Goodbye

As we hurdle through the early morning darkness, our Zambian taxi driver expertly maneuvering between potholes and goats I am afforded time to reflect on our visit to Zambia. It has been a wonderful experience for us.

Stats:
Admissions - 35
Deaths - 15
Malaria - over 30 cases
Births - 41

Dan and I are so thankful to the long-term missionaries and Zambian nurses and midwives who have been so patient with us as we adjusted to the Mukinge manner of doing things. A few Mukingeisms that I will remember are:

“The patient has collapsed.” – the patient has died
“The patients condition has changed.” – same as above
“BID” – brought in dead (not twice daily)
“The patient is from far away.” – the patient is going to be admitted, they have traveled too far to go home today.
“Maybe you can do this.” – DO THIS! (usually directed by a nurse)
“Shintai” – push!
“Mwa bu ka vyepi” – hello how are you.
“Twa santa mwane” – thank you.
“Ko sy di queppe” – where is the bathroom?

Anyway we have enjoyed our time here and look forward to some day returning. The Zambian people are gentle people who have not known recent war. They have been very patient and kind with us.

Note from the night charge nurse requesting me to come to evaluate a patient,
I was referred to as "Dr. Ricky"

Post-partum women awaiting discharge.

Post-partum women awaiting discharge.

Basic Life Support in Obstetrics

Zambian style amniotomy tool.

Dan teaching BLSO

Dan teaching BLSO

 We had an opportunity to teach basic life support in obstetrics to a group of nurses and midwives. Topics we reviewed were: "shoulder dystocia", "post-partum hemorrhage", and "neonatal resuscitation".

Malaria

The emergency department is a ZOO. At any moment it is not uncommon to have a patient be carried into the ED completely collapsed and be really, really sick, or alternatively may not be sick at all. In the midst of this the ED physician is also seeing overflow patients from the outpatient clinic or patients that are referred from the clinical officers (essentially US equivelant of a PA) because they have a question. Fortunately the documentation is on paper and not the extensive dissertation that is required in the US EHR’s and for my friends in the military there are no AHLTA tier I errors.

I have seen over twenty cases of malaria this week alone, the majority of which are sent home on oral antimalarials, a practice pretty much unheard of in the US, where likely all patients with malaria are admitted to hospitals for treatment and observation. While that seems like a lot to me, those who have been here long-term state that malaria season is actually slowing down.

According to the CDC, in Zambia HIV/AIDS is the leading cause of death (20%) and Malaria is #2 (12%). Both of these illnesses are entirely preventable. Many of these deaths from malaria result from either absence of access or limited access to health resources. There are on average 6-7 physicians for every 100,000 Zambians (if memory serves there are >100 for every 100,000 in the US). Most of these physicians are concentrated in Lusaka, the capital city, which is a 10 hours by road from here.

Zambia tries to push health resources out into the community, with nurse aid workers, however with limited financial resources they are limited to some degree by international aid.

Happenings

Women grinding nuts for porridge

Mukinge Hospital was originally founded in 1952 by Dr. Bob Foster, whose parents were missionaries in Zambia. In 1973, the hospital was turned over to the Evangelical Church in Zambia which continues to run the hospital in partnership with SIM (Serving in Missions). The hospital receives resources from overseas donors in the form of monetary gifts, as well as equipment. The Zambian nurses, midwives, and clinical officers (PA’s) are assigned to this location and their salaries are paid by the Zambian government. Western workers are all volunteers.

The hospital provides services without the expectation of reimbursement. In order to alleviate some costs on the Labor Ward, pregnant women are required to bring: plastic sheets, three packs of sterile gloves, and a bottle of bleach. When women come in for an evaluation of labor they first lay down a plastic sheet on the bed, and then, over this they place a thin cotton sheet. If they are in labor they stay, if not they are either admitted to the antepartum ward (primarily if they are in latent labor or otherwise ill, i.e. malaria), sent to the Kelata, or sent home if they live close by. Distances here are primarly calculated in the time it takes to arrive; 15 minutes by car, one hour by bicycle, or three hours by foot, may all be equivelant. So when sending a woman home it is important to know their transportation status, as ten miles can be a long way if she does not have access or resources to get a vehicle in which to travel.

Dan was observing one of the midwives during a delivery and upon the delivery of the head the mother stopped pushing. The midwife promptly smacked the patient on the thigh forcefully and commanded her to push. At which time she imediately delivered a healthy baby. While an effective means of communicating the need for improved maternal effort, I doubt this would go over in our western culture, though I am sure some of the nurses back in the states have thought about employing this measure more than once.

I have been continuing to round in the PEM ward in the mornings and have moved to the emergency room in the late morning and afternoons. In the PEM ward, we have added four more patient to our roster, however we lost Justin last night. He had been doing so well, actually come off of his treatment for pneumonia and need for supplemental oxygen. He had concurrent HIV and was on ARV’s and Septra. Yesterday morning he spiked a fever, then started requiring increased supplemetal oxygen again. We started him back on antibiotics, however within 8 hours he passed away. These children are so fragile and each is on the precipice of death.

Hossana, a 19 month old boy I admitted through emergency, presented with a 3 month history of decreased appetite. All PEM admits get treated with antibiotics for 3 days, the receive an anti-parasitic medication, if they have diarrhea they get zinc, if they have dermatitis they receive topical antifungals, and if they are septic the get a third generation cephalosporin. Additionally they all get screened for malaria, and their mothers are screened for HIV. If the mother is HIV positive then depending upon the age of the child and the recency of breast feeding the child is either testedfor HIV or a CD4 count is obtained. Unfortunatley Hosanna’s mother is (+) as is Hosanna. He refuses to eat much, anorexia is common with severely malnourished children, so we will likely place an NG tube to start tube feeds.

kwashiorkor - "the sickness the baby gets when the new baby comes"

Children once admitted start on feeds with an isotonic F-75 and once their edema resolves are transitioned towards a higher calorie F-100. Once they are at max feeds for their body weight and tolerate twelve (q4 hour) feeds without vomiting or diarrhea they are then allowed free feeds, which includes porridge. The porridge is made from ground nuts, maize, sugar and water. The porridge is cooked on the ward and the mothers are employed in grinding the nuts. Everyone contributes.





Another Call

Dan has stayed on Maternal-Child, getting to know the various midwives. Mary one of the midwives has been doing midwifery for 40 years. There are very few things that get her riled, so when she called us into a repair at about 10pm we new it was not going to be simple. The patient was actually a successful TOLAC. Unfortunately she had and extensive lacertation. Dan and I started to prepare for her repair when all of a sudden we get a shout from Mary saying “we have a flat baby”, meaning the baby is apneic or flaccid, this was a baby of another women who delivered as we were starting our repair. So Dan and I leave the other patient, or actually we just turn around to the “resucitier” or what we would call the warmer, which is in the same room, and proceed to resucitate the baby. The infants heart rate is initially under 60 so we commense with chest compressions and PPV. Fortunately the baby responds appropriately after about five or ten minutes and we are able to return to our initial patient.

Most Zambians are very stoic, calm people who rarely get worked up or overly express emotions. We however seemed to have found the only female in the country who had a profound phobia of needles. Unfortunately unlike most patients with a needle phobia she did not pass out when they were encountered, but proceeded to climb backwards over the bed. So here is Dan trying to hold her down on the bed, with me trying to do the repair. Finally we just decide to take her to the OR and do it under conscious sedation.

Front of Hospital

Kajo Kona (Food Corner), local restaurant

Malnutrition Ward

I moved to cover the Protein-Energy-Malnutrition ward, approximately 11 children from 6-18 months age who are severely malnourished.  As I mentioned previously malnutrition is a common cause of death among children here in Zambia. Children come in with swollen extremities and belly’s. The goals are to prevent hypoglycemia, hypothermia, dehydration, infection as well as gradually reintroduce nutrition. Feeding too much protein or sodium too quickly can result in worsening of the childs status, potentially leading to death. Many of the children have concommitant HIV and/or TB. So these illnesses must also be addressed or their nutritionl status will never stabilize. The nurses and the nutritionist here are extremely patient with the mothers. Guiding them through the long process of recovery. Children must be maintsined on a low protein, low sodium formula until their edema resolves. While this is occuring they usually are losing weight. This diuresis can take up to 2-3 weeks. Once their edema has resolved their feeds they can then be switched to a heavier formular and then to free feeds (formula plus, either breast milk or porrige).

Wilison, is a 18 month old patient who is particulalry grumpy because he has to be kept on the lighter formula because of his edema. Everyday on rounds he keeps saying he wants “more”. He really is a cute child, with a lot of spunk, despite his severe illness.

Dan stayed on the maternal-child ward, managing post-partum and the NICU. He was called to the bedside of one of the 28 weekers who was having respiratory distress. Concerned that the infant was about to die he ran to the bedside to perform his assessment. Running through all the possibilities and treatment options, which are pretty sparse, he was thinking that this could possibly be the end for this infant…then all of a sudden the baby sneezed in Dan’s face. The infant perked up and has been doing much better.

Wilison

Wilison's puffy feet



Peds II, Malnutrition Ward





Wilison

Saturday Call



 

 

My first call here at Mukinge was on Saturday. During the day all was quiet. Rounded on Maternal Child, we have a set of 28 week twins and another singleton who is also about 28 weeks as well (0.9kg). Amazingly they continue to hang in despite all odds against them. After rounding the admissions started to role in, first there was an elderly gentleman with RUQ pain and a 10 cm cystic structure in his abdomen, then a 50 year old female with splenomegaly and ascites, the suspected etiology is  likely parasitic. Then a couple of children with malaria. One is a 3 and ½ yo boy named Nickson. He appeared very ill; pale, diaphoretic, with a bounding pulse. He is struggling to breath. He had already taken a course of antimalarial medications provided by an outlying clinic, but these had failed to resolve his infection.

Malaria here is almost exclusively falciparum. Of the types of malaria this is the deadly one. While mosquito netting is provided, most people do not use it, not sure why.

 

Anyway Nickson was started on quinine IM and IV fluids. As I said he appeared very pale and I’m guessing he was profoundly anemic, it is not uncommon to see Hgb of 2-3, normal is 12-16. The cause is multifactorial; malnutrition, chronic intestinal parasite infection, recurrent bouts of malaria. Unfortunately the hospital is out of blood for transfusion.

Shortly after admitting him I go back to recheck on him, his breathing is labored, he is vocalizing incoherently, and he appears worse. While working on another admission for malaria, the nurse calls me back to Nickson’s bedside. She says his condition has changed. I wasn’t sure what that meant, but I figured she wasn’t calling me back to tell me he has improved. I now know that what she meant is that he has passed away.

The under five mortality rate here is 89 per 1000 live births. That is 9% of children die before they reach their 5^th birthday. The majority of these deaths are a result of diarrhea, malaria, pneumonia, HIV/AIDS and malnutrition. Illnesses that are treatable, preventable or non-existent in the US.

Just because something is common doesn’t make it easy to process both for the parents as well as the nurses and physicians taking care of these patients and children. The night would bring a few more deaths, a young boy with malnutrition and an elderly female.

 

 



Maternal-Child Ward

The following day we were introduced to the maternal-child ward.

Women delivering have a minimum amount of privacy during their stay. Beds are side by side. If the delivery is uncomplicated they stay only 6 hours post-partum…yes that is six hours. During a patients labor course one of the patients became sick and vomited in the bathroom, she was then required to mop up after herself. The L&D nurses here are great, but life is hard, and the expectation for patients in the hospital is that care is performed professionally, however without the manufactured sympathy that we may express in the states.

Delivery Suite.



NICU

Labor "Rooms"

Dan doing a c/s.

Postpartum (only 6 hours granted)

"Kilata", ante-antepartum. Where women who are from "far away" come to stay awaiting labor.

28 weeker Dan is caring for in the NICU.

Twins Dan delivered. Twin two was a footling breech.

 

Arrival

Sorry for the delayed blogging to all who are interested. After being here for a week we have finally found a wifi hotspot. Truth be told it had been kind of nice not being connected to any electronic devices.

We left last week at midnight from Dan’s house which was likely the most dangerous part of our trip as I was driving and don’t remember the last 30 minutes getting to the airport in Raleigh. After flights of 2 hours, 12 hours and 7 hours we arrived in the capital of Zambia, Lusaka. Lusaka is a nice quiet and safe capital city which in comparison to other developing nations does not appear to be quite as congested.

President of Zambia disembarking from our airplane.

Dan crossing the runway after arriving in Lusaka.


 

 

 

 

 

 



Runway at Mukinge.

Home Sweet Home

Frequent power outage, Dan and I sharing a candlelight dinner.



Our plane to Mukinge.

 

Flying over the hospital.



Zambia 2016

This Tuesday Dan Hwang and I will be travelling to Zambia to work at the Mukinge Hospital in Kasempa.



Mukinge Mission Hospital is a 200 bed referral facility that services about 100,000 people in Kasempa and Mufumbwe districts in the Northwestern Province.



The hospital has seven inpatient wards, two OR's, outpatient clinic, and physical therapy. The average hospital census is 160-180 patients/day.

Zambia ranks 26 nationally with respect to maternal mortality rates (440/100,00 live births),for comparison, the US is 136th with 21/1000,00, and Estonia ranks the best (186th) with 2/100,000.

Some key health statistics:
•Neonatal Mortality Rate: 34 per 1,000 live births
• Infant Mortality Rate: 70 per 1,000 live births
• Under-5 Mortality Rate: 119 per 1,000 live births
• 45 percent of Children under 5 are Stunted (Chronically Malnourished)
• Only 47 percent of births are attended by a skilled health worker

Causes of maternal death in childbirth:
Hemorrhage (34%)
Infections due to unsanitary conditions (13%)
Obstructed labor (8%)

If internet access permits, I'll keep you all updated on the events of the trip.

loma de luz staff

Photo of loma de luz staff from '09

Hasta luego Honduras

It’s our last night at loma de luz and we have had an excellent time here. I can’t say enough about the importance of the work that is being performed by the missionaries. The local population would truly be at a loss without the hospital and orphanage. The missionaries display a servant attitude as they go about their daily work. They have welcomed us into their homes and lives, making us feel as though we are part of their family. In essence we are. Each believer is part of the larger family with the goal “to know God and to make him known.” We all have a part in that process, whether it is in our homes, at work, overseas missions or in support of missions.

For me it has been a challenge to maintain this world vision. I get caught in the day to day distractions of life, and to be honest this can occur in the mission field abroad as well. It’s nice to have worked in a location where servitude is the modus operandi. I pray I can carry this attitude back home and to work.

Our last night here we had dinner with the young people that stay at staff housing. Most of these youth are either recently graduated from college or high school or are in the midst of their college studies and have taken six months to a year to serve either at the hospital or nearby at the orphanage.

Anyway, we had a pleasant dinner and were in the midst of playing the salad bowl game when Dr. Daron, a family doc who was on call, was called in by Joele, the nurse working the night shift. Joelle reported that a young lady was experiencing significant vaginal bleeding. While we finished our game Dr. Daron went in to investigate the situation.

Upon further inquiry it was determined that this patient was miscarrying and had a significantly low hematocri at 20. Coupled with her hypotension and tachycardia this patient was teetering on the brink of being critically ill. Dr. Rina (also another family doc, whose house we were at) and myself went into the hospital to assist. One of the significant issues at the hospital is the shortage of nurses. If anyone reading this is a nurse or is considering becoming a nurse, I would strongly encourage you to pray about going to loma de luz to serve for a period of time. Anyway due to this shortage it really requires more physicians to perform the job that it would usually. Which is why Dr Rina and myself went in to help.

I assumed the role of anesthesia provider, Dr Daron assumes the role of scrub tech and circulating nurse and Dr Rina assumes the role of surgeon. Anyway we were able to perform the D&C and stabilize her and I even got to donate a pint of blood for a transfusion for her.
Of note the patient had gone to the clinica de salud (local public health clinic) a few days prior and had been given vitamin K (a vitamin involved in helping blood coagulate). Not to be critical of the outlying clinic but this was not the patient’s problem and had she only done this she would likely have eventually bleed to death.

I would again like to express my gratitude for the hospitality that was provided by all those working at loma de luz Hospital. I will continue to pray for them as they perform the work God has called them to endeavor. These men, women and children went out of their way to make Cody and I feel welcomed. I would also like to say thanks to the patients that I was able to meet, as they were extremely understanding and patient with my Spanish skills. Lastly I would like to express my thanks to my son for his willingness to come on this trip. He sacrificed his spring break to assist with the work here. I hope and pray that the work that God has begun in his heart here will continue to grow. He is quite a young man, and I am proud of him. God Bless to all of you. Thank you for your prayers, until next time…

la voluntad de Dios

So yesterday I was saying how very little had been happening around here. Well yesterday afternoon that changed...

Maria, who looks to be in her late 20's, pregnant with her 7th child (the six other children were home deliveries) arrived after being unable to successfully deliver at home. From what we gather she is at 43 weeks gestation. For reference 40 weeks is full-term and in the states we have started inducing women at 41 weeks to avoid the morbidity associated with post-dates pregnancy.

"How long have you been pushing," I ask.

"Hasta ocho," Maria says.

Since eight this morning and it now being noon seemed reasonable to me. However, to arrive at the hospital Maria was carried in a hammock for four hours until they arrived at a road where they flagged down a truck, and then driven an additional 45 minutes and finally arriving at our doorstep. So we figured she hadn't started pushing this morning.

"Hasta ocho esta manana," queries Carrie, one of the nurses who is learning to do OB.

"No, hasta ocho anoche (since eight last night)."

So Maria had been pushing for 16 hours.

Fearing the worst we search for the fetal heart rate with doptones and are relieved to get a rate in the 140's. I examen her cervix and find that she is not completely dilated. She has what is refered to as a thick anterior lip that is very swollen. Likely, she had started pushing prematurely against a non-complete cervix. To compound the issue she had thick meconium which signifies that this infant had experienced a significant amount of stress as well as presents a challenge in neonatal resucitation.

We make the decision to transfer her the hour to la Ceiba to the public hospital. A few calls are made on the radio to rouse the troops. Dave, as he frequently does, volunteers to drive. He is a former volunteer firefighter and EMT so this work is right up his alley. Amy, an RN volunteers to ride along in case of an emergency, i.e. delivery.

Prior to transfer we pray...

"El nino esta llegando," Maria says upon termination of the prayer.

I lift the sheet to verify what she is saying and sure enough there is the head on the perineum. We quickly switch to delivery mode.

Maria delivers easily at this point with only a couple pushes...a girl...a lifeless girl...

We quickly bulb suction the infant (we didn't have time to get the equipment to perform endotracheal suction). No response...no respiratory effort...no heart beat...

We start the code...providing ventilations via the bag-valve-mask...start chest compressions...we call for more help... shortly thereafter Shaw and Sharon arrive....we place an umbilical line and start to administer IV fluids as well as epinepherine..atropine...sodium bicarb...we get her intubated...tube placement is confirmed...check the monitor and see a rhythm...check the pulse...present but slow...we continue respirations...heart rate slows...we restart chest compressions...more epi...more atropine...more fluid..more bicarb...

Reflecting over medical school and residency training you realize there is no way to prepare a physician for events like this. Laying before you is an apparently healthy looking full-term infant that just needs to breath and move...but now matter what you do you cannot will it to happen...

After an hour of resucitative efforts we declare the obvious, that the infant is dead and further efforts are futile.

Carrie, with excellent spanish explains the outcome to the mother...while tearful Maria is at peace..."es la voluntad de Dios (it is God's will)," she says.

A few hours later Maria leaves, to be driven, then carried the 4-5 hour trip to her village...along with her newborn baby who is to be buried...

Eye Dilema

Not much has been happening here over the past couple of days. I have been working in the clinic, seeing the usual; back pain, abdominal pain, headache, eye glued shut with super glue, parasites etc.

A boy arrives from far from here (hours). Locals don't measure time here in distance as much as they measure it in how long it takes to arrive at a certain location and that is dependent upon the weather. While we are currently here in the dry season, when it rains it can often be impossibe to travel. To get to the hospital you have to cross through one river when coming from the west and two rivers when arriving from the east. If there is rain up in the mountains the rivers can become dangerous if not impossible to cross.

Anyway this gentleman of 16 years was applying super glue above his head and it dripped into his right eye subsequently gluing his eyelid shut...three days ago. So he arrives with an eyelid that is swollen as if he'd been punched or stung by an insect.

Fortunately I have some experience in this sort of thing...eyelids being glued shut that is. Back when I was a resident Dermabond had just come into use. Dermabond is medical grade skin adhesive with the same properties as super glue. Anyway, I was repairing a laceration on the eyebrow of a toddler when some of the glue dripped into his eye subsequently gluing his eyelid shut. I quickly looked at the parents to see if they had yet noticed...they had...they were watching me like a mother bear watches her cub. I would like to say my knowledge and experience from medical training kicked in and I calmly resolved the situation. That however would be far from the truth. I did what any person whose accidently glued his/her fingers together with this adhesive would do, used brute strength to physical seperate the eyelids. It worked amazingly well, the lac was repaired, the eye was open and I told the parents this was a "common occurence when we repaired these sorts of things"...that quote was the result of my extensive medical training...

Alright, back to our adolescent with the same problem. I remember back to the toddler and quickly and forcefully seperate his eyelids. Amazingly it works just as it did 10 years ago, the only problem is that all his eyelashes are now located on his upper eyelid...hopefully they'll grow back...

Playing Soccer

Whitewater Rafting

Shaw, his daughter Jenna, Cody and myself went whitewater rafting today. On the Congrejal river outside of la Ceiba class II-IV. Short trip, approx 2 hours, but lots of fun.

Photos

Cody at beach

Yours truely on top of the water tower.

Cody at Front Gate of Hospital

Cody thinking about getting on that horse...

Dr. Shaw Yount (left), Dr. Joel Tumlinson (right)

performing hospital rounds

Guardian Angel

Liz McKenzie, who I've mentioned previously, manages the orphange with her husband Iain. She is keeping watch over young Olvin here, who going on nine months.

Sadly Olvin was harshly abused as an infant. He has multiple subdural hematomas (blood clots around the brain) and now suffers from development delay, seizure disorder and disorganized swallowing. He has a feeding tube but as is quite common suffers from significant reflux causing recurrent aspiration pneumonias. Olvin, absent a miracle will never be normal.

The cynics among you may say why waste the time, resources and money on someone like Olvin, there are times when I would feel that way. But the guiding principal in service here on earth must be Matthew 25:40, "When you have done it for the least of these, you have done it unto me."

Holy Week Tragedy

"HR3 RWT -Doctor Rick", came the voice with urgency on the other line. They primarily use HAM radio here to communicate.
"Quinientos", I say in return, indicating that the triage nurse on the other line switch to channel 500 so we can talk.
"Tenemos un nino que se ha agohado," she states with panic in her voice (we have a child who has drown).
"Yo vengo," I say in return (I am coming).
I put down the radio and sprint to the hospital from the dorms (no more than a quarter of a mile).
Upon arrival Dr Shaw Yount, who had been doing administrative work in the hospital, was performing chest compression and Norma King, RN was providing mask ventilation. I start into assist the team with warming and resucitation...

This week is "Semana Santa" (Holy Week) in this largely nominal Catholic country. This is their big holiday week. If Hondurans have the finances or if they are lucky enough to live nearby they travel to the coast to enjoy the holiday...

Isaac (4 years of age) had been enjoying the day playing and swimming along one of the local rivers. Like most other children his age, he was likely hopping from rock to rock, searching for bugs and reptiles to play with or torture. Enjoying a week with cousins. Somehow like evry curious child he had seemed to wander off by himself...

Isaacs mom was nearby catching up with her family, cleaning up after lunch. Surely Isaac was being watched by one of the older children. Suddenly her sister-in-law screams that something is wrong, in her heart she knows it's Isaac, that boy is always getting into mischief. As she crests the riverbank she sees the lifeless body of Isaac being pulled from the water. Quickly they carry him to the road and flag down a vehicle to transport them to loma de luz hospital...

We work on Isaac for over an hour, multiple rounds of epinepherine, atropine, defibrillation... We attempt to rewarm his body... He is intubated and a central line is placed... We pray... We think we see some cardiac activity on the monitor... We try some more... We all know that the chance of Isaac surviving would require a miracle... there are no miracles to be had today...Isaacs mother is informed of the news...she is griefstricken...no one should have to bury their child...especially not during Semana Santa...

There are few patients that I remember from my short medical career. Physicians remember interesting cases, and the saying is that you don't want to be an interesting case. We also retain very few memories of success...we seem to preferentially remember our failures...this probably goes for most people in most areas of life. Hug your children, if they'll let you... extra hard tonight...

Cody's Work

Cody has been working construction with Mike Yost (originally from Ohio) and Josh (from California by way of Montana). They have been working on expanding the temporary housing at the orphanage. Iain and Liz McKenzie (from Scotland) run the orphanage and have children there from 7 months to 17 years of age. The expanded homes will allow people to stay who are either here to work/volunteer on a long-term basis or families of patients who need a place to stay while their family receives care.