Medications in the Hospital
The usual time to give daily medications is 1:00 PM. The doctors write the name of the medication directly on the medication administration record, and the nurses do not recopy the medication list. This is considerably simpler than the system most US hospitals use. Mission Hospital does not have a pharmacist.
The medical staff only uses five different antibiotics most of the time: gentamicin, ampicillin, penicillin, chloramphenicol, and cefazolin. In the United States, we stopped using chloramphenicol years ago owing to the slight but unacceptable risk for aplastic anemia. It's a very effective antibiotic and is still used in Nepal. For adults, there is a standard dose for each one, except gentamicin. The nurse counts the number of doses of ampicillin needed and reconstitutes them all at once, and then does the same for the next antibiotic. The doses are piled on a single tray with one divider for each medication; they are not divided according to patient or room number (Figure 7).
Figure 7. A nurse prepares the antibiotics. Image courtesy of Joe Niemczura
There are no trips back and forth to the medication preparation area once the nurse starts medication administration rounds. A checklist is used to indicate who gets what, but the individual syringes are not labeled with the drug name or the individual names of patients.
Many hospitals now use a system that is more like "unit-dose" medication. However, the medications must be purchased by the family and paid for with cash. Hospitals that use this system have a pharmacy on the premises for this purpose (Figure 8).
Figure 8. This is what "unit dose," at the bedside, looks like in one of the newer hospitals in Nepal. Image courtesy of Joe Niemczura
Intravenous Administration
The contents of the intravenous (IV) tray are not what you are used to. Most medications are given IV push. In the United States, many antibiotics are given using a "piggyback" bag, but this system is not used often at Mission Hospital. There are no IV pumps; everything is dripped and the drop rate is controlled by a hand roller on the IV line, the old-fashioned way. Even dopamine, which is a powerful adrenergic drug, is given this way, with the added precaution of a burette.
As a rule, the patients have excellent veins; few people are obese. Many are manual laborers. It is easy to start an IV on a Nepali. No central lines and no peripherally inserted central catheters are used. The hospital does not yet have a needleless system, but as of 2015, more hospitals are using syringe pumps to administer IV medications. The nurses do not routinely wear gloves when handling IVs (Figure 9).
Figure 9. Hospitals in Nepal use a type of cloth tape that appears to be bombproof—it never comes undone. Image courtesy of Joe Niemczura