Thursday, October 23, 2008

Karatu Lutheran Hospital

Jambo!

I have had some time to consider some of the things that I have witnessed regarding health care here in Tanzania.

Karatu Lutheran Hospital is located about 4 miles from the "center of town." As mentioned in a previous blog, the new building was built in 1999, but feels as though it is from the 1950s. The old part of the hospital is now the canteen. There are 2 free standing buildings near the hospital - one for HIV counseling, testing and treatment and another for Maternal/Child health - dedicated to the care of pregnant women and children (mostly for vaccinations). According to many Tanzanians that I spoke with, the government must provide service for any person that is HIV positive, pregnant women, and children under the age of 5.

Inside the hospital is a large waiting area with uncomfortable wooden benches, a chart room and 4 doctors offices that appeared ill equipped. This is the outpatient area that handles most of the routine cases like malaria.

Wandering through this room takes you to a courtyard around which the hospital is built. There is a small laboratory capable of basic tests like CBC, urinalysis and blood smears. They had a Maasai warrior donating blood for a family member while I walked through. Next is a small pharmacy. There is also a room for sterilizing instruments - with 2 autoclaves. It says on the autoclave "use distilled water only," but I'm pretty sure that they just tossed in a bucket of reddish brown Karatu tap water with the instruments. Fascinating. The woman there then packs up the sterile instruments in towels that have been drying in the sun. Sterile? I'm not so sure.

There is one main operating room, where any kind of procedure takes place, including a pelvic exam. This room has a small anesthesia station, with an ether filter and halothane gas. I could not find an endotracheal tube anywhere, so I'm not sure that patients are actually intubated. They had lots of glass vials with labelled bins on the cart, but looking more closely revealed expired medication. I found a vial of atropine in the "promethazine" labelled bin. They had a small cabinet with suturing material. And I found a big bottle of chlorhexadine that they use to prep the patients with. I'm not sure that the surgeons actually use anything to wash their hands with, though. I washed my hands outside of the OR using a squirt from a big bottle that said "disinfectant" on it. There were no suds, and it certainly didn't have the sting of alcohol on my cuticles - I think it was more water. The OR lights had blood splattered all over them.

The hospital is staffed by a handful of nurses and only 4 doctors. All of the doctors are able to perform c-sections, but none have officially been trained as obstetrician/gynecologists. One has a masters in surgery, and was proud to tell me that he is able to handle such difficult procedures such as uterine extensions. All of the c-sections begin with vertical skin incisions.

When I arrived at the hospital, I was supposed to meet with the chief physician. However, he was too busy with the German and Finnish doctors that arrived from Arusha - there to investigate hospital hygiene (and boy did they have their work cut out for them!), that I did not have to sign any forms. One of the staff workers at Minnesota has a friend who is a sort of scrub tech at KLH, Dawson, who showed me around. We went straight to the maternity ward.

The maternity ward was very interesting. There is a small reception area and then a short hallway with 2 large rooms off to the sides and a delivery room at the end. Each of these large rooms has 12 beds squeezed in there. On one side are the recovering c-section patients and on the other are the laboring and recovering normal vaginal deliveries. I rounded on the c-section patients with one of the doctors. The windows open onto the small courtyard, so the room was full of flies. There were no mosquito nets hanging from the ceiling. The doctor that I rounded with could not figure out who he had operated on the night before (despite there being the obvious IV bag dripping into their veins). He kept asking the nurse for their charts - a single piece of paper with their name and tribe name on it. He did make some notes about each patient though.

I was horrified by a few things in this ward. There was a mother who had given birth vaginally the day before to an infant that was charted to be "abnormal." To say the very least, this kid had MAJOR malformations - it had an open spina bifida with its frickin spinal cord practically hanging out of its back - merely covered by a dirty piece of gauze. And it was laying in its own shit which appeared to have been there for quite some time. The poop was creeping up towards this little babies back. The doctor kept scraping the bottom of the baby's feet - a test for reflexes - which was very obvious that there were none - but he kept doing it over and over as if by some miracle the kid would curl his toes. This little baby also had a huge head (hydrocephalus), low set ears and its eyes were very close together. The doctor barely looked at the mother, made a note in the chart that said "refer to KCMC" (one of the teaching hospitals in Moshi - a few hours away). My guess is that this poor mother, who probably lives in a mud hut outside of Arusha, probably doesn't have the funds to even pay for transportation to get her baby to KCMC. I don't think anyone expects this baby to live.

There was another woman there, post operative day #8 from her c-section for obstructed labor. The day before I arrived, they took her stitches out and noticed pus draining from her wound. The doctor that I was with made this huge show in front of all the patients in the room about putting on these sterile gloves - and then removes her dirty dressing with both hands. It was a bit ridiculous. He then proceeded to squeeze with all his might on her belly to express as much pus as possible. The poor woman was obviously in excruciating pain, but made absolutely no sound whatsoever. Tanzanian women are so totally stoic. I just wish they wouldn't put up with such treatment. After he was satisfied with the amount of pus extracted, I asked him if he was going to pack her wound (open about 4 cm) and do twice daily wet-to-dry dressing changes. He kind of looked at me in a funny way, as if that was such a crazy idea, you dumb american. He asked "why would you want to put something in there if you want it to close? watch this. It will close so nicely if there is no foreign body. Let us pray to god that there is no foreign body." He then proceeded to pour in furosol (I have no clue what that is), but it appeared to burn or sting because the patient was wincing again. The wound was then covered with a clean piece of gauze and the doctor went on his merry way and telling me that he was going to start 3 different antibiotics for broad spectrum coverage (not exactly necessary since there was no evidence of a surrounding skin infection). Not once did he address the patient or let her know what was going on or what he was doing or apologize for hurting her. I stayed with her for a minute and she let me admire her darling little baby.

Apparently, being an authority figure here gives you the right to treat people however you feel like it. Teachers here often beat or hit their students if they don't know the answer. And curiosity and asking questions by students is considered offensive - as if they are trying to challenge the teacher's knowledge. It's often punishable with a beating or such severe humiliation. Doctors and nurses regularly yell at patients, which I was witness to and it made my heart hurt.

There was an 80yr old woman, with only a few teeth left, who presented for consultation from the local dispensary. The patient had a few months of vaginal bleeding and they were concerned that she had cervical cancer. They wanted the hospital to do a biopsy and refer for further treatment. Karatu Lutheran Hospital, although equipped with some basic medical equipment (including an ultrasound - though the doctor who could do obstetric ultrasound had left), but they are not anywhere near being capable of doing a cervical biopsy. First of all, they don't have the equipment to even do basic cervical cancer screening with Pap smears, let alone biopsies of abnormal areas. And secondly, there isn't a pathologist around for miles (and maybe there's only a few in the big city of Dar) to actually read and interpret the biopsy results! Before subjecting this poor woman to a pelvic exam, I wanted her and her daughter to understand this. After a very short conversation in swahili, the patient was brought to the main operating room for the exam. It took one and a half hours to arrange for the exam. First they couldn't find a speculum, then they couldn't find gloves. Then we set up in the wrong room because the bed had no stirrups. After getting everything together, they brought the woman in. The nurse immediately began yelling at her and refused to help her onto the bed. When I asked if they could help put her legs in the stirrups, the did so so roughly I thought they might have dislocated her hip. Then I needed her to move down on the bed, so the nurse started yelling at her again. And they nearly laughed at me when I asked for a drape to cover her legs and give her at least some sense of decency. The whole thing was so awful. They brought me the largest speculum they could find - for this poor 80y old woman and her atrophic vagina. I'm sure it hurt like hell. The scrub tech was also highly annoyed when I told him I didn't need to prep the patient or use sterile gloves because the vagina is not a sterile place. Maybe I have it wrong - but it seemed like they have all the intention of being clean - but try to be sterile at the wrong times, and when things should be sterile - they aren't. Anyhow, this poor woman had the nastiest, fungating, infected pus filled exophytic cancer I hope to never see again. When I tried to talk to the patient and her daughter, my interpreter said we should speak to the daughter in private. I don't think my tone was conveyed, because he was also yelling at the daughter and pointing at the patient. The conversation was way too short.

I left the hospital after that and I'm not sure I'll go back.

6 comments:

boogy said...

Meg--
finally got onto your blog...WOW so much for you to take in and process.... just wanted to let you know i am thinking of you

Anonymous said...

outstanding writting from Tanzania. It should be published in the NYTimes with nicholas' blog.

I hope you will have time for Mexicalli some day.

love dad

am258 said...

Love you lots Meg- I know it seems so rough right now and not at all what you are used to in a hospital situation. But just take it all in as best you can- thats what you are there for. To learn and do the best you can to help when you can.

Maybe your stories will help inspire more doctors from your hospital to go over.

Im thinking about you all the time

=) I love you and dont let this hang too heavy on your heart.

Ash

njostrom said...

Yowza! Quite a day in the "hospital". Certainly does make you glad that we're here and have the medical facilities and sterile conditions to heal. Love your blog. Keep on writing, girlfriend!

Unknown said...

Wow! I was actually born there in 83. Hard to imagine how my mother delivered two babies in such awful conditions. Thanks for sharing this.

Unknown said...

VERY INTERESTING THAT YOU NEVER REALLY CARED TO IMPROVE ANYTHING FOR THE SAKE OF HUMANITY. NOW THE WORLD KNOWS THAT KARATU HOSPITAL IS AS SHAMBOLIC AS YOUR ARTICLE SHOWS. AND I FOR ONE SEE HOW IRRESPONSIBLE YOU ARE UNLESS YOU WERE THERE REPORTING FOR THE CNN