Nursing clinicals

When I took this new job helping the nursing students with their clinicals, I knew it would be a challenge...yesterday, I got a reality check.

Definition: clinicals are when a nursing student goes into the hospital and puts the theories they have learned in the classroom and the lab into practice. The instruction that the students receive here is pretty equivalent to what they receive in the states, and they have a good lab in which to practice...but clinicals. I hardly know where to begin.

First, we are supposed to be supervising the instructors who are teaching clinicals. This is difficult to do when the instructor never shows up. So the poor students are unleashed into the hospital setting with no goals, and no supervision. So, mostly they just stand around for a while, then drink a cup of tea and leave. These students are in their last year of school. In a few weeks they will graduate and get a job as a nurse, having never once even touched a patient!

So, we are teaching the clinicals. We arrived at 8 am and I got a tour of the hospital...please lay aside your expectations of what a hospital in the west looks like, and step back several hundred years. Now, the students who were meant to show up at 8:30 started trickling in about 9:15. Oh dear. I assigned one patient to every two nursing students, instructed them to go over their chart, examine the patient, and see what medications they were on, and I would come and see what they had done. (we were in the "ICU" where there were about 5 patients in the room). I stood back and watched for about 10 minutes as they looked at the charts, then they just stood there staring. So, I went to the first pair and asked what they had found out. They said that she was there for Nafas tangi. (literally tight breath). That is a generic diagnosis given to anyone having trouble breathing. Could be asthma, emphysema, bronchitis, anxiety, heart failure, etc... I looked at the chart though, and she was on all sorts of heart medications. The problem is, that the drug names are all written in English...the nursing students don't know English. Sigh...

So, I asked if they had done a physical assessment (examination). No. Ok, first take the vital signs. No blood pressure cuff or stethoscope to be found. Well, you can at least take pulse and respirations. Those are important if the patient is having trouble breathing and has heart problems and is on heart medications. So, one student put her hand on the patient's wrist to count the pulse. I asked her if she had a watch. Oh, no...well, how do you know how many beats per minute? Oh, I have a cell phone she said. Does it have seconds? no. Ok, here is my watch. So, she counted on one wrist, while I counted on the other. she got 60. I got 144. Granted it was an extraordinarily weak pulse that was very difficult to count but the extreme difference told me she had no idea what she was feeling for. So, we worked on that for a while. In the meantime, all 7 of the students had crowded around me and the patient and were leaning on me trying to see and here everything. I think they were nervous and just didn't know what else to do!

After we got the pulse down, I told them it was important to look at the whole body, especially the feet. The woman was 70, and had been in the hospital for 9 days. She was at an extreme risk for a blood clot. there are no PTs here to come and walk with the patient. So, we went to check her feet, and they had 2+ pitting edema (very swollen). Even so, her little legs were about the size of my wrist!

When we finally got through with that patient, I wanted to make sure that I set a good example, so we set out to wash our hands. We finally found THE ONE sink in the hospital...I though I might be sick in it. It was so gross, that I felt it may be better to not wash after all. Turns out that we couldn't anyway, because the pipes are all frozen, and there was no soap to be had. We finally found a pitcher with warm water and we poured it over our hands and rubbed hard. (hopefully the friction removed a few germs...sigh again).

We went on to the next patient, and it went much as before. The chart was nearly unreadable, it was half English and half Dari, and the students hadn't done any kind of exam.

At the end of the day, I had a post conference with them. You know, for what they had available to them, they had actually done ok. Here are the instructions that I gave them.

1. Your patient is a person, not a thing or a body part. When you go up to them, talk to them. They are sick and scared. They don't know who or what you are (doctor, nurse, student, weirdo off the street), and they don't know what you are doing to them. Tell them who you are and what you are going to do. Treat them like a person.

2. You must take vital signs. This is important. Who has a watch? All raised their hand. Bring it to the hospital every time you come! If you don't have a BP cuff, at least get the pulse and respirations, and we will come up with a stethoscope so that you can listen to lungs.

3. To examine a patient, you must touch them. You cannot do a physical exam without touching the patient. (this is a public hospital which means that the patients are very poor. Though you don't have to pay to go to nursing school, you do have to have some sort of money to pay for food and lodging while you go to school, so typically the students are of a higher class than the patients, so they disdain them, and don't want to touch them).

4. Wash your hands. I know that sometimes there simply is no way, as there is no soap or water, but try your best to find some and when you can, wash.

5. Many of these patients have been here for days/weeks. They are at high risk for pneumonia and blood clots, as they just sit and lay around all day. Go to them every hour and have them pedal their feet and take deep breaths and cough. Even that may save a life.


I came to a quick realization that this hospital will never be UAMS or Good Sam, and we will not be able to get the nursing students up to the level of a Western trained nurse. But if I can just get one to wash her hands, we will have saved a life. If I can get one to treat a patient like a human, we will have given someone dignity. If we can make one step forward, lives will be changed, and then we can prepare to take the next step.

A few more notes about the hospital. It is a big, cold concrete building with concrete floors that are caked with mud. When we arrived, someone was mopping, and it was so slick that I thought if I can just keep from falling down today, I will have accomplished something big. The wards are full of flat beds, and patients just sit in them all day. There are no food trays to be passed. Families must provide sustenance for the patients. The patients are dirty, with no place to wash. They must go to a bathroom down the hall, that I would go into kidney failure to avoid.

The doctors come in, treat the patient as an inconvenience, and never touch them (I say again, how can you examine a patient without touching them?) The charts are just a bunch of papers stapled together, with instructions written in English, and no orders are ever discontinued, so when it says Dopamine (an IV medication used to treat extremely low blood pressure), but your patient doesn't have an IV, you wonder what is going on. On the next line, you see Enalapril (used to treat high blood pressure), and you realized that someone lost their mind. But, everything is extreme here. Someone has low pressure, so they give dopamine is such a large quantity that the pressure spikes and they give a medication to bring it back down.

On several of the charts the blood pressures on admission were written as 65/0 or close to it. Then, though they were on dopamine their pressures were not monitored. Now, in the States, with that kind of blood pressure you probably won't survive, though you may. Here, there is no way... NO WAY! I think the pressures are made up by people who cannot here on the low grade stethoscopes they have here. Sigh...

One of our patients had been admitted because she had not urinated in several days. She had been in the hospital for a number of days, but there was no clear diagnoses to be found on her chart. As we started our exam, the doctor came in with her son (you must quickly get out of the way when a doc comes in, as they view themselves as gods, and nurses as roaches). The son had a handful of x-rays with him, showing that his mother had TB and had been treated for only one month, then quit treatment. Treatment for TB is 6-9 months, and antibiotic resistant TB is so rampant here, that if you miss one dose, there is nearly no hope. This woman had been laying in a crowded room for days coughing and exposing every other patient, doctor, nurse, student and visitor to resistant TB. Big Sigh... At least the students recognized that she needed to be wearing a mask.

While we were there, a lady was admitted and the women with her sat beside her and sobbed. I put my arm around her and said, Auntie (a proper form of address for an older woman whom you do not know), is this your mother? She said yes. I asked what was wrong. She said, her blood pressure is 0. I looked at the woman MOVING AROUND IN THE BED AND OBVIOUSLY BREATHING, and sighed yet again.