Dealing with “the system”

Working in a system with opaque organization and limited resources takes its toll. Every day, I resist the urge to alphabetize the patient charts as I rifle through the large overstuffed cabinet that holds the dozens of files for each ward, knowing that there is some logic or at least habit there that I simply do not understand. On phlebotomy rounds with the overworked interns, I rip the stubborn cloth tape to label the reused laboratory blood tubes, silently wishing for stickers or even a pair of scissors, but knowing that the tubes need to be labeled immediately, that this is “the way it is done,” and that I am only a visitor. I want to type up a formulary for the pharmacy, to know what medications are actually available, but I’ve settled for making an ever-changing list for myself. After spending more than ten minutes one day tracking down the single blood pressure cuff on ward 4A (which holds as many as 80 to100 patients), I’ve started carrying a blood pressure cuff myself on rounds, draped around my neck like we wear stethoscopes in the U.S. I’ve also started carrying a thermometer--though it is a travel thermometer, measured in Fahrenheit, and we only use it for axillary temperatures, it is better than nothing.

I do sometimes ask pointed questions of the Ugandan nursing or medical students, if not the greater powers-that-be of the hospital. For example, I keep asking about creating a system for keeping track of treatment sheets for patients admitted “to the floor” (a literal description, meaning there are no more beds available and this particular patient gets a foam mattress on the floor). Typically we tape handwritten treatment sheets to the end of each patient’s bed listing the medications for the day, and these may be a patient’s only form of identification. When the patient has no bedframe, this all-important sheet of paper can get lost. This problem was illustrated most vividly last week by a woman in the ID ward, lying on a mattress in a pool of vomit, largely unresponsive and totally incoherent. Nobody could find her treatment sheet, and without that, nobody even knew her name. It’s not that health providers do not fundamentally care about patients, by and large; it is that any system that requires them to supervise patients in such numbers with so little support leaves them little time or energy to care.

But there is an underlying system here and a way to work that system, as much as there is at Yale-New Haven Hospital. Consults, for example, are notoriously difficult to get at Mulago and are generally directed to individual physicians rather than services. Earlier this week on GI rounds, the team wanted an OB-GYN consult for a woman with gross ascites from likely metastatic ovarian cancer. The attending instructed our team that it is crucial to request consultations only from doctors for whom you can write both first and last names on the request form (because then the doctor being consulted will believe that he or she knows you personally and is more likely to actually come see your patient). We therefore spent two minutes as a team trying to come up with the first names of gynecologists before dispatching the consult request—and, to my surprise, a consultant arrived the very next day.

It is also notoriously difficult to transfer patients between services or to get surgery involved on patients housed in the medical wards. More than once, I’ve seen this same GI team immediately discharge patients who develop acute abdomens and need emergent surgical intervention. Rather than wait days for a surgery consult that will likely never come, the medicine team instructs these patients and their attendants to leave the hospital and immediately come back in through casualty and not to mention that they’ve already spent any time at Mulago. With luck, they told me, the patient will then be appropriately assigned to the surgery team. Conversations like this happen every day, until the ridiculousness inherent in any resource-strapped system starts to seem normal.

In some ways it is lovely to work in a setting with more fluid boundaries and less attention to arbitrary protocol. The hierarchical power structures that so frustrate me in U.S. hospitals seem less rigid here, though I obviously have a limited perspective. For example, last week one of the most senior physicians in the hospital gave us, the visiting medical students, an impromptu hallway lecture on malaria pharmacology. As we stood around the chalkboard drawing enzyme reactions and parasite life cycles, a nurse came and sat down and then an HIV counselor wandered over, asking questions, free to fully join in the discussion. I just can’t imagine that happening in attending rounds in the U.S.

There have, however, certainly been times when I’ve felt personally overwhelmed by the lack of system. Earlier this week I joined a new service on morning rounds. That afternoon, I went back to the ward to see some of the patients again, to fix the details of their histories in my memory and to do more complete exams without the time pressure of rounds. I’d forgotten that in this “system” often there are no interns, or nurses, or health care providers at all around the wards in the afternoons. I walked into the open ward and suddenly, half a dozen men were calling me, sending their attendants to wordlessly hand me the precious hand-written lab results or printed ultrasounds, asking me to do something about the boy vomiting bright green bilious fluid, requesting tablets for pain relief, for nausea, for diarrhea, asking questions I could not answer. I could provide almost nothing, could call almost no-one, and have never felt more strongly like just walking out of the ward and not coming back that day. In the end, mostly to assuage my conscience, I went outside the Mulago “system” and called one of the Yale residents to help negotiate some of the more immediate questions, but the experience was profoundly unsettling.

We all trade similar moments of our experiences around the hospital, moments that are simultaneously frustrating and hilarious, poignant and disturbing. Lily laughingly told us about seeing one man with a tiny cloth hand towel maneuvering between the beds of seizing or dying or vomiting patients, reaching over sprawled attendants in the absolute chaos that is a full casualty ward, just to wipe off each light switch, for lights that do not even turn on. Kaveh told us about meeting a woman who lives in the TB ward, a woman who apparently worked for the hospital for over 20 years, developed TB nearly a decade ago, moved in for treatment, and never left. Other stories are more disturbing, like what it is like to watch a man die from an acute MI in front of you, with no code to run, and no possibilities for critical care even if that initial code were successful. There is no concept here of leaving AMA--against medical advice—in fact, the word the doctors tend to use for patients who simply give up and leave is “escaped.” The official patient form lists patient disposition options as 1: discharged; 2: died; 3: ran away! Sometimes, seeing what I see here on a daily basis, I want to congratulate the patients who choose option three.