The beautiful chaos of Outpatients?

Today has been pretty full on. It started well with a fairly concise morning meeting, followed by surprisingly brief surgical rounds. And it was then to the outpatient department, for what I am starting to feel is the Monday onslaught! The clinic nurse clearly thought so too. 18 patients somehow turned into 35!

It is very different to how we typically practice in the UK where we tend to have ‘slots’ in a defined clinic list. And normally we have some sort of letter to guide why a patient is coming to see us (although the presence or quality of such documents is by no means guaranteed). However, here in Tanzania, there is usually very little documentation with most patients just turning up on the day and wait to be seen – Mondays are known to be surgical OPD. Even the follow-ups can be a bit sketchy with the documentation.

As I am sure is becoming clear with my posts, the practice of a General Surgeon here is VERY general. The broadest UK general surgical remit is joined by a significant amount of orthopaedics, urology and paediatrics, with a smattering of ophthalmology and ENT. Obstetrics and Gynaecology is conducted separately – although there is overlap (not least as ALL the doctors on call do caesarean sections – by this I mean every doctor be they medical, surgical, paediatric as there is only ever one on for the whole hospital!).

The conduct of the clinics themselves is taking some getting used to. Firstly it is noisy, really noisy.  With well over 100 people milling around outside the rooms waiting for their various appointments. Most patients arrive early at about 8am, pay their fees to secure an ‘appointment’ and wait patiently to be seen – our last patient today was at 3pm (that’s a 7hour wait)! So there is a lot of hubbub (although it is all very good natured). And little ‘insultation’ from it. The windows are of the slatted type and of course are open (for the heat) assuming they are not missing the pane of glass.

Our clinic room, looking in from the window!

There is also an organised chaos in the rooms (which I am sure would make more sense if my Swahili was better). Patients will often just come in to drop in notes or the results of a test they’ve just had done, ask a question or request a ‘slip’ of one sort or another. Or hospital staff may sometimes come in to be seen or to wait in the room for a relative to be seen. That, together with the curtain-less windows does mean that privacy is far from ideal. However, there is a definite pragmatism within the hospital in this regard. Although on the streets shoulders and knees are generally covered, there is no hesitation for a patient to whip out a boob or drop their trousers to show what the problem is. I hasten to say that we do have a curtained area (with a new couch today!) which we encourage them to use. Patients are called in for their 'appointment' by shouting their name inside the room (quite loudly) or asking the departing patient to call the name. You then hear an echo of this name being passed around outside until the correct individual is found and enters – it is surprisingly efficient.

And then there are the consultations themselves. I have long been a strong proponent of the importance of the history - the subtleties of the story that patient tells can more often than not tell you what the diagnosis is. My Swahili currently is nowhere close to being able to take a decent history on my own, so I am working closely with my Tanzanian colleagues. And this dialogue with them, is of course one of the main reasons why I am here, it is very educational for us all.

It was an exhausting day and I do wonder about my tactics / approach to Mondays (and perhaps more generally). The need is great which is very difficult to ‘shy’ away from when you are actually here. And it is also important to me to be part of the team and throw myself in to it all (not least to build up the crucial relationships that will enable maximal development of the surgical team). But it does take a lot out of me and I am not sure it is necessarily the best use of my time / energy. A certain amount of involvement with this OPD work is essential to help them develop their thinking, but there are other things I believe are important for me to focus on too (for example procedures within the operating department). Food for thought.

Anyhow, we have found 4 hernias to do and tomorrow, we are going to try them with mesh.