I woke up at 4:43, 17 minutes before my alarm was going to go off. I though about my outfit. Hierarchy is important, and it's only through my status as gringa doctor that I finally managed to get permission to carry this out, but too formal would put people off. So dressing the part is key. I went with a red knit Anne Klein tank top (10 Lempiras at the thrift store across from Congress) and khaki pants, with black shoes. Make-up, earrings, a thermos of tea to keep me awake, and a plate of chocolate-chip cookies I baked the night before for my primary contact, Edith (I'd found out after meeting her the previous day that it had been her birthday). I stuffed a pad of yellow-lined paper that as it turned out had toddler scribbles on every other page, my phone, wallet, camera and magic letter of permission into my shoulder bag (too hippie-looking?) and set off walking (5:30).
I don't think I've walked down the street to the center that early before. A woman stopped by the huge garbage pile at the bottom of the big stone staircase to look at some kids' toys that someone had put above the main pile on the raised sidewalk. A little further down I jumped and let out a quick yelp when I almost stepped on a really large dead mouse (small dead rat?). The air was fresh and the city felt good, cool, waking up and mostly empty. Crossing the central park toward the Cathedral, which last week had been packed with Holy Week vendors and flock, I saw a nurse walking quickly. Another nurse waited for her by the Cathedral stairs. They greeted cheerily and continued walking quickly together. I figured we were all going to the same place, so I followed them.
I realized I had a wider option of colectivos than usual when I saw the nurses walking toward the punto de taxis for La Kennedy. After all, I wasn't going all the way to the university. I asked just to make sure and the taxi stand guy opened the door and said "get in." There was only one space left, so we left immediately. Even though I'd done it hundreds of times, I felt a little bit like when I was in grad school starting fieldwork. Excited, expectant, a little nervous, worried about being too tired. Despite having left on the late side, I made it there just before 6am when the morning shift (turno A) starts. The young woman next to me in the cab asked to get out at the Materno Infantil, which was where I was going, so although I'd thought I had to get in all the way around the block, I got out too. It was the employee (only) entrance, but I showed the guard my letter. He looked at it (for the second time in two days I had the distinct impression that a guard reviewing my document might not actually be able to read), sized me up quickly, and waved me in.
I walked across the parking lot, noting the special parking place-holder signs right in front of the main doors. One of them was for the head of a union, and I wanted to take a photo but felt a little too awkward whipping out the camera yet. Inside, there was a line of nurses leading up to a box on the wall. It was a minute before 6am. Each nurse entered a code into the part on top, and then stuck their hand on the scanner underneath to scan their finger. Presumably an addition of Julieta Castellanos, the UNAH rectora who implemented the same biomonitoring time-clock system for university faculty a couple years ago. Hospital Escuela administration was turned over to UNAH last year, so the tactics that were so successful in "cleaning up" the U (union-busting, speed-up, industrial restructuring, "security" focus, etc.) are being implemented there too (and in general, the response seems positive).
I showed my magic letter (in its original manila folder given to me by the secretary of the doctor who dictated and signed it for protection) to the stairway guard and got waved through again. I was pleased with myself for remembering the way. At the top of the stairs and down the hall I came to the ward entrance and paused. The sign said to ring the bell. A nurse came for her shift, and she herself rang the bell. Turned out the door was padlocked from the inside. Another nurse let her in, and told me (when I inquired) that Edith wasn't in yet, but would arrive any minute. So I took advantage of the delay to look at the material on the walls. The first thing I noticed was this poster:
It reads "No tips/bribes, do not offer and don't allow anyone to charge you anything unless it is through a payment with a receipt from the cashier."
There was also a lot of christian and Catholic material. A flier from an evangelical church was stuck above a poster on the wall, too high for me to read carefully. On the glass doors of the ward itself was a common bumper sticker that read "Paremos a la violencia respetemos a la vida Campaña de la Iglesia Católica de Honduras." There was also a partially transparent white sticker with some footprints and the words "Sigue Jesús" and a little "oración de la tarde" card taped underneath. Above it all was an Ofxam/CIPRODEH "No a la Corrupción" bumper sticker.
An old lady whom I referred to in my notes as an "orderly" although come to think of it I don't know what that term technically means came by with a shopping cart full of baby bottles, some full and labeled. She took those out and handed them to the people in the pharmacy right there, serving the 3rd floor wards.
Another hand-written sign titled "Requirements for entering Pediatric Orthopedics" was taped on the wall by the door:
The requirements were:
A woman standing in the hall with a super shiny sequined pink shirt who had been standing around looking tentative (as I imagined myself to also look) got up the nerve to ask me if I worked at the hospital; she obviously needed some sort of assistance I couldn't provide. I explained a couple times that I was just waiting for a nurse and that I was a professor at the U. Then we both went back to standing in the hall, looking tentative.
Edith walked down the hall at what was probably around 6:15. On seeing me she said "¡Usted sí madrugó!" As we walked in to her small office crowded with papers, medical supplies, and comfy chairs leaving very little floor space, she told me she had been reading up on anthropology since the previous day to find out what it was that I did. She was particularly welcoming and seemed proud to have an anthropologist on the ward. She introduced me to everyone and told me I'd be studying their conduct, which I had to push back a little on. "I'm not here to monitor or judge you!" I interjected.
First she took me to a room where the smallest patients were kept in cribs that looked to my eye more like cages. But just because of the materials (iron bars, rough soldering), not their use or some sort of inherent morality. Here there were three or four tiny kids with broken bones (fracturados) about three years old, two of them still sleeping with their big casts on. I was a little nervous about the fact that none of the cage-like bars were actually in place. It looked so easy for the kids to roll and fall downalthough I supposed that the casts would be something of an impediment there. (An auxiliary nurse later confirmed to me that patients had fallen off their beds while sleeping previously, and that the bars didn't go up because none of the cribs worked anymore). A nurse was giving the shift-change report [forget how that translates exactly] to Edith and an auxiliary nurse.
Edith explained to me that there were three kinds of patients in the ward: regular orthopedic patients (she also referred to them as clean fractures, by which she meant not clean breaks, but rather patients with broken bones who didn't have infections); something that had rini and ortho in it that I didn't catch in time to write down but referred to the pts with bone infections I believe; and plastic surgery pts. From outside the centrally-placed nursing station she pointed out the corresponding rooms. First, the small kid fracture room I'd already seen, then the very large hall, where the "clean" patients were, then the mid-sized room where the "contaminated" patients were, then a one-bed room that was "isolation." I noted that the contamination policy didn't seem very strict; all the doors were wide open and plenty of people circulated in and out. But she later explained that no one was really contaminated right now, so they were using the rooms mostly for regular pts.
As I looked around I overheard Edith talking to an auxiliary nurse (Edith is the only RN on the wardeach ward only has one RN and the rest are LVN/auxiliaries) or parent saying "Siempre Dios pone ángeles ¿verdad? en nuestros caminos."
Edith reiterated to me that she'd read up on anthropological methods, and pointing to the big hall of "clean" fracturados told me to go ahead, go in and talk to the patients and their familiares. I felt awkward about this of course (given my habitus), but marched in as ordered. I looked for a patient who wouldn't mind the intrusion, and ended up going over to a small boy in traction who had a friendly, bored look. I asked him what happened to him. He told me he'd had surgery on his knees. I said it must be boring to be stuck in the bed. He nods, shy. I ask him where he's from and he tells me near Agafam. It's a very poor area by Suyapa, across from the UNAH. I write down my diagnosis ("seems like a congenital condition") which turns out to be true, and I see from the handwritten note about the kid on the end of the bed ("Artigriposis múltiple congénita"). Since there are no televisions or anything, I ask if he has any books to read. He says yes and points to the side of the bed. I try to find the book in the desk. "No," he tells me, "It fell on the floor." It's a bible coloring book. Okay. So I ask if he has crayons. Yes, he shows me a pile on his lap. I ask him how old he is, thinking seven or eight. "Fourteen," he responds. I try not to look surprised.
I went to the girl across the hall a few beds down (the hall was mostly empty), who looked to be at least sixteen. I stood next to her, awkward. "Qué tiene usted, ¿está fracturada?" I ask. "(inaudible)" is what I scribbled in my notes as her response. "What did you say?" "Un tiro" she said with exhaustion, sadness or something similar. She wore a full leg cast. I asked if the shooting was recent, saying also that her toenail polish, visible through the toe-hole in the cast, was pretty. It was different colors and had designs, looked recently-applied and like it had to have been pre-cast. She had been shot in the knee last Friday. A poor-looking, frail woman who I guessed to be her mother, came and began attending to her.
The frail woman asked me something, and I didn't understand right away. She was asking about a wheelchair so she could bathe the girl with a bullet wound to the knee (presumably her daughter). Useless, I directed my question to the woman now with the 14-year old boy in traction. She was washing him and I assume she was an auxiliar but it turned out she was his mother. As Edith had explained to me the previous day, due to staffing shortages (or hiring freezes), jobs that nurses should do were frequently passed on to family members, and mothers were all in charge of washing their own kids now. In either case, she knew the scene better than I did. "¿Usted la va a lavar?" she asked the frail lady, who indicated she was indeed planning on washing the girl. She said that there was only one wheelchair on the ward and it was too small for the girl.
Also, it was being used by the little boy, Carlitos, with eggshell bones (the technical term is Osteogenesis imperfecta- I knew about it from the famous eggshell skull legal case that HH told me about when we were trying to figure out how to get justice from the racist CO courts after LL was attacked; turned out in CO racism is more important than legal precedent). Carlitos, with his eggshell condition (Edith used the term "cáscara de huevo" in explaining his bones) wheeled around in his tiny wheelchair, joking and flirting with all the nurses like he owned the place; Edith explained to me that almost as soon as he left, he'd break something again and be back in.
So, no wheelchair for the quiet bullet-wound girl with pretty toes. "Do you have soap?" the traction-boy's mum asked the frail confused mom. The frail mom showed her little bar of soap (which I later realized were handed out to the parents by one of the auxiliary nurses). What you have to do, said traction-kid mum, is wash her on the bed, like I'm washing him (demonstrating a basic sponge-bath technique- she was clearly a pro). The frail mom tried washing her daughter for a couple minutes then came back to traction-kid mom, asking her directly (instead of addressing me this time) if she had a robe she could cover the girl with for privacy. No, she said kindly, but with a tone that indicated to me that it seemed obvious to her, a regular, what this womancertainly not a regularshould do. You have to ask for a patient robe to cover her with.
A young boy lay in another bed with his left arm and leg in casts. His mother and father, who look particularly poor and rural and are loving with him, tell me he was hit by a taxi in Esperanza, Intibucá. They gently move his limbs about trying to make him more comfortable.
Another cute little girl (under ten, I'd guess, but I'm particularly bad at estimating ages it seems) with an arm in a cast was being gently led in by her father (I assumed) to her mother who waited by her bedside. They had hung a pink princess mosquito net over her otherwise prison/military-looking cot. Later, during rounds, Edith explains to me that the girl had been shot at by thieves who had stopped her family while they were in a car, taken everything from them, and then shot her in the elbow, as she sat between a parent and her little brother. Just for good measure. The page taped to the foot of her bed read "Fractura expuesta grado III A radio izquierda." "Es que aquí estamos expuestos todos" explained Edith.
I wandered around a little more. There was a Little Free Library box up in the corner (I had a feeling I knew who was responsible for its presence). It held a lot of fourth grade math books, and some other assorted kids' books.
The walls had a variety of cartoon characters. I recognized Dora the Explorer, Pluto (I think), and Daffy duck. There was also a strange-looking seal with a sailor hat.
In my notebook I wrote the following statement, which inadequately expresses the glee I felt on realizing what I was looking at:
"Somebody made a cozy for the oxygen tank."
I later realized that all the oxygen tanks had cozies. And at least in the Materno-Infantil hospital (the building is next door to the adult building of Hospital Escuela, or maybe adjoining, still don't have a clear picture of the architecture), they are themed with kid-print fabric. Bears and rainbows and whatever. It struck me as funny because it seemed superfluous, and as if covering an oxygen tank with kittens somehow takes away from its oxygen-tank-ness. But as run-down as the building is, I realized over the course of the day that nurses care a lot about their wards looking clean and pretty. And in the end I have to agree, an oxygen tank with a cozy on it is prettier than a naked oxygen tank.
Out of 20 beds in the main hall, only 6 were occupied. As I was tallying, I noticed that only one kid, a teenaged girl way in the back, didn't have any family present. I later saw some family members come and hang out with her during regular visiting hours, which seem only to apply to family who aren't parents, especially mothers, who seem to have the right to be there around the clock.
In the room that was designated for quarantine with only one bed sat a boy with a cast on. Edith explained to me that the doctors were going to amputate, but God saved his limb (I can't remember now if it was a leg or arm- I think a leg). It had been a shotgun accident. The shotgun belonged to his father's friend and it went off accidentally. The same kid, months earlier had spent five days in a coma, she told me, after getting run over by a car. Edith explained to me that with an escopetazo (shotgun wound/attack) the bullets are dirty, and you have to put the victim on antibiotics so they don't get necrosis. "Este hospital es el de los pobres," she said, "hay que pedirle a Dios que les cuide, no nos queda de otro." This was partially in reference to the fact that the hospital never has the necessary supplies; the escopetazo kid's mother was off buying some kind of bandages and medicines. Family almost always needs to purchase med and supplies on their own, and nearly everything's available within walking distance, from drugstores to the funeral homes surrounding the hospital. But often the drugs in question aren't stocked (whereas there always seems to be a good supply of coffins on display).
Another boy, a friend of the first, came in the room, wearing a bandage on his arm. I asked him what he had, and he told me some term that was way over my head, like I should understand it. After a few puzzled looks (me) and repeats (him) he explained with only mild exasperation "it's a bone infection." He was eating something out of a cup that also had coffee. He explained that it was a pancake, "las hacen y las traen a vender," but that they weren't as delicious as they should be because they weren't sweet. "They're good for diabetics," he added. I later discovered that it was Edith who brings the pancakes. She's health-conscious, which is probably why she doesn't add extra sugar to the pancake mix she told me she buys at Pricesmart.
The boy with the bone infection asked me "Why are you interviewing us?" Unfortunately I wrote down the question but didn't see fit to write in my notes what I answered. Probably something along the lines of I'm trying to understand the hospital environment better, how people get sick and heal and what it's like to be a nurse (i.e., the truth). I probably also mentioned some differences in Hospital Escuela and U.S. hospitals I knew, because the next thing I have in my notebook is his comment that he has an uncle in los Estados, and things are different there because there are fewer guns. I told him that was true in some parts of the U.S., but that other places have a lot of guns.
The escopetazo kid (that's how I identified him in my fieldnotes) asked me about Obama. Is he a good president? To which I gave my honest opinion, both in terms of foreign and domestic policy. Both kids listened seriously, nodding at my points about war, corporate politics and racism. He then asked me about Chavez, "fue un guerrillero ¿va?" I thought about it and answered no, he wasn't a guerrillero, he was a soldier. And he attempted a coup at one point, but he was always affiliated with the state one way or another. His mother, who had returned from the pharmacy and was with us in the room, commented "Querían mucho a Chávez los venezolanos. Si quieren a un presidente tiene que ser bueno ¿va?"
Edith called me to join the residents (two tall young men with a combined air of importance) and her on rounds. They started with the quiet teenage girl who had been shot in the knee, with the full leg cast on. Edith told me it was a bala perdidaa stray gunshot. I felt then, and also later, that this may not have been the whole truth. Or at least that there was much more going on. She seemed profoundly traumatized (in a way that, in this context, a stray bullet didn't sufficiently explain for me).
They moved along to the girl in the far back of the room who had been alone earlier. She'd been in the ward for a while, I think a few weeks, and was cleared to leave that day, once her requirements were fulfilled. "Hoy van a venir a dejar la pinta de sangre," she assured Edith, who then explained the policy to me. It's a flat fee of L.200 (USD$10, regardless of length of stay) and a pint of blood. Since no one wants to give blood, it's the only way they keep the hospital blood bank full. "No pueden salir si no nos da la sangre," she tells me.
Over at the kid-in-traction's bed, the residents fiddled with some weights attached to the traction itself, and argued amongst themselves if one of the weights was 2 lbs or 5 lbs. Edith brought a digital scale out, donated by a group of students who had done some sort of práctica there (it was written in sharpie on the back), but nobody could seem to figure out how to use it. Later on when we were talking in her office I mentioned the scale and she had a little panic, remembering she'd left it in the big hall. She ran out to get it so it wouldn't get stolen. Edith explained to me that the boy in traction had been in and out of the ward his whole life (hence his mother's expertise). He was very poor, and had been born with the above-mentioned congenital condition. He'd mostly walked using his hands to drag himself around, and until they started doing operations to extend his bones he'd never walked on his legs. But now he could. He had to have multiple operations.
We then went over to see the little girl with the pink mosquito net, and Edith told me about how she'd been shot during the robbery. The girl seemed to be in good spirits.
Over in the contaminated room, a number of kids with infections lay in their crib/cage/beds with their parents (mostly mothers). A young boy from Patuca, Olancho had an infected fractura expuesta from a fall in some really dirty dirt. One of the residents handed the other an x-ray, and he held it up to the window light to read it.
A handwritten sign on the wall over the boy in the back corner of the room read "Los niños son lo más importante del mundo, lo malo es que ni el mundo podemos cuidar." Pointing to the boy, Edith half-whispered that be had "RM," hoping I'd understand. Then seeing I didn't, she went ahead and said "retraso mental." An Aguazul truck had run him over.
In the small kids' room, a mother was sitting with her child, who had an arm in a cast. Edith asked what had happened to him and the mother replied that he had fallen from a chair. Edith looked at me knowingly and said "he didn't fall from a chair. That doesn't happen from a fall off of a chair."
We walked back toward Edith's office, and passing a group of family members sitting in the hallway I asked if she could explain how visiting hours worked to me. In response she complained that they were contaminating the floor, but that they never listen. In her office she told me I should wear something over my shirt to keep the microbios off, and gifted me a vest made from blue scrubs cloth. It was a very sweet gesture. Throughout the morning she had been raving about my cookies and alternately complaining that she was eating too much, and sharing them with the other staff, making sure to tell everyone I'd made them. Also very kind. People don't do a lot of baking here in general, so people were far more impressed by chocolate chip cookies than perhaps they should have been. Or else they were just being thoughtful.
I sat in one of the comfy chairs and she in the other, and we chatted about various things. I asked about the nurse-pt ratio in different contexts. She told me in the newborn ward (recién nacidos) where babies with infections, etc., go, the ratio is one auxiliary nurse (~LPN) to 27 babies. She told me that that [despite the pro-breastfeeding posters and official government policy] not all nurses encourage breastfeeding.
And that a sala de lactancia materna was being created. There had been one previously, she told me, but they closed it down. Pepes (bottles) are dangerous, she said. They let them sit around and they get covered in flies (se mosquean).
She told me the comfy chair, the nice purple dumbbell weights on her desk, and a whole bunch of medical equipment and other supplies had come as a donation. She didn't know who had donated it when I asked, but went to unnecessary (excessively kind) lengths to try to find out. I told her not to worry about it, but she wanted to give me an answer. She eventually found a receipt, but all it had was the name of the Honduran shipping agent. Later on she showed me a room full of big black heavy plastic crates full of medical supplies that had been part of the anonymous (whether intentionally or not) donation. But back in her office she emphasizes that almost everything in the ward is donated. That fancy poster behind me with the ward rules that she hadn't yet found a place to hang up in the ward? A gift from a psychology student who had interned in the ward. "Vienen aquí a hacer su trabajo social y me dejan recuerdos" she tells me. At that point I reminded her of the scale and she exclaimed "¡Ay! I forgot I left it there. ¡Me roban las cosas!" ...and ran off to retrieve it. When she came back she told me a series of anecdotes about all the things people (family members, usually) had stolen from the ward, and why she had to keep anything valuable locked in her office.
While she was out getting the scale I began counting the Catholic icons in the office (part of why the space appealed to me so much). I listed one Pope Francis calendar, one plastic Jesus, one Mary postcard, one paper cutout of a Jesus holding large scrolls on each side, one baby Jesus poster with a rosary hanging from it, a calendar that seemed to have a Cathedrals of Honduras theme, one framed virgin, a Pope Francis keychain, a notebook with a crown-of-thorns jesus on the cover, and a new testament.
The Aguazul guy came by to drop off the day's order. There was some confusion about one full large bottle (the kind that go on top of water fountain stations). Edith explained that it wasn't really drinking water. "El bote lleno se llenó de agua de la llave porque se iba ir el agua supuestamente." She said to me "Cuando yo era niña jamás imaginé que iba tener que comprar el agua pero ahora todo el agua está contaminado."
Then she returned to the robbery theme. "Me robaron la cafetera" she tells me. It was one of those industrial-sized coffee making machines. Some kid's father took it into the bathroom to wash it and just made off with it. She had to buy a new one herself, because you can't not have coffee on the ward. And sometimes, she told me, "los ladrones asaltan abajo." "¿Adentro?" I asked incredulously. "Sí, adentro del hospital. Yo andaba con miedo en los pasillos. Ahora con la seguridad se ha mejorado un poco."
Magdalena from the hospital kitchen came by to visit Edith, and to gift her a hard-boiled egg. She waited for her to take it out, so that she could have her container back. She stayed chatting with me in the office while Edith went to take care of something. Magdalena explained to me that there are two kitchens: normal and dieta (dieta is "sin sal"). She told me she has five children and they are all graduating or already graduated from the university, among them two engineers and one daughter about to graduate with her nursing degree. She was hoping for some sort of favor from Edithtoo many days have passed as I continue writing up these notes and I can't recall what it was.
Edith let me into the private locked staff bathroom. Unlike the rest of the unit, which had ceilings, this room went straight up to the roof:
But it was clean and even had toilet paper, and after all the tea I'd been drinking from my thermos to stay awake, was a huge relief. When I left I found I couldn't close the door. The latch stuck and wouldn't give, even when I slammed. So I got out my debit card and reverse-broke-in. When I went to find Edith she said "You couldn't close the door, right? It doesn't close on its own." I told her how I'd done it and she burst out laughing. She then decided to introduce me to the sala de neurología pediátrica. I wasn't sure if her initiative was only because she was being a lovely host or if I was also starting to get in the way. But either way I was happy to have a look around. She brought me to the small staff kitchen, where most of them were on break. A young resident sitting at the nurse's station yawned hugely as we walked past toward the lounge. She seemed to be yawning just as hugely every time I walked past, which in fact reflected my own exhaustion from toddler-provoked sleep deprivation.
The nurses (auxiliares) in the kitchen all agreed I should ask them any questions I had, but didn't go out of their way to offer help. And I was too exhausted to ask coherent questions without seeming creepy or invasive (at least that was how I felt). But Edith stuck around for a few minutes to show me the kids in the hydrocephalia hall. "Estos son angelitos de Dios," she told me. "Me encanta estar con ellos. Trabajé muchos años en esta sala, me encariñé mucho con ellos. En las noches venía y me tomaba fotos con ellos."
After she left I went and sat in the hall. I took my notebook out to look occupied, since my eyes were closing, but I worried that that also made me look creepy again. In any case there was plenty of interest in the hallway. There was a visitor robe system- you can't go in to the pt rooms without a robe. They were hanging on hooks in the hallway with some instructions. There was also a laundry room. There was a big handmade (student project, presumably) poster explaining hydrocephalia, which I wish I'd taken a picture of (note to self...). If I recall correctly it focused on a lack of folic acid as the cause, and didn't explicitly mention that the babies inevitably die. At least that's what Edith told me laterthey have created valves that drain them for a while and prolong their short existence, but nothing that deals with the underlying problem.
Another smaller printed poster solicited breastmilk donations for the hospital milk bank. I wrote in my notes "I wish I had enough left to donate now." And not that my fieldnote-typing self doesn't agree with my fieldnote-scribbling self, but there's a lot to think about in my automatic urge to anonymously give up body parts/fluids. Especially when the ad is so...
...it's just how I always get roped into asylum cases. But that's a longer story that I need to finish writing. A little later on I wrote down some more details from the poster, specifically focusing on the logos at the bottom. There was leche materna donation center, the banco de leche humana Hospital Escuela ("boob w/heart in it"). Also at Hospital Catarino Rivas (I wrote Matarino), Centro de Salud Dr. Alfonso Suazo (1/2 a block from the national stadium), and Unidad de Lactancia Materna at the UPNFM.
On the other side of the hall was a poster, also printed, of pt rights and responsibilities. It had the Hospital Escuela and Secretaria de Salud logos on the top- must have been pre-UNAH takeover. Looked like a translation/minor adaptation from some healthcare industrial restructuring consulting firm originating in the U.S. (especially with pain relief being the primary right of pt):
Their [/your] rights:
- Obligatory donation of a pint of blood
- "1" family member per patient
- Visiting hours: 11:00am-6:00pm
- No suitcases allowed
- Leave the sala [not sure if that translates here to ward or room] at each shift change
Their [/your] responsibilities:
- Every patient has the right to have their pain alleviated, to the extent possible under current [medical] knowledge.
- Every patient has the right to give consent prior to the execution of any medical or nursing procedure.
- Every patient has the right to have their beliefs [and] moral and cultural values respected.
- Every patient has the right to receive information about their state of health, treatment, prognosis, and the progress of their treatment.
- Every patient has the right to confidentiality and that their private life be respected.
- Every patient has the right to quality care and treatment.
The bottom has a modified "do unto others" which plays well with the Christian crowd:
- The patient is responsible for helping to control noise, smoke [?], number of visitors and to be respectful with staff, with other people's property, and with the Hospital
- The patient has the responsibility to inform [staff] about [sp in original sobres] their illness and everything related to it.
- The patient has the responsibility to inform [staff] about infectious/contagious diseases suffered to date.
- The patient is responsible for complying with the proper treatment plan.
- The patient is responsible for the consequences of their actions, if they refuse treatment or do not follow the recommendations of the staff who attend to them.
- The patient is responsible for complying with the rules, norms and statutes of the Hospital.
"I will do with the patient what I would like to have done to me if I were in their situation"
At the end of the hall were some benches for family members/visitors, empty at the moment, and windows. From there I could see a parking lot and what I described as a "newish building" (I later was told it was the Hospital's administration building) and behind it a hill sloping upward, scattered with poor shacks.
Sitting on a central bench in the hallway, worrying about looking shifty again, I noticed an older nurse talking to the yawning resident in her early 20s. The nurse deferentially addressed her as "doctora," asking permission for something.
I wandered back in to the hydrocephalia room. The walls in all the patient rooms were murals, mostly decals of happy large animals. More prominent still were the names of the organizations who had sponsored said decals. The Sunlife Foundation's name was plastered all over the place. Also, the "Beneficio de Café Hilda Valle de Cardona." The mothers (it was only mothers there, as opposed to ortopedia pediatrica, where fathers seemed to be nearly as present) each sat with their baby, so tenderly. It seemed like every baby had a mother present. Except for one, who I think was the fat healthy infant child of one of the nurses and seemed to just be there so she could get her work done.
I noticed another fabulous oxygen cozy, and since it felt wrong to me (despite what Edith had said earlier) to take a picture of the babies and/or their mothers, I decided to take a picture of it.
It was only upon taking the photo that I realized the oxygen tank was there to keep a motionless baby behind it breathing. I hadn't even noticed the baby I had taken a picture of.
This baby didn't have a mother by its side. I went up to look at it and in my notes (not proud of this) wrote "creepy poor thing eyes always half open, too swollen to blink. I could only tell it was alive from sm neck movements. Otherwise motionless, expressionless."
I sat back down on a hallway bench. The older nurse I'd seen earlier formally addressing the young yawning resident approached me. "Antropología," she said. "¿Qué es eso?" I explained something (didn't take notes since I was talking) and that I was trying to better understand the hospital environment there. She told me she was an auxiliar and had been working in the ward for 32 years. Then she got called off and was alone again. I think that may have been my only conversation in that hour and a half or so in the ward.
I looked again at the walls in another room of the ward. An elephant, a bear, a giraffe. Sunlife again and Curaçao (a chain store). Curaçao "recomienda a Mami tomar ácido fólico antes del embarazo" [recommends Mommy take folic acid before pregnancy]. I noted in my fieldnotes "but in a place where it's already too late." It seemed especially cruel to have so many patient-blaming messages (and nothing about the association of environmental risks linked with structural vulnerability and impoverishment) in a ward with terminal "angelitos" and mothers (at least the ones who were there) so clearly in love with their terminally-ill babies.
I took note of a little virgin statue over a small wall closet at the nursing station. The housekeeping staff endlessly mopped the short hall. The nurses, I noted, were going from one room to another, taking care of patients. The young yawning doctor and a colleague just sat at the station. Another went out and returned not long afterward with a small tray of coffee purchased outside. There were no computers anywhere. "It's refreshing," I wrote. A sign on the nursing station board ("Tablero Informático") read "No Prestar Tanque de Oz a Nadie" (actually double-underlined) Also, I noted, "ribbons and hearts."
I stepped out of the ward to the outside hall between the two wards. A man was asking a nurse about procedure. "¿Verdad que un niño que no ha sido ingresado no puede entrar? He asked. "No," responded the nurse, "tiene que ir a emergencia y luego lo entregan acá."
Back inside the Neurology ward I sat awkwardly on the bench again, too tired to properly interact. I noted that all the mothers were hanging out together at the end of the hall (which had previously been empty), chatting with a nurse. It seemed like a nice, community-creating experience.
Edith came to check on me and I jumped at the chance to return to pediatric orthopedics. She wanted to tell me about something she said I should write down in my notebook: she had caught one of her auxiliary nurses sleeping in the dressing room. When she tried to wake her up, the nurse told Edith that she was tired, that she hadn't slept well. Edith told me that that nurse always did this. "You can ask her about it" she told me. I nodded (but declined to take her up on the suggestion). In total for the ward there were three LPNs (auxiliares) and one RN (Edith), and a doctor who came by occasionally.
I sat down at the nursing station in ortopedia with an LPN, Leticia, who looked to be in her early 50s. The nursing station was tiny, but there was enough room for the two of us to sit there if I blocked the passage to the back room. There was no computer, but a large television (topped with a hand-made suggestions box) that only got one channel (something with the reception at the hospital), a tiny television that was mostly used as a radio, and a rotary phone. Through the window one could observe the large hall for "clean" fractures.
A cute hand-made board depicted each of the nurses in cut-out, with their birthdays below.
On another bulletin board up high was this cartoon about the Pope:
Saint Francis says: "Dear tocayo [guy with the same name as me], you should know that now more than ever it is necessary to promote the preferential option for the poor, since in this crisis sister poverty is a permanent guest in many homes..." The Pope responds "This is true, my dear 'Che' Francisco, alongside the poor, let us start out on a path of brotherhood, love, trust amongst ourselves, in the hand of Jesus and the Virgin!!!"
The little kid I'd met earlier with the bone infection in his arm came by. I asked again what the name of his condition was and he told me Osteomyelitis. He was putting his own bandage on and asked me for help. Leticia next to me offered to help and finished the wrapping. I asked her where she would go if she got sick. She told me that her designated hospital was the social security hospital (IHSS). "Yo pago seguro social todos los meses," she said, "un seguro que es cada vez menos seguro." She told me that thank God she had not gotten sick enough to need inpatient treatment, but that when her children were small she had to leave them with a babysitter so she could work. And because the babysitter wasn't careful, one of them got diarrhea at 13 months and almost died. Her breastmilk was what saved his life, she told me.
A resident now standing at the other side of the nursing station was talking on the phone, explaining that boys over 13, once they hit puberty, are sent to the adult hospital. But not girls, he added ("Niñas no"). They stay in the pediatric hospital.
I told Leticia about my experience of malpractice, humiliation and terror at seven months pregnant in the Matarino (and called it that), including the story of the girl with AIDS who had a code and the nurse who enlisted the doctors help in collectively ignoring the pt to instead search for her lost earrings. She told me some anecdotes which had the common theme of the awful discrimination and rechazo familiar of people with HIV in Honduras.
If I win the Diario, Leticia began telling me, then backed up. I mean, I don't really buy tickets, but if I were to win the lottery, I would spend a million on this ward so it would have the latest equipment. The cunas [cribs, but applies to the beds used by the bigger kids too] don't have barrandas, tenían barrandas pero todas están mal, she said. She then told me (in response to my question about it) that sometimes kids have indeed fallen from the beds, "e imagínese que ya están fracturados." I asked her if parents spent the night. "Si tienen las dos manos fracturados les da permiso especial para pasar la noche," she told me, "y las mamás que están amamantando. Aquí apoyamos a lactancia materna. La madre que ama a sus hijos le da leche natural. Hay las que no pueden, verdad, pero también hay las que no lo hacen porque no quieren." Breastfeeding came up a little later in the conversation as well, and Leticia remarked "We have talked a lot about breastfeeding, haven't we?"
I was introduced to an effervescent young psychologist, Naúm, who had worked on the ward (completing his servicio social) until the previous week. Naúm was newly employed in the Sala de Lactancia, where he offered to give me a tour. I mistakenly thought Sala de Lactancia meant "breastfeeding ward." In retrospect, that was kind of dumb. On our way out of the orthopedic ward we passed Carlitos, rolling around in his tiny wheelchair. He joked with Naúm. As we walked off I said he was a chabacán, and Naúm responded "¡Y está enamoradísimo!" (apparently he has developed some nurse crushes). The Sala de Lactancia was actually the NICU, and was full of newborn and infant babies with a variety of conditions, and their mothers. As I looked around, Naúm explained things to me, frequently beginning his sentences with "As a psychologist..." He said as we walked past the halls full of worried mothers (mostly on the young side) that many of the babies were in there for desnutrición but immediately corrected himself twice, first to violencia alimentaria and then to transgresión alimentaria. Neither weirdly social-sciency term seemed an improvement to me, as both placed the blame on the mother and implied an intentional violent/transgressive act.
I noticed a mother nebulizing her baby herself (is that the right term in English?). Naúm explained to me that the mothers had to be there, and fathers were not allowed. "Cada sala tiene sus reglas. En Lactancia sólo la mamá se queda. Si el comportamiento de la mamá es inadecuado, se queda la bebé sola." He added that "as a psychologist," he was the one who got to make the call on "inadequate behavior."
We went to look at the smaller rooms in back of the ward. In one a woman was breastfeeding her small baby. Both were covered in serious recent burn wounds. She had one on the exposed side of the breast from which she was feeding him, and he had one on his exposed cheek. I brought them up when we were in a different room, and Naúm said that with cases like that, "as a psychologist" he had to look for signs of abuse and separate the child from the parent if necessary. Of course that's true. But I didn't want that baby to be separated from his mother, and I felt a painful pang of uninformed empathy, imagining a scenario in which they were both victims of abuse, and needed each other now for survival.
Naúm told me he had worked in the private sector as well, at FICOHSA (one of the biggest coup-sponsoring banks). FICOHSA employs lots of psychologists in the hiring process (para seleccionar personal) and also uses them to deal with ausentismo, etc. He went on, saying that psychologists were important in schools as well, with behavioral problems, and "bullying" (a recent introduction into the Spanish language due, as far as I can tell, to my high school friend Lee Hirsch's movie's wide circulation throughout Latin America). He said they do interventions. He said they don't prescribe as much ritalin here as in the States (in response to my question) but that in the orthopedic ward there are lots of children with hiperactividad (which kind of makes sense, since most of them are just pent up there getting antsy waiting for their bones to heal). Naúm told he he liked working in the private sector a lot. "As a psychologist," he said, "I have many employment options."
Julieta had brought discipline, he said. And "aquí como a nadie le gusta la disciplina..." He told me that "hicieron supervisión ahora en semana santa." It took me a couple questions to realize that what that meant in practice was that monitors went around to bust everyone who took days off. "En semana santa hay gente que se ausenta," Naúm explained patiently. " Hicieron supervisión en todo el hospital." It was also during semana santa (the previous week) when the NO BRIBES posters (including the billboard-sized ones on the hospital grounds entry gates guarded by the guards depicted in caricature on the posters) were put up everywhere.
We went to where he could show me the posters (some of which, including the one pictured above, I'd already seen). On the way to where they were (on yet another floor) we passed a couple policemen on the stairs. When I asked Naúm he explained that they were there for the patients' protection, since sometimes there were gang members who got injured and came in, or who came in looking for people who were injured, etc. He seemed quite happy about their presence.
The posters were in the hallway. I took a picture of the one I hadn't seen yet:
Naúm told me he'd overheard lots of times when guards demanded bribes from family members. He said sometimes family members of pts will bring them food, and "yo les escucho dicen a los familiares 'no, no me traiga almuerzo, tráigame dinero.'" He continued, "La gente que viene aquí es extremadamente pobre y es un abuso pues. Se aprovechan de la buena voluntad de la gente."
A few weeks previously I'd had a conversation with my students who had been doing fieldwork in the Emergency Department. They said the biggest complaints there were about the guards too, and said they were always asking for something "pa'l fresco." Which was followed by an interesting conversation about the etiquette of bribes, something I've never come even close to mastering. In any case even when everybody knows a bribe is being solicited, it seems that it's meant to be framed as a pleasant and normal interaction (maybe it is?) although what Naúm described was something quite different. More recently we had a conversation in class about how coins are now seen as an insult even by kids begging on the street or window washers at streelights, who will throw them back at you. And you can't pay for things like cigarettes with coins if you run out of bills, because not even the chicleras will accept them, despite their being legal tender. They're apparently just too much of a hassle to get rid of. Banks won't take them even, one student (who hoards coins) reported.
Naúm returned to the topic of the psychological health of patients. "Las enfermeras son una causa también," he told me. Especially in the orthopedic ward, he said. He got along with them and all, but sometimes they did things like say, when giving a shot "si estás llorando te voy a poner una pulla más grande." [If you keep crying I'm going to use an even bigger needle].
Back in ortopedia, Edith invited me to the lunch room. She introduced me to María Tomasa, a woman who was eating with the other nurses, and told me she was a volunteer. "Está soltera," Edith explained while María Tomasa listened, "y dice que se siente en casa aquí." Edith was done with her lunch, so she excused herself after sending an LVN (the one she busted earlier for sleeping, I think) off to buy me some avocados on the street. She insisted on buying them for me, which was very touching. Just the two of us at the table now, María Tomasa told me "aquí me conocen desde niña." She said that everyone in the whole hospital knows her. I noticed huge burn scars on her arm and neck.
She continued to explain why the hospital felt like hime, when her real home did not. "Aquí cuando me miran seria me reclaman, les gusta verme divertida. Ahí en la colonia me andan molestando." She repeated several times the statement that people like to see her happy in the hospital. Her husband tried to kill her in '91, she said, "y todos los médicos se enojaron con él. La policia no hizo nada, ¿para qué andar denunciando?"
Changing the tone, but in line with the idea that people like her to be fun at the hospital, she said, "Yo conozco muchos chistes. Son buenos para divertir." "¿A ver?" I asked. Leticia had joined us with her big plate of rice from the cafeteria (free for employees, not great but not terrible food) and was listening too. María Tomasa then told us several moderately dirty rhymes, which were silly indeed.
I asked Leticia if she was a member of ANEAH (Asociación de Enfermeras Auxiliares de Honduras). Her response was firm. "No, gracias a la Rectora. Es lo mejor que ha hecho. Gracias a la Rectora ya no es obligatorio pertenecer a la ANEAH. Yo trataba y trataba de renunciar pero no pude. Uno es libre para escoger. Es lo más bueno que pudo haber hecho la Rectora ¿verdad?"
María Tomasa asked Leticia "¿Qué beneficios da?" and Leticia responded "Ninguno. Dicen que le defienden pero no es cierto." María Tomasa, agreeing with Leticia's logic, employing the rhetorical argument of "why would you need someone to defend you unless you'd done something wrong?" "Con tal de que uno tiene trabajo," she said, "si yo tuviera trabajo fijo aquí yo no fallaría."
Back in the big hall they had a tv on and were watching some cartoon film, Astroboy, I think. One of the mothers explained they were watching "para despertarnos." The kids stuck in their beds all the way back the long hall strained to see the screen, which was on the far endclose for some, and very far for others. The ward's DVD collection was in a kid's shoebox on a table- dozens of disks of dubbed kids movies stacked together without cases.
In my notes: "12:50. Falling asleep on myself."
The pink mosquito net girl's grandparents or tíos were visiting. Again I noted they seemed less poor that the other patients, and were very doting (which all the relatives seemed to share).
I went over to the girl with the bala perdida and nice toenail polish again. I asked her if she was bored, and she answered inaudibly again, too quiet for me to hear. She was alone. I saw a plate of food on her bedtable, untouched. "¿Y no tiene hambre?" I asked. She answered simply "No la alcanzo."
I was a little shocked. Who would bring a hungry immobile girl food and then leave it out of her reach? I handed her the plate and notice there was no fork. Tortillas were going to be a challenge, since she only had one usable arm- her other arm had a painful-looking needle hanging from it to insert things into (what do you call those?). I went to find a fork. I came back with it and wrote "Everything looks so hard. She just eats listlessly & stares into space. 'Ya no quiero' she says & I put the food back."
I went to another bathroom in the ward- this one for family members. I noticed a similar feature in the roof with the first bathroom. Maybe for circulation?
And a couple posters on the walls of the ward:
Back in Edith's office with Naúm, we talk about blood. Blood banks are a mafia, she says. The Red Cross solicits donations but then sells them to private hospitals at L.2,000 per pint. Edith told stories about the relatives of patients, and the trials they go through if for some reason they can't give blood. One pt went to the blood bank and found someone outside who offered to donate for her but he took her money and never donated. Only a family member or neighbor is allowed to donate (to prevent corruption in the process) but where that rule proves an impediment, Edith can provide an exception.
A one-line note, the conversation had veered. Edith: "los niños hidrocefálicos no. Para mí son santos."
Naúm and Edith tell me that Dr. Mendoza, the pediatrician in charge of the NICU (Sala de Lactantes) "obliga a mamás a comprar leche muy cara, la bolsa es de 500 lempiras y sólo dura dos días. él les dice que es mejor que la leche materna, sólo medicamentos caros receta. Ya lo han denunciado pero no hacen nada." They say he gets paid off and gets vacations and presents from the milk and drug companies.
Naúm on violence these days: "hace cinco años mataron a cinco personas en una casa y era noticia. Ahora ya nos acostumbramos." Edith crossed herself.
Edith said "Yo les tengo miedo a los mareros en mi barrio, venden ropa pero no venden ropa venden droga." Basically, they hang used clothing out on the sidewalk but it's a cover for drug sales. She tells a whole story about a fight among youths in her neighborhood. They were getting beat up, the whole neighborhood was there watching. Right there a gang member fired five shots into an opposing gang member's head. All the neighborhood kids saw. The friend of the young man who was killed ended up in the hospital. Edith found out where he was and went to visit him with her bible, to tell him to think of God and leave that life. "Mi barrio antes estaba tranquilo," she said. "El que lo mató, ahí está. Todo mundo sabe, pero nadie sabe nada." The killer is safe because, despite the dozens of neighbors who witnessed the murder, no one is willing to risk their life by turning him in.
Edith says, explaining to me that so much youth criminality is due to mothers abandoning their children to migrate: "Es que las madres se van de m-" -stops herself- "[to Naúm] ¿cómo se dice, de mojado?"
Naúm: "de migrantes"
Edith: "Yo no estoy de acuerdo con esto, van a España, van a los estados..."
Speaking of the hospital security guards, and how previously it had been the employees who worried the most about getting assaulted in hospital hallways: "Esta seguridad asalta pero a los familiares, les pide pisto." Previously, armed criminals had entered the hospital. "Antes, hasta con ametralladora [machine guns] entraban."
Naúm tells a story of an ex Policia Militar now working as a private security guard who he met in the Tegucigalpa where Kafati and JOH live. He had been fired in December [perhaps no longer needed for JOH's pre-electoral displays of force], and began to work for a private company, earning about a third of his previous salary: L.5,000/month, with three kids to support. He had a 12-hour shift, 7-7. Naúm spoke to him for a while (I think he called it a free therapy session) and the guard said "a mí no me cuesta nada mandar a secuestrar uno de estos," referring to Kafati, JOH and their ilk.
Naúm, despite beginning with an apparent structural analysis, ends up completely blaming the guard's psychology. It's an interesting back and forth with both him and Edith, between recognizing deep structural injustices but always seeming to place more responsibility on the individual. Naúm says "uno tiene que aprender a ser feliz con lo que tiene. Por frustración se le mete el diablo." Edith notes of the hospital security vigilantes "el jefe es coronel. No le pagan. Llevan tres meses de atraso. En la calle [as police] ganaban mucho más." The final note I scribbled down before leaving for the day (my shift was over) was Edith's remark, "La gente humilde, usted."
I took a final picture on the way out, right in the main lobby. Another student project poster informing people about the milk bank: