June 1st

I spent my morning back at the hospital today. The doctors were only 30 minutes late today. I decided to do rounds in the male and female ward today. I encountered the same problems as I did during my previous visit. No mosquito nets over the hospital beds, no visible hand washing, not following orders, limited assessments, and treating for malaria without conducting the proper tests. When I broached each issue with each a doctor or a nurse they each came up with a different list of excuses. Malaria nets are not hung because it is unsanitary, or the patients take them, or it is not malaria season. Looking around at the stained and dirty beds and the close proximity of each patient I highly doubt that mosquito nets are the worst of their problems when coming to infection control. There are on average 10 people using the same bathroom; which is cleaned only once a day. There is only one bed pan for the entire hospital. There is one thermometer per ward; the temperatures are axillary but I have yet to witness any form of disinfection between patients. And to top it all off I can count on one hand the amount of times I witnessed a nurse and a doctor washing their hands. As for patients taking the nets this in not really a bad thing. For one the patient will have a mosquito net at home, hopefully reducing the incidence of malaria and secondly it would reduce the risk of infection by putting a clean net on each bed after a patient is discharged.  The last excuse about it not being malaria season I find the most absurd. If it is not malaria season then why is the working diagnosis for over half of the admitted patients malaria? Riddle me that one!

When I broached the issue of hand washing the nurses stated that they do wash their hands. They have a hand washing station located in their office. When I asked how often they wash their hands they laughed and said when they look dirty. As a nurse from America part of me died a little inside. Upon further investigation I discovered that the doctors and nurses did have a supply of alcohol based hand gel at one time, but when the supply ran out it was never restocked.

Addressing the issue of not following orders was a little more difficult and I still feel as though no one was able to give me a reason as to why or where the breakdown in communication was occurring. During rounds the one of the two nurses on duty in the female ward rounded on patients with us. The physician wrote an order to change an antibiotic; the nurse was there and saw the order but never did anything about it. The following day the antibiotic had never been changed. So the nurse knew about the order but never followed through, why? I suppose you could write it off as laziness or lack of reasonability, but that seem like the easy way out.  I am sure that laziness and complacency play a role in orders being missed but I think it also has to do with the lack of follow-up by the doctors, the fact that there is repercussion to not following orders, and there is limited understanding of cause and effect. I have found that across the board culturally Zambians do not understand that their actions can have a direct impact on something or someone else; for every action there is a positive or negative reaction. For example by not giving the patient the proper medication or not drawing the lab sample the health and overall outcome of that patient is compramised. And finally the nurses and doctors are not invested in the patient population. The government mandates that nurses and doctors have to survive two years in a rural clinic, therefore there are stationed on average 300km from their families and are unfamiliar with the culture and people of the region that they are serving.  

The majority of the patients that I rounded on today suffered from perceived malaria, but once again the patients were being treated without a positive confirmation of the disease. The breakdowns in this chain are obvious and numerous. The doctors do not always write the order to test for malaria, despite being federally mandated, the nurses do not always follow the orders, the lab samples do not always make their way to the lab, the lab does not always process the samples, the results do not always get relayed back to the appropriate areas, and the results are at times inaccurate due to lab error, faulty machines, and wrong patient labels. I’m not even sure where to start with that one.

I did spend a short time in the clinic today where a police officer brought a two year old girl suspected of being sexually assaulted by her 14 year old cousin. The physician upon examination determined that there were not obvious signs of sexual assault; there was no bruising or lacerations or signs of trauma, and the lab results for STIs came back negative. I was relieved but I was also curious as to the legal processing regarding sexual assault involving two minors. I discovered that at 14 you are not considered a minor and he would have been tried as an adult. The officer also informed me that the parents can also be considered legally at fault for not monitoring their children more closely. The whole encounter kind of made my skin crawl. I wanted to go home and take a shower, but being in Zambia with no running water nearby let alone a shower I did the next best thing and took a ice cold bucket bath. Woot!