My placement while in Tanzania is at St Elizabeth Hospital, a short 15 minute walk from my homestay in Sakina. The walk to work each morning attracts the occasional unwanted stare, many “hello my friend” comments by locals and a large dose of dust for good measure. I have decided that washing in the morning is futile as by the time I get to the hospital I am coated in my own layer of brown powder anyway. At least I have my scrubs to change in to so I can at least try and resemble a semi-respectable human being. Unfortunately the same cannot be said of my gym shoes or my socks.
St Elizabeth hospital is a 100 inpatient bed hospital, and one of two public hospitals in Arusha. The other is Mt Meru hospital on the other side of town. St Elizabeth hospital makes Wellington Regional Hospital look like a palace. It is primitive to say the least and appears very run down, both on the outside and the inside. There is a maternity department (with delivery suite, antenatal and postnatal wards), paediatric ward, medical ward, a single theatre and two surgical wards (one for males, the other for women and children), an isolated diseases ward (for HIV/tuberculosis/malaria/cancer patients),an eye and dental clinic, an outpatients clinic which caters for orthopaedic and medical patients as well as the usual immunisations and wound dressing changes, radiology (xray only), a medical laboratory, and a pharmacy. There are about 5 doctors working at any one time and the fact that there are only 100 beds certainly does not limit the number of patients being treated. Patients are squeezed into every conceivable space, with two, three or even five or more patients to one bed with many more lining corridors and the hospital grounds.
Each morning I walk in through the guarded entrance, much like entering a prison. The entire hospital grounds are surrounded in high fences, inside of which are a number of buildings painted in a mixture of white, pale blue and grey. The entire place needs a decent paint job, but given that they barely have enough money to buy essential medication, I imagine paint is the last thing on their mind. Cleaners can be found in every corner of the complex, hosing down and scrubbing floors at all times of the night and day. Despite this, the smell of the hospital is something else. As I approach the general medical ward, located upstairs above maternity and theatre I brace myself for what is a mammoth punch to the sensory cortex. An odour so pungent it takes your breath away and so powerful you don’t need a strong African coffee to wake you up in the morning. A visit to the medical ward is enough to curdle milk. It is of course the smell of unwashed humanity confined to a space too small for it to handle. Windows are kept constantly open in an attempt to create a breeze and I have learned very quickly to stand upwind of any patients if I can.
Day 1 was mainly an orientation and introduction to the many staff (doctors, nurses and administrators) that run the hospital, as well as a tour of the different departments. I have decided to spend a week each doing obstetrics, paediatrics, surgery, and infectious diseases, with another week in xray, the laboratory, pharmacy and outreach medical placements in Maasai villages. My sixth week will be on a safari, as well as a trip to Zanzibar. I expect my weekends will mostly be spent visiting local attractions in and around Arusha. I can work whatever hours I like, so I aim to arrive at the hospital between 8:30 and 9am and I leave between 2 and 4pm depending on what is happening.
My second day in the hospital began in the delivery suite and before long I was up to my arm pits in blood. I delivered two babies and sutured episiotomy tears, something I could only observe during my training in NZ. While it was probably the most terrifying experience of my medical training so far, there isn’t much you can do other than roll up your sleeves, and get on with it. Oh and pray that it all goes as expected, which of course it never does! The first lady had a massive post partumhaemorrhage that took 2 hours to control, but of course a blood transfusion was never an option. The second patient was a young Maasai lady who became so exhausted delivering her first child that when push came to shove she forgot to push. Needless to say, the labour was obstructed, the baby got stuck and came out breathless and limp. The obstetrician then became the paediatrician, doing everything in her means to bring life back into this wee soul. Her determination paid off and the wee girl started crying after about 30 minutes. While all of this was going on, I helped the nurses clean both beds as there were many more expectant mothers in the adjacent room waiting their turn to deliver. The delivery suite is a small poorly ventilated room with three beds each separated by a thin white blood-stained drape that offers absolutely no privacy. Women are required to provide their own sterile gloves and cotton wool as the hospital is not equipped to supply this. The beds, like all the beds in the hospital were rusty, dirty and in need of some serious maintenance. The foam mattresses were wrapped in a plastic cover to allow for quick cleaning and turnaround before the next patient arrives. There was however, a state of the art incubator for the babies so they could be kept warmpost deliverywhile the mother was sutured and nursed back to a state where she could walk to the adjacent post natal room.
Women’s and children health is paid for by the government, making up the majority of patients in the hospital. All other services must be paid for by the patient. Day 3 began with a caesarean section delivery of twins. It was to be my first of many theatre experiences and I really don’t think I was prepared for what I was about to see. The first challenge was finding a set of theatre scrubs that fitted. Being the perfectionist that I am I insisted on finding a matching top and trousers. That was the first mistake! The cupboard was filled with an array of mismatching items, none of which looked like they were even clean. I found a light green top. Mission impossible then began. Finding a matching pair of green trousers that actually fit me was a pursuit more difficult than a week of night shifts. The first pair I retrieved from the cupboard were so short they might as well have been shorts. The second pair, so large and without a draw string I risked exposing my underpants. The third pair, which I decided to put on were about 5 inches too short, and I looked completely ridiculous. But time was of the essence. The anaesthetist had already done the epidural and the obstetrician and her scrub nurse were armed and ready. Here I was, fumbling around the theatre looking for a hat and face mask. Twin one was delivered before I was even dressed, with twin two arriving just as I entered the theatre. It didn’t matter though, as I could see what was going on from where I was changing. There were doors but they were never closed.
The concept of sterility is an interesting one for an African hospital. The patient lay naked on the operating table, the surgeon and nurse in gowns that were most probably washed recently. The same couldn’t be said of my scrubs I don’t think. After the surgery, the patient’s abdominal scar was dressed in gauze stuck down with duck tape. The surgeon de-robed and her gown became a cover for the patient so they at least had some dignity while being transported from the theatre to the post natal ward. To transport the patient, the anaesthetist and I erected a makeshift stretcher, made from a thick plastic sheet and two wooden poles. This was then placed, with patient, on top of a trolley lacking any form of an adequate frame. But, like most things in this hospital, it was functional and the patient was delivered safely to her hospital bed, although it too was of questionable stability.
Following the caeserian section, I joined the paediatrician for her ward round. There is only one specific paediatrician at St Elizabeth hospital, a Romanian doctor who has lived in Tanzania since 1989. Her late husband, a Tanzanian man was a gynaecologist at Mt Meru hospital. She is a fantastic teacher, although at times I think her Swahili is better than her English so we don’t always understand each other. Fortunately there is a young Tanzanian medical student, Lucy, whose grasp of the English language is impeccable. We will get along perfectly!
Paediatrics in Tanzanian is far more complex than what I have experienced in NZ. There are many cases of neglect and malnutrition, superimposed on an already high number of comorbidities, many of which are serious. Poor health literacy is and will continue to be a big problem, especially amongst the Maasai tribe. Traditional medical practises continue to be the mainstay of treatment for these people. I witnessed two examples of “witch medicine”on the ward round. The first was a small child no older than 1 year, who had two deep incisions in his gums, right down to the bone. Apparently this is for administration of a herbal remedy, but from where I stood it was nothing more than an excellent access point for infection. This child was at significant risk of a cerebral abscess and death so it was unsurprising that he was into his sixth day of continuous fevers. The second child was slightly older, how old exactly I couldn’t tell you, but he had about 20 or more small vertical scars across his lower abdomen. On questioning the paediatrician about this, her response was simply “this child victim of traditional medicine”. That was enough of an understanding for me. But the most tragic case I saw all morning was that of a 2 year old girl, who lay listlessly in the hospital bed with her mother by her side. Her mother appeared exhausted and desperate. The father was dead, presumably from AIDS. I say this because the poor wee girl had extra pulmonary tuberculosis and AIDS. She weighed 7kg and was nothing more than skin and bones. I really wish there was something I could have done but I was completely helpless. Sadly, the paediatrician was in the same position.
And that concludes my first week at St Elizabeth hospital. Who knows what awaits me next week J
