Saturday, October 21, 2006

On the medical ward.


We've just spent our first real week working in Mbarara Regional Referral Hospital. Not a good week from a healthcare perspective. There was no functioning xray (no films). No access to routine lab tests like haemoglobins or creatinine ( a problem because the highest haemoglobin we'd seen on the ward from the week before was 9g/dl and levels of 4-6 are common as a result of HIV, hookworm and poor nutrition - the test reagents had been stolen). Medicating the patients is a lottery according to what stocks are available (it is widely known that the pharmacy staff steal the drugs and the requisitioning process is nightmarishly inefficient). We still don't really understand how there is so much tolerance of the lack of leadership and managerial inefficiency and the downright crookedness of key personnel ( though alleged death threats to the curious and inquisitive probably aren't exagerated).
This week Samples of blood, sputum, CSF etc could be looked at under a microscope but are not sent for culture. There is a shortage of most drugs. There are cannulae but a shortage of giving sets and IV fluids. There are no scales on the ward. No thermometers. One sphygmomanometer carefully locked in a cupboard. The surgical theatre has been closed since last week as the anaesthetists refused to work in it until it was redecorated and the equipment was repaired. It’s likely to be closed for at least a month.
Nursing care is practically non existent. The 2 nurses administer what medication there is ( though most of the patients have to buy their own or go without if they can't afford it). The patients are fed and watered by their relatives. Noone does routine observations on the patients. The nursing and medical management in the hospial is completely ineffectual.
We keep wondering how this can be a regional referral hospital, and one of two university teaching hospitals in Uganda. It’s interesting watching the reactions of other expat doctors to our obvious distress at conditions on the ward. Having been here more than a few months they have become acclimatised. To stepping over patients and sleeping babies on mattresses on the floor, to the lack of privacy, the poor quality of care, the limited diagnostics and the limited treatment options. I’m sure we’ll get used to it to0, although I’m almost more worried about that than continuing to be horrified.
Most of the patients on the ward are desperately ill. Two young women are paraplegic with spinal cord lesions (one probably from TB in her lower cervical spine, the other of unknown aetiology, she’s 18), one with tetanus. More than half the patients on the ward have an AIDS related illness and many of them have pulmonary TB. There's also malaria, although severe malaria usually only affects children and I’m building up to doing paeds next month! Rheumatic fever is still very common in childhood so I’ve seen more people with terrible rheumatic heart disease here than I have for 20 years in the UK. And they’re really young, in their teens and twenties with awful heart failure, strokes from AF etc. Their only treatment option is to go abroad (to India) for valve surgery, which the ones we’re seeing can’t afford.
Every patient consultation involved a negotiation with the carers about how much money they have available. Can they pay for blood tests and Xrays from the private clinics in town (presumably beneficiaries in more ways than one from the lack of facilities in the hospital). The 22 year old with crashing heart failure and atrial fibrillation from her rheumatic valve disease couldn't afford the few pounds necessary for the frusemide or amiodarone that would give her a few more months of active life. This week there's been no oral frusemide so the patients have been given it intravenously.....
In medical outpatients there are two large tables pushed together in the middle of the room with two couches at the sides. At these tables sit 4 doctors, 4 patients, possibly patients carers/relatives, medical students, a nurse taking blood for HIV testing. These consultations also revolve around whether patients can afford medication and investigations. I saw one woman in her 20’s with the biggest spleen I’ve ever seen. She was wasted with an enormous swollen abdomen, all spleen. Probably postmalarial but no real possibility of finding out why.
On the plus side, once diagnosed, HIV and TB treatments are really good, available and free (funded by NGOs). The diagnosis is usually easy on clinical grounds and HIV testing is routine on all patients who attend hospital as out or inpatients. To preserve some confidentiality patients are described as NYN if negative or NYY if positive. The HIV clinic operates from a newly constructed building which has consulting rooms, chairs and desks. AND only one consultation per room! I’m spending next week in the HIV clinic to cheer myself up…….

1 comment:

Lesley said...

Thank you so much for writing this blog. It serves as a reminder of how wasteful we are in the UK. I am thinking of the medicine that Dylan has had in the past (frusemide and captopril) and not used all of it and then its been returned and I guess thrown away, because it cant be sent out for someone else? Thats just one british patient, how often does that happen? Its so insane - such abundance over here and such scarcity there. How dare we moan about the NHS. Thank you both.