Internal Medicine ward at Karapitiya Hospital

After a long journey to the other side of the globe, I was finally in Sri Lanka. When I woke up to monkeys howling and playing in the trees 20 feet away, I knew I would like this place.

I was excited and nervous to start my global health rotation at Karapitiya Teaching Hospital. Despite the fact that the University of Ruhuna Faculty of Medicine is conducted in English, there is still quite the language barrier with the Sri Lankan version of English and the amount of slang that we unknowingly use. Even the everyday medical language and abbreviations varies between the US and Sri Lanka. I wasn't sure how this would pan out when I arrived on the medicine ward.

Three of us are here in Sri Lanka from the Duke Physician Assistant Program. Since Duke University and the University of Ruhuna Faculty of Medicine have an established relationship in medicine and research, many of the professors and researchers were very welcoming to us. We met with Professor Ariyananda, the Senior Professor of Medicine, and he was quite excited to bring us to Grand Rounds and introduce us to his faculty and fellow consultants before we got started the next day.

Outside the Duke Collaborative Research Center at the University of Ruhuna Faculty of Medicine. 

The next day, we were thrown right into action on the women's internal medicine ward, where we spent the week. We met with the Senior Registrar (similar to our Chief Resident) and she hurried us to the first patient to begin morning rounds. It was definitely intimidating on the first day, rounding with their equivalent of residents and attendings, praying we can remember everything so we can answer any questions they start throwing out at us-  we don't want to make Duke look bad!

After a few days, I was able to understand how the ward works to admit patients, complete investigations and diagnostic assessments and carry out a treatment plan. There are many similarities, but a greater number of differences between the US and the Sri Lankan inpatient wards. The overall appearance of the ward and staff, the admitting process itself, and the types of illness and their treatment protocols are notably unique.

Ward 11- women's medicine

When I first walked onto ward 11, I felt as though I had been instantly transported back in time to a 1940's army hospital. Not only do the nurses uniforms seem characteristic of the era, but the hospital itself is open-air with beds packed in so close you can touch your neighbor. With more patients than beds, some patients are left lining up with their belongings on the floor or with a make-shift mattress on the ground in the hallway. There's no such thing as privacy here! The only attempt at privacy is a green curtain that can be drawn to a close, though this greatly reduces the air circulation and increases the already hot temperatures found on the ward.

Nurses uniforms

View of Ward 9 from Ward 11.

Another distinct difference between the US and Sri Lankan hospitals is the admitting process. Patients can only be admitted to a ward on Casualty Day. While casualty typically means trauma or catastrophic event, here in Karapitiya Hospital, it simply means acute care. Each ward has their own Casualty Day, rotating every 5 days, so on any given day there is at least one medicine ward holding a Casulty Day. It's quite obvious which ward is having their day because the hallway outside the ward is lined with sick people waiting their turn to speak to a House Officer (intern). Because Sri Lanka has a public health system, and Karapitiya is a public teaching hospital, patients are first seen at their local community health clinic or rural hospital and if their illness is deemed to be beyond the capabiities of the small hospital or clinic, they are referred to Karapitiya. The patient brings their diagnosis card (pic below) to the House Officer- a laminated square paper with their personal identification information, their chief complaint, lab work if done, and treatment to date. No fancy electronic medical records here! The House Officer is the first to speak to the paitent; they do a complete history and determine if they need to be examined or treated outpatient. If they are in need of an exam, they proceed to the line for the single admiting bed where the Junior House Office and/or Senior Registrar (residents) examine the patient. They will determine whether the patient gets assigned a bed or follows up with outpatient treatment. Unless the patients illness warrents a longer stay, most patients are typically released to outpatient care after 4 days- just in time for the next Casulty Day.

Medical records -
paper patient charts, radiographs thrown in the pile, loose paper everywhere  

Diagnosis Card.
Completed by the House Officer (intern) and given to the patient to carry with them to any future  hospital or outpatient visits.

Patients are not provided with the same amenities they receive in the US. Patients must bring their own medical record, clothing, toiletries, pillow and blankets. The hospital only provides one pillow case and one blanket which is typically used to cover the bed. Visitors are only allowed between 1-5pm, though one person is allowed to stay at all times. It's quite a sight to see the visitors lined up behind the gate. The masses of visitors are corraled by several security guards manning the large iron gate between the hospital and outside. The only thing that gets you though that gate is a nursing uniform, stethescope, or white coat. Even our Duke liason administrator had to go in with us because she wouldn't otherwise be allowed to enter. At first I didn't understand why visitors couldn't come earlier in the day, but after the first morning of rounding and seeing the massive amounts of student learners and staff surrounding the patients, I understood!

Needless to say, patients who get admitted here are very ill. We have seen many patients with Dengue and Typhoid fever, severe heart murmurs and strokes. Of course we have heard many heart murmurs and seen stroke patients back home, however these cases seem to be much more advanced, having had no treatment or inadequate treatment from their general practitioner. There was one patient who had such a loud heart murmur that it took me a minute to realize that it was her mitral valve making all that noise and not her breath sounds! I've never head such a loud, distinct murmur in my training. I'm sure I could have heard it without my stethoscope! When I felt for her apical pulse, it was as though her heart was punching my hand through her ribs. Thankfully, the patients here are accustomed to medical students examining and questioning them every day, so it was nothing new for me to listen and palpate myself. In fact, these patients have a crew of consultants, house officers, registrars, medical students and nurses rounding on them daily- I counted 38 of us around one bed! And I thought our rounds at DUMC were packed!

Attempting to get a pic of all of the students and physicians surrounding one bed during ward rounds. 

Stretcher in the back hallway. 

Another interesting difference that struck me was the absence of beeping monitors and general lack of technology present on the ward. The ward seemed eerily quiet for the severity of illness among our patients. IVs were hung from a pole, but no pump to enter the patient's information and do calculations. Vitals have to be done manually at regular intervals and charted on a paper above the patient's bed. There were no oxygen tanks hooked up for the COPD patients, no controls to adjust the hospital bed for comfort and certainly no television sets. Furthermore, the lack of technology means the physicians and students must rely more heavily on their physical exam skills. It was impressive how well these physicians could hear breath and heart sounds with all the background noise and conversations amongst providers. And I know it's a silly thing to notice, but providers here are such good percussers! I can hear distinct differences in the resonance and almost pinpoint where the problem is. I hope I will be able to acquire this same level of competency in my physical exam!

The final difference I'll mention is the lack of universal precautions. There are no gloves available on the ward. Nurses draw blood, place IVs, give IM injections, etc, and none of them wear gloves. While AIDs/HIV are not common, I have already seen a patient with AIDs in the first few days and several with hepatitis C and other blood borne diseases. But it's not just the nurses; the consultants, house officers and registrars don't wash their hands between physical exams, even if they just touched a rash on one woman, or had a pneumonia patient cough all over them. In the US, you see hand sanitizer gels and foams by every patient's room and all over doctor's offices. I believe I was the only one carrying sanitizer gel in my pocket and despite not examining all the patients myself, the only one making an effort at sanitation.

I can already tell that I will learn a great deal here in Sri Lanka, both culturally and medically. I'm grateful to have already seen so many tropical diseases that are rare or non-existant in my hometown. This will certainly prove beneficial for future international aid work. Also, learning about the public health system and adapting to the difference in technology will alow me to be a better global practitioner. In the next few weeks, my colleagues and I will also participate in pediatrics, OB/Gyn, community medicine and surgery. There will be many interesting patients and experiences to come!