Officially, visiting medical students are required to work as junior interns on the wards during their elective stay at SFH. I decided to spend almost my entire time working on the male medical ward, St. Augustine. Other medical students have chosen to spend one or two weeks on each ward. However, I don’t think this allows a student to be very useful and borders on tourism. I spent some of my first few days as an observer on the surgery and obstetrics/ gynaecology wards and at the clinics. I also assisted in theatre with procedures such as caesarean sections, bilateral tubal ligations, and laparotomies. During this time I felt like a passenger. Also much of the surgery and gynaecology seems similar to what I experienced back home – only there was a lot more pus… 

I believe there are many benefits to focusing on work in a medical ward at SFH. This allowed me to get to grips with the way the ward works, and to develop good working relationships with the other ward staff. I also developed a much deeper understanding of the important conditions that I encountered. Most importantly, I was able to develop competence in performing the tasks at hand, much to the benefit of the patients I was caring for. 

Although I was initially very inexperienced in treating many of the conditions I saw, I was able to make a difference by taking my time and being thorough. Without a demanding OPD schedule I had the luxury of being able to read up on conditions and modify investigative or therapeutic approaches accordingly. 
 

St. Augustine has two parts – an inside and an outside. The section outside is called Khonde and consists of about a dozen beds on a covered veranda. The patients residing here have their sputum collected for identification of acid-fast bacilli. Those in whom tuberculosis is ruled out may be moved inside, whereas those who turn out to have tuberculosis are transferred to York, the tuberculosis ward.  There is no real isolation ward at SFH. 

Inside St. Augustine are the general medical patients.  The ward is a large rectangular room with beds perpendicularly parked along the long walls, with a long central corridor down the middle. Unlike wards back home you have to watch your footing and push trolleys with care to avoid the many small potholes that pepper the floor. The first six beds near the ward entrance form the “intensive care unit” – so called as they are closest to the nurses desk by the “treatment room”, an alcove that houses the sink and the ward equipment. On the wards there is a wide selection of emergency medications and some equipment for resuscitation – however, there is no facility for defibrillation or intubation. 

During my time on the ward, mosquito nets were set up over most of the beds. These are vitally important, as many patients come down with malaria while they are in hospital, as do many of the attendant family members who stay by the bedside. The nets might also keep away the occasional rogue bat that has been known to stray into St. Augustine. 
Patients are fed three meals a day. Usually this is some combination of rice, rape, nshima, and beans. Often the patients share their meals with their bedside attendants, who often struggle to support themselves during their hospital vigil. 

The toilets (which I’ve never dared to use) are situated at the opposite end of the ward to the main entrance. The patients have quite a dilemma regarding the best bed to be in – they have to be far enough away from the toilets to avoid the full impact of their foul odour, yet still be close enough to have ready access when nature calls. Perhaps it is just as well the nurses give them little choice… 
 

Ward round consists of a doctor (or in my case, medical student) and the nurse responsible for ward management passing from patient to patient with a trolley laden with notes. At the bedside are medication charts, temperature and observation charts, and fluid balance charts. In other words, things are much the same as back home. However, I am always filled with a feeling of quiet surprise when I see a fluid chart completed and apparently making sense. On the whole though, I think the ward runs quite smoothly. The skills and knowledge of some of the nurses was particularly impressive – I learnt a lot from them. 

When I started at SFH, a ward round of more than thirty patients would take me an entire day to finish, much to the chagrin of the nursing staff. However I was determined to be thorough in my clinical assessments, and as my knowledge of the clinical conditions and available investigations and treatments grew my ward rounds shrunk in time. As a result the ward rounds, which started at 0800h, were always completed by lunchtime, and sometimes as early as 1100h. In the afternoons I would monitor the progress of patients, perform necessary procedures, do some reading, or carry out admissions on the ward or in OPD. 
 

A senior doctor was usually available to discuss ward issues. Exceptions were some weekends and public holidays, and a few other rare occasions. Sometimes in outpatients it was difficult to readily get advice from a senior colleague. I have had to make many important decisions completely independently, such as deciding when to do a lumbar puncture or when to start tuberculosis treatment in a sputum-negative patient. I have also independently performed cardiopulmonary resuscitation and procedures such as the administration of cytotoxic medicines. As a result, I now feel confident in performing lumbar punctures, ascitic taps, pleural taps, and needle aspiration of lymph nodes. Thus the clinical responsibility I experienced at SFH greatly exceeded the responsibilities of a trainee intern back in New Zealand. 
 

Every week on Tuesday mornings there is a clinical meeting where a topic is presented. I had the opportunity to present at this meeting, and presented the topic of thiamine deficiency together with a proposal to start a study of peripheral neuropathies at SFH. I felt well received by the staff and enjoyed the experience. Also on Tuesdays, a grand round is held. This takes place at the bedside and generally involves the presentation and discussion of a difficult or interesting case. I also had the opportunity to present a case here. Every second Thursday morning there was a mortality meeting, where hospital deaths are reviewed and the causes and possible preventative measures that may be instigated are discussed. Sometimes medical student teaching sessions were also held during the week. 

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