This week I have been at the small hospital I go to on the Thai border (with the great splints), introducing a new Triage tool developed by an American University & supported by the NGO I work closely with. Today something happened that highlighted to me the futility of triage alone when there co-exists a complete lack of emergency care knowledge or skills. Sorry folks, it's another frustrating clinical story, please change channels if you have heard enough of them from me already.
This morning we (R, B, J & me) were doing 'on the job' training in OPD with the new triage tool when a mother walked up with a fitting child in her arms. The 2 nurses sat at the OPD desk instantly recognized that this was a triage category 'RED' patient & therefore should go straight to the ER.
The ER is actually the old lab that still needs renovating - quotes this week were three times the price as those for similar work in the Pursat hospital due to lack of competition, good capitalistic principles. So there is no ER at the moment & currently patients go straight to the ward - OPD has no room or resus equipment, OPD is just a porch with 2 tables & a few benches.
The 2 nurses didn't get up to see the patient or talk to the mother, so I went to her & directed her, walking with her & the fitting child, to the paediatric ward. We were greeted, when we got there, by one of the MAs (Medical assistants) & an older nurse (both ex-khmer rouge). The MA recognized that the child was fitting & then said he was very busy with a delivery in maternity (which is odd as he had been sat chatting to the nurse on our approach) & left saying I should look after this patient. In the 18 months I have been here I have advised, coached & even run the odd cardiac arrest. I have never seen patients without being with or discussing them after with their doctor or MA - this is because my job title is "medical advisor". Something clicked in my head when that MA left me with this fitting child, for 18 months I may have felt responsible for patients but I have known that I am not really their doctor. This morning I was that 4 year old girl's doctor & I found a whole new level of frustration & anger that was yet to be explored.
So first of all I asked for some oxygen & suction (there I go with my ABCs again!) - this took an awfully long time, inexplicably but eventually they administered 2 litres/minute of nasal speculum oxygen from an oxygen concentrator. When I pointed to the oxygen cylinder for high flow oxygen I was told it was empty. Before leaving the MA had prescribed diazepam to stop the fitting. I asked where it was but again this took an inexplicably long time to come. I asked about rectal diazepam - quicker - 'ot mean', did not have. Then I asked R (who had the unenviable job of being my translator) if they could put an IV line in rather than give it IM. I was earnestly told by the nurse - lets call her 'gold teeth' - that IM didn't cause respiratory depression as did IV diazepam & there was no way they would ever give a fitting child IV. There are national as well as international guidelines of course that contradict this but 'this is Cambodia!'
By this time the child had been fitting for well over 20 minutes so by definition was in status epilepticus so I could see that a discussion on the pharmokinetics of benzodiazepams was probably not appropriate at this time neither would it have been very successful. "What should I tell them?" asked R - "Just tell them to give the bloody diazepam which ever way they want to BUT DO IT AS SOON AS POSSIBLE!" I snapped. The lack of urgency & second guessing of me was beginning to wear thin.
Apparently, I found out later that 'gold teeth' disagreed that the child was fitting. She actually knew that the symptoms were that of a paracetamol overdose & the little girl just needed glucose, because she had seen this many times before. Meanwhile, silly me had bothered to take a history from the mother which told me the child either had meningitis, malaria or an atypical febrile convulsion & had already been given an appropriate dose of paracetamol by the health centre before being referred to hospital.
IM diazepam was delivered despite another nurse securing an IV line before hand to put up a bag of 5% dextrose - by this point the child had been on the ward more than 15 minutes. 'Gold teeth' went to give 10mls of 50% dextrose just at the time that I noticed the child had stopped breathing. As I went to open the airway & assess breathing 'gold teeth' tried to push me out the way. Through R I tried to explain that no airway & breathing was more important to address & could she please stop pushing me away from the child & if she wanted to be useful could I have a bag valve mask to ventilate the child.
The child was taking very shallow breaths - maybe 4/minute. I waited for an bag valve mask. Everyone stood around, R was silent, I asked again for a bag valve mask. Eventually J showed up & went to find what the delay was. The bag valve mask was encrusted with dirt & dust so one of the nurses was meticulously & painstakingly cleaning it. Meanwhile the child continued not to breath very much. With out the advantage of a translator to explain to the nurse that cleaning the mask was less important than me having the mask so I could bag the patient, J just snatched it off the nurse & brought it to me.
There was no oxygen cylinder so I ventilated on air, 'gold teeth' kept (at least 5 times) removing the nasal speculum despite every time me telling her no & putting them back on. Later I learnt that no one other than me & J actually had recognized that the child had stopped breathing but when I started bagging 'gold teeth' told everyone it was because the child had not been fitting so hadn't needed diazepam. By this time the child was no longer fitting but was cerebrally agitated, extended all limbs to pain & had up going plantar reflexes - before she had been having a complex partial seizure which as it wasn't all limbs twitching was not acknowledged as a seizure here in Cambodia.
So as I ventilated with air & tried to reassure the mother I did actually know what I was doing - I have long since given up trying to convince Cambodian health staff of the same - I asked for a normal saline bolus 20ml/kg - the child was tachycardic with a pulse of 160/min & peripherally shut down & Ceftriaxone - meningitis as a diagnosis was a high probability.
'Gold teeth' refused to do either. The child was already on 5% dextrose & that is resuscitation fluid (WRONG!!!) & Ceftriaxone was not indicated as her temperature was only 36˚C. The child's history was fever, vomiting & lethargy for 12 hours, she has been given paracetamol & an oral antibiotic at the health centre, she had been fitting for maybe over an hour - no one had spoken to the mother but me (through R of course) & no one had read the health centre referral slip. My patience was wearing thin.
"But tell her that the MA said this was my patient now & this is what I am prescribing!" - "No" said R "She is refusing to do it".
J marched off to maternity to drag the MA from the delivery & brought him back just as I turned around to discover that for the entire time another MA has been sat at the desk not engaging with me or the patient, not doing her job at all. The child started to breath, now I could focus my attention on the staff.
I started with a rant to R, "I do in fact know what I am doing you know!!!" I exclaimed "Why won't they listen to me?" Because I was told 'gold teeth' says she is "experienced" & doesn't need to read protocols or have any training she just knows everything from past experience. She didn't think the child was fitting - she was. She failed to act with any urgency to stop the seizure. She refused to give the diazepam by the route I requested - she didn't as she thought actually know best. She failed to realize the child had stopped breathing - the child really had. She thought cleaning a mask was more important than delivering ventilations - it really isn't. And now not only did she think that a fluid bolus & Ceftriaxone would kill the patient - when it would of course save her - her next plan was to catheterize the patient, the only time she had touched the patient so far was to palpate for a bladder. I was beginning to doubt the validity of her 'experience'.
I looked to J & asked myself, silently, WWJD?
I grabbed R & went to where MA 1 & 2 & 'gold teeth' were huddled together, probably muttering about how Ceftriaxone could kill this poor afebrile child.
Calmly & slowly with R translating I went through the ABCD approach to seriously ill child. I talked about airway opening & suction, I talked about oxygen & supporting ventilation. I pointed out that she still had a circulation problem & required fluids as she was septic. I explained about how fitting can look different to generalized tonic clonic seizures, I tried to explain about the pharmokinetics of benzodiazepams, I talked about the importance of giving 10% glucose if a bedside blood test wasn't available in all unconscious or fitting children. I gave my differential diagnosis & explained why I wanted to give Ceftriaxone & then I begged, I implored & politely requested they did what I asked.
They did.
After lunch the child was more alert, remained afebrile & after 2 fluid boluses she was no longer tachycardic.
After the vital signs protocol training where 'gold teeth' was the most verbal participant sharing all her 'experience' that afternoon J & I went back to check on the child, she was febrile & mysteriously 'gold teeth' had performed hourly observations (that were stable) recorded for all of today from early this morning even though she only came in at 10 30 am & also a few observations for tomorrow too.
Triage in an emergency care vacuum - what is the point?
This morning we (R, B, J & me) were doing 'on the job' training in OPD with the new triage tool when a mother walked up with a fitting child in her arms. The 2 nurses sat at the OPD desk instantly recognized that this was a triage category 'RED' patient & therefore should go straight to the ER.
The ER is actually the old lab that still needs renovating - quotes this week were three times the price as those for similar work in the Pursat hospital due to lack of competition, good capitalistic principles. So there is no ER at the moment & currently patients go straight to the ward - OPD has no room or resus equipment, OPD is just a porch with 2 tables & a few benches.
The 2 nurses didn't get up to see the patient or talk to the mother, so I went to her & directed her, walking with her & the fitting child, to the paediatric ward. We were greeted, when we got there, by one of the MAs (Medical assistants) & an older nurse (both ex-khmer rouge). The MA recognized that the child was fitting & then said he was very busy with a delivery in maternity (which is odd as he had been sat chatting to the nurse on our approach) & left saying I should look after this patient. In the 18 months I have been here I have advised, coached & even run the odd cardiac arrest. I have never seen patients without being with or discussing them after with their doctor or MA - this is because my job title is "medical advisor". Something clicked in my head when that MA left me with this fitting child, for 18 months I may have felt responsible for patients but I have known that I am not really their doctor. This morning I was that 4 year old girl's doctor & I found a whole new level of frustration & anger that was yet to be explored.
So first of all I asked for some oxygen & suction (there I go with my ABCs again!) - this took an awfully long time, inexplicably but eventually they administered 2 litres/minute of nasal speculum oxygen from an oxygen concentrator. When I pointed to the oxygen cylinder for high flow oxygen I was told it was empty. Before leaving the MA had prescribed diazepam to stop the fitting. I asked where it was but again this took an inexplicably long time to come. I asked about rectal diazepam - quicker - 'ot mean', did not have. Then I asked R (who had the unenviable job of being my translator) if they could put an IV line in rather than give it IM. I was earnestly told by the nurse - lets call her 'gold teeth' - that IM didn't cause respiratory depression as did IV diazepam & there was no way they would ever give a fitting child IV. There are national as well as international guidelines of course that contradict this but 'this is Cambodia!'
By this time the child had been fitting for well over 20 minutes so by definition was in status epilepticus so I could see that a discussion on the pharmokinetics of benzodiazepams was probably not appropriate at this time neither would it have been very successful. "What should I tell them?" asked R - "Just tell them to give the bloody diazepam which ever way they want to BUT DO IT AS SOON AS POSSIBLE!" I snapped. The lack of urgency & second guessing of me was beginning to wear thin.
Apparently, I found out later that 'gold teeth' disagreed that the child was fitting. She actually knew that the symptoms were that of a paracetamol overdose & the little girl just needed glucose, because she had seen this many times before. Meanwhile, silly me had bothered to take a history from the mother which told me the child either had meningitis, malaria or an atypical febrile convulsion & had already been given an appropriate dose of paracetamol by the health centre before being referred to hospital.
IM diazepam was delivered despite another nurse securing an IV line before hand to put up a bag of 5% dextrose - by this point the child had been on the ward more than 15 minutes. 'Gold teeth' went to give 10mls of 50% dextrose just at the time that I noticed the child had stopped breathing. As I went to open the airway & assess breathing 'gold teeth' tried to push me out the way. Through R I tried to explain that no airway & breathing was more important to address & could she please stop pushing me away from the child & if she wanted to be useful could I have a bag valve mask to ventilate the child.
The child was taking very shallow breaths - maybe 4/minute. I waited for an bag valve mask. Everyone stood around, R was silent, I asked again for a bag valve mask. Eventually J showed up & went to find what the delay was. The bag valve mask was encrusted with dirt & dust so one of the nurses was meticulously & painstakingly cleaning it. Meanwhile the child continued not to breath very much. With out the advantage of a translator to explain to the nurse that cleaning the mask was less important than me having the mask so I could bag the patient, J just snatched it off the nurse & brought it to me.
There was no oxygen cylinder so I ventilated on air, 'gold teeth' kept (at least 5 times) removing the nasal speculum despite every time me telling her no & putting them back on. Later I learnt that no one other than me & J actually had recognized that the child had stopped breathing but when I started bagging 'gold teeth' told everyone it was because the child had not been fitting so hadn't needed diazepam. By this time the child was no longer fitting but was cerebrally agitated, extended all limbs to pain & had up going plantar reflexes - before she had been having a complex partial seizure which as it wasn't all limbs twitching was not acknowledged as a seizure here in Cambodia.
So as I ventilated with air & tried to reassure the mother I did actually know what I was doing - I have long since given up trying to convince Cambodian health staff of the same - I asked for a normal saline bolus 20ml/kg - the child was tachycardic with a pulse of 160/min & peripherally shut down & Ceftriaxone - meningitis as a diagnosis was a high probability.
'Gold teeth' refused to do either. The child was already on 5% dextrose & that is resuscitation fluid (WRONG!!!) & Ceftriaxone was not indicated as her temperature was only 36˚C. The child's history was fever, vomiting & lethargy for 12 hours, she has been given paracetamol & an oral antibiotic at the health centre, she had been fitting for maybe over an hour - no one had spoken to the mother but me (through R of course) & no one had read the health centre referral slip. My patience was wearing thin.
"But tell her that the MA said this was my patient now & this is what I am prescribing!" - "No" said R "She is refusing to do it".
J marched off to maternity to drag the MA from the delivery & brought him back just as I turned around to discover that for the entire time another MA has been sat at the desk not engaging with me or the patient, not doing her job at all. The child started to breath, now I could focus my attention on the staff.
I started with a rant to R, "I do in fact know what I am doing you know!!!" I exclaimed "Why won't they listen to me?" Because I was told 'gold teeth' says she is "experienced" & doesn't need to read protocols or have any training she just knows everything from past experience. She didn't think the child was fitting - she was. She failed to act with any urgency to stop the seizure. She refused to give the diazepam by the route I requested - she didn't as she thought actually know best. She failed to realize the child had stopped breathing - the child really had. She thought cleaning a mask was more important than delivering ventilations - it really isn't. And now not only did she think that a fluid bolus & Ceftriaxone would kill the patient - when it would of course save her - her next plan was to catheterize the patient, the only time she had touched the patient so far was to palpate for a bladder. I was beginning to doubt the validity of her 'experience'.
I looked to J & asked myself, silently, WWJD?
I grabbed R & went to where MA 1 & 2 & 'gold teeth' were huddled together, probably muttering about how Ceftriaxone could kill this poor afebrile child.
Calmly & slowly with R translating I went through the ABCD approach to seriously ill child. I talked about airway opening & suction, I talked about oxygen & supporting ventilation. I pointed out that she still had a circulation problem & required fluids as she was septic. I explained about how fitting can look different to generalized tonic clonic seizures, I tried to explain about the pharmokinetics of benzodiazepams, I talked about the importance of giving 10% glucose if a bedside blood test wasn't available in all unconscious or fitting children. I gave my differential diagnosis & explained why I wanted to give Ceftriaxone & then I begged, I implored & politely requested they did what I asked.
They did.
After lunch the child was more alert, remained afebrile & after 2 fluid boluses she was no longer tachycardic.
After the vital signs protocol training where 'gold teeth' was the most verbal participant sharing all her 'experience' that afternoon J & I went back to check on the child, she was febrile & mysteriously 'gold teeth' had performed hourly observations (that were stable) recorded for all of today from early this morning even though she only came in at 10 30 am & also a few observations for tomorrow too.
Triage in an emergency care vacuum - what is the point?
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