Reflections on my first fortnight at the University Hospital

I’ve been going to the morning medical meeting 3 days a week for about a fortnight now, have done about 10 gastroscopies and a colonoscopy, and seen at least twenty referrals of difficult patients in the wards. Also the medical interns banded together and approached me about setting up a clinical teaching timetable, so I’ve spent a few hours in the last week teaching them. It’s still very early days, but I feel I’m gradually coming up to speed with how the hospital works.

Firstly, the hospital is desperately short of senior clinical staff. There are only 4 fulltime specialists in the Department of Internal Medicine, and of these, one is Head of Department and Professor at the University, one is Director General of the hospital (like the CEO), and then there’s one other and me. With the teaching and admin load, that effectively means only one specialist is usually available to supervise 100+ medical beds, 10+ junior staff, and 15 medical students, while also working in their subspecialty.

Secondly, the culture is mostly conducive to learning and teaching. Both senior staff and juniors seem highly motivated to teach and learn, gain skills and take care of patients. It’s just that they’re overstretched between competing priorities. In terms of physical resources, the medical school seems well resourced, and the hospital reasonably well so, at least compared with other African hospitals I’ve worked in. The interns approached me with a clear idea of their learning objectives that were not being met, and have worked hard with me in 2 hour plus stretches perfecting their neurological examination techniques.

Thirdly, the case complexity of the patients we see is often quite high. Many patients have been seen at District Hospitals prior to referral, and thus only the more difficult cases tend to reach CHUB. For example, I spent an hour today working out a treatment regime for a man presenting with HIV, active tuberculosis, and renal failure from his HIV. Treating any 2 of these is complex because of drug interactions, treating all 3 together with only limited drug options was a nightmare. Eventually we found a regime (efavirenz, abacavir, low dose lamivudine, rifampicin, low dose pyrazinamide, isoniazid, low dose ethambutol and pyridoxine for you medicos who care ) that might be effective we hope… So far in the ward I’ve seen Miller Fisher variant Guillain Barre syndrome, strokes, hepatomas, acute leukaemia, unexplained pancytopenia with PUO, haematemesis complicating dysentery, gastric carcinoma, a child with a pancreatic cyst, as well as the usual HIV, chronic liver disease, TB and heart failure cases. Of the gastroscopies I’ve done, at least two thirds have had major pathology (maybe 10% might in Australia) – duodenal ulcers, tumours, gastric outlet obstruction. As I was leaving at 6pm tonight I was asked to see a 21 year old girl with severe acute heart failure, sepsis, multiple joint arthritis and a rigid abdomen. Patients here can be VERY sick.

In conclusion, it really seems that God has provided an opportunity for me to work, learn and teach in an challenging but exciting environment. There’s much suffering and sadness here, but also much stoicism, hope and desire to improve how people are cared for. I met with the Dean of the Medical School today, Patrick, who is passionate about developing the skills of the next generation of student doctors and I’m beginning to share his passion. Today was frenetic; a 7.30 medical meeting, troubleshooting ward round of 4 medical wards, five gastroscopies, a quick trip to the District Office to work on paperwork for our (refused) visas, home for a 10 minute lunch then a 90 minute Kinyarwanda lesson with Catherine, back to take a 2 hour neurology tute and spend an extra hour with two difficult clinical problems and finally home just before 7pm, but overall it felt worthwhile. I’m currently typing in the dark near 2 sleeping children and a facebooking wife, exhausted but quietly content.

If we’re going to stay, however, sooner or later we’ll need a visa. Ours expired 5 days ago and our paperwork has been rejected 3 times so far, so we’re technically illegal in the country at the moment. Our certified copies of police checks, birth certificates and marriage certificate have all been rejected as inadequate, so we may have to courier the originals from Australia, at some cost and risk of loss. Also our moving into a (Diocese or hospital) house seems further away than ever, so we’re just psychologically settling in the Guesthouse, until something changes. Your prayers are appreciated!