How to see patients by yourself in a rural clinic in 20 easy steps

Recently I was reflecting on an insanely busy day in the clinic.  I looked back over the day and thought - I saw about 22 patients in about 7 hours - that is only 3 patients an hour - WHY am I SO exhausted?  But then I thought about what “seeing” a patient entails and decided that I may have unlocked the secret to why it goes slowly (though, admittedly, I have no idea how many patients a doctor in the US sees a day).

So here is a step by step guide on how to “see” a patient if you are the only healthcare worker there:

1.     First, assess if they have a “carnet” or medical record.  If they brought one, it goes in a stack on the desk- so that you can see people in order.  If not, they need to buy one. 5,000fg in our clinic gets you a very nice book (a note book cut in half) that becomes your medical record.  It is very hard for people to get used to needing to bring that with them so that we can track their treatment.  (5,000fg is about $0.60 USD)

2.    Call the patient whose carnet is on the top - sometimes you have to go and look for them.  Welcome the patient and any family members that they brought with them.  Everyone can crowd into the small 8 ft by 8 ft office.  No need to worry about HIPPA violations.

3.    Weigh the patient - our scale weighs in pounds, so you need to convert it to kilograms.

4.    Record the patients name, accompanying  family member, where they are from, age (see note below), and sex in the large medical record book.  (Most of the older people have no idea how old they are - many conversations go something like this….  ME - how old are you?  PATIENT - I have no idea.  ME - ok, how many children to you have?  PATIENT responds - and I calculate from there.  I have also gotten - do you see that tree over there - it was 2 feet tall when I was born - turns out that information is NOT as helpful as it is meant to be.  My other favourite answer - “well, how old do you want me to be?” - and one from last week - “Do you know that guy named such and such in another village?” (I had NO idea who they were talking about) - “he and I are the same age”…..  ummm, ok - how about i just guess how old you are)

5.    Ask about a medical history.  This is tricky.  We usually start by saying “what and what is tormenting you right now?”  It is helpful if you can speak the language - MUCH harder if you have to have someone translate for you.  People tend to hide medical history here for some reason and it takes  awhile to pull it out.  They especially seem hesitant to share what medical treatment they have already gotten.  I have heard some interesting symptoms - here are a few of my favourites. 

            a.  There are things walking around in my stomach.

            b.  There are things walking around under my skin.

            c.  My heart is beating hard and it is sucking the life out of me.

            d.  I don’t have any “man” power.

            e.  Something is very wrong with my son - he cant walk around at night in the dark without a        flashlight.  He keeps running into things if he doesn’t use a flashlight.  (That one caught me off guard.)

6.     Examine the patient.  We have a bed in the office* so they lay on that and we assess them.  We also have a few high-tech devices like a BP cuff, stethoscope, finger oximeter to measure oxygen levels, and a Doppler to measure metal heart tones. 

* Occasionally, the midwife is there too - but she is usually tired from farm work, so she will often lay down on the bed.  So you might need to move her off the bed first.

7.      If indicated, utilize one of the 4 labs tests that we can perform in the clinic: urine dipsticks, pregnancy tests, malaria tests, and tests for anemia.

8.  Make a diagnosis and write it in the book.  Each diagnosis comes with a “code” that gets recorded as well.

9.  Write in the book all of the medicines that you want the patient to have.  Tylenol is almost always included because people don’t keep that on hand.

10.  Rewrite ALL of the medicines again in the patient’s carnet.

11.  Dispense all of the meds into little bags and draw lines on them to indicate how many times a day it should be taken and how many pills should be taken with each dose.

12.  Calculate the price of the meds.  Include a 20% fee on top, which becomes the doctors salary.

13.  Tell the family “ your family member has been seen, and the medicines have been written.  Here is the price.”  Often at this point, you all pause and look at each other and then say - did you hear?  Yes, we heard.  And often, people will ask for a price reduction.

14.  Take the money (always use your right hand - never take anything with your left).  Count it out in front of everyone.  Often, people will not have enough with them.  So they say, give me the medicine and I will bring the money later.  But that is not done in our clinic.  So we usually divide out how much meds match the money they have and they come back later for the rest - when they bring the rest of the money.

15.  Explain how to take the meds.

16. Say goodbye and bless them - saying, May God heal you and give you health.  I always tell them to come back if they are no better.

A few side notes -

-you never want to get moved ahead in line because it means that there is something very wrong.  We always go in order - no matter who it is or how very far they have come.  However, super sick or bleeding people get moved up in line.

-there is but one small window in the office - it is a blessing and a curse.  It sometimes lets in a small amount  of breeze - but also allows people to see into the office and talk with you.  We try to make them sit in the outer room - but they are always fascinated by what is going on with other people.  Also, we try not to dispense meds out of that window - but occasionally, on very busy days, it is much faster to hand stuff out that way - which I am sure is very confusing, because most of the time people get in trouble for standing there 

- but then sometimes are told to come to the window.  The window is also maddening because people like to stand there and plead their case for why they should be seen right away - all the while distracting you from focusing on the patient in the room.

-I like to start my day by sweeping up the mouse and bat poop - makes me feel fresh and clean.  Sadly, there are days that some kid pees on the floor and there is nothing to clean it up with  - so you end up walking in it until it dries.