Going Public - Visiting “Hospital General de Puebla Sur"

Finally, a visit to a public hospital! Hospital General Sur, is the real Mexico, where the regular Poblanos go – and the difference is immediately obvious. The truth is, that Mexico is a 3^rd world country, which means that a “middle class” doesn’t really exist. In 1^st world countries such as the US, the majority of the population are “middle class.” The patients at Hospital General are generally poor, without insurance, and many times illiterate or don’t speak Spanish (they speak an indigenous language such as Nahuatl). Needless-to-say, this is a difficult population to serve.

My visit to HGS was a bit overwhelming. It only has 5 floors, but trust me – there’s a lot going on. The hospital floors are broken down accordingly:

Ground Floor – Waiting Room, Government Offices, Consultorios, Nutrition Office, etc.

First Floor – Emergency and Operating rooms

Second Floor – Internal Medicine, Artificial Nutrition, Cardiology, Therapy

Third Floor – Pediatrics and Infections (the infections area is completely separate with movable class walls so that if there is a patient with the flu or more severe infection, the entire area can be sealed off)

Fourth Floor – Surgeries and Trauma (more along the lines of bone fractures)

The nutrition department is on the ground floor and the girls that work there are amazing. I say “girls” because I haven’t met a single nutritionist (apart from Gabby, the nutrition coordinator at UPAEP) that have been over 30 years old. Proof that nutrition is a fairly new career, especially in Mexico. The department consists of 3 nutritionists, 2 dietistas (techs in the US) and 1 almacen. The almacen is the women who is responsible for the kitchen inventory – she orders the food and makes sure that all of the ingredients necessary for the week are in order. Not an easy job in a hospital that was serving 70 patient meals on the day of my visit. This position is the equivalent of “food management” in the States. The nutrition techs, or dietistas, are responsible for creating the cyclical menu – which is different for the patients and the hospital employees. I’m having flashbacks to my food management course at NYU and how to calculate the quantities of every single ingredient needed per day. I have a great amount of respect for the dietistas and the almacen. The kitchen itself is large and the staff are employees of the hotel – not professional chefs or an outside contracted company like in the lovely private hospitals.

The nutritionists have a large variety of responsibilities which include visiting all of the patients, working with doctors (“inter-consulting”) to create the diets, and communicating with the kitchen staff all of the diets per meal. Each diet is color coded to represent: normal, bland, clear liquids, liquids, hepatic, nephro, low sodium, low fat, diabetic, etc. The ladies have created a system where each diet corresponds to a colored card, which includes the “restricted foods” for that diet on the back. Each card is place on a try with patient name and room number to ensure that no one receives the wrong meal. For example, in a “Bland Diet” the following foods are restricted:

• Broccoli
  
• Jicama
• Cauliflower
  
• Beans
• Meat with cartilige
  
• Deli or processed meats
  
• Melon
• Watermelon
  
• Citrus
  
• Cucumber
• Chocolate
• Radish
• Corn
  
• Salsas (Sauces)
• Zucchini flowers
• Coffee
  

On the 2^nd floor is the nutrition office for artificial nutrition. In this office the nutritionist works on preparing the milk/formula for babies as well as the formula for the patients receiving enteral nutrition. All of the supplements (ingredients for the formulas, vitamins, liquid forms of MgSO4, KCL, NaCL, calcium, etc.) are also kept in this office. It’s extremely important to take precautions not to cross-contaminate when creating the formulas. The patients and infants receiving the formulas are immuno-compromised – so the nutritionists take extra care in this area. So the nutritionists are extremely busy working in a variety of areas to ensure that all the patients of HGS are receiving the correct nutrition. Also, I was impressed by the “inter-consulting” at the hospital. The nutritionists actively review all of the doctor-prescribed diets, and have the ability to change the diet if it is deficient in some way. Personally, I think this is the way it should be. As much as doctors know, they are not trained specifically in nutrition. This is our area of expertise, and we should be respected for our professional knowledge. To have the ability to review the diets and make the necessary changes is an excellent way to ensure that the patients are actually receiving the diets and nutritional support that is necessary for their recovery.

Just to clarify, there is a huge difference between private and public hospitals. A nutritionist working in a PUBLIC hospital encounters the following:

1. More patients to see and more direct-contact with patients. A private hospital may only have a few patients to see in a day, and often the diets are prescribed strictly by the doctors, unless an “inter-consultation” is requested.

2. A variety of complications – patients differ drastically in their conditions, diseases, treatments and needed nutritional support. Nutritionists need to be aware of how to provide the best nutrition in any number of situations, for all types of ages.

3. Patients commonly cannot read, write or speak Spanish – it’s difficult to effectively communicate to determine what is the problem and explain to them the diet or treatment. If they can’t read, handing them a pamphlet on diabetes is worthless. Somehow the nutritionists need to communicate/educate with the patients about their conditions, the foods they can and cannot eat, food processes, when to eat, quantities, variety, eating with medications…

4. The population is poor – food availability is an issue as well as paying for medications. Combine this with a low education level and all the other issues mentioned above…

On a last side-note, although working in a public hospital is a real experience, it can be really frustrating. Be careful not to let you frustrations show, or project them onto your patients. It’s never their fault if they can’t communicate, are uneducated, or any other obstacle. In this case, we are the professionals and always need to act calm, sure and in control – and to not add anymore stress to an already stressful situation. I know, “easier said than done” at times, but I’m asking you to be aware of how your attitude, words, actions or body language could possible make a patient feel more comfortable or the opposite.

As challenging as working in a public hospital can be, it’s reality for the majority of the population and those that work there. There’s a lot to learn about communicating, educating and treating patients. Overall, it’s the best and most real experience you can receive in nutrition.

Some quick tips to help you on your way:

INTERNING ADVICE

1. Be prepared to communicate in ways other than giving a pamphlet or even verbally talking –patients may not speak your language or know how to read. It’s called being “culturally sensitive.”

2. Know the demographics of your patients.

3. Be aware of how YOUR presence affects the patient – try not to project your frustrations on anyone else (patient or anyone else!)

4. Encourage inter-consultation between doctors and nutritionists – teamwork is the best way to ensure that a patient is receiving the best care.

5. Be sure of yourself – meaning don’t think that you’re unqualified or not educated enough. As long as you’re eager to learn AND confident you’ll be capable of learning how to do anything you’re asked to. It’s the truth!

Goodluck!