Written by Hongyu Zhao, MD, PGY-2 and Qing Meng Zhang, MD, PGY-2 at Kaiser Permanente…
First impressions: Out of Africa
The expression, “only in Africa” is an interesting one and has become a part of my daily vocabulary since I arrived. I landed in Lusaka, the capital city of Zambia and home of my new place of work, University Teaching Hospital (UTH) where I will spend a month learning how to treat ill patients in a foreign country.
First, I should say, I am expecting a lot out of this experience. I have been told that it is the only tertiary care hospital in the country and the nervous system of the entire Zambian healthcare system. UTH is also home to the only medical school in the country and has a reputation of having amazing physicians due to its sheer volume of patients and their experience at UTH.
My first day at UTH was a page out of a novel, the hospital was buzzing at 8AM, and people were everywhere. I attended the daily morning report, which consisted of residents and consultants only along with the head of the department of medicine. The residents on call the day prior would review all critical patients they have seen and deaths. It set the tone for the rest of my day, which would be high-fun-paced action and a punch to the brain.
The inpatient medicine service at UTH was a bit confusing and took me a good week to understand, but essentially this is the breakdown. There are 5 teams and one team is on call every weekday. The teams are also on call on weekends (they rotate at times). The admission day starts at 7AM until 5PM the following day. You start the day in filter clinic (basically a ED outside the main hospital). The patients are assessed and we determine if they require admission. If they require admission they are admitted to the filter clinic for about 24 to 48hrs, while they are treated and worked up (investigations as we call it here in Zambia). After that time the patient is rounded on and either admitted to the wards, discharge or pronounced dead. Death rates in the filter clinic were alarmingly high, some say 50%, but what I have seen was more like 10 to 15%.
The rest of the week the team would round on patients on general wards, ICU and high cost (wards service for those who are willing to pay extra for privacy and cleaner beds), while attending clinics such as general clinic, cardiology clinic, echocardiogram clinic and HIV clinic. It is a busy world for a resident in Zambia and the patient volume is intense. There are no limits to how many patients you can admit or care for on a team.
I must say, the hospital is what you would think of when one thinks of a hospital in the middle of nowhere, like Africa. It is old, in need of some serious TLC, overcrowded and understaffed – this is going to be an authentic African experience.
The daily grind: the day-to-day aspects of working at UTH
It is literally an understatement to say I have seen some unbelievable pathology; I am after all in AFRIKA! At this point, I have seen at least 25 patients a day and the majority of the cases I will never see again in my life; such as disseminated TB, cerebral malaria, tertiary syphilis, disseminated KS involving the entire body, systemic fungal infections along with AIDS and severe OI (opportunist infectious). There are a lot of sick people in Zambia and many of them do not seek care until they are at deaths door and the odds of health care making a different is marginal at best.
The medical services are much different to what we are used to back home, let me explain: At UTH there are 5 medical units (teams) that admit patients. Each unit is on call once a week and once every other weekend. The team consists of 2 consults (any specialty ie: cardiology for unit I, renal for unit 4) then registers (what we call attendings), at least 2 residents (PGY-2 to PGY-4) and finally 2 interns and medical students that assist them with their mountains of investigations. I know this seems like a massive team, however there was a reason for this madness, it is known as call day.
Call day at UTH is a major event; it begins at 7:30AM when you get sign out from the previous on call team for only the acute patients. This takes place at “the filter clinic”, which in essence is their admitting building just outside the main hospital, it is a large clinical office converted into the medical admitting office – aka – emergency department. There isn’t a profession known as emergency medicine in Zambia. This filter clinic gets patients referred from all over the country for medical admissions as most of the other public clinics cannot deal with simple issues. At the admitting bay, we triage patients to those that require intervention and admission and those that can be sent home. From those we deem admission worthy we admit them to the filter clinic – essentially a unisex ward with about 100 beds and in a pinch we make more beds by placing a mattress on the floor, (we did this on every call day). The patients would spend about 24 hours in the filter clinic and if they didn’t die they were either admitted to the wards or sent home. This continued until 5AM the following day. We would divide our massive team, where half would do the afternoon and the other the night. During the day, half the team would eyeball the patients in the hospital and the other half would man the filter clinic. We would round in the filter clinic 2 to 3 times in a day to make room for more admission, that way if we deemed someone required admission we would admit them earlier to make room in the filter clinic for more admissions. It was common to see a large line of patients outside the clinic at all hours it never ended and we just plugged away the best we could.
Despite all the differences working in a hospital in Zambia versus back home the thing that drove me crazy were the paper charts. I have got to say the EMR – electronic medical record has been a godsend! I don’t think I will ever practice without an EMR. It was miserable dealing with acute patients with no history and no one knowing what’s going on, I must have seen 25 deaths in front on my eyes that I could have prevented if we had known the patients history and if they had sought care in a timely manner. Sorry, It is a bit frustrating at times to admit defeat when you know you could have saved lives if you had access to a certain medication in a timely manner or if the patient would have sought care when they first presented with their illness and not have waited a month or if your orders were done in a timely manner and there where more than 2 sisters “nurses or RNs” for over a 100 patients. Good, I miss nurses.
On a interesting note, a few of the cases I have seen thus far:
A 80 yo women with a STEMI, 5 days out with on going chest pain and unable to control pain due to lack of medications in the ICU.
A 17 yo boy who looked like he was 6yo stating 78% on RA with a large right pleural effusion on exam who refused oxygen and CXR and left AMA. (suspected TB)
A 31 yo female stating 85% on RA with PCP pneumonia – did not intubate and she got better!
A 24 yo with heart failure, a EF of 25% – unknown etiology and didn’t work him up. The average life expectancy in Zambia is about 40 and given that this patient didn’t have money he couldn’t afford a work up. Stay tuned for the dramatic conclusion of my trip.
The Afrikan People
The Zambian people are wonderful! The majority of Zambians as you can imagine are poor – living in poverty and living hand to mouth; however everyone does have a cell phone (its prepaid in Zambia and actually very affordable.)
Zambia is home to about 14 million people and officially about 20% have HIV/AIDS. The country has 72 official languages, but 4 major ones that are commonly spoken along with English (the British did something right?). The major tribal languages are Nganja, Tonga, Lowsee and Bawse. Interesting fact: the Tonga are polygamists (common in southern Africa) and commonly have 5 to 20 wives. The majority of the population is rural and uneducated. Although Christianity is the dominant religion in the area it is clear that traditional tribal beliefs are still practiced today and quite strong in the rural community.
I have to say, although the official numbers for HIV in Zambia is around 20% or something low, in my experience at UTH it was closer to 90% of all patients. The 10% who did not have HIV, likely were not tested. I think I saw 2 patients out of a couple hundred that were HIV negative. It is an epidemic in Zambia and I am glad that it is being addressed and accepted by the community. All in all, I think its major health pushes like USAID and other NGOs to treat HIV in Zambia that will make the biggest dent in mortality.
The phrase, “you had to be there to understand” is a bit of an understatement. I was in Africa for a month; it felt like a lifetime of experience (yet, not long enough). By my last week working with Unit I, I felt like I knew what was going on, how to order tests, how to work within the system and it was time to leave. I must admit I have seen things that I will likely never see again, specifically the pathology and severity of illness we just don’t see in the states. I will avoid talking about the hundreds of interesting cases I came across and focus on the experiences that I felt made this trip worthwhile.
What can I say about working in an African hospital for a month? I saw things I never imagined I would. I treated patients with what little I had around me. I performed all my procedures with a 16-gauge needle (thoracentesis, paracentesis and LPs – who needs a kit or spinal needle). I got all my own vitals and walked around with a pulse oximeter and bp cuff and it saved lives!!! In the end I learned more then I bargained for not just about medicine, rather about people and living in a society where health care is not a right, but a privilege and how grateful I am for all I have seen and learned.
I highly recommend traveling aboard with global health; it will change your world! I have so much more to say, but I think I will end here on a happy note.
“With the grace of good,” (my favorite saying from Africa).[slideshow]