Written Explanations written explanations with regard to my point of view on the dialyzing of foreign citizens in the HD unit of St. Marina Hospital, Varna Translation from Bulgarian:

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		From: Reneta T. Stoyanova, med. nurse in the HD unit 27-May-2003
To: Dr Kr. Ivanov, Executive Director of St. Marina Hospital, Varna

Mr Director,

In reply to your request # AD-537 / 26-May-2003 by which you required of me written explanations with regard to my point of view on the dialyzing of foreign citizens in the HD unit at your hospital, St Marina, I inform you about the following:

I maintain the veracity of the data given by me about a large number of hepatitis infected patients in the abovementioned HD unit, with this only correction that the HCV-positive are not 23 but 24. I suppose that the head of unit, Dr K. Nenov, Ass.-Prof, has not attempted to disprove this as it can be easily confirmed through a check:

• of the schedule which shows the distribution by shifts of our regular HD patients. The names of all our regular patients are there. This schedule is a plastic plate on which, written in blue ball-point pen upon separate stickers of plaster, are written our patients’ names in five columns – three shifts on Mon/Wed/Fri and two shifts on Tue/Thur/Sat. On this plate, left of the names of our HCV-positive with red ball-point pen is added the letter C. The stickers with the names of HBV-positive are stuck under a sign “yellow room” at the bottom end of the plate. This plate is kept by the technicians responsible for the maintenance of the machines and is available in preparation room # 436.
• checked can also be the results from the serologic tests of our patient for hepatitis.These results are kept by senior nurse Demireva in her room # 440. A check can easily ascertain which patients are HCV-positive and which are HBV-positive as well as whether all patients and the staff are tested regularly every three months for HCV, HBV, HIV and CMV.

I maintain that HCV-positives are dialyzed together with HCV-negative in a common room with 13 stations. By this moment the number of HCV-positives distributed by shifts is as follows (data taken directly room the plate):


Table 1. Number of HCV-positive patients in the unit of hemodialysis at St. Marina Hospital, Varna. by 25-May-2003.

Mon/Wed/Fri:		.
1st shift (7:30-11:30)		5 HCV-positive out of total 18
2nd shift (13:00-17:00)		7 HCV-positive out of total 19
3rd shift (18:30-22:30)		7 HCV-positive out of total 16
Tue/Thur/Sat		.
1st shift (7:30-11:30)		4 HCV-positive out of total 13
2nd shift (13:30:17:30)		1 HCV-positive out of total 16

It is clearly seen on the above table that the number of the HCV-positive is different in the separate shifts, the maximum number being seven persons and the minimum – one person. From the data thus given it can be concluded:

a) that in the big room devoted to infected with hepatitis C patients are at least seven machines;
b) that some of these machines remain unoccupied during the shifts with less number of positive patients.

There are indeed seven machines devoted to infected with hepatitis C patients as far as the infected patients in the two groups with seven positive do occupy the machines devoted to infected with hepatitis C. These machines, however, do not remain unoccupied during the other shifts because with the total of 19 machines (without counting the two which are actually separated into another, “yellow” room at the entrance of the HD unit) a simple account shows that there is no way to serve such a great number of patients for a shift if the machines supposedly devoted only to HCV-positive patients are not used by HCV-negative patients as well.

And behind these numbers stay living people. Below are the names of the people infected with hepatitis C in our unit.


Table 2. HCV-positive patients in the unit of hemodialysis at St. Marina Hospital, Varna, by 25 May, 2003 – enlisted by name (according to data directly from the plate):

Mon/Wed/Fri: 1st shift		[names: classified information]
Mon/Wed/Fri: 2nd shift		[names: classified information]
Mon/Wed/Fri: 3rd shift		[names: classified information]
Tue/Thur/Sat: 1st shift		[names: classified information]
Tue/Thur/Sat: 2nd shift		[a name: classified information]

I maintain my opinion that our unit does not meet the world standards for servicing hemodialysis patients. If someone tries to persuade you in the contrary, Mr Director, just ask them to acquaint you with these standards. You could ask our head of unit – Dr Kiril Nenov, Ass.-Prof – whether he has acquainted his staff not only with their job profiles but also with the world standards of servicing hemodialysis patients. Or perhaps the epidemiologist of the hospital who, as you mentioned during our conversation, had approved of foreign patients being dialyzed in our unit, could come out with written point of view on the condition of our unit. She must have at her disposal data from two or three years ago when, on a mass testing of our patients identified were approximately 80% infected with hepatitis C. And before you feel happy at the optimistic statistics of decrease in this percentage, you could check how of our then patients are still alive and how reliable are our present data, provided that tests are done irregularly, and that we have new patients not tested for months, and that we had shortage of latex gloves until quite recently, and that our patients still make their beds with their own bed linen which not rarely is stained with blood and other body liquids (because the hospital cannot provide for them the most elementary hygiene conditions: beds made with clean linen?) Meanwhile, I would like to call to your attention an interesting table containing data on hepatitis C spread in HD units. Our country is mentioned as well¹.


Table 3. HCV Infection in Dialysis

Country		Prevalence in General Population (1997)		Prevalence in Dialysis Population		HCV-positives (n)		Reference Year
Belgium		0.9%		9.4%		48/510		1998
Turkey		1.5%		31.4%		33/88		1998
Bulgaria		1.1%		65.8%		52/79		1998
Netherlands		0.1%		3%		80/2,653		1998
Moldavia		4.9%		75%		111/148		1999
Italy		0.5%		22.5%		2,274/10,097		1999
France		1.1%		16.3%		216/1,323		2000
Egypt		18.1%		80%		169/210		2000
Saudi Arabia		1.8%		57%		32/56		2001

No comment.

And one last example. A check was performed in an HD center in Ohio, the USA, with regard to spread of hepatitis C despite the correct disinfection of the machines:

“Disinfection protocols were adequate for internal pathways of HD machines, however; equipment externally attached to machines (e.g., priming buckets) and other supplies used on chronically infected patients often were not properly cleaned and disinfected before use on susceptible patients. HD staff should strictly observe infection-control precautions specifically designed for HD centers”².

I think we have the same problem. The priming buckets which we use when we connect our patients to the machines are mixed together in the washing room (which in turn is a small, heavily covered with mould room in the entrance of 436, its sink often blocked and its electric bulb blown up and because of this it is most often dark as well); these buckets are then distributed indiscriminately along the beds of our patients.These buckets are regularly stained with blood from positive patients. With these buckets serviced were the foreign patients as well.

During your conversation with me, Mr Director, you told me that I must strictly follow my job profile, and reminded me that I must always inform my direct chief in the first place in case there seem to be infringement. I have always done so, Mr Director. My most direct chief is my senior nurse. I have informed her orally about infringements but since she does not keep a book for written complaints there is nowhere anything recorded. Next of my direct chiefs, according to my job profile, is doctor on duty/head of unit. I have informed doctors on duty for infringements, orally, of course, because they too do not keep a book for written complaint. I have also informed our head of unit: in the official way, in writing, through the letter I showed you yesterday which your secretary registered under incoming # 777 of 26-May-2003. Our head of unit left it unnoticed. What else could I have done in a consecutive case if not address you without informing my direct chiefs?

Unfortunately, the first you did, Mr Director, when I informed you in writing that our unit, in its present condition, does not meet the world standards for treatment of foreign patients was to call me to a conversation in your luxury office and to require of me “written explanations in relation with [my] point of view on the dialyzing of foreign patients” and instead of promising me that you would appoint an immediate check on the data given by me, you threatened me with disciplinary dismissal. You also accused me of caring only for the foreign patients and told me that there should not be any difference between Bulgarian and foreign patients. I cannot agree more with you: there should not be any difference. That is why I still maintain my opinion that our unit does not meet the world standards for treatment of foreign patients, with only this correction that if it does not meet the world standards for treatment of foreign patients, it does not meet the standards for treatment of Bulgarian patients as well. The issue is not only medical, it concerns, as I told you during our conversation, financial and document infringements, too. But, ultimately, it is a moral issue. Our patients watch how everything is done for the foreigners: the schedule is being altered, the machines are moved from one room into another, white starched bed linen is laid on the beds, compresses are prepared and sterilized with a pair of gloves and gauze within. Gauze! Just ask our patients for how long they have not seen gauze to dip in medical spiritus and clean the skin before puncture as well as to press the place of puncture after dialysis has finished. PLEASE, DO SOMETHING FOR IMPROVING THE SERVICING OF THE PATIENTS IN OUR UNIT: BOTH FOR PROVIDING A REGULAR SUPPLY WITH MATERIALS AND FOR REGULAR TESTING THE PATIENTS AND THE STAFF. This is my written point of view.

Signature:

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¹ see here. Back
² see here. Back