Elective Report – Olufemi Olatigbe
My elective in Mufulira occurred during the month of July. I arrived along with my three fellow medical students at the Ndola airport, which is a city also in the Copperbelt of Zambia around 100km from Mufulira. We all arrived exhausted after our over twelve-hour flight, so we were grateful to be warmly greeted by Mabvuto. Mabvuto is the son of Ethel who looked after the house which we were to be staying at during our time in Mufulira.
As we embarked on our journey towards Mufulira, Mabvuto told us a bit about Zambia as a country. I personally was struck by the vast scenery which made the journey a pleasant one. We arrived at the house in the evening, where we greeted by Ethel. She showed us around the house, and the rooms which we were to be given. I must admit a lot of what was being said I did not take in that well due to being deprived of sleep from the long journey.
That evening we had our first experience of ‘load shedding’. As we were sitting down on the table in the living room, all the lights suddenly went out. Of course, this is something we had not experienced before in the United Kingdom, but Ethel later informed us of the schedule when there would be load shedding.
When we awoke the next day Mabvuto helped us to contact Dr Chiponda, who was to be our point of contact during our hospital placement at the two government hospitals: Ronald Ross and Kamchanga. Since we arrived on a national holiday we were not required to be in hospital the first two days of our time in Mufulira. The third day Dr Chiponda came to pick all four of us up to drive us to Ronald Ross hospital.
At Ronald Ross we entered into the office of Dr Matabile, who was the chief medical superintendent at the hospital. Also present at the hospital was Dr Tumba, who worked in the female medical ward and was in charge of making sure we were organised to the correct people. Those two alongside Dr Chiponda proceeded to arranging our timetables according to what our interest were. Myself and another one of my colleagues were to start on surgery, and the other two medical students on medicine.
They through us straight into the placement, and we joined to the surgical ward round. The general surgeon was an elderly Ukrainian surgeon called Dr Nikoli. What struck me the most about the ward round was the vast difference as to what constituted a surgical priority in Mufulira compared to in the United Kingdom. The most striking example was when I encountered a patient who had a fractured neck of femur confirmed on X-ray. In the United Kingdom, due to where the fracture was this would warrant surgery to have either a total or partial hip replacement. This is because of the risk of avascular necrosis in this area, which if occurs could potential lead to an emergency amputation of the whole leg. However at Ronald Ross hospital, since a total or partial hip replacement was too expensive, they opted for conservative management. This conservative management would however render the man unable to walk ever again without significant support. Since this was my first experience of surgery in Zambia I was quite saddened to learn that this was a common way of practice due to the scarcity of resources.
As my days progressed I learnt that the morning was when they tended to be busy on surgery and things quietened down significantly in the afternoon. I thus started to spend my afternoons in the outpatients department. My time at surgery was however very informative. I discovered that even though there was such a high prevalence of diabetes in Mufulira, there was a reluctance to seek help, in the form of medication and investigations. This was even though diabetic and hypertensive medication was one of the only medications which patients did not have to pay for themselves. Due to this reluctance, there was a lot of peripheral vascular disease, which led to eventual gangrene of the limb. This is something which I had not actually seen in the United Kingdom as a result of diabetes. Since the screening which occurs in diabetics picks up the early stages of peripheral vascular disease before the limb becomes gangrenous. As a result, there were many patients in the surgical unit who were either already amputees, or who would require amputation.
Dr Nikoli also invited us to his surgical clinics after ward rounds. The clinic was extremely busy, with Dr Nikoli seeing roughly 40 patients in a two-hour period. He would tend to take the history from the patients and then we would exam the patient or vice versa. One case which demonstrated the deficiency of resources in Mufulira, was when a patient presented with a hydrocele. This is when this is a build up of fluid around the scrotum. Under the NHS system, a case such as this one would require an Ultrasound to locate exactly where the fluid was. This patient would then most likely have drainage of fluid under ultrasound guidance, to ensure no structures were damaged. However once we had identified this patient to indeed have a hydrocele, Dr Nikoli immediately proceeded to drain the fluid with a needle. My colleague and I were both surprised, because though he did indeed drain the fluid. The environment was not a particularly aseptic one leading to the risk of infection, the patient had also not been given an analgesia meaning he was in substantial pain and most obviously no ultrasound had been done. This could supposedly been seen as malpractice, but Dr Nikoli was an amazing doctor as were all of the doctors and staff at Ronald were. The reason behind these types of decisions, were the lack of availability of resources such as ultrasound. Also due to the low number of doctors, which would be around four to five in the entire hospital, they did not have the time to do procedures the same way things might be done in the United Kingdom.
As mentioned earlier, I also spent some time at the outpatients department at Ronald Ross Hospital. The outpatients department was equivalent to the emergency department in the United Kingdom. It was run by staff called Clinical Officers. Clinical officers were staff who were trained for three years on common clinical cases in Zambia. They were proficient at managing the common problems, but were lacking in knowledge in some key areas of medicine. I did learn a great deal from them especially in the diagnosis and management of Malaria, which was especially common in Zambia, but a disease which I had not encountered in England.
Whilst I was placed at the Out Patients department, I was given my own consulting room, and I had one of the clinical officers with me to help with translating. I would take the patients history, and record the appropriate investigation and management. This ranged from orthopaedic issues such as potential fractures and referring for X-ray which I then interpreted to hypertension management, and recommending appropriate medication. I felt comfortable in this environment because it was fairly similar to a lot of things which I had seen during my time at General Practice in the UK. What differed was when there were patients with, HIV and Tuberculosis. These two conditions were very prevalent in Zambia, and I had to seek the help from the clinical officers in how to manage them.
The event which stands out the most from my time in the out patients department was during my second week at Ronald Ross. I was in my consultation room, when a clinical officer called me to say there was an emergency. I followed them over to see a women unconscious but breathing. Immediately I saw the most senior clinical officer present was one who had just qualified, thus even though I was a medical student, I was the most senior. I immediately ran through the emergency protocols of trying to secure this ladies airway, since she was unconscious and consequently would not be able to maintain it herself. Her breathing was laboured, and when taking her blood pressure, it was over 195/120. Immediately I started to think of an hypertensive emergency, and thus new she would require more senior medical attention. The clinical officers said however that they could not move her to the female medical ward where Dr Tumba was until her blood pressure had dropped. There were also no Doctors available to attend to her. Therefore we put a catheter in to try and offload some fluid. The other problem which I faced apart from feeling out of my depth was the fact that the 1st and 2nd line medication to reduce her blood pressure was not present in a beta blocker or calcium channel blocker. They thus used what they had available. The other problem was that her Glasgow Coma Scale (GCS) which is used to measure her response to various stimuli was around four or five. Once the GCS drops below eight, NHS guidelines state the need to intubate the patient, because they cannot maintain their own airway. However the clinical officers said there were not the facilities for this. They also said they had no airway adjuncts to help maintain the airway. In addition to this we did not know if she had enough oxygen in her system. This is since the only pulse oximeter was not working, thus we had no way of knowing how much supplementary oxygen to provide. The patient was eventually transferred to the female medical ward after two hours of attempting to lower her blood pressure. I found out the next day that she had died.
Sober as it was this was a by far an isolated incidence. Since when a patient came to the emergency department, there was a high chance that even if they reached one of the medical wards they would not survive overnight. I felt that the reasons for this was the lack of resources and training. In regards to the lack of resources, this was most apparent in the lack of investigative tools. Since there were cases of suspected Intracranial haemorrahage or a stroke, however there was no CT scanner at the hospital, therefore no way of knowing. The lack of training was apparent two-fold. The doctors were excellent but due to the small number of them, their workload was far too much. The clinical officers were a good addition to the workforce, but many of them could not interpret basic ECG’s, so required further training.
I also spent some time at Kamachanga district hospital which is a small hospital than Ronald Ross. I spent some time alongside Dr Chiponda, who seemed to be the doctor for all the departments there including the maternity unit. Whilst on the male medical ward I was made further aware of the HIV crisis in Zambia with roughly 50% of the patients I saw being HIV positive. A lot of them had presented late with HIV, thus had complications such as Kaposi Sarcoma, which I had only seen in textbooks in the UK. There was also a case of suspected leprosy, with a patient presenting with deep lesions which confused the extremely knowledgeable Dr Chiponda.
I experienced more examples of scarcity at Kamachanga. They had a functional X-ray machine present, but they had ran out of film for two weeks. They were thus unable to take x-rays for suspected fractures. They also did not have an ECG machine on site. This was a surprise to me, especially from a surgical point of view where, before an operation, this meant no ECG or X-ray would be done.
Overall my time at Mufulira was truly a once in a lifetime opportunity. The clinicians I worked with were truly remarkable, especially whilst working with the limited resources which they had. The citizens of Mufulira made me feel truly welcome, especially Dr Chiponda who invited us to his farm to experience a traditional Zambian cuisine. I also was privileged to attend rugby training sessions at the Mufulira Rugby Club, which was a real pride of the town, and heavy investment went into the club. The experience was one I would fully encourage, for while there were not as many resources available as within the NHS. I learnt to trust and further hone skills which we have gained in the UK without as many investigations. I was able to both pass on and receive knowledge and I know those weeks spent there, are weeks I shall always treasure.