The 7 weeks of my medical elective were spent in a Christian hospital called 'LAMB Hospital' in Parbatipur, North-West Bangladesh. It is a 150 bed hospital which is well known in the local area (and further afield also) for its good quality care and its particularly good obstetrics, gynaecology and paediatric services. Other facilities include a Rehabilitation centre (for adults and paediatrics), male and female medical wards, laboratory and physiotherapy department. The wider LAMB organisation includes a nursing institute, an English-Medium school and many outreach community programs.
During my time there, I carried out a small project for the paediatric department and split my clinical exposure time between obstetrics & gynaecology and paediatrics, with a slightly heavier emphasis on paediatrics. These disciplines are two of my areas of interest and I wanted to explore them further to see the skill base required for working in a low-resource setting such as LAMB.
Working as part of the paediatric team taught me much about the different diseases and different presentations of familiar diseases in this setting as well as the environmental and cultural factors which influence their presentation. Examples of pathologies seen include parotitis due to Mumps, Ricketts, severe malnutrition, TB and its complications, Nephrotic syndrome (see later) and developmental delay/cerebral palsy. In clinic my very limited language skills meant that it was difficult for me to see patients alone and so I took this opportunity to observe and learn from the doctors. On the paediatric and neonatal wards I picked up many of the routine ward-round questions and so was able to carry out daily reviews of patients and to present them to the senior doctors, discussing management plans with them.
My time in Obstetrics and Gynaecology gave me the opportunity to see the importance of this specialty in this setting. It is estimated that 80% of births in North-West Bangladesh occur at home with an untrained birth attendant and the majority have no complications. However, those that incur complications can result in poor outcomes for both the mother and the child and as sadly the trip to hospital is made very late, those attending the labour ward at LAMB are very high risk for complications. Despite this, the maternal mortality at LAMB is very low and to minimise it further, LAMB is actively involved in training and establishing community skilled birth attendance services. I had the opportunity to observe junior and senior doctors making decisions in the best interests of the mothers and their babies and was reminded that, in order to practice safely in such a setting, a high level of training and experience on my part would be required.
Alongside my clinical work, I was asked to carry out a 'chart audit' of the Hospital's Paediatric Admissions for Nephrotic Syndrome. The prevalence of Nephrotic syndrome amongst the Asian Population is approximately 12/100,000 which is significantly more than amongst Caucasians and the LAMB paediatric team see many children with nephrotic syndrome (either in remission or relapse) each week, so the aim of this audit was to show how the Paediatric team were meeting the 'gold standard' set by the guidelines in the treatment of these sick children. I was glad to have this opportunity to contribute towards the work of the hospital and to help guide the doctors in the treatment of children admitted with this condition.
The working week is 6 days long with 'chuti' (holiday) on Fridays. A typical working day in the hospital starts with daily devotions at 9am followed by ward round of the inpatients. In the paediatric department this is carried out as a team, with seniors and juniors reviewing and discussing patients. As a medical student there are ample opportunities to see and examine patients, often with one of the junior doctors and sometimes alone. At 10.30 or 11am the whole team of doctors will go for a 'tea break' before going to the outpatient department. In paediatrics patients who turn up to clinic that day will be seen in their order of attendance. There is a break for lunch at 1pm and then clinic restarts at 1.30pm to run until 4pm. In obstetrics and gynaecology the team is split between labour ward, theatre, scanning and outpatients but their day runs quite similar to in paediatrics. Both departments have a weekly teaching session that students are able to attend in addition to the weekly 'medical meeting' where the departments take it in turns to present audit findings or journal reviews.
Outside of the medical work there is much to learn about the set-up of LAMB, particularly if, as I am, you are interested in/considering working overseas in the future. A visit to the Laboratory and Research department highlights the high standard of care that the hospital strives for, despite its limited resources. However, the most important component of the organisation is not the hospital and its facilities but the people who work there. It was a blessing to see how much the Bangladeshi and ex-pat staff alike sought to serve and love the patients and relatives who attended the hospital. There is so much to be gained by working and walking alongside these people and seeing how they live in a way that is very different to life back at home.
During spare time and 'chuti' days there is often chance to go for walks through the surrounding villages as well as travel to nearby towns as a group (as women are unable to travel alone). The LAMB ex-pat community have weekly prayer and bible study meetings which students are welcomed to and these give a taste and opportunity to learn about the blessings and challenges of serving God in a place such as LAMB.
Practicalities & Advice for future elective students
My elective cost approximately £1500 (£500 for flights, £300 for accommodation, £150 for insurance, £100 for vaccinations, £300 Interserve fee, £150 for miscellany/pocket money) and was funded with some help from family and friends and also a generous grant from the Norman Barnett Languages Trust (Dewsbury). Interserve helped to co-ordinate the whole placement and ensure that things ran smoothly as well as providing a very helpful 'orientation' weekend prior to going and an opportunity to debrief afterwards.
The guidebooks for Bangladesh recommend avoiding the hot March-June season if at all possible. Unfortunately I had no choice however at times the heat could be almost overwhelming so if you are not great at coping with heat I would suggest heeding their advice. Clothing (salwaar kameez and orna/scarf for ladies, shirt and trousers for men) is generally quite breathable and there are many sets of salwaar kameez to borrow at LAMB.
In terms of health, it is a good idea to invest in a good midge/mosquito repellent and the recommended vaccinations as well as being aware of the general food hygiene in order to stay well during your visit. As I have a nut allergy I was very happy to discover that due to the cost of nuts very few people cook with them, however it is a good idea to be well prepared if you have any medical condition.
If there is any opportunity to learn some basic Bengali/Bangla before visiting LAMB this would be much to your advantage. I invested in a 'Teach Yourself Bengali' resource with help from the Norman Barnett Languages Trust and found a few simple youtube videos also helped but whilst these give some appreciation of the script and sounds, they don't completely prepare you for speaking to others – this comes when you are immersed in the culture.
Final Words
This elective has given me opportunity to step far out of my comfort zone and by doing so I have learnt so much. Bangladesh is a beautiful country and I would highly recommend LAMB Hospital for any medical student considering working overseas in the future, yet for any elective to be successful, I would advise you to start planning early and make enquiries (www.CMF.org.uk has a good elective database). Once the destination is decided, studying the culture of the people group, area and language is of high importance. There are many bursaries available to help with funding. Most importantly is reflection of expectations before going, experiences during and thoughts after the elective in order to learn as much as possible from this amazing opportunity.
