May 16th

I finally got a tour of the hospital. The nursing officer was only a hour late, I saw this as a good sign. I have started going everywhere with a book now. You never can count on anyone showing up on time so you might as well pass the time reading. I have also started carrying toilet paper with me where ever I go. Although some places actually have flush toilets chances are they will not have toilet paper. Always good to have a stash with you at all times. Anyways the chief nursing officer took me around to all the different wards and introduced me to everyone we saw. Introductions in Zambia are long and drawn out. To have a proper introduction in Zambia I have found that are certain criteria you have to meet. First off the greeting has to be at least 90 seconds long, you need to include the person’s full name, where they are from, what they are doing here, why they are doing it, and your own person view of the person. Needless to say the tour took 2 hours and since the hospital consists of only 4 different wards this was an impressive use of time.

The hospital is composed of a female ward, a male ward, a labor and delivery ward, and a pediatric ward. Each ward is in a separate building running parallel to each other. The wards are large open spaces with beds lining each wall. There are no curtains and no dividers between each bed. There is one bathroom at the end of the ward with no door. The bed frames are spaced less than four feet apart from each other; they are made of steel and have two inch thick body fluid stained mattresses covered with blankets and sheets that the patients have to provide themselves. Typically patients cannot afford sheets so they sleep directly on the mattress with a chitenge covering them for warmth. The air smells faintly of vomit and urine and bleach. The windows are open with no screens; flies and bugs are free to come and go as they please. Unusually the flies prefer to stay past their welcome.  There are signs on the doors promoting the use of mosquito nets; “Do your part in stopping malaria, sleep under and mosquito net every night!” There are not mosquito nets on any of the beds.  Oh and there is no power. I feel as though there are too many differences between American hospitals and the Mufumbwe rural hospital to bother listing them all. I would be been off listing the ways in which they are alike; there are patients, they are sick, there are doctors and there are nurses. That about sums it up.

I spent most of my morning in the pediatric ward doing rounds with the one of two doctors stationed at the hospital. The doctor would round on each patient, ask the mother a few questions about the child (no fathers were present), review the vital signs, conduct a maximum of 30 second assessment and then scribble down a few orders on the medical card which is a single piece of paper in a yellow folder. For those who are unfamiliar with vital signs they typically consist of heart rate, blood pressure, temperature, oxygen saturation, and a pain assessment which are assessed every 2 to 8 hours in the States. The only vital sign monitored in the pediatric unit was temperature once every 24 hours if the nurse remembered.  The orders along with the vital sign seemed to be viewed as optional by some of the nursing staff. There were several orders from the previous day that were never completed, labs that were never drawn, medications that were never given, and dressing changes that were not completed appropriately. At this point I have only observed for a day so I cannot say with any certainty where the system break down occurred, but it glaringly obvious that the current system is not functioning effectively. It is also difficult to determine the long term effects of the failed system since the documentation and record keeping is relatively nonexistent. One can assume that several patients have suffered from delayed treatment at best and death at worse. Scary.

The pediatric unit is setup the similarly to the men and women wards. The beds are a bit smaller, but the mattresses are just as stained, there are not mosquito nets, and flies are everywhere. There are no chairs for the mothers to sit in, in fact there is no place for the mothers to sit, rest, or sleep anywhere on the hospital grounds except for outside. You can see families cooking outside on small fires, sleeping, and doing laundry.

There was a child in the pediatric unit who suffered from second degree burns covering 30% of her body. She had knocked a pot of boiling water off the fire; it spilled down her face, her arms, trunk, genitalia, and legs. I have never worked in a burn unit but I do recall from school that burns can cause severe dehydration, and they are at extremely high risk for infection, and the pain can be unbearable. I know that some other metabolic processes go on involving electrolytes, capillary permeability, and fluid shifts but I cannot recall the specifics at this time (sorry Professor Huber). The child was lying on a stained mattress with a chitenge covering her body, no mosquito net, and in a room with many other sick and infectious children. I did not observe a single person wash their hands when moving from one patient to another, in fact I did not even see a sink or a basin to do so. The dressing changes were conducted without gloves, without sterile dressings, and without any pain medication. I am embarrassed to say that I had a hard time staying in the room while the child wailed and her 9 month pregnant mother tried to smooth her. The doctor was well aware of the dangers that this child faced, but he said with a shrug “we can only do what we can do.” Fortunately the child’s wounds appear to be clean and healing nicely, she is afebrile, and her white blood cell count is normal; here hoping she stays stable. I am hard time comparing this care with American standards; it seems horribly unfair that because of the country you were born in you are deprived safe and effective health care.

I spent the afternoon diagnosing patients with the other doctor at the walk in clinic. Apparently an American nursing education qualifies you as a doctor in rural Zambia. I have found that in Zambia there are three diagnosis favored by physicians; the first is malaria, then pregnancy, then peptic ulcer disease. If you don’t have one of those then it might be meningitis, if is not that then you are shit out of luck. Skeptical about what I will see tomorrow.