Wednesday, July 8, 2009

Challenges of working at a mission hospital

There are many challenges that arise in working at a mission hospital
  • daily running out of medicines, IV fluid, IV tubing, blood in blood bank, sutures, staple guns, reagents for the lab equipment, and not being told about it until you are out
  • power outages
  • equipment that breaks down because it has been jerry-rigged together
  • not enough resources to fix or obtain the things that are needed to keep the hospital running (i.e. hydroelectric plant, sewage plant, etc)
  • not having access to labs, radiographical studies, or other tests that would make caring for a patient or making a diagnosis better, easier, and less uncertain
  • not being able to trust what others do or report, or what patients tell you

All these things you just take in stride, knowing that you can't really fix most of these things, so you learn to live with, make do, and adjust one way or another. You carry your headlamp in your bilum at all times, just in case the power goes out. You learn to improve your physical exam skills and improve your ultrasound skills in order to make a diagnosis since you don't have the lab/mri/ct that you want. You continue to ask for money from supporters and government until the needs are met. You check your own blood pressures when it is really important, and ask your own important history questions.

Recently, there has been a new problem. Our lab is usually able to give us a complete blood count, malaria smear, some chemistries quite reliably. At times our CBC machine is down, and then they do it by hand and that adds in lab person error so at times it is off, but recently it has been more than off. I had a patient with a white blood count of 51,000, hemoglobin of 18, hematocrit of 59, and platelets of 328. The WBC was high, suggesting possible infection vs leukemia. The next day it was retested - wbc 55, hgb 3, hct 9, plt 12. This is quite a change in just a day when the pt isn't bleeding. The pt looked quite pale and so I thought this 2nd one could be right. I talked to the lab, and they assured me this second one was right. I also asked to see a blood smear to look for leukemia - which he does have. I gave him blood, and we checked his hgb again to see where it was at after the blood - now his wbc is 6 and his hgb is 10. Where did this come from and what am I to believe? If I hadn't looked at his peripheral smear myself, I would be doubting that he had leukemia and that his wbc was 55. So despite what the lab says, I am sticking with my diagnosis and treating him as such. But what am I to believe in the future?

The lab also came to me today and told me that they needed to redo their stains for acid fast bacillus (AFB) staining. We use this to check for pulmonary tuberculosis in patients. We had a period of time, where we didn't order them because they were always negative in pts who clearly had TB. In the past few months, that problem was fixed, and we were getting positive smears, so we started ordering them again. Now, we have another problem, too many positives. I have a patient on the ward with an abnormal chest xray, that I really wasn't thinking was TB, but the AFB came back positive, so I started him on treatment. Today, with the new stain, it is negative - great now what?

Just another challenge to add to our daily care of patients that we must overcome.