February 8, 2017

Adult Care

Inpatient Department

 

The Clinic’s Inpatient Department treats a variety of conditions, with a special isloation ward for patients with particularly contageous illnesses such as Tuberculosis.

 

This woman is receiving special treatment for acute pneumonia

Founded in 1999, the IPD treated all cases in the same space. As needs and the number of patients increased, the IPD expanded its services and facilities, separating the department into different units: medical, children, reproductive health, and trauma/surgery.

The Inpatient Department (IPD) admits patients with severe medical problems (non-trauma) 24-hours a day. The most common cases seen continue to be malaria, acute respiratory infection, urinary tract infection, gastritis/ulcer and diarrhoea. There is also a continuing increase in the number of chronic cases, which include cancer, sclerosis, hypertension, nephritic syndrome and heart disease.

Beyond the regular patient caseload, staff at MTC must be prepared for the unexpected effects of extreme weather, such as the cholera outbreak in 2007.

The IPD is a basic building, but some renovations have provided additional space for patients. There is also an area for the medics to prepare medications, see follow-ups, conduct training, store supplies, have a small medical reference library, and keep an archive of past medical records.

For severe cases that cannot be treated at MTC, the referral programme to Mae Sot Hospital (MSH) is a possibility. Department Manager Saw Muni and the medical staff are faced with the task of deciding who will be referred for treatment, taking into account the survival rate of the patient and the cost of treatment. A lack of facilities and resources makes it a hard process for both the staff and patients.

IPD IN NUMBERS:

Average length of stay 6 days
Referrals per year 170
Number of shifts per day 3 (80 staff)
Number of beds 50 with overflow of 20

Challenges:
 
Late arrival at the clinic is an important factor in the number of deaths per year (approximately 190). Transportation costs to the clinic are high, and illegal immigrants who are less ill are more likely to be arrested than those who are severely ill. Hence, they often delay too long before coming. About 35% of mortalities occur within 48 hours of admission.

In some cases, the whole family travels with the patient to avoid getting lost in the case of arrest or deportation or simply because there are no economic means to travel back and forth to the clinic. The presence of family members increases crowding at the clinic. Beds are frequently close together and patients often have to be accommodated in the space available between the beds. There is an immediate need for isolation rooms for patients with communicable diseases, especially now that there is no longer an external tuberculosis programme for patients.

Staff retention is one of the main concerns of the department. Saw Muni summarises the plight well: “If we look for our strong points, we have trained a lot of medics…if we look for the weak points we have trained a lot of medics that have left”. There is hope that the staff will have more long-term medics and training, especially considering the expansion plans of the clinic.
In 1998, about 80% of admissions were related to malaria.  Over time, the range of illnesses treated has become broader – but the constant over time has been that patients arrive at the clinic with illnesses in advanced states. Since many patients arrive with terminal illness, the IPD functions part of the time like a hospice. Working constantly with terminal patients has a strong impact on the younger health workers. If the patients could have a higher level of health knowledge, act more on prevention, and obtain treatment earlier, many of the conditions, such as malnutrition for example, would be preventable or treatable.  The IPD also faces family issues – a patient may be dropped at the clinic by friends or family, however, these people frequently cannot afford to miss work in order to be their attendant. The responsibility falls upon the medics to support patients who face death without friends or family.

In other cases, the whole family travels to the clinic together. They may live far away and are unfamiliar with Mae Sot. If the family is migrant or displaced already, they fear being split up by circumstances if they don’t travel together.  For example, in the case of arrest or deportation, they could have great difficulty finding one another again. The family may not have the resources to travel back and forth to the clinic every day, or have difficulty travelling freely due to security. Sometimes, the family members will search for work in Mae Sot while attending to a sick family member.

One might be tempted to declare victory when a patient’s condition has improved and is able to go back home. However, for many patients, this merely heralds the beginning of the next set of challenges. They may not have money to get back home, face security and travel challenges, and their old job may no longer be waiting for them even if they do complete the journey without incident.
In order to carry out their duties successfully, the IPD medics must possess medical ability, as well as the ability to counsel patients, support them, and refer them to other clinic social services. One of the most difficult challenges for the medics is to manage the psychosocial aspects. While the death rate is very high, the community spirit of the patients is unbreakable. The HIV/AIDS patients stay in the clinic for a long time, become a close-knit community, and take care of each other.

Unfortunately, there is no space in the ward for relaxation or recreation for long-term patients, and many don’t have sufficient clothing, blankets or basic necessities. One by-product is that the visual impact for visitors can be a shock.  Desperately poor patients arrive with few basic necessities and after long travel.  The patients often leave with blankets, meaning that the clinic is constantly in short supply, some patients are accompanied by an entire family who may sleep under their bed, and they can be very dirty due to travelling and sleeping on the floor. While they may receive good care and treatment, there may be visual shock at the patient’s physical appearance in the crowded and disorganised ward. Dr Cynthia stresses the importance of looking past the initial appearance, avoiding judgment, and looking more closely at the most important elements – quality of care and strength of the community.

Under the misnomer of a “clinic”, Mae Tao Clinic also functions as a hospital facility, with several inpatient departments (IPD). Until 1999, there was only one inpatient department, treating medical, trauma, reproductive health, and child inpatients all in the same space. In 1999, the continually growing patient population led to the expansion of the clinic and separation of departments, eventually resulting in the Medical, Children’s, Reproductive Health, and Trauma/Surgery IPDs that exist today.

Established in 1999, the Medical IPD was a combined service for both adults and children. The most common cases seen continue to be malaria, acute respiratory infection, and diarrhoea, with a continuing increase in the number of chronic cases being seen at the clinic, including cancer, sclerosis, hypertension, nephritic syndrome, and heart disease.  Among children, malnutrition is also a common case, and this was one of the leading reasons for the development of a separate Children’s IPD in 2005; children with weakened immune systems needed to be separated from patients with contagious illnesses.

Beyond the regular patient caseload, staff of MTC must be prepared for the unexpected, such as the cholera outbreak in 2007, or other effects of extreme weather seen in tropical climates. The rainy season from May to September, for example, always brings an increase in the number of patients arriving with malaria. In addition, the further word spreads of the services of MTC, the more chronic cases are presented at the clinic. Even in a well-equipped, modern hospital setting, these cases would be an extreme challenge.

For severe cases that cannot be treated at MTC, the referral programme to Mae Sot Hospital (MSH) becomes a possibility. Department Manager Saw Muni and the staff of the Medical IPDs are charged with the unenviable task of deciding who will be referred for treatment and who will not be. There are procedures and protocols to follow, but this does not make it easier. Staff must first consider the potential survival rate of the patient, and then the cost of treatment, referring only the patients that require a one-time visit to the hospital, and not on-going hospital visits. Of course, these decisions are made in developed countries, but not to this extent, and not on a daily basis. Frustration and sadness is evident when talking with Saw Muni. “I am sad because we cannot treat all of the patients, we don’t have enough facilities or enough money to refer the patients.  If I see sick patients, and I can’t do anything for them, I feel very sad.  And when the patients die…we see a lot of death.”

The Medical IPDs are also plagued with the challenge of staff retention. Saw Muni summarises the plight well, “If we look for our strong points…we have trained a lot of medics. If we look for the weak points…we have trained a lot of medics that have left.” With the introduction of a resettlement programme in 2004, the clinic has suffered extensive loss of staff, but Saw Muni expresses the understanding and acceptance for those that choose to resettle in a third country, “We are human beings. We want to improve our lives. If we are just living, with nothing to hope for…people don’t want to live like this.”

There is hope that the future will see the training of more long-term staff, especially as there are more plans for expansions in Medical IPD.  As an example of possible future development, the department still requires better isolation of patients with communicable diseases, especially now that there is no longer an external Tuberculosis  programme. There is also the hope for greater coordination and partnership with other health organisations, Mae Sot Hospital, and the Thai community. Communicable illnesses like TB quickly become devastating public health issues that don’t recognise borders. The increase in cross-border patients requires greater collaboration in the community to battle health issues.

The IPD cannot alone solve the problem of cross-border tuberculosis, malnutrition, lack of health care inside Burma, or the extreme social and economic challenges of the patients. The IPD aspires to treat the patients with the best care possible with its resources, utilising strong collaboration with other clinic departments as well as other organisations to address the broader issues that result in its high caseloads.

Outpatient Department

 

Our Outpatient Department began as a small space in an old house, but as the Clinic grew, the department did too, and it now has six separate exam rooms and a waiting area. But as our patient load continues to increase, we keep needing more space for the Outpatient Department, which, unfortunately, is not available.

 

In the beginning, all of the medical services available at MTC were provided under one roof. Patients came for treatment of a wide variety of ailments, ranging from treatment for malaria, to having wounds dressed to the delivery of babies. Although many of these patients stayed overnight, this is still considered the origin of the Medical Outpatient Department (OPD). Equipment and medical supplies at this time were scarce and food was limited and very simple. Despite the limited resources of the clinic, no one was ever turned away.

Although the space was small, an effort was made to keep trauma and maternal health patients separate. The original space was an old house, with various improvements added as time and supplies allowed. Originally, the clinic was only open from 9:00 a.m. until noon, but increased patient loads necessitated an expansion of operating hours to a timetable of 8:30 am until 4:00 p.m., Monday through Saturday. Of course, emergency patients were also admitted on Sundays.

As time went on, the number of patients and scope of services continued to increase, with the number of patients requiring specialised services such as minor surgeries, obstetric and delivery services, and child services beginning to overwhelm a single Medical OPD. In 1999, MTC expanded to allow the establishment of separate departments, ultimately leading to better standardised treatment of patients and the adoption of established protocols. After the expansion, the Medical OPD had a larger space with four separate exams rooms, three for seeing patients and one for administering medication. A mere six medics completed all of the renovation work.

In 2000, the Medical OPD moved into a new building with six exam rooms, four for general care, one for chronic disease patients and one for malaria cases.

The Current Department

A separate space to treat malaria patients has always been necessary at MTC, but a separate exam room to treat patients with chronic disease is a newer development. The patient demographic is changing considerably, with more and more patients crossing the border for health services as the state of health care continues to decline in Burma. Moreover, as word of mouth continues to spread regarding the wide variety of free services at MTC, more people are willing to risk the journey in order to receive the potentially lifesaving services.

The department handles all acute and chronic medical problems, ranging from minor conditions to malaria, tuberculosis, HIV, malnutrition, pneumonia, acute diarrhoeal diseases and chronic conditions such as diabetes, epilepsy, thyroid disease and cancer.

Challenges

At this point, MTC cannot fully treat most of the chronic disease cases that are presented, such as diabetes, heart disease, and hypertension. Both the lack of resources and infrastructure to support the health care needs of long-term patients are issues yet to be overcome. Moreover, medics are not yet fully trained to cope with these illnesses, although they continually strive for that knowledge and work to gain it through weekly case studies, and upgrade training programmes. It is a frustration and a challenge for the medics when they cannot provide the proper treatment for a patient, but it is also a challenge when they can.

The staff of the Medical OPD continually work to ensure that patients take their prescribed medicines properly. Unlike the other clinic departments where patients receive their medication directly from the medic caring for them, in the Medical OPD, the pharmacy is a separate unit. Therefore, the medics and the pharmacy staff have to maintain high levels of communication and ensure that communication with patients is also strong. When patients speak a variety of different languages, and often cannot read or write, this presents considerable obstacles. In 2005, new medicine distribution bags were created in order to eliminate the need for a patient to be able to read. Since the implementation of these bags, the dosages and schedule for taking the medicines are depicted through pictures, making it much easier for the patient.

Language barriers and illiteracy have also been a challenge when it comes to educating patients about their illnesses. With Medical OPD continually getting busier, the medics can only spend a small amount of time with each patient, so the hope is to produce more printed education materials to give to patients. However, these printed materials need to be produced in more languages and need to take into account patients who cannot read.

The staff of Medical OPD recognises that until there are radical changes in the political situation in Burma, MTC will continue to see an increase in patients. The staff hopes for the necessary developments to be able to serve these patients.  They need a larger waiting area, more exam rooms, more medics, further training and greater resources to be able to recognise and treat the greater variety of illnesses coming through the door.

 Staff

Two medics work together in each exam room, normally seeing only one patient at a time, but sometimes seeing two at a time if the department is overwhelmed with patients.