How the hospital works (Part 2)

So last time I spoke about patient recruitment and how patients get admitted. This time I thought I'd cover the Medical Wards (St Monica (F) and St Augustine (M)). They are positioned in the middle of the hospital and are long 'Nightingale' wards. Some of the young doctors here think they are very old-fashioned, which they are, but you will still find them in the NHS - at Whipps Cross and Leeds for example.

St Monica

The picture (courtesy of the incredibly talented Will Burrard-Lucas http://www.burrard-lucas.com [do you think this is enough of a plug given that I didn't technically ask to use his pic?]) was taken on an unusually quiet day with the back half of the ward not in use. Will was at the main door to the ward, in the foreground is ITU. The only difference between these and the other beds (leaving aside the severity of the patient's illness) is the proximity to the nurse station (halfway up on the right). There is a side wing that runs along the ward that was previously a covered colonnade - the TB patients are here where there is better ventilation. It is a touch ironic that it's been closed in given that drug resistant TB is increasing along with the number of vulnerable patients with HIV...

The ladies that you see sitting at the end of the beds are called 'bedsiders'. Each patient needs one because it is their responsibility to do a lot of things you'd expect a nurse to do at home. They bring food (the hospital provides 3 meals a day but they only amount to 1000 calories and 40g of protein), do basic cleaning and generally assist the patient to get up and down, go to radiology etc. Patients without a bedsider tend to struggle but the nurses do try to help - the Prof's wife also brings food parcels for them and patients whose families can't afford to buy food at the Chada market...

At night the bedsiders sleep next to the bed (often on the floor). There are 3 visiting 'hours' - actually 45 mins - that are identified by a man hitting a cut off length of scaffolding pole hanging from a tree with some rebar (we can hear it from our house - a nice 6.30am wake up call!). If you try to enter or exit the hospital around the start or end time you have to fight through the throng!!

Illnesses

There is a suggestion that the average patient on St Monica isn't as sick as that on St Augustine. I'll discuss why this might be the case in a second. Common to both wards are Malaria, TB (often secondary to HIV), AIDS related diseases like Kaposi's Sarcoma and 'overdoses/poisoning'. Lots of patients claim to have swallowed insecticide in a bid to kill themselves. They are treated for organophosphate poisoning even if their symptoms are exactly opposite organophosphate poisoning because it's not possible to work out what else they drank. Often they make a full recovery.

On St Augustine they also see men who have drunk the locally brewed drink (Kachasu). The problem with it is two fold - no one knows how strong each batch is so it might be nearly 80 proof for all you know and it might be meths not ethanol, which would be unfortunate. All we know is that if you drink it and come to the hospital because of it you aren't going to be the same again. The majority leave as vegetables, maybe they can walk with assistance, maybe they can't. I think they see at least one a week, mostly young men. Such a waste.

But, the reality is if you come with something identified above, or inoperable cancer, it's unlikely you are going to make a full recovery. Yes, there is some chemotherapy for the sarcoma but the greatest role is often palliation. It is frequently heard at dinner at the end of discussing a case 'We did all we could for them so we've sent them home to die' because, frankly, that's preferable to dying in the ward.

Now, what about these other ladies on St Monica? Well, two things - there's the worried well - as in Europe, women present earlier than men with complaints. And some of them don't really have anything much wrong. However, this is still preferable to the men who present too late and have to be palliated in pretty much every case. The other type are the women who are escaping their abusive husbands. They have terrible non-specific systems whenever he's in sight but as soon as he's gone they smile and are happy. The hospital provides a few days of respite.

Patients are moved around the ward as their status changes. If you get better you move further from the door, if you get worse you move to ITU near the door. It took a few days for Nat to work out what was happening to her patients and then why. The nearer the door you are the less disruption is caused by the  coffin trolley. Deeply practical.

Each ward has one oxygen concentrator (or there might be 3 between the 2 wards, it's not clear). These machines concentrate the oxygen from the air and mean that the hospital doesn't have to store oxygen cylinders. It looks like in the past there was one large oxygen concentrator that pumped oxygen through tubes around the wards. The doctors must assess who their sickest patient is to make sure they get the oxygen. Sometimes this can mean taking it away from someone else that they know would benefit. It's a tough call every time. But quite often the patient or their family won't accept it because 'oxygen kills you'. Correlation is not causation but most patients that go on the oxygen die... it's the same with lumber punctures and some other procedures.

At the bed

Being ill can be a great leveller so I guess it's human nature that people want to be able to retain some of their social status in the ward. This is done by bringing your own blankets. The more fluffy blankets the richer the patient. We find it slightly baffling given that many of these people have fevers and it's over 37 degrees anyway - but blankets there are!

On St Monica you have to be particularly careful of a pile of blanket. Because it might not be that at all!

As Nat is beautifully demonstrating, it might be a baby! Mothers with young babies have them in the bed with them either in a separate bundle of blanket or breastfeeding! This is often a great surprise to the doctor doing an examination on the ward round :-D

The blue nets above the bed are the mosquito nets. Only about 10% get used on the adult ward. We have heard lots of explanations - the people sleep soundly under them, dream and then think they are possessed by evil spirits, they are too hot to sleep under, the adults all have malaria anyway. Fine but for every patient carrying the parasite that doesn't use the net the greater the chance is that I get bitten by a mosquito with it. This is selfish behaviour. And it's very ironic given the number of staff wearing t-shirts urging the use of the nets... This story is repeated in the villages. I'm sorry if you have donated money towards providing mosquito nets but I guarantee you it isn't being used. They use them to make bags and ropes and best of all fishing nets!! They make great fishing nets until you realise you've completely emptied the lake of all fish...

What happens if there isn't a free bed?

When the ward is full, they squidge the beds up closer to each other and put mattresses on the floor. When that's not enough? Then they put two patients on each mattress - starting with the smallest. On St Augustine a couple of weeks back they were so full they had two fully grown men sharing a mattress. No one complains because they are getting the treatment they need, given by a Muzungu, which is why they came here. The rest is just fluff.