WMS Elective Series 2019 (Pt 1)
We've collected reports from some of our final year members whilst on their electives.
We've loved receiving updates from them and we also hope this might inspire and help our 3rd and 4th years to plan their own elective placements...
I planned my elective for New Zealand primarily to do paediatrics at Starship in Auckland - this is a renowned tertiary paeds centre, but also with a NICU PICU and Paeds ED attached for more emergent care
The second half of my elective is a placement in Gisborne - a small town on the east coast of NZ's North Island, allowing me to explore rural care in the island.
There are many advantages to organising a placement in New Zealand; amongst these is the lack of a language barrier between you and the population. As well as this, the Maori and Pacific island populations have very interesting socioeconomic, cultural, and health issues not found elsewhere. This has allowed me to gain experience in little seen UK issues - predominance of rheumatic fever and genetic disease to name a couple.
The process of organising my elective was broadly quite simple; I emailed every hospital in the country in early march / April - Auckland requires early application and if unsuccessful initially I recommend following up to see if there have been cancellations, this is how I ended up getting a placement here!
Gisborne was simpler - applications opening in August / September for the new year
But inquire and plan early - and remain organised! (I'm sure you're all aware of this however!)
The highlights of the country and travel here itself are also numerous! For lord of the rings fans it's a must, and beyond that both islands are packed with stunning vistas, chilled out and empty beaches, and many adventure sports opportunities!
Good luck and remember to enjoy the rest of your med school experience!
Mid elective journal submission Location: Manguzi South Africa Duration: 3 weeks
Placement type: General rural medicine
Manguzi is a small town in the eastern part of South Africa in the province of Kwazulu-Natal. The population here is mainly Zulu with an unemployment rate of up to 90%.
The hospital is rural, has 280 inpatient beds, and serves a large area (including patients from Mozambique)
I spent my time mostly between the inpatient wards, the outpatient department and the resuscitation unit (their version of an A&E). The medicine you see here is interesting, a lot of cases of HIV +/- TB and the subsequent sequelae. For example I saw a nasty case of Fournier’s gangrene in a man with a high viral load.
You also frequently encounter situations where equipment/tests/medications are not available and have to improvise/do with it. For example on the male med ward there was a HIV positive patient with an acute gastroenteritis, his BPs were plummeting and refractory to fluids. Ideally this patient should have been managed in an HDU/ITU setting with an art-line and central ionotrope support. Fortunately the one syringe driver was free in the hospital, and the patient was given a peripheral adrenaline infusion. BP monitoring was an issue was there was only one obs machine on the ward and other patients were also ill and needed vitals recorded.
There’s a reasonable amount of support at Manguzi and you’ll never be left to feel out of your comfort zone. Occasionally you’ll feel like a third wheel as most of the consultations are done in Zulu and the doctor may not translate for your benefit if they’re busy. As far as procedures, if you ask they’ll show/let you do most things, just be careful not to pick up bad habits.
Outside of the medicine there is a wealth of exploring to be done, during my short time in the area I went to the Tembe Elephant Park, Went on a turtle tour and saw baby turtles hatching and making their way to the sea, went to Sodwana bay, visited Ponta Mozambique. There’s lots to see and to and there are lots of friendly comm-serv (staff who have just qualified and are doing a years mandatory rural service) to do activities with.
Overall I would certainly recommend Manguzi for an elective and would advise considering 6 weeks here instead of 3 as by the end of week 3 I felt I was only just getting to know the hospital team"
Obs & Gynae
Always keen to make things as difficult for myself as possible, I decided to spend the first part of my elective somewhere where no GKT student (according to the online database) had been before … yes I know … how adventurous. Sadly though, this was not a mountainous and remote destination, in fact it was the flattest country I think I have ever been to (I have not yet made it to the Netherlands) and only 30 mins from a brand new international airport (courtesy of the Chinese).
On the 26th January I landed in a very hot and dusty Senegal, ready for 3 weeks of (hopefully) obs and gynae in a small mission hospital in a town an hour from the capital city of Dakar. My communication with them had been limited to none and I was very much hoping I would be expected when I turned up on Monday morning.
Fortunately my host, a lovely Brazilian lady, knew the hospital reasonably well and together we made the half hour walk through the dusty orange backroads to the hospital. Garbage collection is done by a team of a generally pretty dusty guy with a donkey and a cart, households pay for them to pick up the rubbish, but there is no policy for the street, so everywhere is littered with heaps of rubbish. Occasionally we disturbed a pig and her piglets rooting at the side of the road, or outside the main gate of the hospital.
I was introduced to the medical director, a Zambian anaesthetist who quickly made me at home with a very welcome offering from his nespresso machine – win. No sooner had I finished it than we received an urgent summons to the theatre – there was an emergency caesarean and we (well mainly him) were needed. Rapidly attired in some incredibly thin and worn scrubs of a fetching sage green we made our way into the theatre. Compared to the incredibly clean and organised theatres of the UK it was a little different, airway equipment and drugs were piled haphazardly on surfaces. Sterilised instruments were in metal tins rather than packaging as they were all reused, even the diathermy. As I later witnessed, all the swabs were hand cut and folded by the theatre nurses and then sterilised in a metal tin, doled out onto the instrument table with a pair of tongs and no counting at all. This lack of counting swabs in and out has led to at least one unfortunate incident where swabs have been left in the pelvis during surgery, only to be found months later when the patient returns with intractable pain.
The team were very efficient, and the baby was quickly delivered and whisked off by the midwives, while I was taken next door to the other operating theatre where another caesarean was about to be performed. I asked what the indication was as this was an elective c-section. I was told it was for a “precious baby”. The mother had had two miscarriages and a previous stillbirth, and no living children. It seemed to me that the hospital carried out a lot of c-sections, often in situations when we would hold back in the UK. They explained that this was because of safety. The hospital lacked a 24h theatre team that could carry out emergency c/s, they also lacked the staff to carefully monitor mothers in labour so if there was any indication of a difficult labour they preferred to go straight to a planned caesarean.
I gradually began to get the hang of my medical French again, though when consultations were conducted in native Wolof I was more clueless than ever. My time fell into a rhythm of O&G clinics on Mondays, Wednesdays and Thursdays, with general medicine clinics on the remaining mornings; and whatever happened to be in theatre in the afternoons and evenings. Often lists wouldn’t start until 4 or 5pm once the surgeons arrived from their jobs in other hospitals, and even then, all the surgeons and theatre team would first sit together to eat from a communal bowl of Thieboudienne (the national favourite of fish and rice). Specialties included ENT, orthopaedics, O&G and general surgery.
A couple of times I braved the indeterminably long 4pm-8am night shift, though this ended up being only a few patients during the evening, with most of the time spent waiting for the take away we’d ordered which took a record 2 hours to make its way around the corner. With the lack of patients (it seemed to be the quietest time of year) I was provided with a key to an empty ward and had probably the best sleep I will ever have on a night shift.
There were a couple of Senegalese medical students also present at the hospital, though they were in there 7th and 8th years of study, with the final years (8th) writing their theses. They had a great deal of responsibility in the hospital and often were the ones doing the night shift, without any other doctors present – equivalent probably to FY1/2. It seems as though even once you graduate there is no guarantee that you will get a job, with the state often only employing 30 new doctors per year, and sometimes none at all, so new doctors may wait 2-3 years before starting work. The UK is beginning to look pretty appealing …
Though a challenge at times what with the language barrier, the unreliable nature of the work load, and the oppressive 40o heat, my time in Senegal taught me a lot. About the need to adapt and do things differently in with fewer resources, fewer staff, and different levels of training. It also led me to appreciate how important it is to have a thorough understanding of the cultural practices and traditions of the local population – in this case polygamous marriages and dubious potions and amulets from local leaders.
Northern India & Nepal
Location: Manali, N India & Pokhara, Nepal Duration: 3 weeks in each
For my elective I went for locations as opposed to types of hospital/medicine.
The Lady Willingdon, Manali, is a little 50 bed mission hospital, 14hours north of Delhi. The place is run by a couple (one general surgeon and one emergency doctor), three doctors who are at reg level, and 6 f1-3 equivalents who are on their rural placement. I emailed them directly to sort the elective, and they provided accommodation on site, all in for 3 weeks cost about £200. Because the location is pretty remote and it is really cold (example- frozen deodorant) there is really great team spirit and it was only once I left and went to the bigger hospital that I realised how welcoming the doctors were- they took us hiking and skiing at weekends, they cooked us dinner, they threw many impromptu dance parties. (I was out there with another GKT student)
There was a language barrier (everyone speaks Hindi), but all the doctors learn medicine in English and are pretty happy to translate. There is also a teaching session everyday and we taught some classes. We got to see conditions and signs I’ve never seen before, so much TB, big tandoor burns, organophosphate poisoning and a lot of trauma- there’s no big healthcare infrastructure there, so patients are scooped off roads after accidents and carried straight into the ER.
The big, slightly confusingly private-but not private (still uncertain) 600 bed hospital in Pokhara, was a whole different ballgame. Medical students are shipped in from all over the world, charged $200 for 3 weeks observership, and promptly left alone. From an elective point of view, it was incredibly interesting to see another kind of healthcare. From a personal point of view, I didn’t enjoy the experience, I never thought I would be so grateful for the multidisciplinary approach we have in the UK, or our use of A-E approach.
For the next 3 weeks I’m making the most of the incredible mountains here and trekking Annapurna circuit. Nepal is an amazing place and there are lots of smaller medical charities/programmes,
I would really recommend it as a destination for elective. In general I would warn people against assuming that bigger shinier hospitals mean better medicine."
We've got more entries on St Vincent and the Grenadines, Peru and Banf in part 2!