Pediatrics at MGH vs. Rwinkwavu Hospital

Saturday, May 13.

I know a little about the Partners in Health mission which is in PIH parlance to provide a preferential option for the poor. I also feel like I know what they mean by this: that in terms of looking at who to serve first with the best of what the world has to offer, it should be provided to the poorest of the poor first because of the innumerable amount of forces working against them. This would include refugees, prisoners, people living in slums etc. That it shouldn’t be that the not-served and rarely represented receive the least last, but that they should get the most first. It is a noble vision. But the reality is this: I go into the Rwinkwavu hospital, and all the certifying bodies in the United States like OSHA would never allow a hospital like this to exist. There are flies everywhere – on the children, on their heads, on their eyes, on me (although a person who just came this past weekend to visit from a refugee camp saw the hospital and feels it’s “not third world, not even a second world hospital.” Coming from a refugee camp she just worked in with little to no resources I’m sure it does look great, so it depends on what your comparison group is I guess. I really believe your comparison and your goal should be the best though, not “its much better than some of the worst.” I don’t think anyone really benefits when you hold a lower bar of achievement for others). But to continue, the staff is not wearing gloves most of the time, I haven’t seen anyone wearing a mask and think they are probably in short supply, people aren’t using any sort of airborne precautions or private isolation with a negative pressure room for children with TB because that just doesn’t exist here. The nurses work with kids who have HIV, TB, malaria or some cocktail of these in seemingly most of the beds and everyone is in the same room together side by side and sometimes 2 to a bed because we just don’t have enough room sometimes.

All of this I had anticipated actually; I really think I had a good idea of what and who I would be working with and for, but part of why I write this is for all the nurses I know back at MGH, who may have no idea about what an area like this does or does not have.

On Thursday I followed the head nurse around to administer meds and there was nothing with which to give the meds. All the moms just pull out their own metal spoons, whatever size they happen to have, and you poor the child’s antibiotic into the spoon from a medicine cart that gets pushed around. If it’s 2.5mL order you pour a half a spoonful into the mom’s spoon, you’re just supposed to eyeball it. And then some of these children protest and wiggle away as should be expected in a child and the antibiotic syrup ends up spilling all over their face and you eyeball how much was spilled and pour out that much onto the spoon again. Then for some reason the most unbelievable to me, was that there was nothing to wipe up the children’s mouths. No napkins, no towels, no nothing to clean a patients face or wipe off a dirty child or wipe off your own hands. When I asked the nurse for something to wipe the child’s mouth she handed me cotton balls. Seemed so basic to at least have a towel, even a reused towel that could soak in Clorox or detergent or something, and I got some gauze and wet it under the one faucet that works and barely dribbles water for the entire pediatric ward of ~40 patients and went to go wipe up the child’s mouth. I could go on and on. Intake and output is not tracked or charted anywhere. There is no such thing as a diaper so diapers are not weighed or counted. No such things as keeping track of voids. They don’t keep track of stool/diarrhea/constipation. Food is not written down. A full set of vital signs aren’t really done as standard part of hourly/regular care. I’ve only seen them take a blood pressure once and they were all working with the cuff with a difficulty that I read as if the cuff wasn’t working right and I thought I could show the nurses how to use a blood pressure cuff the way we do it in the U.S. It’s pretty quick, it doesn’t take that long. And then when I tried it myself, there was no sound coming through the blood pressure cuff so I couldn’t get a blood pressure either. There are no stethoscopes for the nurses. There is no such things as STAT, the method to contact a doctor is to leave the ward and walk to another building and try to find them on your own. And as far as I can see there seems to be a deficit in perhaps a combination of education, understanding or interest if a patient’s status changes (a change in consciousness or increased respirations). As for meds and doctor’s orders, the exact time meds are given is not charted, they just do 6AM, 2PM, 8PM. So tid is the max a med is going to be given and the system seems to not be charted well and not done that accurately. Bed sheets are not changed regularly and although they told me they are changed between patients, the one time I saw sheets changed was after a child had died in it. When I asked how often the blankets are washed, I think they felt they had to answer me with some amount so they said about once a month. Again, I haven’t seen blankets come off yet. They are stained with saliva and hardened liquids of who knows what. Parents take their kids out to latrines to go to the bathroom, and they wash their children outside under the well water. Although some of the Rwandan doctors say that this pediatric ward is cleaner than the other wards, it would be unacceptable for a U.S. hospital. I think about the nurses at MGH on Ellison 18 and how there are many of them who upon seeing this place would refuse to work here because of a) the lack of equipment, IV fluids, meds b) the different standard of hygiene and cleanliness and c) many of these women and children have a severity of diseases that we don’t see in the U.S. and we don’t have the proper equipment to serve them. Syringes and meds are limited, records are not kept of IV intake of fluids on the children, I’ve asked if they would give morphine for certain kids who are screaming and moaning in pain, and they don’t want to give morphine because they think of it as bad since it’s a narcotic and I don’t think they’re used to using it, so kids basically only get ibuprofen for pain. No such thing as low wall suction or cardiac monitors. Oxygen comes from a large tank. Then there is a level of disease children would be in an intensive care unit with the way they sometimes present here. Many come in with electrolyte imbalances and dehydration. Days of vomiting and diarrhea. Some arrive comatose, again flies on the eyes, flies on me. And it is just so bad to me I don’t even know where to start. What is most important in terms of saving a life? Probably patient status changes: change in consciousness, fever >101.5, increased or labored respirations. ABC’s. Airway, breathing, circulation. And then I think about the PIH mission: care just as good for these people as you would want for your own child and all I can think is, “Well then this is absolutely unacceptable. Because my own child wouldn’t stay in this place ever. It would be an “over my dead body” kind of place. And I think, well then, it’s got to get to a level where I would want my child to stay here. And THAT is a FAR FAR vision from the state of things now. It makes me both angry and frustrated - like handing someone an ocean to fill up with a spoon. And yet, somehow the U.S. doctors seem to be managing well. Yeah, the locals are at a disadvantage, yeah it’s a far cry from a U.S hospital, but amazingly, they do what they can. And all the docs here, actually all the PIH staff work incredibly hard. But the poverty is upsetting. And I wonder if I need to get used to it in order to move forward. Right now, I just keep all this to myself. I think after working here awhile, you just acclimate. One of the docs told me she doesn’t even notice the flies anymore. The thing is, I also don’t want to get used to it. Like PIH’s mission, if anything, these people should be getting the best care possible, that needs to be the goal. And right now, this is not it. Not that there aren’t positive things happening, there are. They have a great educational program for kids with HIV, they have a great program to prevent moms from transmitting HIV to their children, and there are other advances. Successes. I love the home visits. Going out into the community and meeting the moms in their homes and talking with them about their children’s well-being is exactly what I enjoy. I have always liked this, in the U.S. and here. The hospital is more well run and well built with a beautiful grounds and better than anything around by far. But the successes seem like just a rain drop into the vast ocean of maladies and I guess if you constantly think about what this place is not, you would just give up, so you just have to work with what you have and see what you do have rather than what you do not. Day 12 and I am still figuring out and finding my place.