Posted by: rhoban | March 10, 2009

Day 9 – UTH, Lusaka, Zambia

Saturday, in CO3, Gynecologic Emergency

Warning: this entry contains some very graphic and potentially disturbing material

To hear today’s story, you can click here. Or here: 

CO3, the “low cost” emergency gynecologic emergency department at the University Teaching Hospital is always busy.  Between 60 – 80 women arrive daily to see a handful of nurses and doctors who also cover labor and delivery, surgery and rounding on inpatient wards. It’s this busy, even on weekends. Yet the women come because this is one of the only government run free hospitals.

The atmosphere is chaotic, an impression enhanced by a profound shortage of staff, supplies, medications and private spaces.  But it’s not chaotic in the sense of “E.R.” chaotic, it’s chaotic in the sense that no one ever seems to have an idea of what’s happening, and there’s a randomness to when and how patients get seen.  Of course, that’s exacerbated for me by my lack of the local language – but even when people are speaking English, there’s a seeming disconnection between how sick some of the folks here are and how urgent anything seems.

This rusty gurney is typical of the patient care equipment in CO3 'low pay' clinic.

This rusty gurney is typical of the patient care equipment in CO3 'low pay' clinic.

Women who can pay come to the ‘high pay’ clinic for services that cost the equivalent of 3-5 dollars.  The fact that women continue to come in the face of all these deficiencies is only a small indicator of the extent of the unmet need.

As I sat, I took notes in the little notebook I carry around with me.  Here are some excerpts:

8:30 am:  I get there, the waiting area is packed.

I wander down the hall and the midwife, Iness Kabamba is leaving the staff toilet, dragging a mop. There’s water on the floor.  She tells me it overflowed last night. If you don’t turn off the intake valve for tank, it overflows.  Someone forgot. I ask her if there’s housekeeping, she tells me she hasn’t seen any today.

Method used to heat water to clean instruments.  This outlet is in the nurses' room, about 30' from the procedure room.

Method used to heat water to clean instruments. This outlet is in the nurses' room, about 30' from the procedure room.

9:00 am:  Kabamba’s lugging a bucket for boiling water to clean instruments before they go into the autoclave.  There’s no hot running water, so she uses an electric coil that hangs into a five gallon bucket, suspended by a stick.  There’s no good electrical outlet in the procedure room, so she heats the water in the nurse’s room and schleps it down the hallway (about 30’).  Then she starts washing up.

10:00 am: Apparently a toilet’s overflowing in the ‘high pay’ ward.  Three men arrive to take care of it.  One carries a plunger, one carries a snake, and the third…?

10:20 am: One of the men leaves, comes back, the three leave.  I ask the nurse.  She says they can’t fix the toilet today.

10:30 am:  Still no doctors. A nurse, Cherisencia Kasiya is taking vital signs at the little table outside the nurses’ room.  Blood pressure – uses the old fashioned mercury sphygmomanometer. Reliable.

I watch for a while… has she taken a pulse? I’m not seeing it.

Mercury thermometer too… shaken down and placed under a woman’s armpit.  Not as reliable – you have to add a degree or two to get the ‘accurate’ reading.  But easy infection control.  They don’t have a lot of alcohol to clean it off in between patients.  I think of all the plastic disposables we use in the States, and am amazed.

Nurse Cherisencia Kasiya takes a patient's blood pressure in CO3.

Nurse Cherisencia Kasiya takes a patient's blood pressure in CO3.

Kasiya writes the women’s names and vitals on little slips of paper that look as if they’ve been torn from a notebook. Then they get laid in a little stack on the table. The women carry their own medical ‘files’ about the size of an elementary school exercise book, with a pre-printed cover.  Apparently, if they lose their records, there’s no copy at the hospital.

An old box of gloves that’s been torn open is where ‘lab results’ get placed. I file through the pink carbon copy forms.  Some are for blood tests done a week, two weeks earlier. I’m utterly confounded how some doctor would ever find results.

11:00 am:  The doctors arrive, Doctor Mupeta is followed by the Congolese female doctor with the wild hair. She’s wearing the same clothes as yesterday.  Mupeta says he was up half the night with deliveries and a caesarian section. We chat.  It’s then I realize he’s not even completed residency yet, and yet, he’s the senior doctor on the ward.

Things get more lively and women start to file into the examination room to be seen.

11:15 pm: A young woman wanders up and down the hallway of the ward . She speaks in the local dialect, so I can’t understand what she’s saying, but she seems unfocused.  She comes up and stands at the table where nurses take vital signs. They shoo her away, but she wanders back in a few minutes later, and finally lays down in the waiting room among the crowd of women there.  They tell me she has a psychiatric problem and is homeless.  She sleeps outside in the campus of the hospital, and wanders through the wards, always complaining of some physical ailment.  She comes to CO3 often.

Noon: Needing a break from watching general activity, I wander to the treatment room at the end of the hall. There’s a woman in a bed in one of the six beds in the room – all full.  She’s got a bag of blood hanging, slowly dripping into her. It’s about half complete.  She has a thick cotton jitenge (one of the colorful cloths women wrap around themselves to use as a skirt) separating her from the rubber mattress.  No sheets.  The mattress is about 2 inches thick. The gurney she lays on is pockmarked with rust.

I ask her when she came in:

“Last night, about 22 hundred (many people here use a military-style clock for timekeeping).
“How many days were you bleeding?”
“Three”
“Feel better now?”
“Some”
“When was the last time you saw a nurse?”
“Last night when they started the blood.”
“Has anyone taken your temperature?”
“No.”

I’m struck by how passive she seems.  Well, to her credit, she’s been bleeding for three days, she probably has the energy of a limp rag.  But she’s there alone and there’s no one with her to advocate for her.  And no one to advocate to – there are maybe 3 nurses floating around.  Kabamba’s in the procedure room with the doctor.  Kasiya’s taking vital signs and doing assessments.

It’s been a while since I worked in a hospital and knew the protocols about hanging blood on someone… but I remember it was something you watched like a hawk, monitoring for a reaction.   The first sign was always an increased temperature…

A view into the 'high cost' patient ward, in the morning before patients come.

A view into the 'high cost' patient ward, in the morning before patients come.

12:15 pm: Lunch break. I’ve brought a little sandwich that I made from breakfast leftovers and a bottle of water. The nurses insist on sharing their lunch with me. They give me nshima – cooked maize pone.  Here in North Carolina  it would be called grits, maybe polenta.  They cook it to a consistency more like polenta.  I dip balls of the nshima into a small amount of stew that is mostly oil, spices and some meat (I don’t ask).  I have a chocolate bar, so, I reciprocate and share it with them.

Once again I’m blown away by how willing these folks are to share when they have so little – Kabamba says she makes only about a hundred dollars a month. And she’s the lead nurse.  The others make much less, but they’re doing ‘well.’

The young woman with the mental illness wanders into the nurses room.  She tells them she’s hungry, they give her a plate of the food.  She squats in the corner to eat.

A chart showing how to estimate varying amounts of hemorrhaged blood.

A chart showing how to estimate varying amounts of hemorrhaged blood.

Just before 1:00 pm: I take this photo.  It’s a picture of a chart on the wall of the nurses’ break room… using a mannequin, it shows how to estimate the amount of blood lost during post-partum hemorrhage (PPH).

1:00 pm: I wander out to the waiting area… Doctor Mupeta has come and gone, done some procedures.  I touch the wall separating the procedure room from the hallway across from the area where the women sit.  The wall gives to my pressure – it looks like it’s about quarter inch thick plywood.  What I know for certain is that the women waiting across from it can hear everything coming from the procedure room – including moaning, screaming, pleading as Mupeta does procedures without analgesia, much less anesthesia.  It’s not sadism, it’s just that they don’t have the medications. The best they can do is give women some paracetamol (roughly akin to Tylenol) 20-30 minutes before a procedure that in the US would merit opiates, or full anesthesia.

Kabamba says she uses ‘verbal anesthesia’, essentially, talking to women during their procedure to distract them from the pain.

2:00 pm:  Something has prompted a mass movement.  At least ten women wander down the hallway to where the nurse usually does assessments. They stand there, waiting.  One argues with the nurse.

Kabamba comes out and starts taking vital signs.  She places a thermometer under one woman’s arm to take her temp. Then someone comes and calls her away.  She’s gone for 20 minutes – I know, because I timed it.

The entire time Kabamba is gone, the woman sits with the thermometer tucked into her armpit.  When she returns, the woman is still sitting there.  I casually mention the thermometer.  Kabamba walks over, removes it, jots down the temperature and dismisses the woman to the waiting room.

3:30 pm: A woman shuffles down the hallway to the assessment table. She’s bent over, wrapped in many brightly colored jitenge that have faded with time and washings.  She’s carrying a opaque garbage bag, you can see that there’s something bloody within.  It’s only then I realize that the bag’s been leaking, dripping blood-colored fluid onto the floor … drip… drip… drip.  I follow the drips back to the entrance of the hospital.

When I get back to CO3, a maintenance man has appeared, he’s mopping up the blood in the hallways all the way back to the entrance.  I ask: it’s a fetus that the woman expelled earlier in the day.  She had taken a bus to UTH, with the bag, to show the doctors. Now, she’s in the room in the back, waiting to get some blood.  I wonder how long the bag’s been leaking.

I wonder how long she’s been bleeding.

That’s when I decide I’ve had enough for one day.  I say my goodbyes, arrange to return on Monday and leave.  I go back to my hotel.  The first thing I do is order a beer and stare into the swimming pool for a long time.

Comments? Send them to ncvoices@wunc.org

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