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Challenges Working in a Hospital in a Low Income Country

By Michael Kosteljanetz

Originally Published: April 10th 2014

 Editors Note: Michael Kosteljanetz is Senior Consultant, Dr. Med. Sci. at the Department of Neurosurgery at Rigshospitalet University Hospital in Copenhagen. On several occasions, Michael has been working and teaching in Rwanda and Ethiopia, where his expertise in his profession is an urgent needed. Michael here describes his experiences with the challenges of working at a hospital in a ressource-poor setting. This article was originally written for students at the Engineering World Health Chapter at the Technical University of Denmark to prepare them for working in developing country hospitals, however it is highly interesting material for anyone with just a slight interest in developing countries!

 

It would not be fair to judge the entire developing world based on personal experience which stems from a brief stay in Addis Abeba, Ethiopia, where I worked at a private Christian hospital and a large public university hospital and three stays in Kigali, Rwanda, where I have worked for a total of 6 months in a public, teaching hospital as participant in a large American-Rwandan project. My daily work takes place in the hospital’s surgical department.

Rwanda’s situation may be different from the situation in other African countries, because the shortage of health personnel here largely is a consequence of the genocide in 1994, where approximately one million people were killed, and among them a great number of health workers. Besides, a great number of people fled to the neighbouring countries and Europe or America.

In many ways Rwanda is a well organized country, partly because of its small size, approximately 2/3 of Denmark. It is very densely populated, almost 11 million people live there. There is a network of roads, the main roads are paved and there is a well developed network of buses that takes you almost anywhere in the country. Mobile phone penetration is around 50% (in 2012), internet approximately 10%.

In my specialty, neurosurgery, there are two neurosurgeons that serve the population, both work in the capital Kigali, where one million people lives. One works at a private hospital, the other at the university hospital. The two departments are affiliated and patients can be transferred from one hospital to the other under certain circumstances.

The hospital where I worked is one of 3 or 4 greater referral hospitals. The country has a great number of health centres, more than 40 district hospitals, most of them run by nurses and general practitioners, who can perform a limited number of operations, e.g. caesarian section. In a few district hospitals there are surgeons who can perform ”neurosurgical” operations e.g. shunts for hydrocephalus.

Although the economy is growing, the country is still poor, the average income being 1/30 of that in Denmark, which of course has major influence on the quality of healthcare delivered. More than 90% of the population has a health insurance, which is very uncommon for an African country. In most cases the patients have to pay 10% of the expenses, which in a poor country like Rwanda may be more than they can afford, even though it amounts to what we would consider a minor expense, say 50 or 100$.

The University Hospital of Kigali, Rwanda was originally built almost 100 years ago and almost all buildings which are pavilions are more than 70 years old, which means that facilities and logistics are far from satisfactory. Most rooms have 8 or more beds. Washing and toilet facilities are of course very scarce.

There is one CT scanner at the university hospital, however, it may not always work. X-ray films are not always available, so most often it is not possible to get print-outs of the scan. Even if one gets one it will only depict a fraction of the entire examination; as a consequence not all aspects and angles of the disease are depicted, sometimes making it very difficult for the surgeon to make a professional decision based on the CT, just as surgical and treatment planning may be challenging. X-rays and scans cannot be transmitted electronically, so in order to discuss a case with a colleague, say when a transfer is considered, one has to take a photo of the scan on one’s smart-phone and send it and again, for which reason the image quality is a challenge. If the patient needs a MR scan they have to go to the private hospital where the only MR in the country is, but the same remarks that apply for CT goes for the MR as well.

The Operation Theater was built in 2009, but in spite of that it is already worn down, most likely because it was built with the poor materials. Many of the tiles in the floor are broken, so that water can collect in the small cavities that have been formed, the humidity has penetrated the ceiling in the theatres so that there is visible mould in most operating rooms. Because of the humidity, but probably also because of poor quality, whatever that can rust has become rusty; the wheels on most tables, where surgical instruments are placed during surgery are broken so hardly any table can roll. Legs of tables and stools are broken or at least most times broken so that they stand askew. The Danish ”Arbejdstilsyn” (Danish Working Enviroment Au- thority, red.) would immediately close the operating theaters due to the electrical installations. Electric lines and sockets runs across the floor even though it is regularly wet from the cleaning and sockets in the walls are faulty. Many of the lights and the operation lamps do not work properly and 1 or 2 out of 4 bulbs often do not work. The doors to all operating theatres are broken, so that they can neither open or close, meaning that they are more or less open most of the time, also during operations, which is practical because the personnel tends to come in and out of the room. Since the sun shines most of the time the room gets hot, and the ventilator switch cannot be reached by most people of average height. The windows have no shadow so the sun shines and sometimes blinds the surgeon.

Operating tables cannot be adjusted electronically as they could when they were new and even to adjust them manually is difficult. Suction equipment which you need to suction away blood during an operation is faulty. The main reason being that the disposable suction tubes, like many other disposable consumables are used not one but several times leading to a change in the stiffness of the tubes, so that they collapse, when suction is activated.

Since the surgical instruments themselves often are robust, made by steel, they are usually working but even simple instruments may not be available.

Now, while you can perform a great number of abdominal operations with a very limited number of instruments, neurosurgery is for the most part a hightech area. Scissors and scalpels almost always work, especially when they are sharpened. Most surgeons use suction, which I have described and a bipolar, which is a kind of electrical tweezers that can burn tissue in a very limited area and thereby induce coagulation of vessels and stop bleeding. Contrary to other surgical fields, bleeding in neurosurgery cannot be stopped by ligature of the bleeding vessel. Our bipolar has been repaired with adhesive tape, so that it works most of the time, which it did not the year before.

Essentially problems related to the operating theaters can be divided into:

  1. Lack of equipment. This can be divided into large, high-tech equipment, which is very expensive to purchase (operating tables, surgical microscope, special aspirators etc) and lesser like normal surgical instruments, hooks etc.
  2. Lack of maintenance.
  3. Lack of sufficient knowledge about the function of the equipment, leading to faulty usage and maintenance.
  4. Lack of renewal/exchange.
  5. Lack of daily consumables that is sutures, gauze, patties (small cotton pieces to protect the tissue, e.g. the brain during surgery).
  6. Lack of special consumables needed for certain operation (e.g. shunts, ventricular drains).
  7. Logistic problems, including storage facilities.
  8. Buildings.
  9. Irregularities in water and electrical supply (rare).
  10. Lack of skilled personel (scrub nurses and anaesthetists).
  11. Lack of facilities for postoperative care and observation (that includes the rooms as well as the personel).

Logistic problems include poor planning and surveillance of the daily surgical plans. If one wanted to be sure that the cases one had planned would be brought to the OR, it was mandatory to be present in the OR, meaning that one could not leave the OR for rounds or seeing patients in the out–patient–clinic while waiting for the preparations for the operation. Because of the long and awkward routes from the wards to the OR (among other things), waiting time before and between operations were often 2-3 hours. Part of the waiting time could sometimes be explained by shortage of a consumable that had to be procured or instruments that were not sterilised.

Roughly the above mentioned can be divided in a) shortage of fundings for buildings, including repair and maintenance b) shortage of skilled personel c) lack of resources for training and education of personel e) logistic problems.

To which extent one or more of these issues are more important than others cannot be concluded from my non-scientific observations, neither can I conclude which means are most appropriate to solve the problems. This will demand further analysis. Considering that Rwanda is a country where the economy is steadily growing there is a chance that some of these problems can be solved because of improved funding but other problems could be dealt with in the meantime.

Note: Neurosurgery is the specialty that deals with the surgical treatment of diseases and congenital conditions and injuries in the central–nervous–system, that is the brain, the nerves, the spinal cord and the surround- ing tissue (meninges and skull and verter- bal bodies). The neurosurgeon removes e.g. tumours, haemorrhages, aneurysms. Some neurosurgeons mainly operate on the spine.

Authored by Michael Kosteljanetz, edited by David Kovacs. Published by the Engineering World Health chapter at the Technical University of Denmark.

Find PDF Version at: challenges-working-hospital.

What’s it Like to Work in a Developing Country Hospital?

It is now a little more than a week ago that I returned from and unforgettable journey to Africa. It’s been such a journey that expands horizons, gives new perspectives, creates new visions and changes beliefs and values. During my stay I worked for a month at local hospitals, an experience that was different in so many ways from what I had expected.

Prior to our placements at local hospitals the students of the 2014 EWH summer institute (myself included) took part in a month-long educational course on “Engineering in the Developing World” and an introductory Swahili course – a program which proved to be of considerable advantage as we were soon to develop a trusting relationship with the departments we would come to work for.
After this first month of education I was moved to my placement along with my group, which besides myself consisted of a student from Duke and one from Harvard. We were to work in two hospitals: Kilimanjaro Christianity Medical Centre (KCMC) and Mawenzi Hospital, both situated in the town of Moshi, Kilimanjaro region.
The KCMC is one of the largest and most prestigious institutions in Tanzania and has a biomedical engineering department consisting of 30 engineers and technicians. Despite good will and hard work from the department, it was obvious that we could do much in both hospitals, just as we could learn a lot from them. Our group alone repaired more than 60 pieces of equipment during our stay. Overall, this year’s EWH summer program returned 4,200 pieces of equipment amounting to 8.6 milion according to the latest figures from EWH.
If I was to draw one conclusion about medical equipment in developing countries today, I would say that it simply should not be allowed to donate without informing properly about that specific piece of equipment in the local language (or in English, at the least):
In so many places we found rooms and whole warehouses filled with piles of medical devices. To our surprise, very often these devices could be put back into service by simple mechanical repairs. We even found completely new operating theatres that could not be used because they were packed full of unused equipment. I was left behind wondering if donations do any good at all – or if they do more harm than good. During our month at the hospital we slowly started to learn the reasons why these equipments weren’t in use: How were people supposed know how to use a piece equipment, if they had no manual for it? Or how could they use a machine, if the user interface was in Dutch or in German? When a repair was to be done after all, many reported difficulties and bureaucratic systems when having to acquire replacement parts, such as a lightbulb for a microscope.
The type of problem that could arise when departments were not provided information about new technologies became clear to me one day at the KCMC, when our group was asked to repair an Infant Warmer from GE. We were told the following: The department had received a completely new machine and put it into a small room where they normally observed newborns in the early hours after a birth. But when the staff began to use it, the machine heated the room up to a temperature so high, that it was unbearable to stay in there.
The solution turned out to be immensely simple: the skin-temperature sensor had mistakenly been placed under the bedside, and had to be moved to the skin of the newborn – otherwise the device would constantly work to achieve a temperature of 35.5 degrees under the bed instead of on the baby’s skin. Thus the machine was heating on and on (and on…).
After having cleared out this first misunderstanding, we explained that the machine could not, as some thought, be used to take X-rays images, but that it merely contained a tray for a detector plate so that you weren’t forced to move the baby around unnecessarily,  and that the machine could not calculate an APGAR-score, but that it contains a stopwatch simply to help you with the task. The problem wasn’t lack of education or ability to understand how a machine works. It was simply the fact that people were not provided the necessary information. Even if some information was provided, it was not done properly: How is a nurse going to read a 500 page manual, while working in a ward full of women in labour? Seeing this and other similar cases, one of our main focuses became developing quick start guides in order to provide departments with a fast and simple way of knowing how to use a device.
Another typical issue that we encountered was how departments virtually never took advantage of vital signs monitors and ECG’s because they had run out of the necessary electrically conductive gel. There are a number of alternatives to conductive gel – in principle anything that contains electrolytes, for example aloe vera or ketchup, can be used. It should have been obvious however (as I did not first think of), that most doctors and patients do not want to use these methods, as they are uncomfortable and inconvenient. I remember explaining to a doctor how he could make his own electrically conductive gel using water, flour and salt. His response: “Is that really recommended?”. Imagine his reaction, had I recommended him to use ketchup. In addition, many Africans are proud people to whom one can and should not just offer anything (just as one would probably not do anyone at home). Therefore, developing a gel that is more likely to be used clinically, and in addition could be produced cheaply using local materials, would be an example of a simple and small, but valuable project for developing world hospitals (while you can find alternatives to conductive gels, I still haven’t seen one that actually looks like the gel that is used in clinics). Notably the KCMC already had the means to produce their own ultrasound gel (which is acoustically and not electrically conductive) so they shouldn’t be too far away from being able to produce their own conductive gel too.
This and many other projects are still to be carried out to make the daily life at a these hospitals run smoothly. Here I have given just two examples of what it can be like to work in the developing world. So many ways remain in which one can help this  parallel world of ours, in which resources are so scarce that we are constantly forced to think in new and innovative ways to provide the best possible health care for the all people.