More Hospital Thoughts

I know I haven’t had too many posts about life at the hospital in Botswana. I have been finding it hard to write about work for a few reasons. First, in Canada, it is typically discouraged to be overly public about day to day work in a hospital since it is very easy to cross the confidentiality line. Second, I have never really written about work on my website in the past. And third, once settling into a routine at the hospital, things started to feel more normal and as a result, particular things on a day to day basis didn’t seem post worthy. Instead, I’ve decided to write about a few themes that have come up. I am also aware that this post may come across as negative, but I’m hoping that it actually just illustrates some of the differences and challenges I have faced during my time here in Africa.

Efficiency

Things just don’t happen as quickly in Africa as they do in other parts of the world. People will often say that they like the laid back attitude in Africa, but unfortunately, this doesn’t always work in a heath care setting. Things that should take a short time, inevitably end up taking longer and as a result, everyone has to adjust. One of the doctors here early on told me to think of it as “everyone drops a level”. What he meant by this, is compared to working in medicine back home, everyone is being asked to do things they would not normally have to do. So there are specialists acting like general paediatricians, paediatricians acting like residents, residents acting like medical students, and so on. While thinking like this does not make the day any more efficient, it does point out the idea that everyone is doing things they are not used to having to do. So, everyone needs to help out.

Early on in my stay, I was told that the quickest way to ensure that a patient gets an X-ray done is to go along with them. So off I went to the X-ray department. When I arrived, they asked me if I had brought the request form with me. I told them it had already been sent earlier that morning. The person disappeared for a long time before returning to say that they were sorry, but the form could not be found. My reply to this was that it was no problem, I would just fill out another form. Silence for a moment. Then I specifically asked for another form to which I was told that they did not have any request forms in the department so I would have to go back to the ward to get another one. That’s right, the radiology department does not have their own request forms. From that point on, I realized that when going to radiology, I should also remember to bring some extra forms even if I was sure they should have already received the original.

Ownership

For the most part, I would say that everyone at the hospital back home takes ownership for their responsibilities. This is obviously most important with respect to nurses, medical students, residents, and physicians taking ownership for their patients. This means, if a medical student or resident is assigned to a patient, they should know absolutely everything about that patient, even more than the attending physician. If there is something with that patient that is not going according to the daily plan or expectations, it is up to the person assigned to that patient to make it right and/or make others on the team aware of the situation.

While working here in Botswana, I have noticed in particular that blame is often passed on to others. More often than not, these others are people who are no longer working that day or people who cannot be specifically identified. I have also noticed that in general, there is a lack of formal sign-over of patients to the night team on-call. While these things do not happen all the time, they do definitely occur more often than back home and goes back to a general feeling that people are not taking ownership of the care of their patients.

Communication

Communication has been a challenge on several levels. The most obvious is that most people from Botswana speak Setswana. This does pose some issues on a daily basis, but not nearly as many as more broad communication issues.

Again, this is a generalization, but I have found that most people do not offer information. It is always work to get the information you need. If a lab result is not yet available, a phone call to get the result is the first place to start, but the lab rarely answers the phone. When they do, they will often say that the test has not been done yet, which of course, I already know, as that is the reason I am phoning. Asking when the test is planned to be done usually yields no further information as the person who is supposed to do the test is invariably away at the moment or they cannot find the sample. Again, this goes back to the ownership problem discussed above.

One morning a nurse came to me saying that a boy’s father had just arrived and was wondering where he could find his child who was admitted to our ward. I asked the nurse if the boy had gone for his CT scan and she did not know the answer. After looking for his chart on the ward and not finding it, not an unusual situation, we presumed that he must still be at his CT scan with his chart. I then asked the nurse if she could accompany the father to the radiology department so that he could be with his child.

A few moments later, the nurse was back and I could see the boy’s father at the far end of the ward. She said she actually found the boy playing outside, and he remained outside. I asked if he had his CT scan and she replied that she didn’t know. I then asked her if she could find out for me. A few minutes later, she was back and said that she still did not know since the boy’s father had just arrived so the father was unaware if the scan had been done. Since the boy had been scheduled for his CT scan that morning, I told the nurse that it was very important that we find out if it had been done, so off she went. More minutes later, she was back and said that nobody in the radiology department was answering the phone so she still didn’t have an answer for me. I then reminded her that the boy is 8 years old, so we could just ask him as he should know if he had a CT scan that morning. She told me he was outside playing so she could not do that at that time. In the end, I had to walk outside with her to find the boy and ask him myself. Turns out, he did have his CT scan already, so all was good in the end, but it took a lot of effort in communication to find that out.

System Flaws

I started making a list early on in my stay about system flaws since these are things that conceivably could be changed. I was not very stringent about keeping the list though, and there are too many of these things to remember right now, but the following list will highlight a few of them.

  • The spare oxygen tank on the ward is constantly empty despite there being a form attached to it that is signed off each day as being checked and full.
  • When ordering tests at the lab, an order is automatically cancelled if the same order has been placed within 24 hours, even if a new sample is being sent. This makes it very difficult to monitor lab results since for each new sample within 24 hours, there needs to be a conversation with the lab. Often by the time the sample is actually processed, a new person has started their shift in the lab, and the conversation is forgotten so the repeat sample is just cancelled anyways.
  • There is no ward clerk so the printing of forms and collecting lab results and X-rays becomes everyone’s responsibility. Of course, when everyone is responsible, no one is responsible. (Back to ownership, again.)
  • The blood gas machine uses special cartridges that only last one week. It should be easy to predict how many of these are needed in a month since they are changed weekly, and therefore, can be ordered accordingly. But, for some reason, we are almost always out of cartridges.

Closing Thoughts

As stated in my initial paragraph, the point of this post was not to be negative towards the health care system here in Botswana. It was intended to point out some of its differences and the challenges I have been faced with during my 16 weeks here. I am sure that I will notice more differences when I’m back inside the now not so familiar walls of CHEO, and I really do think that there is something to learn from each of these. I am also sure that in the coming days and weeks, there will be much more reflection by both myself and Amanda about how these 16 weeks in Africa have changed our outlook in both our work settings and our personal lives. I will try to post more of these thoughts so we can all learn from them.

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