Written by Robert Day, MD, PGY-4 at Kaiser Permanente Santa Clara Ob/Gyn Residency Program while on Global Health rotation at Queen Elizabeth Central Hospital in Blantyre, Malawi in February-March 2018
Queen Elizabeth Hospital (QEH) is a government hospital in Blantyre Malawi. It is the largest hospital in Malawi and severs the center of the country. It is also the only hospital in Malawi that is dedicated to medical education. I had the wonderful opportunity to spend my elective time as a resident at QEH where I worked alongside residents from Malawi.
A typical day begins at 0730 where morning rounds take place. Medical students, interns, residents and attendings are present. The obstetric, gynecologic and oncology cases from the previous day were discussed. The hospital is largely run by the resident service and the morning report serves as a place for the attendings to teach the residents how they might have managed the cases differently. Typically this lasts for a few hours and is followed by medical student presentations that they have been assigned for the week. It was very impressive that…
despite the lack of resources that the doctors were update on the literature and the way things are taught in the western world. I spent a lot of my day supervising and teaching the interns about patient management and guiding them through surgeries. A typical day last until 1800 to 1900.
Typically after morning rounds the teams are separated into OB, clinic and gyn. Many patients are seen on GYN rounds. Patients often travel from very far to be seen at the hospital, occasional patients do not have the money to return immediately to their home. Patients will stay in the hospital days to weeks until their surgery date could be scheduled. Often patients families would stay in the hospital with them cooking them meals, washing their clothes and keeping the company. The attending, the residents and medical students would spend time at bedside with each patient and this was often the time for more medical education.
The surgery schedule was often limited by anesthesia availability, having clean instruments gowns and running water. Often times there was water shut offs in the hospital so there were spare buckets of water to use to wash hands prior to surgery. All surgeries were done with laparotomy. I got the experience to perform more open surgical cases than I had previous experience with this was an educational highlight of the trip. The residents were so well trained in open surgery they could easily guided me through almost any surgery. I was involved in hysterectomy, oophorectomies, and ectopic pregnancies to name a few. However the drawback of so many open surgeries in less than sterile conditions were many patients returned with postoperative wound infections and intra-abdominal abscess. It became all too common to take patient back for a second surgery where we would wash out their abdomen and find lots of malodorous pus that required evacuation. This was another important skill that I learnt.
The labor ward was very busy with majority of deliveries being performed by midwives. A typically day included 30-40 deliveries. Often times these patients have been laboring at home or at community hospital for 3-5 days before they present to Queens Elizabeth. This meant that many patients presented in sepsis, severe preeclampsia or with fetal demises. Patient’s labors were managed with intermittent auscultation. There was the possibility for forceps or vacuum use for assisted deliveries but the instruments were not always readily available to use. The indications for cesarean section were many, and were often very different than we currently practice in the United States. They explained to me that their operating rooms are so busy they take a more conservative approach to managing labor. Unfortunately due to resources, education and the lack of prenatal care the mortality rate of neonates often approached up to 20 percent.
My time at Queens Elizabeth was an excellent educational experience. I was very impressed by the dedication to education, the improvisation in a resource limiting situation and the surgical skills of the residents. It was a great way to learn about a new culture, learn different surgical techniques and learn to practice medicine in a resource poor setting.