Surgery at Mount Meru Hospital
Mount Meru is a 450-bed hospital located in Arusha in northern Tanzania. I was fortunate enough to spend a vacation period working in the surgical department at the hospital.
The surgical department consisted of four surgical wards and a major and a minor operating theatre. The theatres were a stark contrast to what I had experienced in Western surgical units with only one anaesthetic machine to induce patients and one autoclave with which to sterilise the surgical equipment. Despite the lack of equipment the surgeons were more than capable and were keen to teach in English during operations and on ward rounds. The surgical team consisted of the Chief of Surgery and five trainees at various stages of their training. All members of the surgical department were very welcoming and friendly and were keen to hear about how things differed in Europe.
A typical day began with the walk in to the hospital from where I was staying through the town of Arusha. Local vendors and street sellers were always keen to try and sell things to the ‘Mizungos’ (white people) and would often follow you with their wares in the hope that you might make a purchase. Having made it to the hospital the day usually began with a ward round or theatre list.
The paediatric block
The Wards
Ward rounds were conducted in a mixture of Swahili and English. Patients had little privacy on the wards with no dividing curtain between beds and twenty to thirty beds crammed into each ward. Infection control was an issue with no hand-washing facilities or alcohol gel and it was not uncommon to see birds flying around the ward. Wards were divided into male, female, paediatric and septic. The septic ward mainly consisted of burns patients. Burns is a major problem in Africa with many women and children living with open fires used for cooking. There is also still an element of mob-law with fires and scolding oil used to punish crimes. Without the facilities and technology to prevent infection and replace fluids, burn injuries are invariably life threatening and management usually comprises with just covering the wound and providing basic fluid support.
Together with burns, trauma made up the vast majority of surgical inpatient cases. Causes of trauma ranged from motorcycle and road traffic accidents to gunshot wounds and developmental conditions such as osteogenesis imperfecta. During my time on the surgical ward a riot had broken out in a neighbouring town and several patients had been admitted with shotgun wounds and injuries caused by explosive devices.
The mainstay of fracture fixation on the wards was traction. Traction consisted of bags of rocks attached by string to the legs of the patients and hung over the end of the bed. This method was effective but patients were bed-bound for several weeks and traction often had to be adjusted each morning due to patient movement.
Due to the living conditions of some of the patients discharge from the wards was a problem. There were no occupational therapists in the hospital and one patient, who was paralysed following a mining accident, had been in the hospital for over two years as he could not have received adequate care had he returned to his village.
One of the wards
The Theatres
The majority of my time at Mount Meru was spent in the operating theatres. I was lucky enough to assist during an appendicectomy and also got to experience open reduction internal fixation, ectopic pregnancy, hernia and pin-removal procedures.
Theatres were not sterile by Western standards but doctors and nurses did their best to maintain a c environment. Lack of resources also meant that equipment such as suture material was often of poor quality and it was not uncommon for sutures to break during wound closing. Muscle relaxant used prior to abdominal procedures was also of poor quality and it was common for the surgeons to have to search for structures such as the appendix while operating as the bowels had been allowed to move without adequate relaxant. Fluid management was also a major concern as there was no blood available for transfusion and only saline for resuscitation.
Patients had to pay for operations and there were several occasions when a patient had not provided adequate funds and their operation had to be postponed. This was difficult to watch and certainly made me appreciate healthcare provided by the NHS.
Despite the obvious contrast in equipment and funding to surgery in Europe the competency and training of the surgeons themselves was of a very high standard. The team were knowledgeable of procedures and complications and were able to swiftly deal with problems caused by poor equipment or lack of resources.
Conclusion
Working at Mount Meru was one of the most challenging and rewarding experiences of my medical career to date. I feel that I was able to learn much from the surgical department and have certainly captured many of the principles and difficulties of surgery in a developing country.
Alexander Young is a final year medical student at the University of Bristol in the UK
alexanderfyoung(at)googlemail.com