First day on the wards. I was super excited all morning, and could barely sit still through morning report.
Explaining what I did for most of the day requires a bit of a break from regular programming to explain how the hospital is set up here. Keep in mind that I haven’t worked on an in-patient unit before, so some of this may be similar to the States, and I just don’t know it yet. Here goes:
The ward is divided up into five different rooms, called cubicles, each with (roughly) six beds. Some of the beds aren’t actually beds, just mattresses on the floor, but thankfully there’s only one patient to a bed. Besides the bed, there’s a nightstand for family members to put food, etc., and besides maybe an oxygen hook-up on the wall (not available for every bed) and the occasional IV pole, that’s pretty much it. The beds may or may not have side rails. There are no IV pumps or cardiac monitors. There is one portable machine for assessing vital signs, for the whole unit. There is a TV on the wall in one of the five rooms. Three medical teams – team A, B, and C (very original, I know) – rotate admitting patients every third day, so the patients in a given room may all belong to different teams. The cubicle directly in front of the nurses’ station (cubicle B) is sort of supposed to belong to the most acute patients, with the same reasoning as home, being that the staff can keep a closer eye on them.
As far as the teams go, there is an attending in charge of each team, who switches every month – hence why Dr. Kung was taking over on June 1. We’re Team A (it would also be acceptable to refer to us as the A-team, because we’re that awesome). Interns are assigned to a given team for the duration of their rotation, but I think the residents rotate teams. Not as sure about that one.
Also, I think this is an appropriate time for a tangent within a tangent, to explain how medical training happens here. So the ultimate objective of the Botswana-UPenn partnership (the specific organization that I am working under) is to establish a medical school (they previously didn’t have one in Botswana) and train Batswana doctors to apply our standards of practice. The medical school was officially opened in 2007, so now the first wave of Batswana interns are hitting the wards. What did they do before Penn, you ask? Doctors trained in other countries – so far I’ve met people who went to medical school in Jamaica, Australia, Russia, and the Congo – then came back to Botswana to finish their intern years and residencies. There’s another, intermediate step here though. First, you do a year as an intern, then spend at least a year as a medical officer, working for the government, and then you apply for your residency. But you don’t have to – a person can remain a medical officer for their whole career, working basically as the equivalent of a family nurse practitioner or primary care doctor.
Finally, working our way back to my day – along with Dr. Kung, I attended morning rounds (separately from morning report) with our superstar senior resident, Tiny; another resident, Changi (not sure what year he is, but definitely less than Tiny); and intern, Tsaone. Since it was Dr. Kung’s first day on call with this group, we were all trying to figure out the ground rules. Dr. Kung was very clear that she wanted each patient to be seen by one member of the team in a pre-rounding process, so that everyone would present a patient during the actual rounding. Things were complicated by the fact that we were under a bit of a time crunch, because Dr. Kung had to be able to get to clinic by noon. So not everyone was covered in pre-rounds, but we worked our way through, and I was amazed by how sick all of the patients were. This is where I hope my earlier description of the ward will serve to help me illustrate my point – of our 8 patients, at least four had meningitis, TB, or both, three had pneumonia (including one PCP – Pneumocystis carinii pneumonia, a very severe form of pneumonia commonly seen in HIV-positive patients), one had a congenital heart defect that was dropping their oxygen levels to 70-80%, one was having almost continuous seizures, and one was in a coma (which probably will be permanent as a result of TB-meningitis that was caught too late). I know that doesn’t add up – that’s because several of these conditions were co-existing. The most sophisticated equipment any of them was hooked up to, though, was oxygen and IV fluids/antibiotics. The baby with PCP was so sick, we could hear the child gasping for breath from across the room. Dr. Kung interrupted her review of the charts to examine the baby and write orders then and there. But the only oxygen mask we had was an adult size, as was the pulse oximeter (instrument used to determine how well someone is oxygenating). Also, both the hospital CT scanner and the unit’s ABG (arterial blood gas – a machine that does a rapid blood analysis of electrolytes, blood oxygen and CO2 levels, etc.) machine were down. So one baby who may have been developing hydrocephalus (a build-up of fluid in the brain) because of partially-treated meningitis couldn’t get the brain scan we needed, and the results from the labs we drew on admission two days before still weren’t available. It blew my mind.
Most babies have one family member in with them at all times -- usually the mom, though just as often it may be an aunt or a grandmother. Charts (and I use that term very loosely) are kept on rolling tables (kind of like the bedside tables we give patients in the States) in each room, but X-rays, MRIs and immunization records are kept by the family at the bedside. If we need to compare to an old X-ray, and the family didn’t bring it, we’re out of luck. Electronic records are basically non-existent. To make things even more complicated, Dr. Kung herself doesn’t speak Setswana, so if the family member with the child doesn’t speak very good English, things can get pretty complicated.
After Dr. Kung assessed each patient and wrote the day’s orders, she headed off to the clinic. First, though, she asked where I wanted to spend the day, and after I asked to stay on the ward to help with our (quite long) to-do list, she instructed Tiny to let me practice some of my skills. She said I’m very observant and pick things up quickly, which made me very pleased ☺ We started with the sickest baby first (honestly, it’s impossible to even make such a distinction, since they were all so sick), and went to collect blood from the PCP baby. That was my next shock – there aren’t even alcohol preps here. You take a piece of cotton, pour alcohol on it, and voila, that’s what you use to prep IV sites. Unfortunately, the needles are sized for adults – we have small gauge ones for IVs, but anything with a larger bore (internal diameter) is too long. Our baby already had an IV, so we did an arterial stick to get blood. Instead of having a vacutainer (a piece of equipment with a needle in it that you screw onto the end of a needle to fill blood tubes), we have to pop the tops off of the blood tubes, drip the blood in, and then pop the tops back on. The needles aren’t retractable either, so you have to be very careful about where you put your sharps. Again, mind blown.
Worked through lunch, since the next baby we worked on, the TBM/hydrocephalus case, needed a new IV, blood, and a repeat lumbar puncture (if you don’t know what that is, you don’t want to know), and was a hard stick. In theoretical terms, I knew that IVs were sometimes started on babies’ scalps, but I had never seen it done before. Well, we ended up sticking this poor baby at least 8 times on the scalp, in addition to trying each hand and each foot. Even the LP took a couple tries. Poor bunny. I was also pretty surprised at how calm the family was – the baby’s aunt was there for all of the IV attempts, and she never once questioned whether the residents knew what they were doing, or whether we could get someone else, or any of those other questions really frustrated and concerned parents tend to pose in the States. Definitely a different culture/attitude.
I have a lot of confidence in the abilities of the two residents I was working with, Tiny and Changi, but I was also very surprised at what free reign they had. Dr. Kung was gone at this point, and there were attendings from other teams wandering in and out, but they were mostly gone too, because they were done with their rounds. Residents do all the procedures here – nurses pretty much only take vitals and give medications. Most people thought I was a resident, because: a) I’m white/foreign, and b) because I know how to do stuff.
After helping with three of the patients, Tiny sent me to get lunch. It was already past 2, so I just ran outside the hospital to a street vendor. I’d never tried the food before, but Lina liked it and said it was a more traditional meal than some of the other places we’ve been, so I went for it. I got pap (the staple cornmeal dish), some kind of cooked kale and carrot salad, butternut squash, and chicken curry. Also, a pineapple Fanta, just to try it (it tasted like gummy bears!). I took two bites of my food, then set it in the lounge because two of the nurses promised to show me how to place a TB skin test/let me do one at 2:30. They had disappeared when I got back, though, and after waiting around for 5-7 minutes, I asked a different nurse. She said that she was too busy. I grabbed a few more bites of food, repeated the process, and was told that one of the patients had already had the skin test that morning. Tiny was in a study group, so I decided not to push it any further – if I want to make friends with the nurses, it’s best not to mess with them when they’re busy.
Entered charts for an hour or two, then dragged myself home. We had been planning to go to the Yacht club to celebrate the next day’s holiday, but we were all too tired. Stayed in. So tired.
No comments:
Post a Comment