Electives Experience in Pakistan (Holy Family Hospital, RMC, Rawalpindi)

Kathleen O’Dea from The University of Queensland Australia recently came to SU Unit 2 Holy
Family Hospital for a month long clinical elective. Read on as she describes her experience


Prof Asif Zafar Malik, who was the clinical preceptor, is head of Surgical Unit II at Holy Family Hospital and project
director of the Telemedicine e]health training centre there. Week 1 and 2 were mostly spent in Surgical Unit II
at Holy Family hospital.
Jan 15 Introduction to SU II : Staff include 12 junior doctors, 12 postgraduate trainees, & 5 consultants. This team is
responsible for half of the general surgical and orthopedic patients presenting to Holy Family Hospital and cares for
a 45 bed ward, usually full. The team is on call to
receive emergency cases every second day and will have an elective
surgery list 2 days a week.
SU II also hosts the telemedicine training centre and videoconferencing facilities.
Medical services are free for public patients in Pakistan and because of the large population there is a great need.
While medical care appears to be on par with Australian hospitals and up to date medical equipment is available as

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required, costs are cut in other areas. Buildings are old and not well maintained, patient's facilities are basic, (and
they must organize for their own meals), medical supplies are reused (with the exception of gloves and syringes),
safety equipment is minimal.
HFH is the largest hospital in Rawalpindi with 1150 beds and includes all major units, with the exception of psychiatry.
In the morning I assisted in thyroid surgery. Goiters are a common surgical condition due to Iodine deficiency and
patients often present late with large masses and/or complications. Due to low education level and poverty many
patients present late with advanced pathology. Other common general surgical procedures include colectomies,
lithotomies, abscess drainage as well as the universal cholecystectomy and appendicectomy. Also orthopedic conditions
are often complicated by late presentation and difficulty in accessing rehabilitation services. Fire arm injuries
and traffic accidents also seem to be more common here.
However it is the quantity and wide range of pathology that makes HFH an ideal teaching hospital. House doctors
(first year after graduation) here will commonly perform appendicectomies in their first year. With minimal resources
doctors also learn to work in difficult conditions.
When not in theatre I spent time in the ward, doing basic procedures such as IDC insertion and venopuncture.
Jan 16 On call . for the ward doctors this means a 30 hour shift starting at 8am, finishing 2pm the next day, which
the ward staff do 7 times a fortnight. I spent my time in the emergency department, emergency operating theatre
and on the wards. The doctors working in ED and OT do a 24 hour shift 7 times a fortnight. Because there are several
doctors working together and some quiet times, sleep is usually possible. There are beds in the staff quarters
on the ward for this (separate sex of course) which are at least warm, but not particularly roomy! I felt quite lucky
to have a bed however as I noticed many other staff asleep at their desk. Tuesday turned out to be a quiet night,
with one appendicectomy, some minor surgery and some non urgent exploratory laparotomies which would be
done the next day. My time in ED was interesting, but I was quite limited by not understanding Urdu. All patient consults are in Urdu, and while the doctors are quite fluent in English, they are not always able to translate.
Jan 17 Wednesday and Monday are SU II days for elective surgery. Today I saw a laprascopic cholecystectomy
(nothing different there), a modified radical mascectomy on a male patient (rare here too), and release of contractures.
Jan 18 Today was spent with Dr Tahira Malik, Professor Zafar’s wife who is a Haematologist working at PIMS in Islamabad.
See more on Feb 7.
Despite their busy workload throughout the week there are regular academic activities at SU II, including journal
club, virtual ward rounds, presentations given by junior and senior doctors as well as regular audits and mortality
meetings.
The week finished early, to allow for a week trip to Lahore!
Jan 22 Week 2 started with more surgery – thyroid, cystoscopy and TURP, removal of giant fibroadenoma. Some
new procedures for me as well as some interesting advanced pathology. In the afternoon was able to experience
the different services of a private hospital in assisting in a total colectomy at the Valley Clinic. It is a modern and
well equipped small hospital providing services at a standard similar to public hospitals in Australia (the disposable
surgical gowns really made me feel at home). The surgery was another first for me. The patient suffered extensive
ulcerative colitis and though young had opted for a permenant colostomy.
Jan 23 Today I visit another private hospital again to assist in a pyeloplasty at PAEC hospital, a hospital for employees
of Pakistan Atomic Energy Commission. (Many large organisation prefer their own private hospitals as a
cheaper alternative to health insurance.) PAEC hospital is again a very nice modern hospital. The surgery involved
the repair of a congenital defect of a kidney in a young male and was a great opportunity to see an uncommon procedure.
Jan 24 Today included a trip to the endoscopy unit to observe the range of colonoscopy, gastroscopy and bronchoscopy,
but this time without significant pathology.
The breast clinic was also run on Wednesdays and consists of one room, one doctor and preferably one patient, but
not always! Mastalgia is a common complaint here, but apparently is often psychosomatic condition as women
have difficulty dealing with social problems because of their own reluctance to speak about as well as a lack of services.
One patient was admitted with a suspected diagnosis of stage 2 breast carcinoma. It was interesting to note
that the patient was not informed of her diagnosis because of fear she would leave and not return. This is apparently
a common response due to poor education. Instead this patient was admitted for further investigation, and
the bad news would be gently broken to her while still admitted. She would likely have an operation within a week
and during that some admission.
Jan 25 Another day on call, in the hope of seeing more pathology or at least trauma needing sutures! Fortunately
for the people of Rawalpindi it was another quiet night. It was still a good experience for me though.
Jan 26 Friday morning is for academic presentation and I was honored to be asked to talk about my home and university.
The morning also including teaching on medical topics, audit of services provided and evaluation of any
recent mortality cases. After lunch and a break surgery started again at 7pm at a private clinic. An open cholecystectomy
was made more interesting with a congenital anomally of Moynihans Hump.
Jan 27 Saturdays start with a virtual round where every patient is presented and discussed by the team. This is followed
by an actual round. The rest of the day being uneventful allowed me to catch up on my email referrals.
As part of my elective here I am working to facilitate an email referral system for HFH with the Centre for Online
Health at Royal Brisbane Hospital. This was facilitated by Professor Wootton who forwards requests to the relevant
consultants. It is part of a joint project between the Swinfen Charitable Trust and the U21 consortium of universities.
So far I have sent requests for 3 patients of HFH where specialists were not available or a second opinion was required.
Jan 29 and 30 are holy days and public holidays in Pakistan. Week 3 will be spent in medical and Obstetric and Gynaecological
units of HFH.
Jan 31 Wednesday was a short day spent in Medical Unit 2, going on ward rounds. However it was a useful general
introduction to medicine at Holy Family Hospital. Two conditions commonly treated here are liver disease, due
mostly to hepatitis C, and tuberculosis. Multi Drug Resistant TB is also becoming a problem due to inadequate initial
treatment and/or noncompliance. Hepatitis C is relatively common because of inadequate screening of blood products.
Other conditions were similar to Australian medical wards, such as stroke and lower respiratory tract infections.
Feb 1 I was with Dr Ayesha for my first day in Obstetrics. I had been warned this department is especially busy and
there was no exaggeration. Short of beds, operating theatres and doctors, the staff have a very difficult job to provide
adequate care for all the women. Another problem is that many women do not register with the hospital until
she arrives in labor. On my first day I was with the women in the early stages of labour in a small room with 6 beds
(and usually more than 6 patients) and helped with canulas, venopuncture and cardiotocographs.
In the evening I stayed on call and assisted in the surgical OT. Again not busy, but I was happy to see some new
things like suprapubic catheter insertion, and do some new things like remove k]wire.
Feb 2 I was able to watch some births today. One woman had a normal spontaneous vaginal birth, while 2 others
had emergency c]section. All babies were delivered healthy . It was interesting to note that the doctors do not tell
the mother the sex of the child until after they have delivered the placenta and are doing fine. The reason being
that she maybe very disappointed to hear it is a girl, go into shock or just not cooperate with delivery of the placenta.
Feb 3 today I assisted in a c]section for a 35 yo woman who had a history or 6 previous stillbirth/miscarriage and
only 1 child living. The newborn child was healthy, and diagnosed Downfs Syndrome. The mother requested a bilateral
tubal ligation, however her husband would not agree and his choice was respected, because ghe should be
given the chance to continue his lineh. To finish the day I saw another spontaneous delivery.
While the staff do all they can, the services provided here are very poor. Though there are midwives in Pakistan
there are none at Holy Family, so 1 or 2 doctors should be present for every spontaneous delivery as well as performing
c]sections. There is a shortage of nursing staff and doctors will do a lot of the nursing care for their patients.
More work for the doctors means the patients suffer, and rules prohibiting the presence of any support person
in the labor ward contributes to their distress. Termination of pregnancy for non medical reasons is illegal, however
doctors here see many patients suffering from complications of having the procedure illegally.
Feb 4 & 5 Sunday another ''weekend'' at last and this time we visit Topi village and GIKI university, then Kashmiri
day on Monday (public holiday) and a girls day out in Islamabad!
Feb 6 Dr Sarah Zafar, an ophthalmologist registrar, very kindly took me to her work at Al]Shifa Trust Eye Hospital.
Though a private hospital they have a Zakath (muslim thing) department to treat the very poor. Also, because it is
the best eye hospital in Pakistan it is responsible for treating a very large number of patients (around 500/day). and
is a very busy place. (one outpatient clinic staffed by 2 doctors saw 200 patients in 6 hours) I spent the morning at a
cataract clinic and then some time at a pediatric clinic. In the afternoon I attended an academic presentation. This
happens daily despite the large workload of the doctors, as education is considered a high priority.
Feb 7 Today I visited the paediatric department of PIMS (Pakistan Institute of Medical Science), which was a gift
from the Japanese government to the Pakistani people. It is a very nice hospital with modern facilities for children
which includes a haemophilia centre. I spent the morning in the haemophilia clinic seeing the variety of patients
there with Dr Tahira Zafar.
Haemophilia A (factor VIII deficiency) is common in Pakistan because of a racial predisposition, which is exacerbated
by the common practice of consanguineous marriage. Treatment is difficult because funding is inadequate to
provide clotting factors to all patients. Their condition is often complicated by contraction of hepatitis C because of
insufficient screening of blood products. The most effective way of addressing the problem is prevention and there
are now programs focusing on this, however low levels of education is a problem.

Thalassemia is also a major condition treated at the centre. Like most places there is a shortage of blood products.
Here there is a directed blood donation program that requests the patients relative should donate one unit of blood
for every unit received. .
In my short time there I was able to see the paediatric medical and surgical wards which include intensive care
units, each with 44 beds but an average of 60 patients! I also had a tour of physiotherapy unit, which has great
modern facilities and skilled therapists.
Feb 8 I returned to the Al Shifa Eye hospital for their operating day. Having not seen any ophthalmic surgery I found
it very interesting to see how they perform such intricate surgery under microscopes . (it is with lots of practice!) I
watched some cataract surgery, performed using both the modern phaco]emulsification, as well as the older extra
capsular cataract extraction method. I also watched an orbitotomy for removal of a tumour. This soft tissue tumour
had extensively infiltrated the orbit and destroyed the lateral rectus muscle, but fortunately other structures were
intact.
Feb 9 & 10 I return to HFH for my last 2 days. Friday and Saturday are interesting with presentations and audits and
the rest of the time is finishing things off.
I am very grateful for Professor Wootton for helping me to organise this elective and further support and emails
during my time there. Also I am indebted to Professor Zafar for his ongoing academic support and encouragement
as well as his wonderful hospitality as a guest in his home.

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