Surgery Internship Romania 2003

Prologue

Why would I go to a country such as Romania for an internship? Good question, because isn't Romania a European country with good hospitals? My father has been involved in helping hospitals in Romania for many years now so I've seen a lot of photographs and videos of the place where I was going. Even though Romania is a European country, I knew medical care in Romania and medical care in Holland are two entirely different things. The prospect of a strict hierarchy, poverty and corruption scared me a bit. You realize how fortunate you are to have been born in a country like the Netherlands. Sure we have our own problems in medical care such as waiting lists and understaffed hospitals but in Romania they have to deal with shortages of money and equipment, people who can't afford surgery, underpaid specialists etc. Doctors get paid under the counter by patients who can afford it. There is a big gap between the rich and the poor in this country so only the happy few can benefit from this kind of medical care. Below my report about my journey to Romania.....

First meeting and organization hospital

Sunday I visited the hospital in Sibiu for the first time. Sibiu is a city at the heart of Romania, approximately 300 km from Bucharest. You'd think any European city has a fairly up to standard hospital. This is not the case in Sibiu. When I entered the hospital, I was under the impression that I had just leaped into the 19th century. From the outside it seems a modern hospital with some maintenance issues, but once on the inside poverty radiates in your face. It appears some departments are spread across different buildings which means patients have to be transported between these buildings through open air. During the summertime this is no problem but winters can be very harsh up here!!

At first we will take a look at the surgery location. This will be my working area for the next four weeks. As you enter the building, a rather typical smell hits you in the face. This is not the fragrance I'm used to in Dutch hospitals. It's a smell of bad hygiene and infection. Today it's Sunday so not many people are around: a couple of nurses and one physician. There are two surgical units. I will be working at Surgery I which mainly deals with general surgery and some vascular surgery. Surgery II takes care of thorax and orthopedic surgery. The two units share six OR's with the Urology department.

The ward of Surgery I consists of 10 rooms with 4-6 beds in each room. Space between the beds is minimal and you will not find any curtains between the beds which makes privacy a non-existing concept. The beds are worn out and almost none of them can be adjusted to different heights. Men and women are separated and so are the septic and non-septic patients. The toilets have no seats and can't be flushed. Patients have to bring their own toilet paper. All personnel have to buy and clean their own clothing, anything goes as long as it's white. This means you see a lot of variety in clothing as well as donated clothing from western countries (I've seen plenty logos of the UMC and Red Cross Hospital from the Netherlands..!!). After an examination of my unit we took a quick tour through the rest of the hospital. Everything looks poorly and worn out, sometimes you encounter some old Western European equipment or renovations. I'm looking forward to the next four weeks.....

Starting my internship surgery

Every working day starts at 8 o'clock a.m. with the shift-change (in Romanian). Fortunately, the medical terms are in Latin so I can understand some of it. My supervisor Dr. Silivasan links me up with the oldest resident: Marius. I'm glad he speaks English so he can explain a lot of things to me. Just like in Holland, it's customary the youngest residents present the patients to the Professor (Prof. Sabau). The Professor then decides which operations will be scheduled for the day (approx. four operations a day) and which will be postponed. The most urgent patients are put first on the list, the others will have to wait till the next day or even the day after. Every surgeon thinks his patient is urgent because no operation means no money. That's why almost every day a discussion takes place between the Professor and the surgeons. What follows is a quick visit to all patients by the Professor, the surgeons, the residents and me (I'm the only woman; apparently there're no women who want to become a surgeon). First the ICU, which looks fine compared to the rest of the hospital. The ICU consists of two floors, each containing 8 beds. All patients lie in single-cabins and every cabin is hooked up to a respirator from Holland. The attending surgeon informs the professor about the policy of treatment. Then we visit the patients who are scheduled for today's operations to asses their status. The patients that have been operated the day before are also examined by the Professor.

Finally we pay a visit to the septic rooms. These rooms are mainly occupied by men whose legs, feet or toes have been amputated due to a neglected or mistreated diabetes mellitus. These men, mainly country-men, have been "treated" by a local physician for years, simply because that's all they could afford. By the time they are committed to the hospital, the damage has been done: black toes and feet, wounds which will not heal etc. It all ends up in the same procedure: amputation. The smell of rotting tissue and gangrene hits you in the face when the door is opened. Every bandage is removed for examination of the wound by the Professor. Removal of the bandages is done by the same scissors, no gloves are put on and hands are not washed between patients. I couldn't believe my eyes that first day. After a week or so you get used to it. There is simply no money for gloves, scissors or disinfectants.

Then the operations start. A Romanian home made mouth cap and a Dutch disposable hairnet are handed out to me. I have to use these items for the next four weeks: all "disposables" have to be reused for at least a couple of weeks for financial reasons. That's why they prefer equipment that can be sterilized, that way you can use things over and over again. All needles, tubes, probes, anything which can be sterilized is recycled. The operating tables are hardly adjustable to different heights, therefore operating is hard on your back. Windows are opened when it's a hot day because air-conditioning does not work properly. Small auxiliary lights are placed next to the big operating lights because some lamps are broken. Surgeons wear their own clothing underneath a sterile green or yellow coat made of cotton. Sterile gloves are available for a couple of years now but soap and disinfectants are a rare commodity. An abdominal retractor is a desperately wanted piece of equipment but it can't be bought due to the lack of financial means. This means an extra pair of hands is needed just to do the job with a set of spatulas. They've really mastered the skill of operating with a lack of means at hand over here. Cotton stitches of different sizes are being used, I've hardly seen any dissolvable stitches. I think the patients have to pay extra for it.

Some surgeons own their own equipment. They never leave it at the hospital so no one can "accidentally" take their instruments and so they will not get lost somewhere in the hospital. I wonder what happened to the donated instruments. It's becoming clear to me that there a lot of payments are done under the counter but no one wants to talk about it. Whenever I ask about it, the subject is rapidly changed to something else. I can understand that. My attendant is the only one willing to talk about it: he earns a total of €800 ($1,012) a month, €200 ($253) is paid by the hospital, the rest of it comes from under the counter, are gifts given by patients or is received by performing other obscure activities. The operations are being performed by the residents but the supervisors get paid for it. At 2 o'clock p.m. they're all done and they go home. Between 5 and 6 o'clock p.m. they come back to visit the patients they've operated that day.

Medical care Romania

Romania is land of contrasts. A wealthy gynecologist/pharmacologist has built a brand new hospital just two blocks from here. I was invited to have a look around. This is a private hospital with a western look and feel: everything is brand new, the rooms are like hotel rooms, all equipment is up to date. The hospital will start in November 2003 and the doctors are from Romania, the United States and from some Western European countries. Immediately I'm invited to come and visit next year as a trainee. I'm astonished.....so it's possible to build a modern hospital in Romania!! But which Romanian can afford this kind of medical care? The patients will probably be tourists and a few wealthy Romanians. One thing is for sure: when I get sick in Romania, I'd like to be treated in this hospital!