This is part 4 of a series of posts about what my ministry is like.
Remember, I'm just sharing my personal experience with this particular hospital in this particular country. Other missionaries at this same center will have different viewpoints, as will missionary PTs serving in other places.
_____________________________________
_____________________________________
So what happens next after we do the clinic exam and we don't find a fistula and therefore don't schedule her for surgery?
If the woman needs further gynecologic care, or is pregnant and needs referral for free prenatal care, we'll send her with her brown card and tell her what days those particular departments run clinics. Or if we suspect the woman is HIV+, we refer her to the on-site AIDS center where they will do testing, counseling, and provide medications.
We have limited access to imaging--really only x-rays and ultrasound--at the main hospital of which the fistula center is a part, and our lab does the more common tests (like HIV, malaria, hematocrit, blood glucose), so we can write out the order slips for those tests. If the test is related to VVF, especially the blood tests we do pre-operatively, the tests will be free of charge to the patient.
In the case of a patient who is leaking urine or stool, in the absence of an identifiable fistula, we have a couple of options. If the leakage is only every once in a while, occurs with specific activities, or she complains of difficulties urinating/leaking after urinating she'll be referred to pelvic PT for pelvic muscle retraining. Other women only leak at night (often because they can control their leakage by urinating fairly often during the day), so we'll prescribe her a medication to reduce bladder spasms and help with incontinence caused by an overactive bladder muscle. She'll pick this medication up from our nurses' station and they'll tell her how to take it properly. Others will complain of a recent onset of urinary leakage, usually combined with other symptoms that make us think she has a urinary tract infection, so we'll treat her for that.
Referrals to pelvic PT are pretty easy because I'm usually sitting in on the Tuesday clinics, I read her intake form and main complaint, and all of us in the exam room work together to decide the best course of treatment. I have the opportunity to say, "I'd like to work with her," or "I think she could benefit from pelvic PT for ____," or if it's a easy re-education thing, I can teach her right then and there. I've gotten very good at demonstrating the technique of double voiding to ensure complete urination and reduce urinary retention... "When you feel like you want to piss, you go to that place, and squat down. When the urine is finished, stand up, shake your waist like this, then squat down again. More urine will come. Then you can stand up and fix your skirt." It's funny to see the nurses mimic my own motions as they translate it for the patient!
Since clinic can run into the afternoons on Tuesdays, I will usually see any new patients on Wednesday mornings when a nurse or Ladi are free to translate for me. This is something that's new for me; in the US, I'd want the doctor to see me that day if possible. Especially if I'd traveled many hours to come to the hospital and waiting til the next day means that I'd have to stay overnight in the hostel. But here, the women don't mind at all! Many would have to stay another day anyway, since the buses and vans leaving from the motor parks leave by noon. As long as I can see my patients by about 10am, they can travel that same day. Or, if they're going to remain with us for a week or two for PT, staying overnight that first night helps them get started settling in and meeting Mama Esther that runs our hostel. Also, the free meals we provide to our patients in the ward and in the hostel is another incentive to stay.
In the case of a patient who is leaking urine or stool, in the absence of an identifiable fistula, we have a couple of options. If the leakage is only every once in a while, occurs with specific activities, or she complains of difficulties urinating/leaking after urinating she'll be referred to pelvic PT for pelvic muscle retraining. Other women only leak at night (often because they can control their leakage by urinating fairly often during the day), so we'll prescribe her a medication to reduce bladder spasms and help with incontinence caused by an overactive bladder muscle. She'll pick this medication up from our nurses' station and they'll tell her how to take it properly. Others will complain of a recent onset of urinary leakage, usually combined with other symptoms that make us think she has a urinary tract infection, so we'll treat her for that.
Referrals to pelvic PT are pretty easy because I'm usually sitting in on the Tuesday clinics, I read her intake form and main complaint, and all of us in the exam room work together to decide the best course of treatment. I have the opportunity to say, "I'd like to work with her," or "I think she could benefit from pelvic PT for ____," or if it's a easy re-education thing, I can teach her right then and there. I've gotten very good at demonstrating the technique of double voiding to ensure complete urination and reduce urinary retention... "When you feel like you want to piss, you go to that place, and squat down. When the urine is finished, stand up, shake your waist like this, then squat down again. More urine will come. Then you can stand up and fix your skirt." It's funny to see the nurses mimic my own motions as they translate it for the patient!
Since clinic can run into the afternoons on Tuesdays, I will usually see any new patients on Wednesday mornings when a nurse or Ladi are free to translate for me. This is something that's new for me; in the US, I'd want the doctor to see me that day if possible. Especially if I'd traveled many hours to come to the hospital and waiting til the next day means that I'd have to stay overnight in the hostel. But here, the women don't mind at all! Many would have to stay another day anyway, since the buses and vans leaving from the motor parks leave by noon. As long as I can see my patients by about 10am, they can travel that same day. Or, if they're going to remain with us for a week or two for PT, staying overnight that first night helps them get started settling in and meeting Mama Esther that runs our hostel. Also, the free meals we provide to our patients in the ward and in the hostel is another incentive to stay.
The referral system is pretty different than what we have in the US. There, the doctor will usually fax over a drug prescription, submit orders for imaging or bloodwork directly into the patient's medical record which is then forwarded to the correct departments, or the patient may walk out with a paper referral form for physical therapy. Very little is trusted to the patient to keep track of and there's little opportunity for the referral to get lost or illegally changed. Here, everything is written and handed to the patient who is then responsible for going to the the pharmacy to "collect the drugs" or for going to the right place on the right day to be seen in that clinic.
No comments:
Post a Comment