Dr Kalpanee Wijendra / Anaesthetic ST5 / Warwickshire
Dr Kalpanee Wijendra is working as an anaesthetics registrar in England but after the Covid pandemic and a long time working in UK ICUs she was looking to challenge her horizons. Her research and job applications took her to rural South Africa with the Tshemba Foundation where she worked alongside our very own Dr Alex Taylor. Here she explains the incredible work she was involved with, the challenges she faced and how these contributed to the truly bidirectional nature of the development and learning from such a job.
Stepping Into The Unknown
In my experience, to go against the grain in a medical career requires bravery, determination and a sprinkle of imagination. The emphasis on trainees to meet portfolio requirements and pass exams is often at the expense of personal career goals. Although specialty training has its own challenges, demanding vast commitment and dedication, during the COVID-19 pandemic, I found myself completely exhausted from looping through the same day on ITU. I wanted a change. I was fortunate enough to stumble upon an email calling for Global Health Fellows to volunteer in low-resource settings. I sent off my application, received a place, and took a step into the unknown.
The fellowship offered multiple placements to choose from. I settled on South Africa, as I hoped it would ease my transition as an English speaker. Then I had to choose between working in a well-supported, busy hospital where my anaesthetic logbook would flourish or working in a remote rural setting, where I would be out of my comfort zone. Both scenarios were tempting for different reasons. I chose the latter and embarked on my global health adventure.
Tshemba Foundation
The Tshemba Foundation is a wonderful charity which provides volunteering opportunities for healthcare professionals to work in a rural hospital in Mpumalanga (Northeast South Africa). Volunteers work clinically whilst also contributing to health education and engagement in long-term local health projects. The ethos of the charity centres around sustainable change within the local community. Tshemba is unique because of its setting. The volunteers from around the world live together on a private game reserve alongside the ‘Big 5’: lions, leopards, rhinoceros, elephants and African buffalos.
For nearly 5 months I lived and worked with clinicians who had led unconventional yet fascinating lives. I was particularly inspired by a few clinicians whom I got to know very well and now regard as my mentors. A South African GP and author who has travelled the world and practiced medicine on every continent. She is a force of nature, who taught me to embrace the wilder life. Also a Dutch trauma surgeon shared his inspirational stories of treading the path less trodden and his career in the International Committee of the Red Cross (ICRC). Meeting and working alongside international volunteers were one of the many highlights of the Tshemba Foundation. They encouraged me to be fearless in taking the scenic career route, combining Anaesthesia with Global Health.
Tintswalo Hospital
Tintswalo, located in Acornhoek is a 423-bed District General Hospital in the beautiful province of Mpumalanga. Unlike hospitals in the UK, there was no consistent consultant supervising or on-call; instead, the hospital was run by medical officers of varying experience. From my observation, South African junior doctors are more generalist than their British counterparts. I was impressed to find that after only two years of postgraduate medical training, these doctors were independent in most procedures from giving a general anaesthetic to performing a caesarean section.
Challenges
The working conditions in rural hospitals are challenging for many doctors in South Africa. From my own experience and observation, South African doctors in low-resource environments, often work without basic medication and equipment. Overwhelmingly notable is the huge health inequality that exists between black and white people, even 30 years after the apartheid. These inequalities are far too complex to unpick in one article, however, I will explore a few examples that I encountered during my time in Tintswalo.
One of the biggest challenges is the long-standing water shortages which are the result of insufficient infrastructure to support the growing population. When these water shortages occur, no water is supplied to the entire Acornhoek area, unavoidably affecting the hospital. As a result, only emergency surgery such as caesarean sections can go ahead. These shortages can go on for weeks and often come without warning. The lack of water for drinking, cleaning and sterilising has a devastating impact on the local community. During my time at Tintswalo, the people of Acornhoek became so enraged that they protested outside of the hospital. This protest resulted in funds being mobilised to supply water containers for emergencies.
At the Tshemba Foundation, we were fortunate to not have water shortages, as the foundation was located half an hour away from Tinswalo Hospital in a small town called Hoedspruit. However, we regularly experienced power cuts or ‘load shedding’. The biggest personal challenge I found during load shedding was the disruption of communication with friends, family and colleagues due to cuts in the local and national power supply. Despite at times feeling isolated, the scheduled power cuts lasted only a few hours and I found the forced disconnection from the world rather peaceful, especially after the intensity of my clinical duties.
I had to alter my clinical practice based on these limitations. For example, due to a lack of availability of large-sized syringes, I had to use only 5ml and 2ml syringes when giving countless general anaesthetics and during the resuscitation of a patient in a makeshift ITU. At any given time, the hospital only had 3 units of O-negative blood available for resuscitation, therefore during surgery, I had to ensure high-risk patients were transferred to specialist hospitals and be very proactive in minimising blood loss by working closely in collaboration with the surgeons and utilising alternative products such as plasma expanders.
I also had to adjust to working with limited medication available. For example, at the beginning of my time in Tintswalo the only available muscle relaxant was Suxamethonium, which is a short-acting muscle relaxant and unsuitable for long procedures which require prolonged intubation. I had to use muscle relaxant-sparing strategies to continue to safely anaesthetise patients. Another big adjustment was the limited analgesic options available in both the theatre and the wards. Where possible I used local anaesthetic, which was often available due to its limited use and encouraged the surgeons to do a local infiltration, which previously was not common practice in Tintswalo.
The limitations of equipment and medication, despite being inconvenient and challenging, were easier to adjust to than the emotional toll of systemic failures. These I found much more difficult to bounce back from. A particular case I found most upsetting was waiting 3 hours for an ambulance to pick up a pregnant patient whose unborn child was exhibiting signs fetal distress. Unfortunately by the time this patient presented to the hospital, we found no fetal heartbeat. Something potentially avoidable with more resource for pre hospital services.
Working Together
We often worked with the local doctors to overcome these challenges through shared decision-making. In these circumstances, it is common to feel alone and helpless, but I felt we had a lot of support from both the local doctors and the Tshemba Foundation. For example, when there is a critically unwell patient in the hospital, colleagues would rally together to help each other as there are no formal pre-allocated medical emergency teams. When the power failed and we had to stop the theatre after a spinal anaesthetic, the entire theatre team made the decision together to not operate in the dark, prioritising the safety of the patient and her unborn child. When I needed to transport a mother with fetal distress in a private vehicle, which belonged to the Tshemba Foundation, I had the full support of the group.
As a Foundation we had fortnightly debriefing sessions to jointly discuss all the challenges and barriers we were facing, and then we would work together to form solutions. This was an effective space to problem-solve and it was inspiring to see how the volunteers used their initiative and creativity to overcome challenges. For example, I wanted to encourage the identification of surgical patients earlier in the week to allow for optimisation and possible transfer to higher-level hospitals if they were not suitable for Tintsawlo. This had been historically challenging. One of the surgical volunteers after a debrief session initiated a grand round within the surgical team to identify potential patients for the semi-elective list later in the week. This changing of working culture by initiating MDT ward rounds was one of the biggest improvements within the surgical department during my time in Tintswalo, and it arose as a collaboration between the volunteers and resident doctors.
Health Education Opportunities
During my placement, I noticed that there were gaps in nursing care in some of the medical and surgical wards. Unlike doctors, once graduated in South Africa, nursing staff are not obliged to complete further training, annual CPD courses or events. Educational activities are often not available due to a lack of funding and resources. As a result, some nursing practices are outdated and, in some cases, unsafe.
This fuelled me to devise a nurse training curriculum and deliver teaching alongside my Tshemba colleagues. We involved the senior nursing staff in the hospital and pitched the idea of a rolling teaching curriculum which covered basic observations and points of escalation. The curriculum consisted of 10 nursing topics which covered theory elements, demonstrations and opportunities to practice with each other. The sessions would last around 45 – 60 minutes, with each topic being covered a few times to enable staff from day and night shifts to attend. We set up a pilot session covering blood pressure measurement, which was observed by the head of nursing in the hospital. The pilot had a positive reception and the curriculum in its entirety was rolled out. Even after my time with Tshemba ended, the training programme has continued to be a successful initiative.
I was also able to support my junior colleagues who were thrown into complex anaesthetic cases with little experience and provided a safety net that they were not used to having. Unfortunately, I did not have any senior anaesthetic colleagues to support me, therefore the cases that I felt were beyond my capacity to resolve were highlighted to the clinical manager (the equivalent of the clinical director of a hospital), who then authorised the transfer of the patients to a higher-level hospital with consultant cover. I did find working without the direct supervision of consultants rather uncomfortable, so I ensured boundaries were established with the clinical manager about which cases I would not be able to lead on.
The extensive knowledge of equipment needed for primary FRCA exams came in handy when I saw a donated French syringe driver lying about. I used my knowledge of equipment alongside translating apps to source consumables and write a working manual to get the syringe driver to work. This syringe driver and the manual have now been approved by the province to be used in the Tintswalo, offering the team a safe way of infusing medications.
Reflecting On My Experience At Tshemba
Upon arrival at Tinswalo Hospital, I became quickly aware that I was the most senior anaesthetist in the hospital. I realised that there were no consultants to ask for help or discuss my plans with. I felt well out of my comfort zone. The biggest adjustment for me was an awareness of the lack of safety netting which I had been used to in the way of having multilevel systems in place to prevent harm and consequently the weight of my independent decision-making. The circumstances required me to step up and take on a leadership role. There was no time to allow for self-doubt. I felt immense pressure in decision-making, especially trying to ensure I was making safe decisions in challenging circumstances.
During my time in Tintswalo and following my return to medicine in the UK, I did consider how the charity Tshemba fits into the wider picture of Tintswalo (a low-resourced district general hospital). I wondered if by volunteering we were helping bridge a service gap which potentially disincentivizes the health authorities to allocate funds to more doctors and services to help the local population. Once I understood the system more, I recognised that these systemic failures and lack of resources were present and unresolved years before the Tshemba Foundation. Also, sadly many of the local doctors are burnt out and demotivated, which means that processes such as quality improvement and education had fallen by the wayside and this is where I saw a real place for Tshemba. The projects I engaged in I felt were sustainable and hopefully contributed to ongoing patient safety. My contribution was a drop in the ocean, but I hope that it ultimately contributes to a wave of positive change.
This was the hardest anaesthetic placement of my career so far but equally the most rewarding. I felt that my presence really made a difference to the patients I looked after and the colleagues I worked with. I learnt how to adjust to an incredibly challenging environment and how to advocate for my patients and colleagues. In South Africa, I learnt to trust my anaesthetic skills and my instincts – perhaps my greatest lesson and what I treasure the most from my Global Health Fellowship.
Living and working for the foundation along with other international volunteer doctors was one of the greatest privileges of my career so far. The Tshemba Foundation for me was a place of inspiration. My advice to anyone who is considering pursuing similar fellowships that are on offer is to go for it! Take the leap! It certainly will be the biggest challenge of your career but the best thing you will ever do.
Highlights:
- Living amongst the Big 5 in spectacular surroundings.
- Working in a low resource but highly rewarding environment.
- Travelling and making lifelong friends.
- Being part of a cause and collectively working towards supporting a community.
- Being able to do the job you love, somewhere else in the world.
