TB training - another perspective

Once again my lovely VA hits the nail on the head....

Reflection in case of Training

Event Description

On the second week of September, my boss, Mrs. J, Mr.R, and I went to a small hospital near border. We were going to stay there for four days for lecturing TB and following up Triage. I was very excited to visit there. 

On the first day - Triage revision in the afternoon, there were no participants, according to Dr.Esther’s speech.  She spent the whole evening on computer work and waited for them. But there was no one appears. This made me very angry and disappointed after hearing this. I just wonder why they did not join the triage lessons even though they did not really understand it. I thought that maybe they were lazy to get the training as nurses and doctors in the hospital. I really concerned what would happen the next day for my TB training translation.

On the second day in the morning, we followed up the Triage process at OPD.  The process was very slow. The nurses were very difficult to recognize what kind of patient they would put in triage form. These because they could not read triage books or even ask patients ‘symptoms. They could not define what the worst compliance patients had. In this process, they spent long hours to know patient is red or yellow or green.  Mr. R tried to explain them about triage. He pointed out the right direction to read and get quick on this form. But it did not work out. So it meant that the triage training was unsuccessful. Also, in this morning, I saw the interesting cases for triage. One young girl who had sore throat and high fever was informed orange patient, for they misread in oxygen amount in oximeter. It was upside down reading. It turned out that they were unable to read properly in oximeter result. So they would like to get training on this. Another patient- a little baby who was diagnosed that she had hand and foot mouth disease was gotten incorrect treatment as pined out by Dr.Esther. Dr.Eshter asked to change the prescription to only Para Cetamol use because she had slightly fever and not serious. By the way, one a little girl was incorrect diagnosis patient who doctor though that she had pneumonia. But indeed, she had asthma. It demonstrated doctor here is not good at treating patient.  In end of the morning, there was one man who came with fractured hand was admitted straight to surgery ward without triage. We realized that he who is a police and brother in law of Golden teeth was considered in priority after asking the nurses at OPD. It is the way of Cambodians to be corruption.  Furthermore, one interesting patient came. This patient who hanged himself was in coma. Dr. Eshter asked bag-mask oxygen for resuscitating this man. But they did not have that material. Mrs. J and I run to find it in surgery ward and maternity ward. Only surgery ward had it. Unfortunately, there was no adult air way tube. Mrs. J hurried to take it in car. At the end, we got the bag- mask oxygen. Nevertheless, our material did not use to revive him.  They applied Oxygen concentrator. Anyway, it helped the patient. I noticed that Doctor at this ward listened to Dr. Esther by using sleep medicine to help him and neck x-ray to check whether he had neck fracture or not. It was good for hanged man but that was a very bad morning for triage result. Anyway, in the afternoon, there was TB training. Unbelievable, there was only one doctor came. In seven minute, he got the TB handout and received a phone call; then he left quickly. We waited for another people. However, there was no one attended as we had expected in the first day. I felt very frustrating with this. I just did not why most of Cambodian nurses or doctors are not eager to learn more. I felt that they do not want to improve their capacity because they think they already knew it. It made me very upset to see my nationality in danger in future. This second day story let me down so much.

On third day for TB training, there were some nurses and a doctor participated. We lectured them about TB in children. Dr.Eshter tried to define them about local sign and general sign of TB of extra-pulmonary TB and pulmonary TB very clear. But they still did not get them even though I translated them several times. I did not know why they did not understand it- whether it was because of my interpreting or they did not have basic knowledge in TB in children. I tried to find the way to get them easy to take in this lecture. However, they did not pay attention in this. They turned their deaf ear to this explanation and talked on phone, instead. I was so sad and very dismayed that those people not listen to us. It showed that my translation was useless for them although I did my best on translation. I felt so bad to them. If they can aware of TB in children, the patient will not die due good treatment. Until in  the evening, Dr. Esther told me the TB training was not achieved because they did know nothing about our training when she asked them  about general sign and local sign of TB while she accompany by Mr.R taught them Regimen including other TB.  After getting this information, I felt very frustrating. We had done our best, but they just did not want to accept it.  Then, we walked around the ward to see patients. When we arrived in pediatric ward, we saw asthma girl whom we had seen on second day. Dr. Esther asked her aunt “what did Doctor told you about her?” She replied that “she had pneumonia”, but in fact she was suffered from asthma, according to Dr.Esther diagnose. Suddenly, little girl defensed quickly” I do not have pneumonia but I only have a cold”. Dr.Eshter was very surprise to hear what she said. She was brighter than Doctor to know what her illness was. We really appreciated this. Until in the evening, there was one patient who came with gastric hemorrhage. He was really sick and sent directly to ICU ward. Unluckily, there were no doctors around the hospital because they were all on commission. This was not appropriate for hospital not having doctors in hospital which could kill patients. Immediately, a male nurse asked Dr.Esther to see this patient as well as suggested her to role as doctor position today. He very concerned about the patient. Dr. Esther examined him quickly. She gave him on bolus serum and advised his wife how to take care her husband. This was an important point that I really excited. The nurses were very nice to patient even though they were unprofessional. They had compassion and sympathy to patient which differ from nurses in Battambang referral hospital. They behaved nicely to patients. I think if they are more trained, they will treat the patient professionally and compassionately. This good sight on nurses has changed my mind to them. I appreciated their jobs as they had those kindnesses. All of these really cheered me up although I had the bad result of TB training. 

On the final day, in the morning we lectured nurses about triage again. Dr. Esther gradually described it by giving the examples which I was acted as simple.  She concentrated in second section in triage form, most of them did not understand even in reading as well as defining what kind patient should be put.  As the same in Battambang referral hospital, they neither listen nor paid attention in this lecture although they did not make out.  Some of them were busy at texting or talking on phone. And others were talking together. They thought they already got it. This was common reaction of Cambodian nurses as I have believed that there was no point for us to give them more- at this really irritating me.  Moreover in this training, most of male nurses often played around me as in case of study. One male nurse was really shy at me. And it was made the teaching become worse.  I just could not believe that. They were rather shy than open minded to new people or knowledge. It really annoyed me. As result, only one midwife and one nurse could grasp this lesson. This was end of training day. In afternoon, we walked around the ward and checked patients up- G hemorrhage and hanged man in ICU ward. The G hemorrhage was getting better. For the hanged man, he was self-discharged   from hospital even though nurses tried to explain him to stay in hospital. But I felt glade that he was better. However, one thing caught my interest was that nurses ask Dr. Esther about one patient with complaining persisted chest pain for several days who she had seen before. She told him to take two specimens to test TB because she thought he could have TB or cancer according the illness history including chest x-ray- collapsed lung. She said that she had tried to tell this to doctor before but he did not followed at all. It maybe he had not been trained before we gave the lecture or he just ignored which made the patient want to leave because he did not improve instead he getting worse on chest pain. Dr. Esther came to explain him about his illness and the treatment we will take. She said that” you are probably have TB according to your chest x-ray, in TB treatment it will take  long time - it could be six months or more depending on your situation.” She continued that” we will take your sputum to test and find out whether you get TB or not. I ask you to stay in hospital better than stay at home which not good for your health”. This really made patient understand his illness and willing to stay in hospital. It was good to tell patients about their sickness which causes patient trust in doctor treatment as I noticed. After finishing this, we left this hospital. We hoped this patient will get correct treatment. 

Thoughts and feelings

For the first day, I felt very frustrating with their absent in Triage training. They were not interesting in learning something again though they did not understand about the process in triage. They thought that they were enough and did not need someone to train. This idea blocked them from build their knowledge up. 

On the second day, I was more irritating when they could not access triage and kept disappearing in training-TB training. For triage, they could not identify red, yellow, orange, or green patient in this form because they were trouble in defining the worst complication or in reading triage book. They spent too long to admit one patient-probably 15 minutes. It wasted a lot of times. I though this because they did not attend in training or they did not listen while teaching. After I saw Mr. R explain them, I found out that they were not really intelligence at all. They knew nothing. They just knew how play around with patient. And for power patient, police man –the brother in law of golden teeth, was transferred without triage. This told us powerful patient is more important than others. To be ministry official has advantage in all of facility. This was really try me hot. I thought this   because they had money and powerful face. So money face would make triage quickly. Anyway, doctor and nurses were unskillful. They could not diagnose correctly and treated well. I could say they lacked of skill.  But they were nice to patient as well as guest and listened to Dr. Esther in some kinds, such as sleep medicine, next x-ray. I felt they were a little opened to learn. I felt less negative to them than Doctors and nurses in Battambang referral hospital.  Instead of feeling a little positive sight on their mind, I could see they did not have enough emergency material in ICU medicine as in case of hanged man. When they needed mask-bag oxygen, they had to run to Surgery ward. It took long times to get this stuff. The patient could be died while they were running. But fortunately, he was revived on the next day although they struggled with this. I was happy to see that. 

On Third day of training, I felt very blue and angry with health staff there when they did not pay attention in our lecture although we tried to our best to explain them. They just ignored it, I believed. They tried to ask the same questions which wasted our time a lot because some of them did not listen at all while someone asking. This annoyed me so much. As the result, our training was not successful. I told myself that there was no point for us to give them more, but I felt better after I saw the nurses here was very kind to patients. They were very warm and worried about the patients. This removed my negative feeling to them; instead I really wanted to go and do trainings with them because if they concern patients, they will treat patient well once day after they get training. So I decided to I will try over again if I have chance to visit there.

On final day, in Triage retraining, I was so frustrating with their attitude in training and toward to me. They were playing around in class including me who presented as example of patient while Dr. Esther explaining. They were just dying to go for lunch or home, not care how hard we tried them to process triage well by spending our time to give them lecture again. They would never give their ear to us unless we do bring food or pay them, I reckoned. I started to have more negative again in my brain. All in this morning I was sick and tired of this. But in evening, I very impressed with Dr. Esther work. She gave good demonstration to the patient and nurses. She told nurses about patient diagnoses as well as pointed out how to examine this patient. The nurse really listened to her. For the patient was willing to stay in hospital. I was really happy to see this. However, I still concerned about nurses here on the way back home. I hesitated whether they follow or not because mostly they just listen but don’t practice. If they don’t do as Dr. Esther has told, the patient will take risk in his life. So I pray to Buddha to bless him.

Evaluation & Analysis

Good done:

-To revive the hanged man: Doctor did good job on resuscitating hanged man. He gave good care to this patient. He examined his neck through neck x-ray as he did listen to Dr. Esther.  I could see doctors really good at traumatic injury as well as interesting in learning new in some kind as this case. So we can work with them once day.

-To feel compassionate and sympathy: Some nurses there were nice to patient. They behaved well. They treated patient in some kind as their family. They spoke gently to patients as they gave medication to them. They did care the patients’ lives; for example, nurses in ICU medicine run to ask Dr. Esther to see the patient when there were no doctors around ward due to commission. They suggested her to role as doctor and to prescribe the treatment in doctor note which they could use it at night after Dr. Esther left. Also they asked her how to treat as well as examination one patient who suspected either TB or cancer according Dr. Esther. These told me that they had compassion and sympathy to the patient. It was good for patient to have those kind nurses and for us provide them more training because they eager to offer good service to their patients.

-To consult the TB patient: Dr. Esther explained to the patient who wanted to discharge from hospital when he did not improve his chest pain about his illness including what we would do for him. She told him about diagnose as well treatment we will take. He really understood his disease and reconsidered to stay in hospital. This consultation inspired the patient willing to stay to get treatment. So the nurses should tell every patient about their illness and treatment in order to get trusted from patient who won’t reluctant to stay in hospital for long times.

Bad done:

-insufficient emergency equipment: When we needed mask-bag oxygen to revive hanged man in ICU medicine, they did not have this material. So we had to run to find it in surgery ward which took us a long minute to bring it.  Unfortunately, they did not have adult air way tube. J was rushed to take it in car.  I could see they really lacked of emergency equipment. They should have this as they are ICU ward where every serious sick patient comes. But I could not blame them because this hospital is poor. There is no point for us to blame anyone when they do not have anything.

-Inability doctors& nurses: Doctor there could not diagnose patient correctly including treatment.  They incorrectly treated EV-71 baby and asthma girl. They did not really look into patient symptoms. They did it just as their habit. They should have examined patients carefully. I could say they lack of knowledge in this because they have been trained little. Therefore, they need more training to build their capacity up.  For nurses, they did not access triage very well. It took a long minute to get one patient flow. The reason was that difficult to define what color would they put patient in this form. They could not recognize the worst complaints of patients and read oximeter result. It showed us that they did have basic knowledge. They really need to be trained again.

-poor human resource management: There is very crucial to have doctors in the ward all the time. They should not allow all doctors to leave the ward even though they were on hospital commission. Without doctors could kill patients, especially sever sick patients because they could not get treatment quickly as they need. So they should have keep some the most important doctors in the most emergency wards such as ICU ward, pediatric ward, etc. They should have put patient in priority. So they could have both advantages- keep patient and get on training.

-not eager to improve knowledge:   Nurses did not pay attention in both training – TB & Triage. They just came as followed the director order. They were dying to have lunch or to go home. While we were teaching, they were talking, playing around, phoning, etc. They really did not care what we were trying to explain them to get easily on triage and aware of TB in children. It turned out they were not very interesting in this because they just ignored them. They should have grasped this training, for those trainings are fundamental knowledge for them. They can have a lot advantages on this if they acknowledge them.  So in order to let them pay attention, we should warn them about what we are going to do if they do not take in these lessons, such as if you want to work and open ER soon, you need to understand this; otherwise, ER will not be opened. We need to talk to both director and staff here. I think they will listen to us because they really want ER.

-Not present in training: They did not appear for first& second day of training.  They really dismayed us and wasted our time.  They should participant our training, for they did not understand about it at all. It may be they lazy or busy. So in order to avoiding this again, we need to inform director of hospital often beforehand. Also give him the warning sign like I would never give lecture or help you again if you still keep this. It is good way to make red card to them because human will follow up if they see the red card.

Future Action:

As role as translator, what I can do is trying to translate effectively in lecturing through asking them often whether they have question or not and giving them a short summarize in each parts in training. My repeating sometimes can get their interesting or remember because they hear it several times. I hope this will work out.