Week 3: Pelonomi

5/26
So I am stationed at Pelonomi hospital this week, and though I have been told that Pelonomi has a reputation as the worst hospital in South Africa, but I haven't seen anything too bad.

Yesterday (Monday) Cariene, one of the four dietitians, took Hannelise and I through the burn unit and explained to us the steps of burn acre:

1. Cool the burn (at least 30 mins under cool water)

2. Assure the patient has an airway and adequate circulation. An emergency tracheostomy and drip may be required.

3. Determine % TBSA and severity of wounds. -Epidermal: sunburn, hot water, 1 wk. to heal if correctly managed -Superficial Dermal: 14 days to heal -Deep Dermal: 21 days to heal -Sub Dermal: exposed muscle, bones, tendons, no capacity for healing without skin graft Total Body Surface Area is calculated using the "rule of 9,"

4. Clean and dress the wound to avoid infection and heat/energy and fluid loss.

5. Address nutrient needs, feed within 4-12 hours after burn. Adequate enteral nutrition throughout the healing process protects villi and gut flora integrity and prevents additional complications such as curling ulcers or refeding syndrome. Patients are usually given the low fat house diet, 9739 kJ (2330 kcals), 352.1 g CHO (61%), 126.2 g Protein (22%), and 43.4 g Fat (17%) along with protein energy supplements if necessary. Curreri's formula is the most commonly used energy equation. Patients may benefit from supplements containing vitamin C and zinc for wound healing, or a multivitamin containing vitamin A and D. Iron deficiency is not of great concern for wound healing, because high ferretin levels may feed infection.

6. Monitor U&E and albumin at least weekly. If albumin is less than 26 administer a semi-elemental supplement for easier protein absorption. Often Peptomen Prebio is given in addition to a normal feed to allow for better absorption while also maintaining the capacity to digest larger molecules. Monitor Hb weekly if shown to be an issue. Monitor the amount eaten and patient feelings towards the feed. Also make sure the physical/occupational therapists work with the patients to prevent contracture .It is quite painful, but necessary for maximum mobility.

Since shadowing in the hospitals, I've seen a lot of nasty things like calcified toes, gangrene, mouth cancer, colostomy bags, bloody oxygen masks, you name it, but I think I encountered the nastiest yet in the burn unit. I have no idea how this poor lady survived for several days at home before admitting to the hospital, but she suffered from sub-dermal burns from the knee down on both legs. You could see all of the tendons, muscles, and bones in her legs, and it was gruesome to say the least. But the sight was not half as nauseating as the smell. I have decided that bacterial growth on rotting flesh is definitely my least favorite smell, as it almost made me lose my breakfast. Another guy across the hall had only 9% burns on his right arm and hand but suffered from HIV and his hand was completely shriveled and dead, resembling frostbite. His room smelled even worse. Unfortunately he passed away last night.

It seems that most adult burns are products of open fire pits, alcohol, or both. There are also a substantial amount of burns due to domestic disputes. If a man is admitted with boiling water burns, one can usually assume he was either drunk and trying to cook, or received it from his wife. Women who suffer from burns due to domestic disputes are rather lit on fire or pushed into fire pits. Most child burns are due to household accidents, but it is always important to analyze the story to make sure it matches up with the burn characteristics. Every now and then there is a case of child abuse that is evident, such as a clear burn line where the child was dipped into boiling water. Thank goodness for social workers.

Today was a pretty relaxed day as well. I accompanied Anika, another dietitian, around the general medicine wards, learned of a refeeding patient, and revisited the problems with having an uncooperative nursing staff. At Universitas, Pelenomi, and most other government hospitals, the sisters may or may not follow the diet orders verbally given and written out on a specific sheet in the patient's files. This is especially a concern for malnourished patients at risk for refeeding syndrome. Usually Anika starts the patient out with a 10-15 kcal/kg bw nasogastric tube and divides that amount by 18 hrs to determine the ml/hr that ought to be given on the machine, so it is very important to follow the orders exactly.

We also stopped by the neonatal unit and found a new mom that needed help with latching, which was a surprisingly easy case as all she needed to do was rub the baby's cheek to stimulate the reflex. The rest of the day was a bit slow, as the dietitians didn't have any more work for me, so I worked on this post a bit and encouraged Wieda to become the president of South Africa.

-Jordan


5/27
I was with Nicoliene today in the pediatric wards, my favorite place to visit in the hospital. We checked in with numerous SAM patients, noted Mid Upper Arm Circumferences below 11.5 cm and oedema states, and Nicoliene updated any diet orders for the day. If the infant (6-12 mo.) shows no signs of oedema, then 130 ml/kg bw is prescribed of whatever fluid is being consumed. If oedema is present, 100 ml/kg bw is prescribed. I love the pediatric wards not only because I love babies and children, but because it is so gratifying to see the patients pick up weight and improve on their growth charts. If the mommy is on board and the nurses follow the diet orders, improvement is far more likely than with adult patients that do not want to listen or heed the diet orders. Also, with the children it is very evident when they are not feeling well or when they are feeling better, but adults are a bit harder to read. The amount of SAM cases in the government hospitals here is very high compared to the US. I very frequently see 9 and 11 month-olds weighing less than 4 kg (8.8 lbs), babies that are HIV positive, and babies that have not received any immunizations due to the extremely low level of education and care among mothers. As a health care professional, one cannot allow oneself to become depressed by the depressing; health care professionals need to be positive, uplifting, and compassionate to the patient. I used to think that I could never work in a hospital setting, but after what I have experienced so far, I wouldn't mind doing it for a while. However, I find follow-ups with outpatients far more gratifying as you can develop relationships with patients and track progress. I went for a quick run after our return and came to the realization that I only have 9 days left in Bloemfontein :(

5/28

It seems that Pelonomi is a very low-stress environment. I accompanied Wieda and Hannelise to do some nutrition screening in the general ward, visited Wieda's blue book (nutrition assessment) patient with RVD and meningitis, and visited Hannelise's blue book patient with 30% burns. Her patient experienced the burns exclusively on the front of her body and additionally suffered from RVD (HIV). The etiology of the injury was either due to a household cooking accident or a domestic dispute. The files always list HIV as RVD in order to preserve patient confidentiality, because the medical files are easily accessible to anyone in the hospital as they are laid out on the table beside each bed. She couldn't stand, so we roughly measured her length using a measuring tape and visually estimated her weight. I really love counseling, educating, and interacting with patients. The only patients I don't prefer to greet are the prisoners and the ones in the isolation ward. We go in there with masks and such, but med-resistant tuberculosis is a very frightening disease. Also, sometimes I really wish God didn't call me to love the people who are hard to love, because I have some serious resentment towards rapists, molesters, and child abusers. I believe that rape is the worst thing you can to to another human being, far worse than murder. I still have some serious work to do on my own heart if I am ever to become a beacon to the people that I despise the most. Pretty much the rest of the work day was spent voluntarily reading through Krause's Food and the Nutrition Care Process, the Bible, and Out of the Silent Planet. Also, I am finally grasping a respectable amount of Afrikaans, as that is the language that I hear in over 75% of all conversations. Give me two more years and I'm confident that I could become fluent. I am greatly enjoying this week because all of the dietitians are very sweet and I enjoy the company of Hannelise and Wieda, but I do hope that next week is a bit busier. I don't do well under low-stress situations.

5/29

Last night the roommates had a party that ended at 5 am this morning. I hung around the kitchen with them for about an hour to spectate, and then retired to my room to chat with the family and Ryan. I am getting excited about Swaziland as it is 7 days away now, but at the same time I am getting kind of nervous because I will have little to no access to communication, grocery stores, or hospitals. I've looked into getting a cell phone with MTN Swazi, and it looks incredibly expensive to call internationally. The postal service reaches as far as Piggs Peak, which is an hour away by the nearest grocery store, so writing letters is not a convenient option either. I may have access to email every few days, but I am preparing myself for complete isolation from the modern world. I'm going to call it an adventure and leave it with a better connotation. I was told that I will be volunteering at the primary school in Bulembu, but I think I may also check in on the local clinic and volunteer there is I have time. Now that I am more familiar with interventions for common diseases like SAM, RVD, PTB, pneumonia, CVD, hypertension, DM, and such, I feel an obligation to apply some of my knowledge through volunteering while continuing to build up my reservoir. I love being with people, even cranky people, and it is quite affirming to find that under further investigation I am still not deterred from the medical field. I especially love the pediatric ward, which I got to visit today with Nicoliene. Being able to hold and bring a smile to the face of a baby that suffers from SAM and RVD is a privilege, as that baby is not merely a product of disease and poverty, but a spectacular and precious creation of God. Her life is just as important as mine, if not more.

No one lives without struggle, it is a necessity of life and a prerequisite for mercy and redemption. That is the only way I can understand the chaos of the human condition and the seemingly randomized birth placement across disparities between the privileged and the deprived. I cannot imagine a life without faith in a world without hope. I am affirmed that there is a God because there is a such thing as corruption, and therefore rebellion against some innate morality. I am also affirmed by the presence of beauty and hope in the midst of struggle and tragedy. Love is irrational, yet even the rational fall into it. Not everything has to make sense; some things I hope to discover, others I hope to never understand, and there is much that I may never know. I'm okay with that. I love the chase and I love who I'm following.

Back to nutritional rehabilitation in South Africa, I've experienced a bit of the wake from the Integrated Nutritional Program's objectives. One of the most prominent changes brought on by this initiative is the Kangaroo Mother Care policy, which I discussed in an earlier post. I really love how strongly health care professionals discourage bottle feeding and formula company advertising. Yes, we use formula in the hospitals quite frequently whenever the mom cannot produce enough milk or if mom is not taking her ARVs. However, most of the mothers in the hospital breastfeed, which brings warmth to my heart, especially in teaching new moms how to breastfeed. Mommas are always very happy to hear your instruction and they get very excited when training leads to success.