“Now don’t forget to wash your hands….”

So yesterday I went as usual to the Friday morning meeting where the medical students and house residents gather for a summary of the ward statistics for the past four days. But this time there was a power point set up instead. The man was a representative of the “sanitarization committee” at the hospital, composed of representatives from each general area within the hospital. And he was here to remind the doctors and medical students to wash there hands – among other things.

The first half of the presentation was basic, 2^nd grade information about the importance of hand washing and the types of soap/antiseptic available. After going through this embarrassingly basic reminder, he went on to say that “Now we have barriers at our hospital to hand-washing…there is a lack of accessible sinks, running water and soap, and there was overcrowding and understaffing on the wards. But nonetheless, “be sure to wash your hands after you touch ANYTHING!”

Next he went on to introduce the new color-coding scheme for waste, involving three different colored trash bags to distinguish between pharmaceutical waste, sanitary waste such as bloodied pads, and general garbage that would be “found in an office.” He then explained that there would be one of each for the ward – a ward containing 15 doctors, 30 nursing staff, and up to 60 patients in a ward. The idea that there would be only one set of these color-coded trash bins per ward was ridiculous.

The third part of his talk was to introduce new needle-cutters that would be given to each ward. They were nifty little contraptions really – a small plastic box with a hole in the top in which you placed the syringe after using it and you press the box which causes a razor blade to close the hole, cutting the needle and dropping it into the box for safe keeping. Of course, there were to be all of two per ward…. A nurse then got up and they handed out the boxes to all of the med students and residents present along with sterile syringes to practice cutting it with the box. While it wasn’t difficult, it was important that the syringe was plunged all of the way before cutting it, or the remaining liquid would spray out. Additionally, it was important to make sure the syringe was pushed firmly into the hole so that the razor blade cut the rubber part of the syringe and not the needle itself. It would only take once for that to happen to cause the razor blade to dull and become ineffective at cutting any more syringes.

Nurse: “By the way, it is important to show and teach all of your many colleagues who can’t be present right now how to use them correctly so liquid doesn’t squirt out and the razor blade doesn’t break or become dull….we haven’t got extras….”

After the demonstration, the rep opened the floor to questions/comments. The first was from a house resident suggesting that they put more than two needle-cutters on a ward, seeing how it would cause staff to wander around with the needle in hand looking for an available box – or alternatively wasting time waiting for one to be available before treating a patient. The man agreed that it would be better to have more, but explained they simply couldn’t afford more.

The next comment was by a medical student recounting how a British med student (one of my friends) had told him that the British were phasing out long-sleeve white coats because studies had shown that the cuffs pick up a large number of pathogens from the patients and medical instruments. Additionally, they had mandated the removal of ties, or sticking them under the shirt, for the same reasons. The rep, in a truly Ghanaian fashion, responded by talking in circles about how there are two sides to evidence and research always had mixed findings…and the hospital couldn’t afford to buy all new short-sleeve white coats (never mind they could simply roll-up their sleeves!)…and besides it took nearly a year just to get the idea of color-coded trash bags to actually happen today. He finished by suggesting that the student write a letter to his committee and they would look it over.

The final comment was from the back – one of the chief house officers: “Please, every day we are in surgery doing caesarean sections, and we only have short gloves to wear. We only are allowed to use the long gloves (past the elbow halfway to the shoulder) if the patient is known to be HIV positive. But we have many patients who have not been tested for anything, and are therefore potentially even more of a risk. And everyday we are splattered with blood the length of our arms and it is very dangerous and worrisome…can we please have long gloves for all of our surgeries…we need to protect ourselves and not just our patients.” The rep was sympathetic and admitted it was very important for the doctors to be protected, but explained that as of now there was not the money for the expensive long gloves, and that he should write a letter to the committee…

I was incensed, appalled, frustrated and angry after the presentation. How could he open the floor to suggestions and comments and then shoot them all down with a “write us a letter and we’ll think about it”? Not to mention his round-about bull responses to very important, valid questions and suggestions. But I suppose it isn’t really his fault – if there’s no money there’s no money. And it is also Ghanaian fashion to do everything veeeeery slowly without any concern – even when it comes to trying to save someone’s life. So maybe in a year they will get around to applying for funds to provide surgeons with long-gloves…

As I waited with those same house residents for our rounds to start, I asked one of them if he felt frustrated for being told to wash his hands and then told that there is no soap or water to do so, and to use the new trash bags and needle-cutters despite the fact that there aren’t enough, and he shot down the evidence for rolling-up sleeves, and that their request for long-gloves was shot down. He laughed (which always frustrates me- they laugh about death, about the lack of resources etc.. which I recognize as a coping mechanism but still bothers me) and said that yes it was very frustrating, but that that is how it has always been. Nothing happens fast, if at all.

One of the major things that shocks the British and us about being at the hospital is how slow everything moves: A woman will go into an eclamptic fit and the nurses will just watch her seizing and then stroll over to give her an injection; a women will come crawling to the delivery bed with the baby’s head already out and the midwife will yell at her for pushing and then saunter over to put on gloves just in time to catch the baby. And it is clear that this is a major contributor to the rate of mortality. It makes me want to yell at the doctor’s and nurses to DO SOMETHING. But after witnessing the woman with no insurance who died of renal failure, and the inability for the doctors to even secure surgical gloves, I recognize that the slow, apathetic responses of the health care staff are coping mechanism for their lack of support by the hospital in terms of necessary supplies, patient insurance, and the feeling of inevitability of death.

It makes one want to wash her/his hands…of it all.