Too many patients, not enough patience

The end of June saw the departure of the old guard that had been there for 6 months or a year. Due to UK job change over happening in early August, there is often a deficit in doctors as many of the UK Doctors finish up to sort things back home, and there is a lag between when the new ones arrive.

There was supposed to be three doctors from New Zealand during this period, myself, Yasmin and another doctor Malcolm. However, he pulled out only a few weeks before our intended arrival as he still hadn’t sorted leave for his 6 months away. This was very frustrating for us, as not only did it delay our paperwork which was being batched together, but more importantly left is a doctor short for a couple of months. Compounding this, I had a couple of good friends who had been declined spots prior to his withdrawal on the basis that there was going to be a full complement.

So come end of June, it was just Yasmin and I as the only two doctors on the female and male ward respectively, each with a licentiate working its us. Matthews, the one I was working with, and Pharaoh who Yasmin worked with, are in their internship year as part of their training. Most come from being clinical officers who have 3 years of basic training. They complete a further two years, and go on to act at the level of junior doctors most commonly in rural hospitals. Many of them are very good, and an efficient way to provide a reasonable level of care to a large amount of people in rural locations.

A ward of 30-40 patients is still a lot to get through, considering that our threshold for discharge was pretty low, so the ones that were there were pretty sick. In comparison, the Department of Medicine I worked in back home,  With a similar sized ward with similar proportion of sick patients who would be in an ICU, had six teams of doctors, each with a consultant, registrar (my level) and a house surgeon. Instead of 18 doctors, there was Matthews and I. And across the corridor, Yasmin and Pharaoh had the same deal.

It is hard to remember back exactly how busy things were, especially as we were just getting settled in, learning the language, and getting our heads around how we were to manage things given our resources. We certainly weren’t getting to clinic before lunch which was the aim, and most days it was a battle to keep our heads above water. Throughout our time, we were graced by a good bunch of elective students, with many New Zealanders, Brits, Dutchies and a smattering of others. They were put to work, and were soon running the ward, seeing patients, fetching results from the lab and doing procedures. Ant, a NZ student I had when I arrived, became my right hand man, following behind me on ward round doing the many procedures needed. That one needs an acitic tap, this one an LP, that one a pleural aspirate. He’d get things set up and then I’d pop back to do it with him, with him soon getting to the level of doing them unsupervised, such were the frequency.

Those two months were a bit of a blur, with some long days. One that still sticks in my mind is when Matthews was away, and the ward was chocker, having annexed the eye side ward for our patients that couldn’t fit onto our normal ward. Ant and I were still rounding after dinner, finally finishing at 10:45pm.

It’s funny the things that can make you short tempered and irritated when you are tired. Cockerels crowing at 6 am when you planned on not waking up for another 45 minutes, power cuts when you are trying to do your evening round, or no food being left when you get to the mess late for dinner.  It certainly does make you less compassionate. I had no stop myself at one stage from getting angry at a guy who was very sick with liver failure from hepatitis B induced cirrhosis. He had gone downhill to the stage where he wasn’t able to process the  breakdown products of normal body processes, which leads to a buildup of ammonia and other related toxins, making him confused and delirious. His medical condition precluded him from following any commands such was his encephalopathy, and despite our best efforts, getting IV access into his veins for fluid and antibiotics, was proving difficult with how combative he was. It certainly wasn’t a conscious effort to be obnoxious, and he needed urgent care. But you’ve got to get through another 30 patients then head to clinic, it can be taxing. After not improving on the limited care we had available, his family made the largely financial decision to take him home to die, as it is much cheaper to get someone in a shared taxi when alive, then have to transport someone once deceased.

Late July Dr Tembo, a Zambian doctor arrived, which added a much needed third doctor to the two wards. When we were at our lowest ebb in terms of staff, I couldn’t help but feel aggrieved that good and competent colleagues were turned away from coming due to a perceived (or at least soon to be) full complement.

When we were called in after hours, normally being woken from much needed sleep, it was always gutting despite it being our job and almost all calls being well and truly warranted. Your first thought Is why do they have to come now, at 3am with their sick child. But when you think about it, and the answer is somewhere along the lines of: because they were travelling all day to get her by hitch hiking on lorries or bicycle taxis or by foot, and that them simply coming to hospital means they have spent several weeks of family income, to seek care for their child who has a decent chance of dying from their diarrhoea, pneumonia or malaria. at the end of the day, little of our complaints fares very well compared to what the patients and the families endure on a daily basis, and was something I tried to think of every time the phone went and I trudged in, in the middle of the night.

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