In Which I Become an Amateur Medical Anthropolgist

As many of you know by now, I finally got registered as a nurse with the Ministry of Health in late November and have now been at the hospital for the past few weeks. Over this time I feel both that I have learned a lot and that I have no idea what's going on half the time. I'm currently working on the maternity ward, which is a concept I don't think exists in the US. It's basically all inpatient OB/GYN except delivery. Women who are in labor are kept in the maternity ward for the first part of their labor and are transferred down a floor to the birth center when once they are in active labor.

Approaching the hospital

Near the entrance of the hospital, parking garage to the right

Grand staircase that greets visitors just inside the entrance

The maternity ward is, in fact, an actual ward, which I hadn't seen in person until coming here. There are 36 beds total, 18 on each side of the hall. All beds are visible from the hallway through a clear glass wall (think US nursery style). Beds are clustered into 6 bed "rooms" (in quotes because while there are partial walls between the clusters, it is still possible to walk between all "rooms" located on the same side of the hall). There are no curtains between beds. If more privacy is needed there are cloth partitions that are available to put up. And forget about having private conversations. If someone's within earshot, they know your details. As might be obvious, there are no private bathrooms. On either end of the ward there are patient bathrooms that consist of three stalls and two sinks. I don't think there are showers but I've never gone inside to investigate.

It's not uncommon to see women breastfeeding without covering themselves, even when men are present (although this happens in public spaces too – imagine that!), or just walking around with their chests only partially covered. It was reassuring to see that breastfeeding is considered to be a normal part of life, not something to be hidden (as in the US context).

As you can probably tell just from the floor setup, nursing is Bhutan is very different from nursing in the US. I will attempt to describe many of the differences here, but just thinking about all of them is overwhelming. What I miss in this initial post will no doubt come up in the future. Here goes:

Work flow/patient management: I can't claim to be an expert on this (and have a feeling I may never quite understand how everything works) but I can at least tell you about how it differs from past nursing I've done. Here nurses are not assigned specific patients to follow throughout a shift but instead have more task-based work. By this I mean that nurses will go perform certain tasks for certain patients (for example, start an IV, change a dressing, check a blood pressure, etc.) depending on what needs to get done. I personally don't like this for several reasons, the main reasons being that there isn't a lot of personal interaction with the patients and a chance to get to know them and, if something were to start going wrong, it would be harder to tell because the nurse isn't as familiar with the patient's baseline. This nursing setup is somewhat made up for by an attendent-based system of patient monitoring. This means that each patient usually has at least one person with them (friend or family member – those not with the patient often camp out near the elevators, bedrolls and all) who is responsible for telling a nurse if something is needed or if something going wrong. The attendants are also responsible for bringing the patient food, water and all personal items (including bedding) as the hospital furnishes very few of these. With so many people coming and going in these large wards, and very little cleaning between patients, it's probably not a surprise that the overall level of cleanliness is somewhat low. That is, the ward is not obviously dirty (it's mopped daily), but it is very common to see cockroaches (mind you, just the small ones) and other bugs crawling on the walls.

And even though nurses rarely write things down, they all know what's going on with each patient. I assume they are used to keeping all this information in their heads but it's certainly not a skill that I have mastered yet! Part of what I've come to realize in the short time I've been working as a nurse here is that nursing school and the required clinicals provide a way for nursing students to learn the role of the nurse and how they fit into the medical system. Since I obviously didn't go to medical school in Bhutan, I missed out on all that and am trying to learn all of this somewhat informal knowledge through observation.Working in a new cultural context certainly makes you realize the things you learned without even trying.

Two nurses work at the desk. Paper charts = endless paperwork

I've thought quite a bit about these work flow and patient management issues in order to try to make sense of them. Based on how I was trained in the US, the system here makes little sense and seems full of room for mistakes and unnecessary emergencies. I can only conclude that there is more of a community system of care going on (with community being patients, friends, and family members that are in close proximity within their 6 bed clusters and, of course, the nurses and other medical staff when they are present). This cannot and would not happen in the US because of privacy issues and private or semi-private patient rooms. I can't be sure, because no speaks to each other in English, but it seems that everyone has a general understanding of what's going on around them and keeps track of any patient changes and what might need attention. For example, one day I was checking on all the babies with one of the other nurses and one of the mothers couldn't remember if her baby had peed yet. A mother from a bed across the room piped up and said, "Yes, the baby peed. I remember." I've talked about this with other Americans who have experience at the hospital and we all agree that the system seems to work. It is, of course, not perfect, but seems to function in a way that is beyond our understanding and is surprisingly effective. For now, it doesn't seem like this patient management system can change due to the high patient to nurse ratio. Today, for example, there were four nurses (including me) working on the ward with 30 patients and several babies. Yeah, it's a busy place and this leaves minimal time for functional improvements.

Medications:  Medications are kept in short wide-mouth bottles made of opaque plastic that are stored in a cabinet near the nurse's station. On each bottle is taped a label with the name of the medication (some spelled wrong) and sometimes an expiration date is listed. Each day a pharmacist comes to the ward to refill the bottles. She does this by popping all of the medications out of their blister packs and dumping them together into the bottles (which is why the expiration dates are probably not all correct).

Pharmacist restocking medications

Medication records for each patient are kept in a binder. Each patient has their own page on which is hand-written their medications, dose, route, and time to be given. No allergy information is listed (or really anywhere in the chart that is obvious to me). The dose is sometimes written as "one tab" or "one ampule". To my knowledge there is only one dosage of each medication available on the ward, but still, I would like to know the amount to be given. 

To prepare medications, each is removed from their little plastic bottle and placed in a small medicine cup that has a number taped to it (I think it's actually rare for the medical staff to know the names of the patients – they are referred to by their bed number). The number corresponds with the the bed of the patient who is to receive the mediation. Then the medications are then distributed to the patients, sometimes by a different nurse than the one who prepared them. 

Meditations are charted as administered by crossing out the time that they are due. No signatures anywhere. I don't usually prepare the medications because I have a hard time understanding what's going on on each page. Between the sloppy handwriting and array of differences in drugs (some are not available in the US, some are rarely used in the US, and some just have different names than in the US), I'm not very efficient at the task.

Injection preparation area

Charts: Medical records are not electronic (which is probably not surprising) and are thin binders that  are reused between patients and that contain an array of papers from different sources. Patients are responsible for keeping all of their outpatient records, which for maternity includes all prenatal care. The government has designed and distributed a Mother and Baby Handbook that all women carry and that contains all important information related to pre and postnatal care, as well as child growth and development information. It's very helpful to have all that information standardized! As with the medication records, the medical records are very hard for me to understand. Between the handwriting and the abbreviations, of which I think many may no longer be used in the US (or I may just be unfamiliar with some of them), I rarely can get a complete picture of a patient's history. In addition, very little is recorded about a patient's condition during their stay; mostly just general observations and doctor's orders.

Supplies: For me, part of feeling competent as a nurse is being familiar with the equipment available and that is something that I'm lacking in certain areas here. For example, the IV tubing is totally different and the IV solutions are in plastic bottles instead of the bags that I'm used to. There are also no IV pumps so it's back to the basics of counting drops manually! These are very small changes, but even those can throw off a normal routine. In addition, many items that would come in kits in US hospitals are assembled by the hospital staff themselves. For example: gauze and umbilical cord ties. I've spent parts of shifts folding gauze and packing cord ties to be sent for sterilization. I've also had to learn to dip gauze in Betadine solution and wring it out using forceps in order to be able to clean surgical incisions. The first time another nurse watched me do this she said, "You've never done this before, have you?" Nope! I've pretty much only used pre-packaged/pre-soaked swabs. And that was very obvious.

IV solution storage

Wrapped and sterilized dressing kits on the lower shelf

Uniforms: As my parents did in the hospital nursing days, I too get to wear white. Every nurses dream, right?! The nursing uniform is a white collared shirt, a black sweater or blazer, and a white kira. I was dreading wearing white, but it's not as bad as I was expecting. Since there is no birth taking place on our floor (except the occasional unexpectedly fast labor) and the attendants do much of the hands-on care, we're actually not exposed to much body fluid (which is always a good thing even if you're not wearing white...).

Bhutanese Nurse Emily

Sisters/brothers: Nurses are called "sister" or "brother" (so I am "Sister Emily"), which simultaneously has a nice familial quality but also makes me feel as if I have somehow become a nun. Matt and I think that this nomenclature may come from the days of medical missionaries in India (they use the term there too).

Whew, that's a lot of information and I'm sure I haven't even gotten it all down. I will no doubt be doing more posts about the hospital and my experiences there since there's always a lot going on and a lot to take in. So far I have enjoyed being there despite the very different working conditions and their constant humbling effect. The nurses have been great and very helpful. They are very smart and competent, and are definitely doing their best given the situation. All the staff I have met have been this way, in fact. Any of the negatives described in this post are not the fault of any staff but rather an adaptation to a system that is severely understaffed and underresourced. What I have missed the most is getting to know patients and their families personally, especially when their families with new, cute little additions! I get it where I can and try to check back in with patients and give them a little extra attention as I am available.

Anyway, that's all for now. This is Sister Emily, your amateur medical anthropologist, signing off.

But before I leave for good, let me remind you: please don't spit in the hospital