My morning begins at 6:45am. I usually set the water to boil before I get dressed so it has cooled down by the time I finish eating. I step out into the cool morning by 7:30am. I arrive at the clinic about 8:00am. After greeting everyone with "buenos dias" and un beso, I find either Amalia, Juanita or like this morning, Dr. Miguel.
Amalia is the nurse who is in charge of administering and recording vaccinations for all children that are assigned to the clinic ages 2 months to 18 years in this government funded health clinic in Teotitlan del Valle. She has been an incredible teacher to me both in nursing and with my Spanish. She has allowed me to shadow her and to assist in preparing and administering the vaccinations. I've given intramuscular TDP and Hep B vaccinations as well as MMR subcutaneous vaccines. Here they use cotton balls presoaked in the mornings with alcohol to clean the site and no gloves. Vials are not wiped with alcohol each time before a needle is inserted if ever (I did). However, Amalia washed her hands well and consistently with each patient. She provides education about each vaccine to be administered and treats the parents, as well as the children, with kindness and respect.
In the afternoons, I join Juanita and her crew of 4 nurses in the waiting room. Their primary responsibilities include patient check-in, vitals, and glucose. I have been able to practice all of the above responsibilities numerous times. Interestingly, they use glass, mercury thermometers (some do not work, others break) under the arm and electronic BP cuffs (one size for everyone 12 and up) and electronic scales. I spent one day practicing with my manual cuff that I had brought from home then checking with the electronic one if I got a high or low reading. The nurses didn’t mind. We count the radial pulse in place of taking the blood pressure in children under 12 years.
. No one has given me direction as to where I should work or observe. This morning I shadowed Dr. Miguel, the gynecologist. He explained ultrasound readings and data and allowed me to observe every appointment. Between the appointments, he wanted to practice English and help me with my Spanish. The majority of his patients are pregnant. He was patient with each one, answering their questions and explaining all of his findings. Today, I observed an exam on a 30 year old woman who was 42 weeks pregnant. It was determined she was in labor while dilated 4 cm and 70% effaced. Her vitals, as well as the fetus’, were normal. Because there was no delivery nurse available, they sent her to a nearby hospital by ambulance. I accompanied the woman, her husband, and their family doctor from the clinic to the emergency room. Here they don’t use seat belts, not even in an ambulance. I sat beside the woman in the back of the dirty, messy ambulance and buckled her in myself. Upon arriving at the hospital, we left the husband in the small waiting area in the ED (standing room only). After handing over our patient’s chart to another doctor who, without acknowledging our patient, hurried off; we left her standing beside a chair, alone, in an already packed corner, in the Emergency Department. I can’t explain how upset I felt to leave her standing there alone. I wondered if her husband would get to see her again before she delivered. I wondered if they would decide to go ahead and give her a cesarean since she was overdue and she’d been left in the ED, or because no one was with her who knew her to advocate for her. I wondered if her stress level and that of her baby’s had increased while being transitioned so quickly from a quiet familiar environment to a busy, crowded one surrounded by strange, preoccupied faces.
The health team here, consisting of two family doctors, a dentist, a psychologist, a social worker, pediatrician, a gynecologist, gastroenterologist, seven nurses, and two janitors have their roles and seem to stick to just those roles. I rarely have seen any nurses interacting with the doctors on a professional level. However, on a friendly basis, they exchange kisses, hugs, smiles, and jokes throughout the day. They may even go into town together to pick up lunches for everyone. I found that the nurses who check in patients rarely, if ever, ask questions regarding the patients’ chief complaint or record any other information accept for the vitals. I have observed the doctors conferring with one another a couple of times. I have seen the director of the clinic only a couple of times since I began, and one of those occasions was for an hour long party during which a woman and her three children waited (entire hour) for the dentist to finish eating his cake and partying. The second time was to conduct an hour and a half long verbal cat fight during the middle of the morning with all the nurses regarding a complaint a couple of nurses had made the day before regarding another nurse’s “laziness”, while two women with appointments for their children to receive vaccinations, waited. Unfortunately, I couldn’t administer the vaccinations because first, I did not have supervision and secondly, the meeting took place in the vaccination room.
Almost every day I have made it a point to discuss related health topics with the health provider I’m working with. Today, after a lesson in Oaxaca’s major health concerns with Dr. Miguel, I suggested to him the opportunities that the nurses have to educate patients on particular health concerns during their check in, such as distributing literature or offering a check list of areas of health risks for the patient to mark for the nurse or physician to respond to. He received the suggestion with such agreement that we discussed it for some time.
At four o’clock, I take the 30 minute walk home while enjoying the beautiful mountains everywhere. Tomorrow I should begin a 4-day, 45 minute exercise program for children that I set up with the psychologist from the clinic. We’ll see how it goes!
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