I will warn you now that this is a long post that gets somewhat technical. I have struggled with it for over a week as I tried to decide how to approach it. The organization, decisions about content, and analysis all continue to frustrate me, but I thought it important to share.
The husband of a woman who works at Hands of Hope is currently in the hospital, and Susan and I were invited to visit him recently. Let me say first that from all reports I have received, Thailand’s medical system is pretty well respected. The experience highlighted differences in culture, standards, and priorities of care.
I originally met this man at a smaller community hospital in my first week here. From what has now been reported to me, he was suffering from a fever for approximately 1 week, while still working planting rice and refusing to see a doctor (maybe men are similar the world over). When he finally went to the hospital, he was dehydrated and continued to suffer from the fever. He was receiving intravenous (IV) hydration, but was in a large room with approximately 10 patients interspersed throughout. I was told that several of the other men were farmers as well, and there was the indication that some believed it could be from chemicals in the field where they were planting.
I do not know if this man has HIV or not. As an important side note, I have no idea of how any patients or workers are infected with the virus. When you are in a space with a mission to ‘Just Love,’ it matters not, unless of course someone feels the need to tell me their story because it is important for them to share.
Susan and I have been told that he has not been doing well; we hear a bit about his condition, and that he was transferred to the larger hospital here in NongKhai. We go to visit at around 1900 on a Tuesday. We enter the hospital and choose to take the stairs to the 2nd floor. As we reach the second floor, there are around 15 people on mats taking a rest in the elevator lobby area. We leave this area by walking through an open pair of double-doors into a large, open room with no air-conditioning and what I count is 48 beds.
On my right is a wall and on the far left is a row of windows with openings out to a balcony where the patient’s towels are air-drying. The beds to my left are in 12 rows of 4. Most rows are set-up with the heads of the bead abutted, and there is a small ledge that divides them. The ledge has electrical outlets, suction containers, and oxygen. Hanging above each of the beds is a rotating fan, there are no curtains, IV infusions drip by gravity and most patients have at least one family member helping tend to their needs. I am told with a smile, “the patients and families really take an interest in each other’s medical situations.”
As we approach the man we are there to see, he has been intubated (had a tube placed down his trachea for mechanical breathing) and now has a beeping respirator at his side delivering 60% oxygen (we normally breath about 20% from the atmosphere). He has a nasogastric tube (tube that goes up his nose and down to his stomach) for feeding, and he has a portable cardiac monitor at his bedside that shows a heart rate in excess of 130 beats per minute. He does have a fever of 38.5 degrees Celsius, but his chart shows it has been has high as 40. He has only his family at the bedside, but on a positive note he appears to be controlling his respiration rate (breathing) on his own for the most part. His daughter puts water on his lips with a cotton swab when he asks.
He is alert and tries to communicate with his family by writing on a notepad with a marker. His wife tells us that he is frustrated by the difficulty communicating, but he is clearly not functioning as well as he was when I first visited him. His hands are both swollen, and he has strange bruising up his right arm (the same that the IV is in). His wife states that he is not receiving any pain medication. He has been diagnosed with “a lung infection,” and she is concerned that he is being made to suffer. I do not know if he will survive, and I agree with the reports that his situation is dire.
As you can see, healthcare in Thailand is clearly different than in America. Before we get too carried away with the comparisons, let’s put these healthcare systems into perspective. A quick Google search shows a ranking in 2000 of Thailand at 47 and the USA at 37. Here are a few quick numbers that I have been told, but have not verified:
- In this region there is approximately 1 doctor for 20,000 patients.
- For the outpatient portion of the hospital, each morning between 200 and 300 patients arrive for their appointment with the doctor. Their appointment is for that day, with no particular time. They arrive early, they sit, and they wait.
- In the hospital, during the day there is approximately 1 nurse for 10-12 patients, at night that number drops to 1 nurse for 15+ patients.
The experience of this visit, combined with the limited exposure I have had to the healthcare setting (we had blood tests, chest x-rays, and urine drug screens recently for our work permit application) leaves me with a mixed group of emotions including awe, envy, horror, and an awareness of my ignorance about the systems in place. I have been struggling to decide how best to organize the following section, but I think it is best to talk about what stood out and reflect on it from several different standpoints.
As we initially walked into the room, I think my assumption was that we were walking through another unit to get to the ICU. I was pretty shocked that he was among what appeared to be a general population of patients. In the U.S., I would expect that this man would be in a private room if at all possible. From an infection control point of view, I was slightly horrified that this man, with a case of some sort of pneumonia, was in a large room with no curtains and a circulating fan above him. I can only imagine the trail of bacteria emanating out of each sick individuals’ body and being carried around the room as they bounce between the airflow of the fans. However, the bed arrangement could be very well planned with healthier patients nearer sicker patients. It is possible that if he has HIV, that his pneumonia is less worrisome because it may be less-threatening to a person without a weekend immune system (such as PCP pneumonia).
The vast number of family members in the room was a quick example of how we are in a relationship-driven society versus our individualistic society. A culture where the medical system even acknowledges that family will be around to help tend to the sick. On the other hand, the hierarchical aspect of Thai culture means that doctors are not questioned. I was interviewed about how I would react to a doctor giving orders that I did not agree with prior to being accepted to the program because challenging a doctor can negatively alter the care of the patient.
Going back to the individualistic versus relationship values for a second, remember that comment about how people take interest in each other’s medical conditions? In the U.S. we have HIPAA (the Health Information Portability and Accountability Act). The act, rightly or wrongly, instills fear in doctors and nurses concerned about being overheard speaking in different patient rooms, or accidentally giving out information about a patient to a wrong person (and this is not only the U.S.; remember the nurse suicide after the radio hoax surrounding Kate Middleton?). The thing that strikes me here is that the family members become a temporary community and support system for each other during this difficult time.
I have a lot to say about the fact that this patient was not sedated even though he was on a ventilator, but I have decided it is more relevant for a post I am working on about my experience with end-of-life care here. I have also omitted innumerable differences I have seen in medications, safety equipment, etc…
In the end, the differing approaches to healthcare are what stick out to me the most. In America I feel that our past wealth has resulted in a tendency to throw money at problems and expect them to be fixed, but we continue to see that this approach is failing in many areas. In Thailand, that just does not seem to be an option, and although poverty is rampant, access to healthcare is excellent. Each country also prioritizes differently based on available resources, culture, and many factors I will never know.
Finally, for a touch of the daily life - differences in priorities, language, and way of life never cease to amaze me. I feel that my mind is in overdrive amidst: my daily work toward learning the Thai language; working a new job and attempting to still connect with people whom I can hardy speak to; and processing the differences in language, culture, and ways of life (and the people here speak two languages, the local Issan and Thai). Perhaps all of this, and the heat, are responsible for my fatigue and sleeping 7-8 hours a night! For those of you who know me well, you recognize how much I hate sleeping and how irksome this is!
If you made it, thanks for sticking with this post, I know it was a long one and on of my least eloquent thus far!