation was conducted under the meagre bulb of a laryngoscope. The mother and baby were fine, even if I did lose a pound or two in sweat. Mid way through the rains, sometime in January, the British container arrived. Apart from many other items, new sutures arrived and no longer did we have to struggle with the old blunt needles for operations. The supply lasted my time there, but it will not last much longer and again reminded me of how dependent we were on overseas funding.
Just as my enthusiasm for the long nights of obstetrics was beginning to wane, deliverance arrived in the form of James, another British trained surgeon at a similar level to me (although with 2 years anaesthetic experience as well). Having some one else to discuss cases, and to operate with, re-invigorated me and made a big difference to my enjoyment and the standard of patient care we were able to provide. Laura and I were married in May, which was an extra-ordinary experience (which I think my mother has described in more detail - click here) and made the rest of my time there fantastically enjoyable.
For any one in the medical profession, time spent in St Francis is a wonderful experience. I had always been jealous of my physician and paediatric colleagues as they had plans to come and work in Africa. For some reason I thought that there was no place, or use for a surgeon in this environment! I could not have been more wrong. Surgeons (and included in that are Obstetricians) are at least as useful at St Francis as medics, and are desperately needed. If any one can go, I would heartily recommend it, both for your and Zambia’s benefit.
Rob Bethune MRCS