Kamuzu Central Hospital Paediatric Elective
Kamuzu Central Hospital is a busy tertiary hospital in Lilongwe, Malawi. The
paediatric department has four wards. Ward A is made up of a 6 bed high
dependency unit, 20 bed emergency area, 25 bed step down, 20 bed nursery for
children under 6 months and a nutritional rehabilitation unit. The other wards are
surgical, long stay/ malignancy and neonates. The paediatric department is very
busy with around 50 new admissions a day in Ward A alone and about 300 patients
throughout all the wards. The Ward A emergency zone contains the sickest children,
many would be in an intensive care unit if in the UK. Most are medical patients
though the ward does look after both post operative and trauma patients.
My medical elective was spent on the ward A emergency area. The typical day
consisted of a handover meeting at 8 am. This was followed by attempting a ward
round on the very busy children’s emergency ward. The ward had around 20 beds
commonly with up to 3 children on a bed, so there could be up to 50 patients
accompanied by their mums ‐ a lot of bodies! The unit was understaffed and poorly
supplied. It would often run out of the vital few drugs and equipment that even the
basic wards should have. For example, we ran out of basic antibiotics and gloves
during my stay. The ward round was often interrupted by new sick children arriving
and children deteriorating. Most of the children had acute respiratory infections or
malaria with severe anaemia and/ or cerebral involvement. HIV prevalence was as
high as 1 in 5 and malnutrition very common, not good co-morbidities to have. Many
interesting conditions came on to the ward, for example, complex cardiac
abnormalities (e.g. teratology of Fallot and truncus arteriosus), Burkett's lymphoma,
Steven Johnson syndrome, hydrocephalus and situs inversus. After the ward round
jobs were undertaken ranging from taking blood and testing haemoglobins to
ordering bloods tests with opportunities to perform femoral stabs, lumbar punctures
and ventricular taps. At the same time as doing the jobs new patients had to be
seen. Many of the patients were anaemic due to malaria, commonly having a
haemoglobin of about 3-4 g/dL (normally 13 g/dL) so up to 30 blood transfusions had
to be arranged and given a day. There was then an evening ward round to check the
children were ready for the night.
The interprofessional team in Malawi was structured very differently to the UK. In
many instances they were a bit behind with their understanding of the roles of other
health professions and team working. The duties of the doctors and nurses were
similar to the UK’s, however, parents played a more important role in the nursing
care of their own children. On the ward we would be lucky to have two nurses. These
nurses would be responsible for all the patients on the emergency ward which could
be up to 50 patients, so they were very worked off their feet. This meant the parents
had to get involved with their children's care, it was not uncommon for parents to
feed their children via nasogastric tubes or manually ventilate a child who had been
intubated. Parents also played a crucial role in identifying when their child became
sick and they were encouraged to call for help.
There was one physiotherapist who covered all the patients in Ward A, not just the
emergency zone, so she had to work hard and this consequently meant a long wait
to provide children with physiotherapy. There were no dieticians, although with all the
malnutrition the paediatric department would have really benefited from this. There
were a couple of specialities in Malawi that do not exist in the UK. The first were the
vital signs clinicians, this profession spent their day moving from ward to ward
performing and collecting vital signs on the children. This helped to relieve some of
the work load of the nurses, however, there was a definite lack of communication
between this profession and the other professions as children with worrying vital
signs were often not handed over. The other different profession were the clinical
officers. The clinical officers are similar to nurse practitioners in the UK although their
training was provided through the medical school. This profession filled the gap
between the nurses and doctors and revolved around performing much of the
cannulation and blood collecting. The senior clinical officers were also involved with
decision making similar to the doctor's responsibilities.
There was a lack of effective interprofessional and even intraprofessional team
working. There were often three different medical ward rounds running at the same
time each with a doctor working on his own and not discussing what he had seen
with the rest of the team. The doctors, nurses and clinical officers worked very
independently which was in part due to culture but also due to what they had seen
their seniors do. For example, in the UK we are taught that if a cardiac arrest occurs
the first thing you should do is shout for help. There were many instances when I
looked up and saw a health professional trying to resuscitate a child on their own.
After some convincing we did improve ward rounds by including nurses and getting
the doctors to work together better, however, they were still a long way off from
working truly effective as a team.
My work there was very demanding with long hours. The amount of sick children
meant that death was sadly a common occurrence, with on average three children
dying a day. I was involved with at least one cardiac arrest a week. This of course
was hard to deal with but also meant that I could make a difference by recognising
deteriorating children and beginning interventions that would increase their chance of
survival. I was commonly responsible for my own patients, which would include their
resuscitation, a steep learning curve! Help was normally available however there
were times when senior help was not available. I got to perform a wide range of
practical procedures, some in the UK would be performed only by more senior
doctors, however, I also got to improve my nursing skills such as drawing up drugs
and preparing fluids for administration. This gave me a better appreciation of the
roles that other health professions have.
My experiences will stay with me for a very long time and will shape me as a doctor.
The lessons I learnt about effective team working has really emphasised its
importance to me. I have seen how situations can go wrong when professions are
not working together. I really saw firsthand how collaborative practice can improve
patient care and I hope at some point to that I will be able to return to a developing
country.
James Selby
jamespselby@gmail.com