HIV Service and the Warehouse at Sihanouk

We were at the Sihanouk Hospital Center of Hope for another interesting day. We started off by meeting with the manager of International Volunteers named Sideth and the Hospital administrator, Dr. Gerlinda Lucas, a Medical Doctor from the Phillippines who had experience in Hospital Administration from working in Hope Worldwide Hospitals in Afghanistan and Russia. She was very impressive with her knowledge of operating a hospital system and she had very strong objectives around keeping the hospital in operation until funding kicked back in January 2012.

We were taken by Sideth to the department of nursing education where we were introduced to Mr. Horn Hong (known as Hong). He is in charge of nursing education for the hospital. We spent some time with Hong learning about the educational needs for wound care and he booked us to do two lectures to the nurses- one on Tuesday and one on Thursday.

Cathy and Mary with Mr. Horn Hong, Nurse Educator

                                    
Hong first took us to meet a nurse who works in the HIV clinic. One important service the hospital offers is the availability of life-prolonging antiretroviral drugs (ART) for patients living with HIV/AIDS. More than 2,800 HIV positive patients are currently being treated by the hospital. We saw many young men and women attending this clinic. Several young women looked to be in the end stage of the disease and were given beds to lay down on, oxygen masks were in place and their sweet little children sat beside them on the bed. This was heart breaking. The nurse from this clinic will take us to the city hospital on Thursday with a reconstructive surgeon.

Hong then took us on a tour of the Warehouse to view the donated supplies sent by charities. There were several large boxes of medical device materials that had just come in and we worked with Hong and the warehouse staff to sort through the supplies, pull out the wound care dressings and supplies, and identify as many of the medical devices as possible. We were struck by the fact that while it is essential for this hospital to receive supplies, the supplies were sent all mixed together and spread in the box. There were no labels indicating what the products did and it was apparent that the staff did not know what many of the products were used for due to the language barrier and the lack of wound product knowledge.

They took us over to the shelving area where they had very neatly categorized and placed boxes of wound care supplies. Again, there was a similar situation that while they had boxes of some wound care dressings, they were not sure as to how they would be used. We went through many of the supplies and reviewed the indications for use and Hong took notes for follow up. We discovered products for continence care (two step cleanser and skin protectant). We instructed Hong as to how they could use these products. It became blatantly clear to us that there is a disconnect between the warehouse and the surgical clinics regarding products.  The warehouse staff are unaware of the products types and usages and the staff in the clinics are therefore unaware of what they have available to them. We hope we can somehow narrow the knowledge gap here.

We found boxes of mixed medical supplies from charities

                               
We then saw several boxes of ostomy products that were all mixed up between four large boxes. There were products which had been donated representing all main ostomy company brands. None of the boxes were organized and there was a lack of understanding as to where and how these ostomy products would be used and applied. We offered to come and organize and label the ostomy products by type of ostomy , size and coordinating products. We will also develop a "Product Selection Tool" for the use at this Cambodian hospital.
We were then introduced to the Surgical Charge Nurse, Sam Oeun and she gave us more information on nursing care of wounds. We had the opportunity to see one of the staff nurses change the dressings on a woman who had been in a moto accident and sustained an acute , traumatic wound to her left knee.  Much attention is given to sterile procedure and technique when doing dressing change due to many patients have multi resistant bacteria.  Surgical patients are put in isolation when they come to the surgical clinic and wound swabbing identifies many with resistant organisms.  MRSA, VRSA, EBSL is rampid here mostly due to the fact that antibiotics in Cambodia can be bought in the local drug store with no prescription and people self medicate at a very early age. Isolation rooms are identified  with a sign taped to the door. Sam Oeun told us that they always wash there hands when they leave the room, but when we inquired if they washed their hands upon entering she said they do not. We reviewed the principles of handwashing with Sam Oeun - "wash in and wash out". We explained that resistant bacteria is on everything including chairs in the waiting room, IV poles and other equipment.  Infection control techniques, or lack of them was identified to us by Dr. Haerner as a huge problem in the clinics. What is also interesting was we noticed most nurses wear masks all the time (the same mask through out the day).  Hong told us that this started during the H1N1 outbreak last year when they heard on the news they should wear masks.  Of course, they are wearing the wrong masks and do little to protect them from the transmission of bacteria or virus, but education to get them to stop wearing them has been futile.  Because there is a shortage of these masks they wear them all day from one patient to the next, unknowingly putting themselves at risk and their patients.

Sam Oeun explained to us the many wound care cases they see in the clinic.  It is typical for woman in the country side to care for their wounds.   For woman who have fungating breast wounds due to breast cancer the typical treatment for odor control is to crush charcoal and apply it directly to the wound. They continue to do this everyday until there is a thick crust of charcoal over the breast.  If and when they seek treatment at the clinic, the staff are unable to remove this adherent charcoal crusting and they perform a mastectomy.  She said many of these woman are young.

Cleansing solutions used in the clinic are a mixture of 3 teaspoons each of Hydrogen Peroxide, bleach and vinegar in 1 litre of Normal Saline.  This solution is used to clean infected wounds.  Betadine is mixed in water in a bowl to soak infected/dirty foot wounds.  Hydrogen Peroxide and normal saline are used in the OR to irrigate and  cleanse wounds.   Honey from the country side is used on wounds and they find it very effective in healing.  Any honey is used and usually bought in the local market.  Gauze is also bought in the local market for the clinic and sterilized in the autoclave.

The temperature outside was extremely oppressive. Shade and clean drinking water are needed by everyone. We are preparing for our wound care lecture tomorrow.