6 June 2012

Universitas Hospital

Summary

 Today I went on rounds with the doctors and dieticians again.  I also attended a presentation on Bariatric Surgery and was fortunate enough to meet a successful pateint.  Once again I learned of more interesting facts and differences between hospitals in the states and in South Africa.

Detailed Account

Since my blog was so long yesterday I was hoping for the initial shock and learning from the hospital to be over but that was not the case, so it looks like it’s going to be anther fairly long blog…  I think I’ll divide it up again into the dietetics/education learning (numbers) and then into the environmental/cultural observations (letters).

1.       I began with rounds in the gastrointestinal, oncology, etc. wards, once again a large group of doctors and dieticians.  The most threating patient I saw during this time was suffering from insulin dependent type 2 Diabetes.  He was a non-compliant patient and recently partook in alcoholic endeavours.  His life choices resulted in gastroparesis, a difficulty during gastric emptying.  Therefore he must eat small low-fat meals frequently although he could no longer stomach these in his severe condition.  The dietician switched up to a diabetic supplemental fluid which he also vomits.  The next obvious choice would be to feed him with TPN intravenously but many doctors balk at this idea because having an IV in for a long period of time increases the risk of sepsis.  At this point the most important thing is that the patient receives nourishment before starvation occurs.  To repair his gastroparesis a jejunal extension is required for the patient to go home with a permanent feeding tube.  Unfortunately the Universitas Hospital’s extension expired in 2001 so they are at a loss for a plan of action at the moment.

2.       I went about with many dieticians today but some was repetitive of yesterday so I won’t go into that today.  We were given an extremely interesting presentation on Bariatric Surgery (aka Gastric Bypass).  In order to qualify for the surgery in South Africa one must have a BMI above 40 or above 35 along with comorbidities.  The Universitas Hospital is only given a small amount of money to perform such surgeries; therefore they can only take about 10 patients per year.  Due to their low cost circumstances they usually only consider patients with a BMI of over 50.  Comorbidities fall into many categories including; metabolic, cardiovascular, respiratory, gastrointestinal, urological, dermatological, neurological, endocrine, reproductive, psychological, and musculoskeletal.

As of now the process to be accepted for the procedure is…Dietician -> Endocrinologist -> Dietician -> Physiotherapist -> Psychologist -> Social Worker (if necessary) -> Surgeon (for clinical evaluation) -> Surgeon (surgery) -> Plastic Surgeon.  In this process the dietician refers the patient to the appropriate doctors and follows the patient for assessments throughout.  The endocrinologist evaluates the diseases that the patient has and varies the dosage of the medications based on the weight and health of the patient.  The physio teaches the patient exercises they can do to help with mobilization and losing 5-10% of their body weight before the surgery can be performed.  The psychologist assesses the compliance and dedication of the patient along with previous issues like depression and eating disorders.  The surgeon/physician will determine if a patient is a good candidate and ready for the operation.  Lastly usually after a year or most a plastic surgeon will help with skin removal and augmentations.

We mostly focused on the sleeve resection surgery and the Roux-en-Y gastric bypass option because those are the two offered at the hospital.  The sleeve surgery closes off a portion of the stomach, connecting the esophagus to the duodenum (first portion of the small intestine).  This appears to one long tube, resembling a banana.  During the Roux-en-Y surgery a new stomach pouch (roughly the size of a quarter is created and directly connected to the jejunum (middle portion of the small intestine).

Gastric Sleeve Resection

Roux-en-Y Gastric Bypass

 After the surgeries most patients will continue to lose weight for up to 2 years and hopefully reach a BMI of 35, although they will never have a normal BMI.  The nutritional diet post-operative follows a schedule that resembles…

2 Weeks pre-op: low volume diet

Day 1 (post-op): NPO (Nothing per Orem, nothing through the mouth)

Day 2/3 – 4: Clear liquids in small sips waiting 10-15 min between sips

Day 5 - 14: Full liquids up to 60 mL at a time in small slow sips (ex. Smoothie, soup, Ensure)

Day 14 - 28: Pureed food up to 150-200 mL at a time in small slow sips (1 min between)

Day 28 - 42: Soft foods blended or chewed very well, no fruit skins

6 Weeks: gradual return to pre-op diet, 150-200 mL with vitamin, mineral, multivitamin, Iron, B12, folate, and calcium supplements forever

It is important that patients do not drink during meals or 30 minutes before or after a meal because they have a high risk of experiencing feelings of ‘dumping syndrome.’  Since there is such little space in the stomach the food and liquid must fight for the area, therefore the food could be regurgitated or pass to quickly for nourishment.

We were fortunate enough to meet a successful patient who had received a sleeve restriction 7 months prior.  He began at 232 kg (512 lbs) by the time he met the dietician and proved he was a candidate for surgery he had reached 216 kg (476 lbs).  At this point in his life he was practically immobile, walking with a cane and becoming short of breath rapidly.  He was morbidly obese on Glucophage for Diabetes and also suffered from gout and joint pain.  When he went in for surgery he was at 205 kg (452 lbs), losing almost 10% of his body weight.  Today he is still obese but he glows throughout at 175 kg (386 lbs).  He is completely off his Glucophage and one of the friendliest and most optimistic people I’ve met.  I am positive he will continue making wonderful progress throughout the next years and will maintain his healthy weight.

a.       I found it incredibly unsettling some of the inadequacies the hospital and patients have to face due to a lack of funds.  Previously I mentioned the tube that had expired in 2001, to obtain that tube would take 6 months and by then the patient would be dead.  I was also told today that a patient had been in tremendous amounts of pain after a surgery but the hospital was out of morphine so they had to substitute with a lesser pain medication.  They are doing the best they can with what they have but it is disappointing that this is all one of the best hospitals has to work with.

b.      I must say the dieticians are wonderful at their jobs.  They are all extremely well educated and know their material through and through.  They are also very caring and personable with their patients.  Patients appear to brighten up a bit with the dietician enters and they enjoy sharing and learning about how to live healthier lives.

c.       I realized our ethical procedures are much more strict in America than they are here or in the enforcement here.  On many occasions I have noticed people discussing a patient’s conditions and personal issued (even regarding HIV) in the open and in other patient’s rooms.  I am a bit bewildered at the openness and lack of privacy/confidentiality but it seems common.

d.      I have made a discovery…there are gloves lurking about the hospital!!! Unfortunately they are not being used in the most optimal ways.  I observed a woman taking blood today and she used a glove as the tourniquet, but not on her hands for her own safety…interesting.