First impressions of working at Berega
Our names are Laura Pearson and Sarah Leftley, a young doctor and a young nurse from the UK, and we have come to work in Berega Hospital for a spell, to experience first-hand the needs and challenges of rural Tanzania.
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We are staying in the guest house that the hospital kindly (and wisely) makes available to any visitor:
Laurence asked us to sketch out our first impressions, coming from the sophisticated NHS, to a mission hospital in rural Africa.
Here are our first thoughts.
Doctors & Clinical Medicine
Doctors are expected to be specialists in everything - this we can't get our head around this - the doctors here are physicians, surgeons, GPs, paediatricians, obstetricians and so on. Their jobs are extremely hard - often on-call 24 hours a day for a number of days. Often there is only 1 doctor to see in excess of 50 inpatients and then to undertake any operations that are needed. We can't imagine what a consultant surgeon would say if he was told he had to do a ward round on the paediatric and geriatrics wards!
Ward rounds are 3 times per week, but often incomplete, some patients not getting seen for 5 days or more by a doctor - this is due to time constraints and demands on the doctors. However, sometimes sick patients are not flagged up by the nursing staff, which is a worry as deterioration is missed. However, even though these patients are paying for their hospital stay and for their treatments, we haven't heard one person complain about any aspect of their care. At home, people complain they've waited a hour to be seen in a walk in clinic and relatives will complain if they haven't been able to speak to a doctor for 1 day!
Lack of access to investigations and medications makes management challenging.
Death
The resignation of people to neonatal death shocked us. We can only suppose that is seen so often here
that people seem to almost expect it and accept it as the ordinary.
A 31 year old lady planned for c-sec went into labour before c-section date. She was found to be anaemic. No blood in the hospital. The family had to donate blood before she could be taken to theatre. Once in theatre (delayed by 5 hours or more) she was found to have ruptured uterus and the baby died. If blood was available and she had gone to theatre sooner, maybe the outcome would have been more favourable. It's hard when you see this happen, knowing that it wouldn't happen at home. We just take that for granted.
It is important to note, that the staff here are working in very difficult conditions and most patients are discharged home after successful treatment. Maybe at home we rely too much on investigations and machines when actually, nothing is more important than taking a good history and performing a thorough examination. In our short time here so far, we have been reminded of this and we are learning from their ability to provide accurate assessments without any other tools.
Treatments
There are more medications available than we had expected there to be. Cheap drugs from India mean that most conditions can be treated, if the prescription can be afforded. Everyone seems to go away with a prescription. There's a book that all attendees are written
in, along with diagnosis and treatment - we couldn't find a blank treatment box! We were surprised that there isn't more
antibiotic resistance, especially as most of the prescriptions are for
antibiotics.
Staff and systems
The nursing role is very different - they do bloods, cannulas, while family members seem to provide care, give meds etc. There also seems to be a large knowledge to practice gap as they seem to learn and be very knowledgeable in conditions when asked. However they can't always seem to relate this to patients clinically and see the importance of derangements in observations (often low blood pressures are recorded and no one is informed or they don't relate this to the patients condition). Ward rounds are often interrupted by chatting and other non-urgent matters by other staff which is very different to home!
Almost all patients now have observation charts at the end of their beds but getting the nurses to complete them can be a bit of a challenge and they mostly only see the importance in temperatures and no other vital signs! The nurses do however work in very difficult conditions with limited supplies, but they also rotate around wards so there doesn't seem to be a lot of ownership/pride in the wards themselves.
As a result, patients can end up being neglected: A burns patient who had been in for 4 days and only been given 1.5L fluid and not had obs due to extensive burns - when we first met him he was tachycardic and shaking. He hadn't been given pain relief for 2 days and had no dressings as they don't have the correct dressings here. Issue here was in part lack of doctor availability and handover of sick patients and perhaps lack of education in nursing staff about management of burns and recognising a sick patient.
A child with meningitis who was very sick with fevers over 40 degrees for a number of days and wasn't getting regular or complete observations. When the observations were done, and the doctor assessed the patient and saw him not to be improving, he was able to change management.
Facilities
The sterility in theatre is better than we were expecting but we were shocked to see that for anaesthetising patients they just use a guedel airway!
The lack of privacy on ward rounds surprised us, but patients don't seem to expect it, which almost surprised us more. The next patient often comes into the clinic room before the previous one has left, examinations on ward done with a very small screen that doesn't cover everything.
Money & Poverty
It is hard prescribing medications knowing that the patient or their family is going to have to pay - added pressure to get the right diagnosis and optimal treatment. If a patients' condition changes - it is hard to change the medication knowing that the family has paid for the medication that they are already taking. It's tough seeing patients who can't afford basic medications - some patients leave before completing treatment or only take certain treatments that are prescribed because they can't afford it. It makes us frustrated thinking of the patients that we see at home every day who take the NHS for granted and moan about how bad it is, they really need to come out here and see what it's like in a developing country.
There is a pressure to diagnose there and then - no "go home and see how it goes, then see your GP if it gets worse", like we often do when seeing patients in A&E or MAU at home.
Diseases
Different diseases are predominant compared to the UK - death from malaria, burns, meningitis, childbirth, and accidents are all so much commoner.
Amazing Tanzanians
The ability of the Tanzanian people to remain happy and
positive despite some of the hardships they face is wonderful to see and puts
things very much into perspective.
Everyone here has been so welcoming to us and willing to help us as well
as learn from us.
The frustrations that are outlined above are only the first
impressions of our time here. As time
goes on, we are finding more positive things to take away to improve our
practice at home and learning that not everything that is different is
necessarily for the worse and that less investigations and treatment doesn't
always mean poor care. The doctors and
nurses here do the best with what they have and outcomes are, for the most
part, better than you might expect.
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