I turn from the stock shelves. There’s a boy of perhaps fifteen or so sat on the clinically metallic stool. The nurse gestures towards him. He puts his foot on the table of dressings, saline, iodine, scissors and a thick ointment in a ‘Quaker Oats’ tin.
Issa has asked me to observe the talibé [street child] medical clinic, believing I will have ‘lots of ideas’. The two staff nurses have a different aim: I am to work today.
I ponder whether this is a good idea: I’m only just on the NMC register, and I must not work beyond my capability. Having said that, there are two experienced nurses watching me, and this presents an excellent opportunity to learn by means of ‘participant-observation’, rather than being yet another ‘toubab’ [white person] who stands around watching, only to write a report that risks lacking practical subtleties: Whilst I am only giving Issa my ‘ideas’, I nonetheless want them to be informed.
I gingerly sit on the nurse’s chair. I take the street child’s limb in my hand. There is a minuscule open wound on the side of his foot. If this child had a home, family, and pair of shoes, the wound may never have occurred and, if it did, likely would not require treatment: it would simply need to be kept clean. However, for a child forced to beg on the streets, who washes only periodically and does not wear shoes, the wound could prove deadly serious.
I wash the child’s sandy foot with sterile saline, using pieces cut from a large roll of gauze. I use new pieces of gauze to dry it. Although there are a few tubs of expensive dressings donated by volunteers (many the same as I used whilst working with district nurses in Sheffield), these are piled in a corner. In any case, I do not know whether or when they will be replenished, the wound is only small, and sometimes the oldest methods are the best.
In the spirit of this, I clumsily cut a large piece of adhesive dressing into an appropriately-sized square, using newly washed hands and gloves. I then place a clean piece of gauze in the centre of the dressing. Fortunately it sticks. I pour a little iodine onto the gauze centre. This has taken me some time, for I am used to using ready-made dressings. It is, however, likely much cheaper and easily as effective. In terms of clumsiness and speed, surely practice makes perfect?
I turn to the older of the two qualified nurses for approval. She has been watching me throughout and now offers a nod of consent. I place the home-made dressing over the wound.
I then have to decide a review date: I do not wish the dressing to fall off and the wound to become infected, but neither do I wish the child to revisit too frequently as redressing too regularly can also risk infection. I therefore advise the child to return in three days, or if the dressing falls off: whichever is sooner. Again, the experienced nurse nods.
Finally, she takes the child’s name, approximate age, and marabout [religious educator] and writes these, along with a short description of the care given and date it of review, in a book.
For the rest of the day, every consultation except one relates to a foot or leg wound. The other relates to a swollen penis, for which he waited until the two female nurses had gone to lunch before approaching me alone. Not having the knowledge or skills to diagnose, I advise him to see a doctor and I notify Issa. In the UK we sometimes lack an adequate ethnic minority skill mix in nursing to deal with some ethnic minority patients’ particular concerns, languages, and needs. Here, having a male member of staff in a clinic that cares almost entirely for boys might be useful, but difficult to achieve.
My initial concern, especially when realising that dressings are ‘constructed’ rather than removed entirely ready to apply from sterile packets, was cleanliness. This is perhaps in the front of my mind because Issa has asked my opinion on the cleanliness of the clinic. I need not have been concerned. The clinic and its materials are unscrupulously clean. There are small changes that could be made, such as staff drying hands with paper towels rather than fabric ones (as these can attract bacteria) after they wash them. However, most of these changes depend on buying additional resources – paper towels may be cheap to us, but in an environment where everything is donated, they are not cheap to reliably restock.
Further, I mention to the nurse that the donated dressings are not being used. Donations from volunteers are kind, I suggest, but perhaps not always what is needed. I have put words into her mouth, but she does seem to genuinely agree. I suggest (but sadly am unable to promise) a system where nurses list and prioritise their resource needs and volunteers and sponsors try to procure or fund them reliably. Certainly, it seems the constructed dressings are cheaper and more versatile than the donated ready-made ones. And my initial concerns that they may not be as clean are unfounded if due care and attention is taken when preparing them.
I reflect on how the centre has changed, especially in terms of the sustainable effectiveness of its care. To think that what begun in 2006 as a project raising money to give street children bread has turned into such an excellent care model is incredible. The centre has places where the talibé can shower, offers a them clean clothes and sandals when they need them, educates them in a couple of school-rooms, has offices for staff and meetings, and a sandy quadrangle in the centre where they can play. None of these buildings, staff or achievements existed in 2006: it was a few mates congregating behind the old railway station to hand out basic food.
I cannot help but think that recording which talibé shower and how often, and which ones need wound care in clinic, will reveal that some of the most effective care the centre provides is prevention of infected wounds. Such a study may strengthen applications for funding for the centre and its nursing facilities, by demonstrating with evidence what we know from practice.
Issa asked me for lots of ideas. I’m not sorry to let him down. He no longer needs my few ideas (which I’ve detailed in this blog nonetheless). What I’ve seen in my morning at the clinic is that the centre works in providing cost-effective child-centred holistic care. It works very well, in fact. It is, however, testament to Issa’s humility and commitment to service improvement that he is always keen to listen to comments, even from someone as inexperienced as myself.