The Muhimbili hospital experience part 1

The Hospital Experience at Muhimbili Hospital

The Entrance to Muhimbili Hospital

Sorry this blog has been updated much later and behind schedule than anticipated, to suggest the internet has been only a little unreliable would be like suggesting the Pope is only a little catholic!  Nevertheless, I’ve managed to try and amalgamate my hospital experiences at Muhimbili hospital into one blog…one very loonngg rambling blog that may be best read over a couple of sittings (if you’re not bored to tears after a few minutes!!).  Before I start this segment, I should put a small disclaimer in here to state that having only spent 6 weeks in Tanzania, there is no way I could fully comprehend the complexities and challenges faced by the medical system there so this blog should in no way be interpreted as a perfect representation of how things are, it is merely my opinions and some anecdotal experiences I had there and I can only hope those reading this will take it as just that.

I tried to come to Tanzania with an open mind and few expectations as to what I would see or experience. It is fair to say however that no matter how prepared I thought I may be for what I would see or do, I couldn’t have imagined what awaited me at the Muhimbili Emergency Department, the only one of its kind in Tanzania and a tertiary referral hospital.  Tertiary referral in Tanzania quite basically means that injured patients must first attend their local practice or a local hospital (sometimes 1, 2 or more) before being referred onto Muhimbili to be treated, usually because the local hospital is not equipped to handle the degree of injury or illness the patient is experiencing.  In concept, it’s not an entirely bad idea as it means more basic injuries can be treated without the need for travelling upwards of 6-8hrs at times to reach this hospital, however in practicality, it equally means that someone who’s been scooped up off the road with massive head or other injuries from an accident, even if they were only blocks away from Muhimbili, must first go to a local hospital which is not likely equipped to deal with them to get a bit of a ‘patch up’ job (which, in some cases, means getting something like a head wound sutured with pig’s skin) before putting them back in an ambulance/taxi and send them to Muhimbili.  By this point when they arrive, they have sometimes lost a lot of blood, have diminishing obs, have had no pain relief, and in some cases, are too far gone by the time they reach Muhimbili for successful resuscitation. Obviously this is not true for all patients I saw however it was not uncommon to see that scenario quite regularly.

Some of the Hospital Grounds - The E.D. is in front

Medical School campus

Walking into the entrance to Muhimbili hospital the first day, I was first struck by how spread out the hospital was, in fact, it was not so much of a single hospital, but a large variety of buildings of different sizes, shapes and colours over a large expanse of land housing the various medical specialities along with a dental school, medical school and allied health (ie nursing, physio etc) school.  The buildings were joined in some cases by open aired walkways made of concrete where patients often lined the sides of the walkway, either sitting out from the various wards for some ‘fresh’ air or awaiting some form of treatment.  The road walking to the Emergency department (A&E) was a large dusty unpaved road filled with people, medical or otherwise walking to and fro amongst the numerous taxis, cars and bjaj’s which didn’t seem to have a discernible ‘right of way’ system so crossing the dust road at times, could in itself, result in a visit to the emergency room if your timing was off lol.  It took around 10-15 minutes to walk to the Emergency Department by which time I often arrived looking far more tanned than when I’d left the house, purely as a result of the amount of red/brown dust which stuck to our skin in the heat.  We were advised to wear ‘street clothes’ to the hospital and change there, which, in retrospect I was so glad to have done as it would take at least a few minutes to dust myself off, wash my arms/face and feet in the bathroom before changing into my scrubs to begin the day (or night as the case may be). 

What struck me as I first walked up to the A&E, was that it didn’t seem much different to any UK A&E entrance (well, with the exception of the dust roads); the front entrance also served as the ambulance bay with a covered concrete paved driveway where ambulances could pull up to drop off patients who could then be taken directly into the A&E (AKA Emergency medicine department – sorry I’m using these interchangeably although it could be argued successfully that there are some distinct differences between Emergency Medicine and A&E.  For the purpose of this blog however, I’m not going to go into the differences as it would take a while, be a little too in depth & quite frankly, probably a little boring for those non-medics reading this).

Entrance to the Emergency Department

One of many wards/departments

 I was first taken to be introduced to the head of the department, a lovely older professor whose role was to oversee the activities of the department.  I’d tried to learn as much medical Swahili as possible before coming intertwined with some pleasantries such as ‘nice to meet you’, ‘lovely weather’ and  ‘excuse me sir, your arm seems to have fallen off’ to better converse with  patients & staff. I think, however, I ended up being more of a source of amusement for the professor with my poor accent and limited vocabulary (not to mention making a faux-pas on my first day of mis-pronouncing the number 10 (phonetically pronounced Koo-mee) with (Koo-ri) which apparently is a colloquial term for a ladies private bits!  At least he was able to see the light side of this and I like to think he appreciated my attempt to at least try speaking the language.  Following introductions and getting my temporary badge, I was then taken to the Emergency department to meet the team and get a tour of the department.

I’m not sure what I expected of the emergency department in Tanzania, but I must admit, I had some preconceptions of seeing a less sterile ward type environment with 3-4 people per bed, overcrowded waiting rooms, minimal staff with only ceiling fans, if anything, to cool poorly equipped treatment rooms (a stereotype, I know, but in fairness is what I was to see in the rural village hospital and some wards at the hospital outside the A&E).  I was very pleasantly surprised to find the emergency department to resemble a very modern, clean and heavily air conditioned area complete with 4 large, separate treatment bays, each which could take 3-4 beds comfortably, possibly 5 beds at a push before becoming a little overcrowded. Each room/bay had an 1 observation monitor (to watch blood pressure, O2 sats and pulse etc), an oxygen providing unit on the wall and several trolleys and desks, equipped with similar equipment you would find in the UK like syringes, cannulas, intubation equipment, fluid giving kits, blood taking equipment and several different types of fluids for infusions.  Several bays housed movable defibrillators and there were a few portable ultrasound machines in a couple of the bays (little did I know what an essential piece of kit that was at the time, which I’ll come onto later).  All in all, first impressions were quite good, particularly the centre area with multiple computers for staff and a big wall board, not dissimilar to those seen in the UK, which listed the doctors on duty, cases being considered and other ‘normal’ protocol details.  There were a number of doctors and nurses about, all very welcoming and dressed in various coloured scrubs, depending on their roles within the department.  Many spoke excellent English, particularly the doctors, with most nurses speaking proficiently to the point that between my broken Swahili and their English, we could converse pretty well (although it has to be said that their English was far better than my Swahili).

One of the Emergency rooms

Everything seemed well organised in the department with the only thing noticeably lacking at this point being patients!  There was one patient in a far bay being attended to by the nurses however the rest of the rooms were empty.  I was to find that due to the nature of this being a referral hospital (and being quite early in the morning), patients would often not arrive in greater numbers until later in the morning when they were transferred from elsewhere by ambulance & then numbers would again dwindle in late evening with the exception of some of the most serious cases which could arrive throughout the night. During the day however, numbers of patients varied quite a bit and the department was generally fairly busy.  Around the corner from the Emergency bays, were a further 6 treatment rooms, again, quite similar to those found in most developed countries where day cases of ‘walking wounded’ were treated, freeing up the emergency bays for the more serious conditions. Beyond a security locked door after the treatment rooms (also the main entrance into the department), were 2 triage rooms for initial consultations and the payment booth, where families or friends could pay for the patient’s treatment within the department. 

From my understanding, at Muhimbili and the majority of hospitals, care is not free with the exception of several groups of people including those who are pregnant, children under 5, and for those with HIV/AIDs, TB and diabetes.  For all other patients, starting fees just for being assessed are 10,000 shillings (the equivalent of around £4UK), which for some, can be more than they can afford.  I have been told however that if an emergency case comes in and they are unable to pay or no family is around, they will be treated first, regardless if they are able to pay or not and the finances would be sorted out later, a policy I quite agree with rather than having patients turned away.  Generally, patients must also pay for any investigations, treatment and medication they subsequently receive, with a simple CT scan alone costing upwards of  $200-300 USD.  Considering that a ‘high’ income here is around 600-700USD per month (which, from what I understand is what many doctors are on), a single investigation could cost a low income family a half a year’s salary, and that’s before any treatment costs. It didn’t surprise me therefore, that many patients seemed to wait quite a long time until things were pretty serious or advanced to actually attend a hospital, perhaps in the hopes that their problem would clear up without any need for treatment.  I think it is safe to say that people in Tanzania don’t attend hospital unless they really really need to, I don’t recall seeing patient with a cold or flu, or even worse, man flu which we all know is worse than childbirth…

 One of the first cases I followed a doctor to visit once I’d been shown the department was a middle aged gentleman who was brought in following a run in with a motorcycle.  I was told he’d suffered a fracture to his lower leg (at this point, those with sensitive stomachs may wish to stop reading until the following paragraph!). Entering the room, the first thing I noticed was a couple pieces of what was likely his tibia laying on the floor beside him, with his foot somewhat dangling precariously close to the edge of the bed, remaining attached by only a single tendon at the back of the foot.  What got me was the chap was lying there calmly, fully awake and alert, having not yet received any pain relief, and even managed a small smile as the doctor began talking to him.  Besides the blatently obvious problem, he was pretty badly bruised and scraped elsewhere with a further possible fracture to one of his arms and a bit of a gash on his head.  It was decided that the immediate action needed was to have his leg splinted and the bleeding from his leg and foot stopped and stabilised, prior to moving him across to the Orthopaedic institute, in another building, where they could  continue his treatment.  One of the nurses went to get a splint so the fracture could be stabilised and whilst the doctor went to check on another incoming patient, I decided to pick up the pieces of shattered bone on the floor and place them beside his leg…not that I figured I was being much use or that anything could be done with the pieces but it seemed a better choice than just standing there waiting and staring at what had to be the worst injury I’d seen in my medical training to that date. 

Reading an I-stat machine - a fast blood analysis machine

The nurse returned carrying a large cardboard box so went over to look to see what kind of splints he had brought for this man’s leg& foot.  Looking inside the box, it was totally empty, prompting my next question of ‘where is this splint you plan to use? Are you out of splints?’ which the nurse found quite amusing.  Smiling, he took a pair of scissors from the table and began cutting the cardboard box at which point it dawned on me that this cardboard box was to become the splint for the leg.  Apparently another department had taken all the ‘proper’ splints some time ago so the Emergency Department relied upon cardboard, fashioned into the necessary shape to become a leg, or arm ‘cast’ tied on with strips of wrapped gauze.  At this point it has to be said, one thing I came to appreciate about the doctors/nurses here is what they lack in resources, they certainly make up for in creativity and ingenuity!   Once the cardboard had been cut into an L shape to support the leg and foot, we were ready to try and reduce this poor guys fracture and fashion his foot into the cardboard splint. 

One thing I realised very quickly is that painkillers (amongst many other ‘common’ UK/US/Canadian medicines) in Tanzania are in short supply in the hospitals.  For a bad injury such as the open fracture (ie foot falling off) we were treating, a patient would get 5mg of Morphine.  To put this in prospective, this is what some patients in the UK may get if they went to the hospital with a very bad toothache or some bad stomach pains!  If the pain was totally unbearable, then they may get 1mg of Ketamine or 5mg of Diazepam and possibly a further top of a further 5mg of Morphine at some point later but it was really a case of trying to treat with the lowest possible pain relief due to the limited availability wherever possible.  After this chap was given his 5mg of Morphine, myself and 2 others began the task of attempting to hold the food in place whilst applying the makeshift splint to the leg.  I couldn’t believe how stoical this gentleman was, it was clear he was still in agony however he hardly made a noise, only letting out small whimpers occasionally as his foot was rotated around a hundred degrees, manoeuvred, then wrapped with gauge around the cardboard, with further gauze used to pack the massive hole between his foot, the visible fractured bones/ muscles, & the rest of his leg.  The pain he was experiencing almost brought tears to my eyes as I’m pretty confident that had I been in his position, I would have passed out long before we’d finished.  We took turns talking to him as we wrapped saying ‘Pole Sana KaKa’ (meaning I’m very sorry brother) which was all that could be said but seemed far too little given the situation, not to mention the pain he must have been feeling from his other injuries which still needed tending to.

After we’d finished splinting the leg, a cannula was placed to provide some fluids and he was left to rest whilst plans were made to have him transferred out of the department.  I’ll never forget this man because after all the pain that we must have caused him manipulating his leg and ‘reducing’ the fracture while he was wide awake, having to watch the whole process and on so little pain control, the first thing he said was a very sincere ‘Thank you’ in Swahili.  That was the first of many ‘Thank you’s’ I was to receive from people that I should have been thanking for being so brave and strong in the face of horrific injuries and pain, who never uttered a single complaint about anything and were grateful for even the most basic treatment received.

The matron, Megan, Abi and I on the general med ward

That was one of the first of a number of patients I saw and helped with that day, each patient with illness or injury almost as severe or as bad as that first gentleman.  The only thought I had when leaving the hospital that day was that I was definitely not in Kansas anymore.

Washing hands - note the sink is not connected and there is no basin! (on a general ward)

Part 2 to be continued….