First impressions

“Welcome Dr Ghana” was the sign that greeted me, held by Isaac from the Zambian Anglican Council on my arrival in Lusaka airport 10 days ago. A good guess - I worked out it was me he was waiting for! After a day in Lusaka I made my way to St Francis’ Hospital after sweating my way through the bustle of the bus park and the 7 hour bus journey to Katete – unfortunately my arrival had slipped the memory of the administration staff and the usual hospital transport had not been arranged. The journey was relatively uneventful and I arrived in one piece, complete with luggage, including the sacred 500 pairs of sterile surgical gloves which had arrived nail-bitingly last minute, the night before I left the UK, which will see me through the next 5 months in the surgical department here.

St Francis’ Hospital is a rural District General Hospital funded by a combination of the Government and the Anglican and Catholic Councils. Care is provided to patients entirely free of charge, provided they fall within the hospital’s catchment area. It has around 350 beds but this number varies depending on how many patients there are in each!

Catho 2: a semi detached property with a convenient location

A little electrical experimenting

So far so good – I’m settling in to life in Zambia, adjusting to the heat (having failed to mend my fan which, despite a new plug still does nothing), gradually making my little house, Catho 2, more homely and meeting lots of very friendly and accommodating people. The surgical team consists of two consultant surgeons, Prof Robert from the Netherlands and Gemma from the UK, a Zambian doctor, Victor, and two licenciates – Geoffrey and Jane – who have undergone basic medical training and rotate through surgery, medicine, paediatrics and obs and gynae. There are also 6 doctors from the UK here who are running the medical wards, 3 of whom I already know from the Diploma in Tropical Medicine, and an ever changing group of medical students who are mainly based in medicine and paediatrics (we have only recruited one to surgery so far!). The set up is basic but much less so than I was expecting – I have a small but comfy studio house with bed area off the end, kitchen with slightly eclectic array of crockery and a bathroom, complete with a family of cockroaches which continue to reproduce despite my best efforts and catch me off guard, usually when I’m in the shower. To my delight I have a decent bit of garden complete with veggie patch which I have started to cultivate – this morning I sowed mixed lettuces, rocket, basil, thyme and tomatoes, accompanied by beautiful singing floating across from the Zambian service at the nursing school opposite. I have yet to make it to the English service as it starts antisocially early although one day I will drag myself out of bed for it.

A visitor in the decorative but non-functioning bathroom sink

Hospital days start at 7.30am with meetings or ward rounds. I’m based on Mukasa, the female surgical ward which has around 40 beds but usually sleeps more than this, with patients sleeping on mats on the floor of the entrance corridor and treatment room. It’s been particularly busy recently as a visiting fistula surgeon operated on around 40 women the week before I arrived, and they have been gradually recuperating on the ward. Mukasa is a standard Nightingale ward with a side room for burns patients (stiflingly hot in here to prevent burns related hypothermia) and an ‘ITU’ – the closest 6 beds to the nursing station, identical in everything other than location to all the others.

The moth eaten appearance of osteomyelitis

Elective operations are performed on Mondays, Wednesdays and Fridays, with only emergency ops the rest of the week. There is a huge variety of cases from broken bones (children falling out of trees trying to get to juicy mangos) to hernias, perforations from typhoid, volvulus (twisted loop of bowel), road traffic accidents and assaults. I have been spending my time in theatre debriding wounds/burns/ulcers, doing sequestrectomies (using a hammer and chisel to chip off dead bone due to osteomyelitis), incising abscesses, removing foreign bodies from hands and feet (eg. the broken off needle from a sewing machine, buried deep next the bone), inserting suprapubic catheters (under local, using open dissection as there are no Bonano catheters here) suturing lacerations and assisting in laparotomies, under the supervision and with the assistance of Prof, Gemma or one of the licenciates.

Happy customer - my first open suprapubic catheter patient, relieved of two days of urinary obstruction

On Friday I was called from theatre by a student nurse from Kizito, the male ward who came with the message that ‘there is an emergency, you must come quickly, there has been a road traffic accident’. I found the patient, a man in his 40s, lying in bed on the ward in an expanding pool of blood, his head wrapped in a blood soaked chitenga (traditional patterned African cloth, used for everything from carrying babies to sanitary towels) surrounded by a crowd of nurses, students, relatives and interested onlookers. After a rapid assessment, and some hefty fluid resuscitation we whisked him along to theatre leaving a trail of blood behind us, sending a nurse running ahead (well, quick walking – no-one runs here, not even in an emergency!) to alert the theatre staff. Removal of the chitenga exposed an arterial bleeder from a scalp wound and a deep laceration filled with shards of glass from his chin to his ear, which was hanging off by the lobe. We set about suturing everything back together and Gemma did a very neat job of reattaching the ear, with fingers crossed that there was enough tissue attached to prevent it becoming necrotic. Fortunately for the patient his only other injuries were minor scrapes – I have heard many stories of others who have come off much worse.

Theatre 1: the aftermath

Investigations are relatively limited – the lab can provide a haemoglobin level but not a full blood count at the moment (equipment problems), some liver and kidney function tests but no electrolytes which makes potassium replacement a bit of a guessing game. The radiology department can provide x-rays which are usually of pretty good quality and ultrasound scans which are less reliable. Prof has been known to announce ‘we will take this patient for a CT’ which means we will open them up in theatre and see what the problem is. There is one CT scanner in Zambia which is in the University Teaching Hospital in Lusaka and at a cost to the patient of £100 per scan and a 7 hour bus journey away it is out of the question for most patients.

Not a bad view for washing up

There are ongoing financial problems at St Francis’ – this month the government has not paid the hospital which has had a knock on effect. There have been daily power cuts and by the end of the week there was no fuel to run the hospital generator – an emergency operation was delayed by 4 hours while a driver was sent to Chipata to buy more as the closer petrol station in Katete had also run out. We also had a suture crisis with only enough remaining to schedule operations that didn’t require sutures, allowing some to be held aside for emergencies. In addition the hospital staff have not been paid but are still expected to work, and many support large families, relying on their monthly salary. Although a relatively politically stable country, Zambia still has its problems, not to mention the immense poverty that is seen every day here and the high HIV positive rate (14% at the last count).

Sundown

It’s not all doom and gloom and hard work though – there is a great social side to life here, with everyone living on site in little houses, and evening meals for doctors and medical students provided by the doctors’ mess. The weather is fantastic, although it is currently the rainy season it is mostly hot (~30degrees) and sunny, with a downpour every few days. I have been eased into hospital life gently, without any overnight on-calls this week, and only a ward round to run on Saturday morning but the rest of the weekend off. I have thoroughly enjoyed my first week and I’m sure the next few months will fly by. Internet access is pretty good and I have already heard from a few of you – it is lovely to hear how everyone is getting on, whether at home or abroad, so please keep in touch. If you don’t already have it my email address is charlottegunner@gmail.com – I would love to hear from you.

Sunday afternoon barbecue under the shade of a mango tree