'Generalism' in rural Zambia

We’ve now been two weeks at Chitokoloki, and are beginning to get settled into some new routines.  The working day begins at 7.30am with a long ward round and Tuesdays and Thursdays are ‘operating days’.  This phrase requires inverted commas because so far, we have operated every working day of the week!  So far, in his first 10 working days Stuart has performed or been helping with 27 different operations, covering multiple different specialities.  Stuart trained as a general surgeon with a colorectal specialist interest, but here in rural Zambia, ‘general surgeon’ means something entirely different!  

In the UK, the operations we have done so far would have required at least 6 different specialists: an obstetrician, gynaecological oncologist, urologist, paediatric surgeon, orthopaedic surgeon and oral/maxillofacial surgeon.  All would have involved large theatre teams including of course anaesthetists.  So far, all of our operating has been performed without the help of an anaesthetic doctor.  Until recently, Chitokoloki had an anaesthetic clinical officer (a non-physician clinician) but since he left for further training, the anaesthetic service has been provided by the hospital’s permanent missionary surgeon, Dr McAdam or by our nursing sister-in-charge, J-R Elwood.  The theatre team has been completed by our theatre nurses/assistants, Nyuma, Kayombo, Jack and Fred.  Jess is doing her best to stay out of theatre but so far has been persuaded to cross the threshold to help with neonatal care following caesarean section, and has put in a chest drain.

Jess is a GP but has similarly been covering many specialist areas which would normally involve other professionals.  Two of the patients that Stuart has operated on were little girls with cancers, and Jess has taken on the role of paediatric oncologist to them as she reconciles current evidence with the pragmatism of what is available.

The mentality of care here has to be different.  According to the World Bank, Zambia has 1.48 specialist surgeons per 100,000 population.  Contrast that with the UK, which has 133 specialist surgeons per 100,000.  This means that there is a significant amount of unmet surgical need and that the existing surgeons both have a high workload and a need to provide a wide range of surgical services.  These inequalities are particularly pronounced in the rural and less developed areas of Zambia.  

While there is stress involved in operating beyond comfort zones, there can also be significant satisfaction in stretching yourself to provide a much-needed service.  So far, the most challenging operation Stuart has been involved with was removal of a large kidney tumour (Wilms) in a 6 year-old girl.  This poor girl’s tumour was occupying about half of her abdomen.  Stuart was able to access expert advice ahead of the operation from some of the paediatric surgeons based at the Royal Hospital for Children in Glasgow (many thanks, Stuart O’Toole and Michael Jacovides!). Stuart and David McAdam operated for an exhausting, intense five and a half hours, but ultimately managed to completely resect the tumour and the girl is recovering well.