We’re a little more than halfway through our
internship. In some ways it seems like it’s gone by fast while in others, not
so much. Steph says the days are going really slowly but the weeks fly by, and
I have to agree. At this point, I guess it’s way past time to talk about the
hospital, which is why we’re actually here. Before I
do, however, let me preface this by saying that my views in no way represent my
school or anyone affiliated with it, nor are they in any way intended to
reflect on the hospital or its staff. If anything, I would simply like to raise
awareness of healthcare services in another part of the world that I have been
fortunate enough to visit.
Stephanie and I are OT (occupational therapy)
interns at a government-run hospital in Zanzibar. For my Kenyan friends, it’s
basically the equivalent of a provincial hospital (if those still exist) or a
smaller scale Kenyatta National Hospital-type. The closest I can liken it to a
hospital in the states is Ben Taub in Houston (and perhaps Harbor View in Seattle)
in that it offers free/low cost services, but is of course considerably smaller
and has significantly fewer resources. Ours is one of two or three [other]
hospitals in Zanzibar, and there are also several community clinics on the
islands. That said, Stone Town being the capital, I suppose it’s is the largest
hospital in the archipelago.
Where are we?
At the beginning, we had a bit of a difficult
time figuring out where to go. A super friendly security guard traipsed all
over the hospital grounds with us the Friday before our internship began (‘coz
earnest students that we are, we wanted to make sure we didn’t waste time
getting lost on our first day), trying to help us find the OT department and/or
our contact (whom nobody we asked knew or seemed to have heard of…). Plus we
had no idea what time to show up for work on Monday. You see, “excellent
communication skills” is probably not a skill one would (or should) find on a
resume around here. Anyway, after making a few stops in random buildings and knocking
on a few locked office doors, we ended up outside the Orthotics/Prosthetics
department…although we didn’t know this at the time because there was nobody
there. The hospital seemed kinda deserted, with many offices/departments closed
or seemingly staffed by just a couple of people. We chalked it up to it being
Friday. Thankfully there were several helpful security guards around to help us.
Come Monday, we showed up bright and early
and somebody directed us to hospital administration for paperwork, etc.
Naturally they weren’t expecting us, and we had to explain who we were, where
we were from, why we were there, what department we’d be working in, who our
contact was (by this point we were wondering if this guy actually existed!),
how long we’d be there…you know, all the stuff we’d included on the forms we
filled out a year ago. After a couple hours of being shuttled from one room to
another (sometimes to make room for other interns – mostly from Europe – who
were also starting that day), and repeating the same information, there still
didn’t seem to be any record of our internship, so we were asked to fill out
the forms again. I really hope those
passport photos we had to attach to our application forms way back when are not
in some random person’s possession somewhere in Zanzibar…. We also eventually
met our contact (he did/DOES exist!), and he took us over to the actual OT department (YAY!!) where we
would work over the coming weeks.
The hospital
As you can probably surmise, the hospital is pretty
typical for most developing countries, beset by limited funding and a lack of
basic amenities, not to mention politics and policies that affect day-to-day
operations. The wards, some of which we got to see when we were invited to
observe rounds one morning, are pretty difficult to describe. Patients lie on
threadbare mattresses, which are little more than thin pieces of foam, most
without bedding (bed linens) to speak of. Most had kangas (a common East African fabric)…in lieu
of sheets. A few did have sheets – or at least a single sheet – though from the
mismatch of colors, I guessed they weren’t hospital issue. With the exception
of a couple of screens that family members could pull around one’s bed as
needed, patients pretty much have no privacy in the dormitory-style wards, most
of which have a capacity of 25-30.
Speaking of family, they are an integral part
of patient care. We learned that there are not nearly enough nurses on staff,
so patients’ family members end up performing many nursing functions. A single
nurse is typically assigned to cover two wards during a 7-hour shift (10 hours
on overnights) with the help of two orderlies; i.e. probably 40+ patients,
since the wards are almost always close to/at capacity. The patients we saw
during rounds included people with orthopedic injuries, spinal cord injuries, burn
victims, amputees (usually people with diabetes)…I could go on and on….
Among the patients’ belongings on the floor
next to and/or below their beds, we saw thermoses and other food containers…it turns
out that the hospital only provides bread to patients in the morning but no
other meals, so families pretty much have to bring in food daily. Although we
knew, and had been warned before rounds began, not to expect the hospital to be
like any of ours (in the U.S.), it was still hard to see. Yet, through the pain
and discomfort, many patients smiled at us, joked with the doctors…one [a burn
patient] was even asking for a smoke, or maybe weed, a.k.a. bhangi. The most I could decipher with
my rusty Swahili was the doctor admonishing him to quit smoking the crap (I’m
paraphrasing) that got him there in the first place. At the very least, I’m pretty
sure we provided some entertainment by being the subject of discussion for some
time after our visit(s). Hey, anything to help them get through the day!
(Though I can’t lie…that’s not what I was thinking at the time:-/)
EARLY (okay, fine…7:30) on Thursday mornings,
we attend an in-service presentation for hospital staff – mainly physicians,
nurses, therapists, pharmacists, etc. Visiting interns in all these areas are
welcome (encouraged) to attend, and I must say they have been quite interesting
and informative. One Thursday, the guest presenter was a pharmaceutical rep
promoting several drugs available from his company. It wasn’t the most riveting
presentation – a typical sales pitch, and one more relevant to the doctors than
anyone else. The room was unusually serene....even the annoying ring tone that could
always be counted on to startle us all awake by going off at least 2-3 times
during those meetings (it usually went on for a while before the phone’s owner
answered it and carried on a conversation…right there…in the meeting…!!) was
silent. Until…the drug rep started handing out free samples. Can you say STAMPEDE!?!
I wanted to shield Stephanie from the rush (she’s so little – I was envisioning
her possibly getting trampled), but we both kinda had our hands full with all the
free swag. We had to take everything
we could get our hands on or else we’d stand out even more, right?!? (Plus our
department head, we think, gestured for us to take them.) But don’t worry – we
turned all the contraband over to our supervisor.
I must say…the Thursday morning meetings
since then have been pretty gosh darn dull.
Ahhh OT (…& more)!
The OT department is an outpatient pediatric clinic
on hospital grounds. The clinic is on the second level of a two-story building
overlooking the Indian Ocean, directly above the physical therapy (PT) clinic.
The OT clinic is pretty well-equipped as far as clinics go - with a decent
amount of therapeutic equipment, large floor mats for therapy, some toys,
games, puzzles, exercise balls, etc. It is staffed by one full-time therapist
and an administrative assistant/janitor. There is another occupational
therapist at the hospital (our one-time “mystery” contact), but he has a dual
role, including a job as head nurse (patron) of the hospital. His other
responsibilities keep him pretty busy so he rarely comes to the OT department.
So, unfortunately, the hospital’s staffing shortages are not limited to
nursing. Downstairs, there are two PTs along with two or three
aides/assistants. As you can well imagine, interns are a mostly welcome
addition to any department.
The children who come to clinic pretty much
all have one thing in common: They are PRECIOUS! Even when they are being
bratty and crying – sometimes simply because the sight of a mzungu (Steph) is just too much for
them…haha! J They have various diagnoses: Cerebral Palsy,
Erb’s (Brachial Plexus) Palsy, Down Syndrome, Autism, developmental delay,
fetal alcohol syndrome, and so on. Most are carried in by parents,
grandparents, nannies, siblings...some walk with much difficulty, diligently
keeping once or twice-monthly therapy appointments. Many of them have to take dala dalas to get to the hospital and/or
walk long distances. All to be seen for 15-20 minutes. There simply isn’t
nearly enough time to see everyone for the typical 45-50 minute sessions we’re
accustomed to in the states, so sessions consist of lots of parent education on exercises they can do at home to help
improve or maintain their child’s physical condition. We work nonstop from 8
a.m. until the last patient is seen – usually early afternoon. That may sound
like a pretty short day, but the reality is, the therapist staff has doubled
while we’re here (Steph and I work together/as a team), so try to think of how
things are when there are no interns helping with patients…and just one
therapist to see everyone. So many of us want to (and talk about) making a
difference. She (the staff OT) does. Every day.
Twice a month, on Wednesdays, we go into the
community – to health centers in either the north or southeastern (we
alternate) parts of the island to provide therapy to those who cannot come to
the hospital for whatever reason – distance, inability to carry children who have
gotten too big and/or difficult to manage, finances (funds for transportation),
etc. Guess what? The children there…?? All also PRECIOUS!!
On the Wednesdays we don’t go out in the
community, we go to Orthotics/Prosthetics to observe a very talented orthotic technician
do serial casting on
children with club foot/feet. He is AMAZING!! Most of the children he works
with are infants – it’s best to begin club foot correction at two weeks of age,
but he also takes difficult cases (children who are 3, 4, etc.) His work is
supported by an NGO and
he too is making a life-changing difference in these children’s lives. And the babies,
you ask…? Yep, you know it…ADORABLY PRECIOUS!!!
For all these services (therapy, casting,
etc.), the parents/caregivers pay what they can afford…and the rest is funded
by the hospital and donations. Most everyone seemingly scrapes together even a
few coins to bring. We have this one patient that comes every two weeks – her
grandmother brings her. Except…we recently found out that this lady isn’t
actually her biological grandmother. She is someone who saw a special child in
need of love and care, and took her in. They are often late for therapy because
public transport from their home is overcrowded and unreliable. When she gets to
the hospital, she has to have someone to carry the child up the stairs to the
OT department, because she cannot physically manage it. I have no words. The
least I/we can do is provide the best care we possibly can to the child, and
carry her downstairs for her even more special grandmother to make the journey
back home.
Our adult patient
One day, about a week and a half into our
internship, one of the physical therapists asked us if we’d like to work on a spinal
cord injury case with him. Sure…we were open to learning any/everything! The
patient was a 24-year old who broke his back when he fell out of a tree while
harvesting cloves on a spice farm, apparently a common injury on Zanzibar and
Pemba. He had been in the hospital for at least six months! He was
understandably tired of being there and ready to go home, having gone through
many ups and downs – with significantly more lows than highs – during that
time.
When we first saw him, we were overwhelmed at
the thought of being able to work with him with very few, if any, of the items
that would typically be at our disposal at a better-equipped facility elsewhere. Furthermore, he did not have a wheelchair…nor
would he have one at discharge. He, like many other spinal cord injury (SCI) patients
in Zanzibar would likely have to depend on people to help him perform most, if
not all, day-to-day activities for the rest of his life. A life that was likely
significantly shortened due to his injury. (Many SCI patients here succumb to
severe infections from bed sores or catheters a few months or years after their
injury.)
So here we are with this young man who can’t
walk…a fact which hasn’t really sunk in for him yet. No wheelchair. No supplies
of any kind. No nothing, as my mother would say. :(
But occupational therapists are creative…we
make stuff from nothing! (*vigorous chest thumping*) Steph came up with the brilliant idea to make him a rope ladder (to help him pull
himself up to sitting from a supine
position {laying on his back} in bed)…YEAH!! So what it took us a few days to find rope of any kind
(let alone appropriate-ish rope) in Stone Town!?! Still…WE MAKE ROPE LADDER!!!
(**more chest thumping**)
First, back to our initial visit after rounds.
My first question to him was had he been out of the ward since his injury and
subsequent surgeries, and I was shocked (but not really) when he said no…not
once in six months!! I can’t even imagine! We commandeered a wheelchair that
was in the ward for patient use and brought it over to his bed. It took 3-4 men
to lift him out of bed and place him in the wheelchair. His brother pushed him outside,
onto a balcony on the same floor…just a few (15-20) feet away. Our guy got to
breathe fresh air and see the ocean for the first time in six months. I’d like
to say that I’ll never forget the smile on his face…but truth be told, I was
sooooo very nervous about everything else, Steph’s the one who told me about
the smile. (I know – she’s an AWESOME
friend!!) The important thing is…he smiled.
We have since worked with this young man and
his family/caregiver(s) teaching them some basic skills to help him be more
independent once he went home. Upon learning that we were working with him, our
OT supervisor offered to give him a [bariatric] wheelchair that had been
donated to the OT clinic. “Naturally,” we threw our wheelchair fitting training out the window and
jumped at the offer! After all, any W/C was better than none.
I can’t lie…there have been moments of
frustration – many of them – due to language issues and, I guess, cultural
differences, some of which affected what we want to do to help him. Through it
all, sweet Steph keeps reminding me that we have to “Meet the patient where
they’re at…” so true.
I teared up when he was discharged. This
young man may not have been my first patient, per se, but I will definitely
always remember him and soooooo wish him well.
