Monday, July 7, 2014

Joys and Frustrations

It's been a while since I last posted, so I'll attempt to catch everyone up to speed with what I've been working on at the hospital. After a few simple repairs early in the first week (refer to previous post), Casey and I began to take inventory of each department which included recording the manufacturer, model, serial number, and the hospital's code. Fortunately most machines had all of these, but there were a handful where the serial number was completely worn off or there was no hospital code. After taking inventory for the departments we had visited earlier in the week which was about half of them, we began our first real repair in the maternity ward.

Earlier in the week during inventory, Adeline, head of maternity and neonatology, had showed us 2 delivery chairs which were broken but still being used. The entire maternity department has only 3 delivery chairs for what seems to be one of the busiest departments at the hospital. All of the chairs are the same type and are supposed to be able to go from horizontal to partially angled, but only 1 of the 3 could actually do this. On the underside of the chair, there is a lever arm that allows the chair to go from horizontal to inclined but this was broken in multiple locations on the 2 chairs so the chair remained horizontal. Despite it being the worst position for a mother giving birth, the staff continued to use the chairs since a partially operational chair was better than no chair at all. After examining the functioning chair to see how the lever arm works, Casey and I began working on one of the chairs. It's hard to describe the mechanical repairs we did without you actually seeing the arm, but hopefully the pictures below will supplement my explanations.

The top part of the arm which connected to the back of the chair was supposed to interlock pieces, but the bolt and nut system was too low so we had to take the top section apart and adjust the bolt and nut. One of the bolts connecting the arm to the chair frame was missing and the other was broken, so we had to remove those and find replacements. Keep in mind this is Rwanda and not the States where Home Depot and Lowe's abound, so finding 2 bolts became a 2 hour process which involved going to 5 hardware stores to eventually find bolts of the right diameter which then had to be modified by the welders who cut them apart and added a piece in the middle so they were long enough. Now that we had the new bolts and had fixed the top section of the arm, it was back to the maternity ward to install the arm. Holding true to the past couple of weeks, what seemed like an easy process turned into several more hours of work. The plates on either side of the chair frame that the bolts needed to pass through were far from precise and did not align, so we had to have the welders adjust the holes in a plate for us. Finally we were able to force the bolts through after about 30 minutes of fighting with the arm and plates and re-attach the top section of the arm so that it interlocked. Add a little bit of WD-40 on the arm, and it was as good as new!
One of the new plates the welders cut for the delivery chair in maternity.

The interlocking parts for the chair.  When pushed down, the small metal button to the left of the block in the middle allows the chair to be raised or lowered.

The new plates and bolts installed!



During the repair process and what seemed like 10 trips between the maternity ward and maintenance workshop that day, we slowly acquired many curious eyes watching over our shoulders. I guess seeing a white maintenance woman fixing a chair is quite the spectacle! So many of the staff would periodically stop in the room to see our progress and were really excited that we were trying to repair the chair. Bringing some of the nurses into the room to show them how to correctly operate the chair once we had repaired it was one of the most gratifying experiences in Rwamagana so far. The excitement on their faces was contagious when they saw the chair working like it should and one of the nurses in her limited English told us we were very good technicians. That nurse has become our #1 fan and always waves at us, even if we are across a giant courtyard.

With one chair repaired, Casey and I began to tackle repairing the next chair. The interlocking mechanism on this one was also too low and the bolts to connect the arm to the chair frame had been bent into an elbow. Initially we thought this repair would be simple since we had fixed an identical chair the previous day, but we should probably stop expecting that since there's always something that comes up and complicates the situation. Using pliers and a wrench to hammer the bolts through and eventually break off part of it that was stuck in the chair frame, we removed the faulty bolts after an hour of work while inhaling the not-so-pleasant smells of the delivery room. Back at the workshop, we started trying to adjust the bolt and nut system but the nut was diagonally threaded and was impossible to twist. When all else fails, brute force sometimes pulls through. After several minutes of hammering, we got the nut correctly threaded and were able to fix the interlocking mechanism. Unlike the other chair, this chair was missing the plates for the frame which were necessary so that the bolts wouldn't slip through the gaping hole that had been formed in the chair frame so we made a template for the plate and had the welders make 2 for us. After another 30 or 40 minutes of fighting with the bolts to fit through the deformed chair frame, the third and final maternity chair was fixed.

After finishing the inventory partway through the second week, we began to attempt some more repairs but the equipment we've been working on has been very complex. The hospital here has maintained their equipment fairly well and practically all of the small devices are either working or completely broken, so we've been left to try to repair the large equipment like PCR cabinets, refrigerators, freezers, autoclaves, water distillers, ultrasound machines, phototherapy lights, and patient monitors. Unfortunately, I can't say that we've had very much luck fixing any of these yet. Last week became very frustrating at times because we would figure out what was wrong with a machine but we either didn't have the tools to repair it or needed a completely new part that we can't make. The PCR cabinet is fairly new but had a software error; the refrigerator's fan was disconnected so I re-wired that but one of the pipes in the back was broken and I was going to use oxygen tubing to replace it, but all of the coolant had previously leaked out; the water distiller needs a need relay; the ultrasound machine has a cracked screen; who even knows what's wrong with the phototherapy lights made from 320 LEDs; and the patient monitor needs a new spO2 board and ECG board.  Besides some of the big repairs, there are also little things that would be so simple in the States but are virtually impossible here but are crucial because they can literally be the difference between life and death.  The entire hospital has 1 defibrillator, but is uses electrodes instead of paddles and they have run out of electrodes which means that simply because of a lack of resources, patients can die from reasons that can be treated.

Among the many attempted and abandoned repairs, there have been a few small successes which help to keep us motivated. The hospital got a new fetal monitor but it wasn't printing, so after hours of troubleshooting and deciding it was the thermal printing system, I e-mailed the company and 2 weeks of e-mail tag later, they are sending us a new part since the monitor is still under warranty. Once the part arrives, hopefully it will be an easy swap and the monitor will be back in use. Cyprien, the Rwandan BMET at the hospital, found a 9V battery which we were able to use for an oxygen concentrator so that the alarm system now works. Next week, the hospital is being reviewed for accreditation which is a huge deal, so we have also been working on typing up some of the protocols and documents needed for the accreditation.


Finally, thank you so much to everyone for all of your support and continued prayers. In the good times and the tough times, it's comforting to know that I have so many people supporting me from back home!

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