Adventures — 21 November 2015 at 5:05 pm

32 Degrees East (and 14 South) – Adventures in Surgery

Charlotte Gunner / Clinical Fellow in Urology / Sheffield, UK

Charlotte describes her decision to take a year out of medical training after completing FY2, and the challenges and rewards of working in the surgical department of a rural Zambian hospital.

Pre-meditation

A senior colleague once told me “the NHS is a sausage factory; the ingredients go in and you work your way along the conveyor belt”. As the end of FY2 approached, I knew I just didn’t want to become a sausage.

I had known throughout medical school that I wanted to have a career in surgery, but I also knew that going directly through training in the shortest route possible wasn’t for me. Having taken a year out between school and university I had already developed a taste for adventure, for new experiences and for life abroad. Following this with an elective in Uganda I felt very strongly that Africa was a place where I would like to spend more time.

I was told by several consultants that this would be career suicide and that I would struggle to get a place on a training programme if I took time out – especially to travel. I sought a range of senior opinions, including some significantly more encouraging. It was with a certain satisfaction that I was able to sit back and watch my colleagues lose sleep over job applications while I set about making plans for my year away.

There seemed to be three main options that were being bandied about amongst the ‘year off-ers’: to go travelling and try to avoid work as much as possible, to find paid work in New Zealand or Australia or to volunteer in a resource-poor country. I was in a minority amongst my peers in thinking that the latter option was the most enticing.

With my Foundation Training behind me, I knew I had a good grounding in the basics of medicine and surgery, but felt aware that I was still very junior in my experience and skill set. This motivated me to prepare as best I could – first by studying for the Diploma in Tropical Medicine and Hygiene (DTMH) at the University of Liverpool, and then to take the time to find the right hospital where I could be of use, but also have appropriate senior support. The DTMH set the tone for the rest of the year in terms of the challenges I would face, and my enjoyment of them. I would highly recommend it to anyone interested in working in the tropics, regardless of speciality.

Through useful contacts I’d made during my Foundation jobs and post-diploma locum work, I secured a position as SHO in General Surgery and Orthopaedics at St. Francis’ Hospital in Zambia, where I would start after attending my interviews for Core Surgical Training.

To Zambia

The five months I spent at St Francis’ brought with them great happiness but also immense and sometimes heartbreaking challenges, complex decisions, ethical dilemmas, many frustrations and a very steep learning curve. I worked alongside Zambian juniors under the supervision of a Dutch surgical professor and a British consultant surgeon, staffing the junior on-call and routine rotas.

Managing sick patients with minimal resources required adaptability, the like of which is rarely demanded in our comparably resource-rich NHS. The psychological pressure created by the nature of the workload could have been overwhelming if it weren’t for the strong support network created by the staff of the hospital community, all of whom live within the hospital grounds. Having senior support was a ‘must have’ for me as I did not want to put myself in ethically dubious situations of operating literally and metaphorically outside of my capabilities.

Some of the challenges I faced included life-threatening osteomyelitis, enterocutaneous fistulae following delayed presentation with typhoid, domestic violence, a 62-person RTA (the kind of major trauma scenario that even ATLS doesn’t dream up), deaths from snake bites (no antivenom available in the country) and scores and scores of open fractures, life threatening burns and delayed-presentation malignancies.

Basing operative decisions on individual functional need was absolutely fundamental to treatment in Zambia – one patient came to see a visiting orthopaedic surgeon complaining of a fixed extension deformity of his left elbow. Following discussion it was agreed that he would have this corrected and fused at 90 degrees, generally considered a position of more useful function. The day of surgery arrived, and as the patient was being wheeled into theatre he suddenly exclaimed ‘Stop!’. He had realised that his job as a farmer demanded long hours using a hoe, in which his left arm was extended and his right flexed. If we fixed his left arm in flexion he would no longer manage to work. He left, delighted with the realisation that he already had the best configuration of elbows.

Reflections

I’m sure I have gained personally far more from my relatively short time working in Zambia than I was able to contribute. So much of what I learned can be applied to work and life in the UK. A particularly poignant learning point for me was not to lose sight of the patient as a whole –  in Zambia, ‘life over limb’ came into play on many occasions, and I was reminded of a saying of an orthopaedic consultant I’d worked with in the UK: ‘it’s no good having the best looking leg in the morgue’.

There were many moments of great satisfaction: seeing patients discharged home after months in hospital, the gratitude of pain relieved by incision and drainage of a chronic abscess, the relief of a limb saved when a patient had been told at another hospital that amputation was the only option.

I would encourage junior doctors considering taking time out before specialty training without hesitation. My application to UK Surgical Training was in no way hindered by my year abroad – if anything it was enhanced. My experiences in Zambia have featured heavily in every interview I have had since my return, (not always because I have brought it up!) and never has it been received negatively. The only downside of taking time out is that once you have tried it, you will want to do it again. For the moment I am happy at work in the UK, but I’m sure it won’t be long before I recognise that familiar feeling of itchy feet…