CHENG Yee Han,
Bachelor of Medicine and Bachelor of Surgery
The Chinese University of Hong Kong
Overseas medical clinical attachment, Zambia
I am extremely honored to receive the Reaching Out Award of this year. My sincere gratitude goes to the donors for their generosity and support. Thanks to the generous support from the award, I have had a great experience during my four weeks of overseas elective clinical attachment and I do want to share this joy and experience with you.
After the fourth year of training in our medical school, every medical student is required to have an elective attachment of at least four weeks in any of the hospitals in any part of the world. The Faculty of Medicine encourages us not to stay in Hong Kong but to grasp this chance to explore different parts of the world. The main purpose of this attachment is to have clinical exposure in different parts of the world and observe different disease patterns, appreciate different practice of medicine, exchange experience with the local doctors and make contributions.
I have been longing for a visit to Africa so I have applied a hospital in the Zambia. Zambia is a landlocked country in southern Africa and the capital is Lusaka. Although it is a third world country, it is one of the most politically stable countries in Africa. People are very friendly to outsiders. Besides, the official language there is English so communication is not actually a big problem.
The hospital I had my attachment was called the Salvation Army Chikankata Mission Hospital. It is located in the Chikankata, which is a small city of around two hours drive from the capital. Chikankata is a rural, friendly and hospitable place and although the need is great, the people are so grateful for the help that we can give them. The hospital is founded by a Christian missionary organization and it aimed at providing caring and loving medical service in order to show Jesus Christ’s love to the patients.
There are altogether seven doctors in the hospital. They need to manage all kinds of medical problems, such as medical, surgical, pediatrics, obstetrics, gynecology, infectious, psychiatric and so on, with such limited manpower. They also got limited resources. One common problem that we encountered was run out of medications and equipments. Therefore doctors always need to show their creativity by treating the patients with handmade devices.
The daily routine is simple in the hospital. Every morning at 0730, all doctors and ward managers will gather in a seminar room to have a brief "handover meeting". The doctor who was on-called the night before would have to report all the new admissions to the others and also they would bring out any difficulties or suggestions for discussion there. As all the doctors in the hospital are Christians, they would start their day with a prayer. They will pray for the staff as well as the health of the patients. This practice is really adorable.
After the handover meeting, we would follow the doctors to the wards to have their morning ward rounds. They would follow up their patients, make management or discharge plans. Although this practice was similar to Hong Kong, I did observe a major difference in disease patterns. As I was visiting Zambia in April and it was just the end of the rainy season, which is the peak season of mosquitos’ bites, there are many cases of malaria. It was so rare to have malaria in Hong Kong and all cases are imported cases from the tropical area so it is difficult for us to learn about the details of it. However, malaria is so common in Zambia that almost every adult there have been infected at least once in their life. It is a disease that could potentially kill and should not be missed. Therefore, the hospital has tried to introduce primary preventive measures including education to the patients and also giving mosquito net to them for free. However, even after imposing these measures for some time, the number of malaria cases is still not showing any down trend. Doctors and nurses later found out the reason behind and it was actually a sad explanation. The people there are actually not using the mosquito net given, but rather selling it for money as they are too poor. Poverty is the fundamental problem that is not expected to be solved within years.
Apart from ward rounds, the other activity included the out-patient clinics. Doctors need to spend more than five hours in the outpatient clinic every day. Some patients have an appointment for follow up while some are just walk-in patients. Unlike in Hong Kong, all patients come to the clinic according to their appointment. Therefore, it is hard to predict the patient number each day and it usually end up with long waiting time for patients and long working hours for doctors. Besides the unpredictable and uncontrollable number of patients, there is also one other big difference compare with Hong Kong's clinic. In Hong Kong, patient data and past medical records are computerized and stored in the Hospital Authority database. Every time when patients attend the public hospitals, their records can be retrieved easily and systematically. These are very important in helping the doctors to make an accurate diagnosis and appropriate management. However, in the Chikankata Mission Hospital, the system of patient record collection was just introduced for two years. In the past, there was no record for any patient. Every hospital attending was like a new one to the doctors. They did not know what kinds of medications the patients were taking, what kinds of chronic diseases the patients were facing. This was really a great challenge to the doctors, especially the patients in Chikankata are not well educated and they cannot clearly and accurately describe this essential information to the doctors. This situation kept unchanged for many years until two years ago, a couple from the United Kingdom, who have devoted themselves to the Chikankata Mission Hospital for three years, have imposed some changes. The wife was a pediatric nurse in the United Kingdom so she was contributing with the same post in the mission hospital. The husband was not a medical staff. He worked as a clerk before he came to Zambia so he worked in the administration department in the mission hospital. After one year of working, the couple has spotted out the problem and decided to make changes. As the resources are so limited there, it is not possible to expect a computerized system. They started to prescribe one exercise book to each of the patient. Doctors are asked to document the history, physical examination findings and management plan in it while patients are required to keep this exercise book well and bring along the book every time they attend the clinic. According to the couple, it was a tough time to implement such change. Doctors thought it increases their workload in documenting the clinical information. Nurses were complaining its troublesome in checking the identity of each patient. Patients were not used to the system and did not understand the benefit of this practice so always forgot to bring their own book. Many problems have to be solved and education has to be done. However after some time, the system became more mature. Different parties started to get used to that and they started to found the advantage of clear patient records. And now, the system is well established and well accepted by the local people and staff. Thanks to the UK couple, this introduction of patient record in the Chikankata Mission Hospital can really be regarded as a revolutionary breakthrough.
Besides the ward rounds and clinics, every Thursday is the operation day. That is all the arranged surgeries will be done on Thursdays and all doctors will participate in it. There will be no ward rounds, no clinics or no other clinical duties except the operations. Doctors in the hospital are capable in doing most kinds of surgeries either in adult patients or in pediatric patients. It is actually quite unexpected that a rural hospital can handle those big surgeries with such limited manpower and resources. But it was because of the limitations, the doctors and nurses there are so well trained to face emergencies and unexpected situations.
For every surgery, there was supposed to be an anesthetist who handles the anesthesia and surgeons who handle the surgery. However one month before our arrival, the only one anesthetist in the hospital was killed in a traffic accident. This news shocked the hospital. Surgeries were once stopped because of lack of anesthetists. Patients who need surgical treatment were all referred to the capital hospital for further management. Nevertheless, most of the patients are poor. They cannot afford the transportation, the accommodation and so on. Therefore they would rather wait in the Chikankata than go to the main hospital. The patient need was so huge but the hospital was still not able to hire another anesthetist. And finally, the doctors decided to resume part of the surgeries. Though they were still not able to perform surgeries that need general anesthesia, the local anesthetic as well as spinal anesthetic surgeries were resumed. The surgeons were also handling the anesthetic part now. Once again, we can see that though doctors in the mission hospital are not working in the optimal environment, they are still trying their best to make the best use of what they have, including the knowledge, the skills, the resources etc., to help.
In addition to the usual work inside the hospital, there is a doctor outreach trip every Wednesday. There will be one doctor going out each time and the seven doctors in the Chikankata Mission Hospital will take turns to go. Besides one doctor, there will also be some nurses to help. They will go to the small rural areas around the Chikankata. The aim was to extend their service to those poor people are living around but are not able to afford the transportation expenses to the mission hospital. I have got a chance to follow one doctor outreach trip. Among the four trips in the four weeks of my clinical attachment, this was the only one place the senior doctors recommended. It is because this destination called the Chikani was the nearest one to the hospital. I was expecting an easy journey as it was the closest one but it turns out to be a harsh one. We were asked to gather at 630 in the morning and help packing up materials that might be needed such as medications and bandages. Then we had an almost three hour drive to the Chikani and the road was so bumpy that most of the nurse and I got motion sickness. When we arrived, there was already a long queue waiting for medical consultation. The doctor worked so hard and was working for five hours without any rest to help all the patients before he had time for his lunch. There is great diversity among the severity of the cases. Some are simple uncomplicated cases such as common cold or gastroenteritis while some are worrying cases such as acute asthmatic attack and melanoma. I can see from the eyes of the patients that how thankful they are when the doctor is helping them. This was a really tiring journey but it was surely a meaningful and memorable one.
To conclude my elective attachment in Zambia, I found there are really many poor people in need. Though as a student, I cannot contribute much in terms of medical skills or money, people can still appreciate your caring and love if you have try your best to help. And finally, let me thank for the support and encouragement from the Reaching Out Award again. It is the generous support from the award makes this trip possible and so fruitful. I sincerely hope that other award recipients of this year and also in the coming years also have a great experience and can make the best use of the support.