Even when I think I’ve seen it all,
I haven’t. It’s amazing the things we take for granted with health care—wearing
gloves, for instance. I haven’t seen one nurse or physician wearing gloves. Perhaps
in the CCU (ICU), but not on the wards. So when patients with HIV, tuberculosis,
bacterial meningitis are physically examined, have blood taken, sputum collected,
injections given or dressings changed, the nurses (or sisters, as they are
called) do not wear gloves. The sisters are interesting; they try to be kind
but it seems to cause them great pain to answer any of our questions (i.e. why
did that patient die? Or how do I call the lab? Or my favorite, the patient
over there may be having a heart attack, do you think you could give her some
nitro?). They complain about being overworked, which undoubtedly everyone in
the public sector is. However, patients regularly miss medications—their omission
rate is somewhere around 60%. For comparisons sake, I’d say ours is somewhere
in the 10-20% range on a bad day. Patients that should be receiving 3 bags of
fluid a day receive none (of course, there are no infusion pumps to speed up the
process even if they did). Everyone is catheterized so that they don’t have to
attend to them as often, which often leads to patients pulling them out. Renier
warned us on our first day to wear closed toed shoes because it’s not uncommon
to have a bag of urine leaking on the floor after a patient has pulled their
catheter out.
Another interesting thing happened
today. I was reading a patient chart when a nurse came to take blood (again,
gloveless). Before inserting the needle, she laid it on the patient’s bed,
uncovered. Now mind you, these beds are not like our beds. They literally have
blankets and comforters on them—there is no standard bedding. It looks like
everything has been donated, which I’m not totally uncertain it hasn’t been. So
in addition to the general lack of aseptic technique (nurses spike the IV bags
on the floor, not under ventilated hoods in clean rooms like we do, and
certainly without first wiping it down with alcohol), the bedding could
potentially be covered in coughed up sputum, a patient’s urine which she
decided to cover up with a blanket and lay back down on, or layers of scratched
off psoriatic plaques (yes, all of these things have happened). Since the sisters are so “overworked” it’s not
uncommon for these things to go unattended for the majority of the day.
Needless to say, I was shocked when she continued to stick the patient with the
needle.
Not only are gloves few and far
between, but hand washing is probably just as rare. There are sinks abound in
the wards, but with nothing to dry your hands on, I think the sisters are just “too
busy” to worry about such things. I also can’t forget to mention that actively
infected tuberculosis patients are not in isolation rooms as they would be in
the States. In fact, even their multidrug resistant and extremely drug
resistant tuberculosis patients are not in isolation (even though they are
supposed to be, even there) because there just isn’t enough space.
Space. Resources. Physicians. These
are all things that are incredibly lacking in this setting. During our initial
tour of the hospital, Renier took us through the “casualty” floor, which is
their emergency department. He said on a good day, there would be people
sitting on the floors waiting to be seen or admitted. It’s not uncommon for a
patient to arrive at the hospital on Monday and not be fully worked up and
admitted until Thursday (so next time we complain about a 3 hour wait in the
ER, maybe we should be thankful instead). The thought of patients piling up on
the floors due to lack of space is enough to make me nauseated. The scarcity of
physicians in the public sector only compounds the problem—they keep leaving in
hoards because they are mistreated and underpaid by the government. In fact, it’s
not uncommon for doctors, pharmacists, or sisters to go months without getting paid.
The thing that frightens me most is
what happens when a patient dies in the wards. We have been lucky enough not to
have witnessed this yet. However, Renier tells us that when rounding at 7am,
before the sisters have attended to the patients for the day, we may find a
patient in her bed that has expired the night before. I can only imagine if I
were lying in a hospital bed and in the middle of the night, heard my neighbor,
whose bed is three feet from mine, gasping for air and no one comes to check on
her. These patients are not monitored, so unless they yell out (which the often
do to no avail) or a sister just happens to be in the same room, they may die
and go unnoticed for hours. And whereas we would have a formal write up on our
demise (“patient died of cardiac arrest after three rounds of defribrillation,
epinephrine, and 20 minutes of CPR”), these charts will read….
“patient found dead this morning.”
No explanation given.
