University Teaching Hospital

Moli bwnaje!

So here I am, back at UTH (University Teaching Hospital).  It’s a strange feeling to explain. I am so excited and so pleased to be back and seeing old faces and friends again. It’s all seemed pretty positive (on the welcome back front at least!) so that’s a big relief!

Main entrance to UTH and below inside main entrance looking at the canteen 

 Just to get you all up to speed: UTH is the largest hospital in Zambia.  It not only serves the Lusaka area (estimated population of 1.4million), but is a referral centre for the rest of the country.  It officially has 1655 beds and 250 baby cots (floor mattresses are strictly not counted in these stats). It also serves as a tertiary referral centre for most of the surgical sub-specialties and has a 10 bedded intensive care unit.

Green inner courtyard and corridor
behind trees

It was originally built in the 1960’s and is actually quite an interesting looking building. I, for one really like the red brick part as it has uncovered sides to the walkway so essentially you are outside in the fresh air when you move about – which is great and the various trees and grass that are dotted about give it quite an airy feel. There’s two reasons that’s a plus; firstly when walking along in the morning it is quite possible not only to break one’s neck or fall flat on your bottom due to the floors being shone to an inch of their lives by all sorts of cleaners using a very distinctive polish called COBRA but also to become completely and utterly high on its distinctive smell. Fair play I have never walked on cleaner floors (outside the wards) or tread on more slippery surfaces apart from in the Cardiff ice rink! 

The second reason is that there are a few stairwells that lead from the main entrance to the the ICU corridor and also the ‘canteen’ which if you descend further down take you to the mortuary. It is often beyond description the smell of death that floats up readily from the basement up the stairs. This is particularly bad by the afternoon and also when its hot. So yes, the airy outdoor corridors are a real bonus for me here. As well as the often colourful glimpses of chitengi dress material out on the washing lines/drying on the grass.

 

 However don’t be deceived by the appearance! Not all that glitters is gold. Internally there are huge problems. Maintenance and upkeep seem to have gone missing since the 1960’s and there seems to be a patch up job on top of a patch up job wherever you look! Basic resources like water run out at times (though not so problematic right now in the rainy season!) and surgeons rely on water butts to store water to wash their hands when it is summer and the electricity is unreliable. But that’s by the by to be honest, one can find ways around those problems. 

Water butt for surgical hand washing -
note also the 'disinfectant soap'

However what’s interesting to me is that when I was last here the oxygen plant was being heavily upgraded. They have huge oxygen concentrators (basically clever machines that take the air we breathe filter it through various steps and churn out pure-ish oxygen at the end). Fantastic – just the ticket here where consumables and resources are poor. When I was last here they were sending this ‘pure’ oxygen down the various oxygen pipes to theatres where they were then plugged into the anaesthetic machines for us to deliver anaesthetics. However when I was last here the pipes were so old, leaky and in such poor repair that the pressure in the system was such that by the time you got to the upper end of the corridors to maternity, paediatric theatres as well as sometimes main and the intensive care unit the pressure in the wall pipes was about half of what it should be. 

Basically in simple physics we need 4 bar pressure (4 x atmospheric pressure) to come out of the wall. The anaesthetic machines start alarming in a loud pitched manner constantly when it falls below 2 bar – which was what we got in the theatres on a good day when I was last here. It seems now, however that the pipes have ‘had it’ so we now run all the theatres and intensive care unit and wherever else needs oxygen off large cylinders. Fear not they are still filled up by the new shiny oxygen plant concentrators so that would seem like a reasonable substitution. This unfortunately leads to two big problems: –

Broken pressure dial. On the plus we have plenty of
oxygen left in the cylinder!

Firstly you have to constantly keep checking the cylinders to make sure you are not going to run out and that you call for a new one in time to change over. The second is that the cylinders (which are Chinese) have pressure gauges on them and instead of the usual bar they are in mega pascals and not the usual kilopascals (1 atoms = 1 bar = 100kPa) if their dials work that is. The danger here (and I have only been here two days and have already raised my eyebrows and changed the settings a few times – if the pressure dial isn’t attended to properly and decreased accordingly then the pressure delivered to the patient is colossal and much like pumping a large amount of pressure into a balloon you can imagine what happens next to the balloon or lungs… eek!

 And to throw in a third for good measure, we have been assigned 20 new anaesthetic machines  (though we only seem to have two at present and one has already broken) – delivered from China – picked out by a hospital matron and Surgical Director with no discussion with any anaesthetist…. But I won't go on about the failings of this particular system or make but suffice to say it has a special anaesthetic tool called an Oxygen analyser attached to it. It is a small little fuel cell that detects the concentration of oxygen in the supply – essentially a little quality control test. Interestingly, these lose their powers of deduction over time as the fuel cells get old. Anyway these are brand spanking new. They are detecting the oxygen concentration correctly. Each cylinder that comes from the oxygen plant is meant to be close to 100% oxygen. When all else fails and the patient has low oxygen you give them 100% oxygen, it’s the back up (well and only solution here as we don’t have any other gas (no air or nitrous oxide to give anyway). However thanks to the new machine we have now removed that aura of security blanket of 100% Oxygen. No cylinder has yet to supply more than 56% oxygen… Oh dear…. 

On the plus side – the machine does come with Isoflurane (anaesthetic vapour agent) vaporisors and we currently HAVE a supply of Isoflurane to use as well as Halothane (another older agent). HOW exciting, yes I know its almost obsolete in the UK but the knock on effects here are amazing – especially in those patients who have liver failure or repeat anaesthetics (Halothane is bad for the liver).

 And as I have heavily harped on about the subject of physics and anaesthetics I throw in a last little gem of a picture for the gas board amongst you. Here is an anaesthetic machine I spied on my return. It is not being used (at present!) but was brought down to us for use during the centenary celebrations. Yes that is Ether and Cyclopropane on the back bar! Its so amazing I’d love to bring it home, but fear the excess baggage cost would exceed a box of Suggamadex!

Boyle's machine with Halothane, Ether and Cyclopropane

So this has turned into a bit of a anaesthetic heavy post – apologies for that! But it gives a bit of a flavor of some of the challenges anaesthetics face out here. Hopefully a few clinical caveats to come!