A typical working day you say? Nothing here is ever typical!

10th October 2010: A typical working day you say? Nothing here is ever typical!
So the time comes to share with you a typical working day in the life of moi. It is only now that I think I have enough knowledge of what I am actually doing that I can tell you! It begins thus:

06.30am- I awake remove my ear plugs, and doze listening to the bassy bongo flava music, and the families of patients cooking and talking. I again question why I am awake at such an ungodly hour, but then I realise that I do not have to switch lights on because it is dark outside, or walk over a mile in freezing rain; quite the contrary, the sun is shining, and it’s warm outside.

6.50am- I get up, get ready in about 5 minutes and have a cup of sweet tea. I greet my housemate Faith, who has probably been up since 4.45 am (!) and has already returned from an hours walk around the village. Although highly commendable, I am not going to be joining her.

07.25 am- We head across the makeshift football pitch/grazing area for cattle outside our house, to the hospital gates, (a 2 minute walk at most). It’s not a long walk, but the ubiquitous sand here in Nyangao makes it an effort. My feet are look like dirty street urchin’s feet by the time I make it to work! The families are all waiting outside the gates bringing water, food and other supplies in and out of the hospital. The patients normally arrive with two or three members of their families, and most of these members stay, prepare meals for them, help wash them, and keep them company. Whole family groups sometimes come and stay.

07.30 am- This is the official start of the morning meeting, however this is Africa, and so the actual start is fluid. I go first to the lab, and greet the person who has been on call over night and collect the daily report on the numbers and types of blood currently in stock

Oncall here includes many tests and procedures. Haemoglobin levels, creatinine and glucose in the blood are regularly tested, plus blood bank can be busy if emergency operations such as Caesarean sections occur overnight. If technically difficult tests are required like investigating cerebral spinal fluid, or night blood films for filiariasis, then the second on call is called. At present only two people in the lab are able to be that, as very few of the lab staff members are adequately trained. Monica my counter-part who is the Lab in charge is one, and Mr. Kamenya who at technician status is the most technically qualified member of staff. I luckily do not have to do on call, and I savour that, although they all have my number in case they would randomly need me for something.

There is a bed in the lab by my office, and they often sleep there if they are called out very late. It reminds me a little of the tiny room I had to sleep in when I was on call in Maidstone, except the lack of bedding and ensuite toilet/shower.

07.35 am – I sit down in the hospital meeting room and greet the medical teams that are required to attend morning meeting every day. This includes the surgical team, the obstetricians, general medicine, the doctor in charge who is also the dentist, a paediatrician, the Patron who is in charge of the nursing staff, Barbara the VSO pharmacist, Dr. Faith the HIV and AIDS coordinator, the radiographers and little old me. Phew. It sounds a lot of people, but not everyone always turns up.
Most of the clinical staff are made up of clinical officers. These have no tangible formal medical education, but have been to school to start their studies. The AMOs are more highly qualified, and there are only very few fully qualified doctors, the Polish surgeon and my housemate Dr. Faith being two.

The meeting is always held in English, which is very handy! We begin with a report on the admissions and on call events overnight. As I said before, mostly this entails emergency Caesarean sections. This report also reports any deaths which occurred overnight. This can vary greatly, i.e. from none to about five, but I have become aware that there are many more than that on occasion, and are unknown at the time to the reporting staff. I then report the number of bloods we have in the blood bank, i.e. which is normally very little. Barbara reports on the numbers of certain drugs that are low, or have run out, and on many occasions asks for clinical advice on how to proceed with such low stocks. Sometimes there is an answer, most of the time questions are greeted by silence. It can be hard to obtain answers from the staff here, as they are not accustomed to speaking out in public domains, even when they are used to a meeting every morning.

The last part of the meeting is a review of all the x-rays from the previous day. I have learnt a great deal from these sessions; how to see TB infiltration, how to see enlarged hearts, livers, and pneumonia. The most shocking though are the broken bones. The majority of operations here are reduction and internal/external fixation of broken bones. They are normally caused by car and motorcycle injuries. However, sometimes they are incidents of falling out of coconut trees, playing football, but sadly also beatings. There have been quite a few female and male patients that have come in with multiple fractures of arms due to domestic violence. It is a reality in any country all over the world, but it is always a distressing reality. Another unwelcome sight is the number of young children suffering from TB, and the number of end stage AIDS sufferers with a myriad of pneumonias, and other infections. Although from a medically trained eye it is fascinating and educational, it is also desperately sad.

08.00 am- Yep that meeting may look intense, but normally only lasts about 20 minutes. I then return to the lab and greet everyone in my best Kiswahili. I greet everyone individually, as to not to would be rude. The greetings can take some time, but I enjoy having a giggle with them all. Once a month we sit down to a lab meeting, and discuss any issues that the lab management team have alongside those of the lab staff. I am here partly to help improve quality control and health and safety in the laboratory, so at present the meetings are mostly to do with setting up and maintaining controls of tests, and infection control. The meetings are held in English first and then Monica will translate into Kiswahili. I am really happy that these meeting seem to be going so well. Unlike the doctors at morning meeting, the lab staff are not afraid to raise their point, or disagree with one I have raised.

I think this has improved due to an event that occurred a few weeks ago. As part of my remit to improve health and safety awareness in the lab, I tried to ensure that all lab coats were not taken home to be washed, but washed by laundry at the hospital. Everyone seemed happy at the suggestion and it was organised. However, on the day that washing was set to happen, no-one agreed to hand over the coats. I was away that day, and I found out when I returned. I spoke to a few of them, and they said that the washing machines did not clean the coats adequately, and that they smelt. It became obvious that this particular improvement would not be a success. I called a little meeting, and asked them to tell me from now on if they were not happy with something I proposed they were to tell me, and that we could work together to see how to tackle the disagreement. I may be here to educate and help change certain areas, but there is no point in me making changes if they will not be followed at all, or only whilst I am here. In the end I made a compromise, that they could take their coats home to wash, only if they were to take them off and wash their hands when drinking chai and eating! So far they have kept to that promise! Plus now they are not so backward at coming forward about proposals I put forward!

09.00 am – Anyway I digress. The morning is a time of cleaning and preparation in the lab, and so it gives me an opportunity to work with Monica in the office. I am also here to continue training Monica in computer skills, i.e spreadsheets, word processing, emailing and the computerised stock system created by Johanna my predecessor. Once a month we will do a full stock check of the lab, and update the stock system. From this we then decide what stock we need. This would be quite simple if the system ran as it should, but hey it never does. I won’t bore you with full details, but here are some points about buying here in Nyangao:

• First we go to the Medical Stores Department (MSD). The government are supposed to pay a certain amount of money into this wholesaler every year. Currently they have severely underpaid into our account. We also have an account here linked from donors to the hospital. One such donor is the Elizabeth Glazer Foundation. They have set up a free sexually transmitted infection programme, from which the lab are supposed to get the majority our supplies. However, for many months these important supplies have been unavailable for uncertain reasons. We are constantly in discussion with this foundation about our need for new reagents, but advancement is a very slow process. However, to push too hard here is to make things go even slower, so it can be a political nightmare! Therefore for the lab, a trip to MSD for us normally yields very little.

• Our next port of call is to ask other hospitals in the area for supplies. The regional hospital in Lindi which has close links to the District Medical Office, always seems to have a good supply of everything, and luckily we have a good relationship! That can tide us over for a few weeks, but we are constantly aware that our supplies will disappear!

• For other things not associated with the free programme, we buy from suppliers in Dar es Salaam, and Mr. John a mysterious man, who can you almost everything you need at a price of course! All in all though, I have learnt that to beg and borrow is the best bet.

10.30 am- CHAI TIME. The lab cleaners and some other staff sit at this time to eat and drink tea. I normally provide samosas that I buy from Michael in theatres! I can go to the main tea room in the hospital and eat and drink better food with the doctors, but I like to stay with these ladies in the lab, and I use this time to try and chat to them all in Kiswahili. This is the only food I will have until dinner, so I try and eat, but potatoes and cassava in chilli sauce is not my favourite thing!

11.00 am- It starts to become very busy in the lab now, as the numbers of patients waiting outside rises. Lab staff collect the specimens from inpatients in the wards, but outpatients come to lab personally, where their blood is taken by the staff, or they are given specimen pots to do their relevant business in. When I say specimen pots I actually mean old medicine bottles for urine, and small match boxes for stools! I have succeeded in ordering a three month supply of disposable plastic bottles to make sure that at least we have safe specimen containers for stool samples, but I am not sure how long we can afford them for!
The patients wait until they receive their results, sometimes they can stand or sit upright, but mostly they have to lie on the concrete floor outside. There is not a great deal of space for waiting in this hospital, and there are so many patients! It can be distressing to see at times, especially when it is a lone young women crumpled on the floor, but there is so little that can be done except make sure she has her results as quickly as possible, so she can be admitted or treated. The lab staff do trry to work very hard during the busiest times but often the waves of patients just keep coming. As yet I am not very helpful practically. I am hoping that I will be able to do some technical stuff soon, so I could assist them if required.

12.00 pm. I tend to be in the office most of the day, and I use the afternoon to continue updating and writing SOPs, training questions, or currently collating data for our donors and the Ministry of Health. This is a crazy and sometimes seemingly impossible task. No results are individually computerised. There is only one computer in the lab, and the ministry requires all results to be written in books that are then sent to the government. Therefore I am collecting data manually, which is slow and I think a waste of my time. So after this quarter I am going to figure out a way it can be done more quickly and efficiently. I am not sure how that will happen just yet…..

14.00 pm- On certain days when the number of units of blood is less than 15, I will order more from the Mtwara blood bank. This process involves us asking for blood in reference to current stock, and what we think we require, and sending an email of our request. The zonal blood bank then wait on average 4 days to send any blood to us, and it is often much less than we asked for. This is not the zonal blood banks fault. There is an obvious lack of safe donors available in Africa, and these tend to be secondary school children. When the school holidays are in full flow, the number of donors dries up, and therefore they have little blood to distribute. On these occasions we have the ability in our lab to allow family members to donate blood, and we test for the obvious blood infections. Yet, family members can be found to be positive for certain diseases, which mean problems for the patient, and consequently problems for the family members. When the blood is finally sent it is sent alone in a cool box on a public bus! It shocked me the first time, as I was sure someone would have stolen it, or it would have been damaged, but it arrives every time safe and sound.

15.30 pm This is the end of the working day for me, and often by this time I am pretty darn tired. It is not as crazy busy here as life at home, but the work is constant and sometimes intense! I am still trying to find out how to effectively start my objectives for sustainable capacity building here in the Nyangao maabara, but as you can see, my everyday work is rather full already. Yet I am getting there slowly! I say Jioni njema, to the lab staff, and all those I see on my walk home, and start thinking about what wondrous meal of tomatoes, peppers and onions I can create tonight and the cold bottle of Kilamanjaro beer that I have waiting in the fridge. Some working week habits never change!