Inpatient Care

Peruvian art - hospital depiction

My sister recently reminded me that I’ve never written about my experiences in the hospitals here. The truth is, I’m not sure how to correctly portray inpatient care without sounding completely negative. Thus, my disclaimer: This post is not intended to point fingers or look down on the culture, but rather I hope that by talking about some challenges we can move forward with change in some of these areas in the future. Here goes...

I worked in one hospital in Perú for about 3 months, right when I first arrived. In all reality, the hospitals here are not as scary as I expected. While they are crowded (generally 6 patients and their families per room), they are less crowded and seem a bit more sanitary than the hospitals I observed in Africa. However, they’re a far stretch from anything I’ve seen in the US. No high-low beds, TV’s, meals, “pain buttons,” assistive devices, DVT prophylaxis, clean sheets, or support bars for bed mobility here! Gloves, soap, blood pressure cuffs and toilet paper are generally non-existent. The patient charts are very difficult to read/navigate. There’s little patient modesty/privacy. I won’t even go into the smells or sanitation issues. They are very strict about visitors- I’ll never forget one day when a 3-year-old girl with a wrist fracture screamed and cried for her mom (who, like everyone else, was banned from coming in the hospital)– for the entire shift, poor thing.

The patients’ family is expected to pay for everything in advance. (They usually aren’t even admitted to the emergency department without waiting in line to pay first!) If they can’t afford, for example, the pain medications or the surgery, then the patient just has to tough it out. I’ve seen a lot of x-rays of horribly displaced fractures that are treated with conservative management, when they really should have surgery. I’ve also seen some scary looking external fixations and a lot of issues with contractures, bed positioning and a general lack of patient education following surgery. That’s right - no bed mobility, let alone gait training or assistive device fitting!

Another challenge is interdisciplinary communication (or lack thereof). Here in Perú there seem to be power issues between the doctors and other professionals, and some do not seem to respect those who have “lower” roles. Nurses are commonly shunned out of the room during rounds, and I’ve never seen a doctor communicate with a nurse before, aside from scribbling notes in a chart.

Peruvian art 2 - hospital depiction

My profession of physical therapy also appears to lack respect from some of the doctors. One surgeon told me that they are afraid for “the PT’s to come in and screw up their work.” In fact, I was supposedly the first PT to ever work with post-surgical patients at that particular hospital. Sometimes PT’s from the outpatient clinic are called in to other parts of the hospital for respiratory therapy, but they do not normally work with patients in the surgical units. It seems elitist that the doctors included me but not other PT’s in the surgical ward. While it’s true that the local PT’s have less years of schooling than those from the US (3-5 years after finishing high school at age 16), many are good clinicians. On the other hand, the majority of treatments I’ve observed applied within PT here are modalities (ultrasound, TENS, magneto-therapy, infra-red, hot packs, whirlpool therapy, etc.) so I see both sides.

Despite the incredibly vast needs evident in the 40 or so patients residing in the surgical ward, they selected 3 or 4 per shift that they thought would benefit from PT. When I tried to tactfully point out the numerous benefits and cost-effectiveness of physical therapy pre and post surgery, I was told, “Well, some people claim that’s the case, but I won’t believe it until they conduct a study about that here in Perú. In fact, we need a study here in my hospital first.” However, the difficult part with my argument is that one of the roots of the problem is in the education the PT’s receive here – first we must ask, would they be prepared sufficiently from their education to provide inpatient care?

There’s certainly a huge fear of early mobility – doctors also told patients to remain in bed one-two months once they leave the hospital, regardless of the case and surgery involved. You would think with the high DVT rate (not to mention the many other complications following immobilization and bed rest!) they would change their patient advice. Many of these culture-embedded challenges are large and controversial to tackle in one year’s time! I’ve certainly learned that in working abroad, you have to pick your battles, and in my year here inpatient care is unfortunately not one of them.

The PT work is difficult, especially without access to assistive devices, blood pressure monitors, and pain medications. Also, a big problem with many of the patients who are waiting for surgery is nosocomial infection- pneumonia is quite common. I’ve also been in the Tuberculosis ward once, and let’s just say, it’s not my favorite part of the hospital. Though my time working inpatient care was short, I had some pretty eye-opening experiences. I saw many examples of treatment that would have been lawsuit material in the US. One of my patients had a toe amputation secondary to diabetes, and because someone in the hospital wrapped his limb so tightly after the surgery, they had to go back in a few days later and remove nearly all of his foot from the tissue death.

Peruvian art 3 - hospital depiction

The amounts of injuries caused from trauma were overwhelming. It was certainly not an upbeat place – I had several patients with spinal cord injuries – one was a young mother, at 18, spinal cord severed at T5 and incredibly heart-breaking to work with. With economic hardships, no health insurance and a lack of affordable physical therapy services – I often wonder what’s become of certain patients – where are they now? What is their quality of life like?

I was lucky to have the opportunity to watch some surgeries during my time with inpatient care. In one case, the patient suffered multiple fractures from a car accident and the operation repaired a shattered femur. The surgery itself was similar to what I’ve experienced in the US, but it was less sterile and a little slower, namely because the facility does not have a real-time x-ray machine. They had to bring in this giant x-ray machine, wait to get it all set up, remove everyone from the room, take the x-ray, remove the machine, wait for the image, discover it had movement artifacts, and then re-do the whole process before they could continue! All in all, about an hour of the time on hold to get the x-ray results before they could continue on with the surgery!

I learned a lot during my short time in inpatient care and have many more stories. Some of what I saw makes me cringe at the thought of ever having to be admitted to a hospital here. However, I also interacted with many great, hard-working doctors and nurses who were dedicated to serving their patients with the best care possible, given the limited resources.

My sister recently spent a few weeks volunteering at a different Trujillo hospital in labor and delivery. She has some great insight into a completely different side of the Peruvian hospitals (and also a lot stronger of a stomach than I do)! You can read about her adventures here:  http://travelrunlivelove.blogspot.com/2011/05/tears-of-joy-and-tears-of-sadness.html

Peruvian art 4 - hospital depiction (is that baby reading a book?!)