I have finally completed my one month surgical rotation at Black Lion (Tikur Ambesa) Hospital of Ethiopia. My 4 weeks were both short and long: short because I can’t believe I am already back to the cold weather of Chicago, but also long, because I experienced so much in just four weeks.
During my time at Black Lion, I rotated through three different surgical specialities: paediatric surgery, Neurosurgery and General surgery. My experience at Black Lion was educational, informative, and met all the objectives I had originally created. My entire goal for going to Ethiopia was to learn more about the national health system by working under the largest governmental hospital of Ethiopia. I strategically chose Black Lion Hospital for three reasons.
- It is the biggest and tertiary level hospital. Any medical condition from any corner of the country that cannot be treated locally is referred there. It is thought of as the ultimate place of death or healing in Ethiopia.
- It has a very rich human resource; the physicians that work there are the best of the best.
- Since it is a tertiary level hospital and everyone there is referred from all the corners of the country, one can collect very diverse opinions and ideas and meet people from very different areas of the country. The only group of people excluded from this population is the wealthy, with whom I found other channels to communicate. My travel to Ethiopia was very successful in that I was able to talk to very diverse populations from the wealthy to the poor, from the educated to less educated, from the young to the old, from all regions of Ethiopia. By doing this I was informed of the current condition and state of Ethiopia; which is both very poor and in so much despair.
It was a pleasure to participate in the care of medically and socially complicated patients with some of the most skillful, exceptionally patient, and caring surgeons.
As a visiting medical student I was to function as an intern under the supervision of another intern and attending physicians. I was to scrub into different procedures in addition to caring for specific patients on the wards. The routine of a typical day depended on whether we had to operate or not. It included morning sessions, bedside rounding and procedures.
Morning sessions involve detailed report of all surgical cases seen in the Emergency Department and the wards (admitted, discharged, operated, or deceased). Uncomplicated cases are usually discussed briefly whereas complicated cases are discussed in detail by the attending physicians. All surgeons, residents and interns on the surgical rotation are required to attend the morning session. After morning session, the different teams disperse to the operating room (OR) or round on each of their patients. On days where procedures are not scheduled, rounding involves a lot of education to patients and surgical residents by the surgeons. The afternoon then involves prepping patients for the OR the next day, minor bedside procedures, patient education and counseling by the residents and other small tasks. The day usually ends anytime between 5:00 and 8:00pm.
Night times are covered by interns, residents, and attendings on duty. On weekdays the person on duty stays 36 hours in the hospital, while on weekends the shift is 24 hours. The interns usually do much of the work in the emergency department and wards. I was on duty twice in four weeks. During these times, I participated in the admission and workup of patients in the emergency room and some bedside and OR procedures. Minor bedside procedures included suturing of scalp laceration, aspiration of abscess, and irrigation of traumatic urethral/bladder hematoma. In the OR procedures included evacuation of Epidural hematoma, subdural hematoma, elevation of depressed scalp fracture, repair of dural tear, appendectomy, and removal of aspirated foreign material from children.
Black Lion Hospital is a tertiary referral hospital. The patient population is extremely ill, with complicated medical and social problems for many reasons. Among them are lack of education in the general population, lack of enough health professionals, lack of infrastructure in the entire medical system (not just transportation but also level of communication), the presence of bureaucracy, presence of corruption; lack of latest medical equipment such as CT scan, MRI, ultrasound, laboratories, medications, pathological stains, etc.); and occasionally lack of curiosity and passion in the practicing health care professionals. I was struck to realize that there is no standard of care and that the well-being of a patient mostly depends on the goodness and ethics of the specific professionals taking care of the patient.
There are many reasons why patients present to Black Lion Hospital very late in the course of illness. According to the United Nations Human Development Resource report in 2012, the mean year of education for Ethiopians is 2.2 years. Because over 85% of the population lack the basic understanding of disease when they first get sick, they first seek traditional medicine that includes finding a traditional healer or “Tsebel” (getting washed with holy water) which are readily accessible. This usually takes a few years.
When traditional medicine fails, they present to their local clinic or hospital (usually rural). The local medical professional does the initial assessment and writes them a referral to a secondary level hospital. Many of the secondary level hospitals are located in smaller cities of Ethiopia. These secondary level hospitals can usually perform basic general surgery procedures. Very few have equipped staff and medical supplies to handle complex or subspecialized surgical cases; such as paediatrics, neurological, orthopaedics, and complex general surgeries.
The secondary hospital then writes a referral to the tertiary level hospital which is Black Lion. This process can take anywhere from weeks to months to years, depending on factors both clinical and logistic. Timeframe is determined by the acuteness of the medical problem; the educational and compliance level of the patients; the distance to the tertiary level hospital; the financial situation of the patients and their families; and the bureaucracy of the local clinics and hospitals. Once the patient reaches Black Lion, they make an appointment in the referral clinic.
In the referral clinic the physician assesses the patients and decides if the case is operable or not. If it is operable then the patients are stratified into two groups: urgent (something that needs to be operated as soon as possible because if delayed can kill the patient) or elective (less life threatening). More than 90% of the patients are urgent.
In a perfect medical setting with enough resources (medical staff and medical infrastructure) the urgent surgical case would be done within a few days of the patient’s presentation to the clinic. However in “low resource” countries like Ethiopia, the urgent cases usually take anywhere from 3-6 months to be operated on. Due to the high load of patients who are in line, many urgent cases are delayed, leading to disease progression, complications, and often death. Thus, the time elapsed from the first time a person notices symptoms, to the time the patient actually gets modern day medical treatment, could be anywhere from a few weeks (mostly in the case of trauma) to years if not decades (in the case of chronic diseases).
Hence, no one can deny the deeply rooted, and extremely challenging medical conditions that exist in the underdeveloped and developing countries such as Ethiopia. As presented above the barrier for patients from receiving proper medical care is multi-layered and extremely complex to fix.
When I first thought of working at Black Lion Hospital, I did my research about the hospital and learned that it was the biggest hospital in Ethiopia and is a tertiary level hospital. In my mind I took that to mean relatively well-organized, well-staffed, and well-supplied hospital. In practice, while Black Lion has very well trained, motivated, highly specialized, humble, and compassionate surgeons; their hands are often tied from achieving their highest potential in practicing the standard of care for their patients and doing ground-breaking research. They operate under a broken and highly dysfunctional system and are one of the most underpaid professions.
Black Lion Hospital serves thousands of patients a year, but even today does not have a functioning MRI machine. As of Today the Hospital has one dialysis machine, one CT scan, one Radiation Therapy machine, and one ultrasound machine. Illnesses that require anything beyond common medications usually have months of waiting time.
While it was painful to see patient after patient suffer not just from their naturally occurring medical condition but also a broken system; I cannot deny the beauty, positive attitude, level of care, and compassion that exists between patients and physicians. I was in tears when a five year old male patient with urogenital malformations walked out of Black Lion with his family after a successful operation. Never mind that due to an electrical failure and delay in retrieval of a reserve battery, the operation took place under handheld cell phone lights.
Despite the disparities, there were so many reasons to celebrate. Very complicated cases such as infiltrative goiter, massive brain cancers, abdominal cancers, and congenital malformations are surgically fixed every day. Only the few pictures included here would give you a glimpse of these cases!
At the end of my time, while I walked down the hills of Black Lion to Desta Hotel (where I stayed), I felt all types of feelings: chill, frustration, joy, hopeful, hopeless and when my body did not know how to feel, tears went down my cheek. I often asked “could there ever be a way to fix these dire conditions, while continuing the good work? How can I be part of the change?” I know sitting and watching never has been and never will be an option. But what is my role in this? How do I become the change I wish to see?
These are questions I am constantly engaged in as I approach the end of medical school and the process of choosing a specialty in the medical field. While it is very difficult to tackle these questions I also feel honoured, privileged, and blessed to look forward to a rewarding career in medicine, where one has every opportunity to impact individual patients and their families, as well as hospitals and societies at a larger scale. So “Whether our task is fighting poverty, stemming the spread of disease or saving innocent lives from mass murder, we have seen that we cannot succeed without the leadership of the strong and the engagement of all so let us work in partnerships between rich and poor to improve the opportunities of all human beings to build better lives.” Kofi Annan