My#Elective#experience# inTanzaniaandIndiaby# …...My#Elective#experience# inTanzaniaandIndiaby#...
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My Elective experience in Tanzania and India by Naomi Sabrina Oliver
Introduction:
My medical elective was something that I had been looking forward to ever since embarking on a career in medicine. The endless possibilities of infinite locations, rare conditions and new experiences excited me to say the least. And finally after much preparation, enduring horrible vaccines and lots of packing-‐ the time had arrived. I chose to do my elective in countries that I had not visited before that would provide me with a culturally enriching experience while placing me outside of my comfort zone. I wanted to be able to compare and contrast what I had previously experienced in the UK as a medical student. I decided to do a split placement, spending 4 weeks of my elective period in each country. By doing this I hoped to end up with a very unique elective experience. With the obvious advantage of being able to experience two different locations instead of one. So I decided to venture to Tanzania and Zanzibar first, followed by India
I have always been extremely passionate about obstetrics and gynaecology so decided to pursue this speciality in both locations. I had previously looked at the statistics available on maternal deaths according to each country, noticing that a huge variation that exists. Tanzania reported an average figure of 790 deaths per 100, 000 and India which reported an average figure of 2301. Putting aside economical differences between countries and endemic disease, I wanted to explore whether women were receiving adequate care during their labours. So I conducted an audit looking into the monitoring women received during admission to the labour ward: including modalities and frequency of use.
My main outcomes from my elective that I wanted to achieve were:
-‐To gain a better understanding as to why such a huge variation exists between maternal mortality statistics by carrying out my audit.
-‐To gain raw clinical exposure and experience
-‐And finally to compare and contrast Obstetric care given in other countries to familiar practice in the UK.
I spent four weeks in Tanzania in total. Three of which were based in the Amana Hospital, Dar es Salaam followed by a one week experience in Kivunge village hospital in Zanzibar.
The Amana hospital is a district hospital approximately dealing with around 1400 people a day and delivering around 80-‐100 babies a day on average. New mothers are kept in hospital for around 4-‐6 hours following delivery before later being discharged home.
Day one began with my tour of the Amana hospital. I had been told prior to arrival that the hospital was extremely busy and at peak could have up to 100 births per day yet nothing could prepare me for the fast paced and very efficient environment I was about to embark on.
The main delivery room contained eight beds grouped in two’s where labouring women were, around the corner to that was a bench where those who had delivered within the last 20minutes or so were sitting followed by a large counter where lots of screaming new born babies were placed. I had never seen anything so busy in all my life. And to add to the pressure, there were lots of women waiting in the next ward to come over to the labour ward to deliver. There was so much going on. Babies were being delivered every 5 to 10 minutes at peak with new patients replacing them within 20minuites of the births. I felt completely overwhelmed and decided to observe and attempt to take it all in, so at least once I returned the next day I would have a better idea of how the system worked.
Tanzania: The next day I returned with lots of enthusiasm eager to get involved and help. I asked a midwife if she could show me what should happen during a normal delivery in the hope that I would be able to conduct deliveries by myself by the time I had completed my placement. She was all too keen to help me. The only problem being the sheer pace of the department, abundance of blood everywhere and intense heat led to me nearly fainting every 15minuites. Lots of the staff found this very amusing. One of the lead consultants for obstetrics and gynaecology came to see me, explaining that obstetrics and gynaecology wasn’t for everyone and that it may be a better idea to move me to a different department such as paediatrics. I felt very disheartened by this; it wasn’t like I had never seen a delivery before. How could the fantastic experience I had been looking forward to be over so quickly? I was determined or maybe too stubborn to give up. I asked the doctor to give me one more chance and put my fainting down to the intense heat and such an extreme change in environment. I returned once more the next day, this time dressed in cooler attire and loaded with caffeinated cool drinks.
The third day on the department proved to be one of the most challenging of all. Thankfully my syncope attacks had disappeared which was great however I was about to learn how unpredictable medicine can be. Without notice a maternal cardiac arrest was rushed into the delivery room. All the doctors, nurses, midwives, medical students and spectators rushed over to her assistance. In the meanwhile eight women were actively in labour. One patient let out a loud scream, so I went over to her bed only to discover that she was crowning.
I shouted for assistance and used my initiative by putting on a gown and pair of gloves while getting the necessary equipment ready to deliver the baby. By this time the midwife had arrived and agreed to supervise me while I attempted to deliver the baby. I then supported the perineum while delivering the head followed by the body under supervision. This was a very challenging experience to me as this was the first baby I had ever delivered however I tried to remain calm while pressured and felt some security in knowing I possessed the background knowledge and understanding of the physiology behind labour. Not to mention the experience of watching a few births both in the UK and Tanzania.
Luckily the labour was straight forward resulting in the delivery of a healthy female infant. I then completed the delivery by giving the patient an injection of oxytocin and delivering the placenta. I felt exhilarated by the experience and had a deep sense of satisfaction that I already achieved one of my goals three days into my placement. To celebrate, I decided to deliver another baby, so I did. Two babies in one day, I was really on a roll. After the staff had seen the huge progress that I had made in such a short period of time, they congratulated me and told me that I should stay put and not change to paediatrics.
Over the next two weeks I continued to build on my experience by delivering more babies and assessing patients when they first arrived. I also had the opportunity to brush up on my cannulating, catheterising and venepuncture skills. Things were going well until one day I was asked by a midwife to conduct a delivery, I agreed, then walked over to the patient…on further examination the patient had quite a small fundal height. I wondered whether I had been given a non-‐pregnant patient by mistake. I looked at the midwife puzzled. She then explained that this patient had suffered an intrauterine death at 28weeks gestation.
Immediately I felt outside my comfort zone and wanted to back away. I was unsure if I would be able to cope emotionally with delivering a dead baby and felt unsure about the whole process itself. However when talking to the patient she seemed very upset and emotionally fragile as one would expect. I showed her lots of empathy and support while building a rapport so by the time it came to delivering her baby I felt as if I ought to be there for her and promised not to leave her side until it was all over. The delivery was very quick, although the patient seemed sad, she also seemed relieved once it was all over. As was I. This experience has taught me that whatever emotions I’m feeling that they are probably 10 times worse for the actual patient . No matter how I feel about the circumstances or case im involved in, it is always important for one to remain professional and level headed.
However at the same time, I felt it was important to acknowledge that I felt uncomfortable about death and found support by talking to the other medical students at a later occasion.
i.
So what have I Taken away?
• Raw clinical experience of labour • Chance to refine skills of cannulation, catheterization and
venepuncture • Awareness of some of the issues that exist outside UK • Greater appreciation for ethics, patient autonomy and good
patient communication • Realisation of my capabilities and where I can develop further
India:
I worked in the Medical trust hospital which is a private hospital based in Cochin, Kerela once again in the obstetrics and gynaecology department. The Medical trust is a 750 bed hospital multi speciality hospital considered to be one of the most well equipped hospitals in south India. It was established by the founder Mr.PA.Verghese in 1973. Over 1000 medical professionals work there to efficiently run the hospital on a day to day basis.
I welcomed the opportunity to spend more time in clinics and on the ward as I had not done much of this in Tanzania. My day in India would consist of morning ward rounds at 9am followed by outpatient clinics until 1pm. Then clinic would commence again from 4pm to 6pm. On Tuesdays and Saturdays elective surgeries took place. As I wanted to conduct more deliveries and complete the second half of my audit I had given my number to the staff in the delivery room, so that in the event of a delivery they would call me at any time throughout the day.
At first when based in clinic I struggled. The language barrier was a huge obstacle for me, I could occasionally pick out the odd medical word from a conversation to try and deduce what was going on but most of the time I felt out of the loop and bewildered. However the consultant noticed this, so was keen to debrief with me after every patient as well as translating each patients presenting complaint. This really helped. During the consultations the two doctors I worked with would take a thorough history followed by examination. I relished the opportunity to do some examinations and performed bi manual examinations, vaginal examinations, obstetric palpation and breast examinations. In the UK I had practiced such examinations but I hadn’t been given so much opportunity to be able to practice such examinations and refine my skills.
I felt a breech presentation for the first time was taught how to demonstrate prolapses and practiced distinguishing between benign breast lumps.
Being in clinic allowed me to see a huge array of conditions that I had not had the privilege of seeing before. These included: Molar pregnancies, HELLP syndrome, Adenomyosis, and pre ecclampsia.
Another aspect of the placement I particularly enjoyed was my time spent in theatre. I observed lots of hysterectomies and the removal of a large ovarian mass. After surgery the consultant would often challenge me by saying okay so if you were to perform a hysterectomy how would you do it? This was useful as in the UK the emphasis of my degree is on medicine at the expense of learning about surgical techniques and procedures in detail. This gave me a real incentive to read up on lots of techniques while getting the chance to discuss the clinical relevance as to why each step is performed. I really enjoyed this and this gave me a thirst for surgery unlike any I had ever had before.
I unfortunately didn’t get a chance to complete my audit in India as there were simply too few births taking place. Out of the allocated two weeks dedicated to doing my audit only three births took place, one of which I missed as it was during the early hours of the morning and the other two occurred very quickly with short notice not giving me a chance to observe and collate data on how often maternal and foetal monitoring were taking place. However from observing a patient that had come in due to reduced foetal movements it was evident that continuous electrical foetal monitoring and ultrasounds were being used-‐ which is something that I hadn’t previously seen in Tanzania but an all too familiar picture of what I’ve seen in the UK.
One of my clinical highlights of India was initially seeing a patient that presented with a large abdominal mass investigations showed an elevated CA-‐125. The patient was promptly taken into theatre to remove the mass. Histological results confirmed that the large mass removed was not yet cancerous and revealed a good prognosis for the patient. Continuity of care was excellent in this case. Due to such small obstetrics and gynaecology teams cases are followed through right to the end. All too often in the UK I had witnessed a number of different health professionals involved in a patients care and found it difficult myself to follow patients through to discharge.
Another doctor I had been working with was keen for me to demonstrate how I would examine an obstetric patient. While doing so she asked me lots of questions, some of which I answered well others not so well. However the greatest lesson to me of all was that with some things in medicine that I had learnt in the UK, I had learned them blindly without questioning why they are clinically important to do. This made me go away and think to myself, ‘so why do I want to perform/order this investigation’. Now from now on when I’m learning new information I will try to learn the clinical significance of it too at the same time as well as indications and contraindications.
I thoroughly enjoyed my time spent in India, particularly time spent in the outpatient department and during ward rounds.
So what have I taken away?
• The opportunity of seeing medical conditions that I haven’t seen in the UK before
• A greater appreciation for why individual investigations are performed
• A realisation of my own capabilities and areas where I can improve
• The importance of good effective team work • A greater appreciation of the concept ‘continuity of care’
Audit results As I was unable to record data from births in India. This just contains data collated from Tanzania:
In total 40 patients were audited in a two week period between the hours of 8.30 am and 2PM. Patients that had arrived more than 1 hour before myself, or where I hadn’t seen all of the observations carried out on them were excluded from my study.
Patients who I actively helped without being asked due to medical reasons are also excluded.
Average maternal age range: 20-‐25 age range, 40%
Average parity: nulliparity 37.5%
Average gravadum: 1, 40%
Outcome:
Maternal mortality rate first 6 hours 0%
Foetal mortality rate first 6 hours 10%
7.5% Caesarean sections
60.% Spontaneous vaginal deliveries
32.5% Induced vaginal deliveries (use of oxytocin or ARM)
Monitoring Blood pressure
Pulse Temp Respiratory rate
Vaginal examinations
Palpation
Maternal: Frequency 9(22.5%) 5(12.5%) 1(2.5%) 2(5%) 12(30%) 7(17.5%) Monitoring Fetoscopes Ultrasound Continuous
foetal HR
Foetal: Frequency 19(47.5%) 0 (0%) 0(0%) Percentage of labours observed receiving each modality or observation
Discussion of results:
My results of Tanzania demonstrate that just under half of all labours had fetoscopes used. Fetoscopes were not used routinely, when they were used, this was usually because of a delay in the second stage of labour or in the presence of meconium. The most common maternal monitoring that was performed was measuring blood pressure; however this was only done in just under a quarter of all observed cases.
Observations were also more likely to be done in the morning when the labour ward was less chaotic compared to the afternoon. Also on two of the days I audited, observations were carried out on all patients during that morning, as the staff had mock medical exams and were being assessed.
I asked a nurse as to why she thought there were so little observations being done. And she admitted that the labour ward was just too busy, so if labour was progressing well it was allowed to continue without any interruption until delivery was imminent. However ideally observations on both the mother and child should be carried out every 4 hours during labour.
Conclusion:
In conclusion, my audit results have given me a small insight into why such variations exist between maternal mortality statistics. Namely that there are other pressures such as being under resourced both equipment and staff wise which then makes providing adequate care for each patient much more difficult. However there is so much more to explore and given the opportunity I will continue to conduct research during my career.
I would like to thank my sponsors, Wellbeing of Women, Ethicon and the Royal College of Obstetricians and Gynaecologists for providing me with funding towards the cost of my elective.
I would also like to thank Work the World (Tanzania) and Medics away (India) The two companies who helped with the organisation of my placement.
I would like to thank Dr Johannes Marko from the Amana hospital for overseeing my audit and teaching me during ward rounds (Tanzania)
And finally I would like to thank Dr Girja Gurdas and Dr Anitha Nathan from the medical trust hospital for being both inspirational, welcoming and teaching me all about the wonderful world of obstetrics and gynaecology.(India)
References
1. NCCWCH. 2007. Intrapartum care: care of healthy women and their babies during childbirth. National Collaborating Centre for Women's and Children's Health. London: RCOG Press. www.nice.org.uk [pdf file 3.09MB; Accessed September 2008]
Acknowledgements and Thank you’s