Infection control: one of a health professionals most used and most hated buzz terms. We hear it every day, we do it every day, we think about it in everything we do – even when we’re not on the job. I, for one, avoid touching stair or escalator rails, think twice about using ATMs next to a popular night spot and think of creative ways to open public toilet doors without touching anything. Now that I’ve painted a picture of myself as a bit more odd than I already come across, I’d like to tell you about infection control on my very recent trip to Nepal.
For those of you who don’t know, I recently spent a few weeks volunteering in a health clinic in rural Nepal. This clinic was a small, walk-in style GP service catering for the residents of the local villages. I won’t go into too much more detail here but feel free to check out my photos from the clinic and look out for more tales from my time there.
Infection control in the clinic was one of the many eye openers that I came across. When I say “eye opener”, I mean with horror as hand hygiene was almost non-existent. There was a tiny basin (one hand a time for my gigantic man hands), a bar of grimy soap and a grotty towel hanging from the window bars. That was it. One look at the options and I decided to primarily rely on my alcohol hand rub; every travellers must-have. Over the course of my placement, I used several bottles of the stuff to the point that I almost feel sick when I smell it now.
On top of the inadequate washing facilities was the frightening lack of gloves. That had one box in the clinic and that was mostly used when the nurses were washing instruments and benches. Even if I’d wanted to use them, they were sized “XS” – I would have split every one of them open trying to get my hands in. There was also a small box of sterile surgical gloves, out of date and covered in dust.
The small tray of instruments (scissors, forceps, kidney dishes and a couple of other goodies) was hand washed in soap and water then ‘sterilised’. The clinics sterilisation process involved a tray with an insert (much like a vegetable steamer) where water goes in the bottom, instruments on top, lid on, then heated over a gas flame for a couple of hours. This was the best option they had and it was done every day.
As a result of the low standards of infection control, I did things during my placement that would have resulted in a speedy expulsion from any nursing placement in Australia. While I used my trusty hand rub after every patient, I did other things without gloves that I probably shouldn’t have. It didn’t stop the locals of course, so I figured while in rural Nepal, do as the locals do.
On one occasion I had a gentleman come in that needed a dressing change, as motioned by the nurses. I gingerly took of the crusty bandage, doused the area in iodine and rinsed my hands under the nearby tap before I took a good look at the wound. It looked like a small puncture wound, no more than a centimetre across. The wound was located on the underside of his forearm right near the elbow meaning the angle that he was holding his arm at made it look like he had quite a large muscle there. As a farming community I didn’t find this unusual, until I saw his other much scrawnier arm.
I gestured for the man to hold both his arms in the same position and notice the one with the wound was rather swollen, probably about 30% bigger than it should be. I tentative prod using my finger and a wad of swabbing resulted in a small dribble of haemoserous fluid along with a thread of yellow pus-like fluid. I gestured to the nurses that I wanted to get some of this out and they were at first confused but soon understood what I was trying to do.
Due to the lack of clean kidney dishes, gloves or pretty much anything else, I decided to go outside with the patient. I grabbed a handful of swabs, the bottle of iodine and donned my eye-protection I’d brought from home for precisely this reason. Using two tightly rolled balls of swab to put something between my fingers and his skin, I positioned myself to avoid any serious splashback and went to it.
What came out was the most heroic amount of pus, blood and generic fluid that I’ve ever had. It was gross yet extremely satisfying; especially when the fluid started slowing down and large chunks of pus started oozing out. After what seemed like ages, the wound stopped its discharge and I assessed the ejection – it was a lot and it was gross. The arm was a lot smaller and the skin not so stretched. The man also looked happier to have the pressure relieved. I cleaned it up with even more iodine, cleaned myself up with a huge amount of hand rub and kicked dirt over the pool of wound sludge. It was all completely unreasonable in my country, completely common-place in rural Nepal. I must say it was rather liberating.
I also did a lot of general wound dressings, typical cuts and grazes you’d expect from a rural community in any country. One wound was on the knee of a young mentally disabled boy who I met. He was a happy guy, keen to have a chat with me in Nepalese uncaring of whether I understood it or not. Through a lot of hand signalling and basic interpretations from the nurses, I was able to ascertain that he was a bit of a scamp and had got away from his family’s watchful eye and accidentally taken a fall, straight onto the hard ground, knee first. His knee was a torn up mess of skin and old blood which had been dressed two days before by the clinic nurses when it first happened.
What I was presented with was a crusted up wound with only a small part of the dressing still intact. Unfortunately that part of the dressing was a ball of cottonwool fused to the wound bed. It was stuck down rather well and my tentative attempts to remove it were thwarted by tears in his eyes and his frantic grab on my shoulder as I knelt over his knee. There was nothing more for it but to douse it, yet again, in iodine. This probably stung even more but didn’t tear apart the already healing wound. Just to remind you, this was all done without gloves again. I did what I could with tweezers and forceps but at times there’s nothing more for it but to get in there with your fingers.
The boy was fine and I managed to make him laugh at some stupid faces while I redressed it, this time not using cotton wool and pointing this out to the nurses. I’m not sure they agreed as the general technique there seemed to be “that’s how we always do it”, but I felt like I’d helped slightly. The boy and his mum headed off, him chatting away to his mum and her giving the occasional “mmhmm” to tell him she was listening to his ramblings…or at least pretending to, typical mum.
The last man I want to talk about was an older gent who had an old wound on his leg. It was a chunky affair that came from a rock in a field that he had fallen on some three weeks before. When I took off the dressing, I was presented in a wound filled with white pus, scabbing, patchy epithelisation and a scary red surround. This wound needed help.
I picked up a swab with some forceps and doused it in iodine before digging in gently trying to remove a bit of the mess. The nurse near me was horrified and stopped me, indicating that I shouldn’t touch it. I tried to tell her that it had to come out, at least some of it, but she would have none of it. Once again I was confronted with the “that’s how it’s always been done” ideal and I knew I had to seek backup. The doctor chose this moment to come into the room and I rejoiced, mostly because he spoke some English. I told him what I wanted to do and he simply nodded his agreement before leaving. It was all I needed to bypass the nurses and I went back to work. The nurses crowded around as well as the man’s seemingly endless family to see what I was doing as I inexpertly tried to debride the wound. The tweezers and forceps were clumsy to use and I had to be extra careful to not get my hands too close – I had no idea what bugs were roaming about in the muck. More than once I wished fervently for just a segment of the wound shelves of the wards at home, but it was not to be.
After several minutes I was as happy as I could be with the wound. The wound bed was visible and free of the grit clogging it all up. I went with the only disinfecting/flushing agent available, yep, you guessed it – iodine, and bandaged it up. That was the last time I saw the man, but I hope that his wound showed some improvement.
All of this was done without gloves, poor hand washing facilities and a small bottle of alcohol hand rub. While I may sound like I am disapproving of the health clinic, I’m actually impressed with how well they manage with hardly anything. I expected things to be so much worse for the patients, but their stoic good nature gets them through amazingly well.
Despite this, I’m so glad I can wash my hands at any whim I have along with when I actually have to by hospital policy – I’ll never complain about it again.
Written by Brad Winter.