This week at the border hospital much to my surprise I was actually able to deliver all the training I had prepared, including the use of a their first ventilator. As usual the MAs were quite reserved to the point of being slightly disengaged but the 2 young nurses who are being trained up as nurse anaesthetists by the chief nurse anaesthetist were very enthusiastic & asked lots of questions.
At the end of the session the gentlest, most approachable MA smiled & said quietly that I should treat them all like children because that's the level they operate at - I couldn't argue. But then shouty khmer rouge MA suggested I should show them how to use the ventilator with a case in the OR to help them gain confidence with using the machine - I couldn't argue with him either.
The following day we were asked to help anaesthetise a woman for an elective caesarean section, using the new ventilator - spinal anaesthesia is not possible due to a lack of local anaesthesia, perhaps I could support this when I go back to the UK my Cambodian NGO colleague - R - suggested because I clearly haven't given enough so far. It was my first time in theatre here & the first C-section I'd attended for a while. In fact the last one was when I was visiting my friend in South Africa - we were mid Braai at his house when he got a call to help with a C-section at the rural hospital he worked & lived in. I went with him & ended up at the top end in my former role as an anaesthetist whilst Karl scrubbed up & helped deliver the breech baby whose bum was out & his head was still in the uterus - crying in a muffled, echoey, surreal way that I will never forget. It was a healthy baby boy who just need an extended surgical incision to help deliver his head safely. We then went back to our Braai & Boerewors. I relayed this story to R as we got changed into scrubs - he wasn't really impressed other than to know what pressor I had used to raise the South African's mother low BP.
The anaesthetic staff really impressed me, it oddly felt very much like an operating theatre from my previous short life as an anaesthetist, a long time ago in the UK. They had all the drugs they needed labelled & ready, all the equipment was laid out, there was BP & oxygen saturation monitoring but the patient was awake strapped to the operating table like a stainless steel crucifix, no one was talking to her or explaining what they were doing & the new ECG monitor was not being used, so things were just a little different than the UK.
Before I realised it they were doing a RSI intubation, without any cricoid pressure & then they were looking at me expectantly to attach the patient to the ventilator. The motivated, keen young nurse had already checked all the settings & the machine was happily ventilating a rubber lung so we transferred it over to the patient as the surgeons started to cut down through the abdominal layers.
Soon after the machine alarmed a low minute volume warning & the anaesthetic nurse immediately checked the patient, more from habit than my training the previous day I am quite sure. He found she had good air entry, normal chest movement, her pulse & oxygen saturations were all fine. So then without my prompting he started checking the machine & its tubing for any leaks, almost immediately he found a small hole in the tubing, which was then promptly sealed temporarily with tape.
Him & his fellow trainee asked lots of questions about mechanical ventilation - they had never seen a ventilator used before. However they always periodically went back to check the patient, give her top ups of IV anaesthetic or some Ketamine for pain. It was an attentiveness that I rarely see here.
Then the baby was delivered - grey, limp, not breathing - and the waiting midwife took the child to a cold stainless steel table. The table was bare, no towel for drying - just a paper sheet, no suction, no bag valve mask. These things were each asked for slowly, in turn, whilst the baby continued not to breath, losing heat from his wet skin in the aggressively air conditioned room.The Paediatrician in me itched to go over to cover & dry him with a towel whilst the OR staff were struggling to move one of the operating lights to act as a warming light.
The young male nurses & my work colleague continued to play with the machine, adjusting alarm parameters & fiddling with the humidifier. "Ermmm,"I tentatively asked, "Should we go & help the midwife?"
R shrugged & told me that they have had plenty of training on helping babies breath. In a sense he was right as the suction & rescue breathes, as well as towel, all did eventually arrive but just not as the rate that I would have carried it out at.
I agitated. "Be patient Dr Esther!"- I was instructed.
It puzzles me how in the same room for the same clinical case the quality of care can be so varied. The anaesthetic & surgical team were completely prepared for the case - medication, oxygen, monitoring, suction, surgical equipment all at the ready and yet when the baby was delivered there wasn't even a prepared area to resuscitate him. No towel, no warming light, no suction, no bag-valve mask, yet they were all available in the hospital. The midwife knew what to do, my collegue was right she had plenty of training but there was no preparedness, no forward planning, no sense of emergency.
If you had come to this hospital a year ago the ER had only just opened - it was brimming with newly purchased emergency equipment that no one really knew how to use. Today you would see that there is extension building work to accommodate for the increase in patient numbers, often there are patients sleeping on the ER veranda as the 2 trolleys inside are occupied by sicker patients requiring oxygen & monitoring. Nurses will do 'ABCs', they will monitor & record vital signs, the drug cabinet is neat & organised - checked & restocked very day, the whole area (apart from the building work) is clean & well maintained. This has been an excellent demonstration of how basic resources, space & preparedness has resulted in better patient care, which in turn increased patient attendance which improves Hospital income due to the user fee increase.
Whilst feeding back to the Hospital that afternoon on their yearly assessment R brought up the issue of preparedness - what I had witnessed with the neonatal resuscitation & how being ready for emergency cases will improve patient outcomes. Because he is Cambodian he failed to also feedback how impressed I was with the organisation of the anaesthetic & surgical team and how the development of their ER has been exemplary but he remembered to name & directly quote me for the less than positive feedback.
Today I went to see the mother & her baby boy - the first patient to ever have a ventilator used on them in the history of the hospital. She was a bit sore but the baby was doing well.
Today is my last day at this hospital. Words can't really describe how sad I feel about this, leaving just as improvement in patient care & positive change are gaining momentum here. The tail end of Tropical cyclone Haiylan's blustery, grey cloud laden skies & cold, persistent drizzle is a perfect match for my current mood.
At the end of the session the gentlest, most approachable MA smiled & said quietly that I should treat them all like children because that's the level they operate at - I couldn't argue. But then shouty khmer rouge MA suggested I should show them how to use the ventilator with a case in the OR to help them gain confidence with using the machine - I couldn't argue with him either.
The following day we were asked to help anaesthetise a woman for an elective caesarean section, using the new ventilator - spinal anaesthesia is not possible due to a lack of local anaesthesia, perhaps I could support this when I go back to the UK my Cambodian NGO colleague - R - suggested because I clearly haven't given enough so far. It was my first time in theatre here & the first C-section I'd attended for a while. In fact the last one was when I was visiting my friend in South Africa - we were mid Braai at his house when he got a call to help with a C-section at the rural hospital he worked & lived in. I went with him & ended up at the top end in my former role as an anaesthetist whilst Karl scrubbed up & helped deliver the breech baby whose bum was out & his head was still in the uterus - crying in a muffled, echoey, surreal way that I will never forget. It was a healthy baby boy who just need an extended surgical incision to help deliver his head safely. We then went back to our Braai & Boerewors. I relayed this story to R as we got changed into scrubs - he wasn't really impressed other than to know what pressor I had used to raise the South African's mother low BP.
The anaesthetic staff really impressed me, it oddly felt very much like an operating theatre from my previous short life as an anaesthetist, a long time ago in the UK. They had all the drugs they needed labelled & ready, all the equipment was laid out, there was BP & oxygen saturation monitoring but the patient was awake strapped to the operating table like a stainless steel crucifix, no one was talking to her or explaining what they were doing & the new ECG monitor was not being used, so things were just a little different than the UK.
Before I realised it they were doing a RSI intubation, without any cricoid pressure & then they were looking at me expectantly to attach the patient to the ventilator. The motivated, keen young nurse had already checked all the settings & the machine was happily ventilating a rubber lung so we transferred it over to the patient as the surgeons started to cut down through the abdominal layers.
Soon after the machine alarmed a low minute volume warning & the anaesthetic nurse immediately checked the patient, more from habit than my training the previous day I am quite sure. He found she had good air entry, normal chest movement, her pulse & oxygen saturations were all fine. So then without my prompting he started checking the machine & its tubing for any leaks, almost immediately he found a small hole in the tubing, which was then promptly sealed temporarily with tape.
Him & his fellow trainee asked lots of questions about mechanical ventilation - they had never seen a ventilator used before. However they always periodically went back to check the patient, give her top ups of IV anaesthetic or some Ketamine for pain. It was an attentiveness that I rarely see here.
Then the baby was delivered - grey, limp, not breathing - and the waiting midwife took the child to a cold stainless steel table. The table was bare, no towel for drying - just a paper sheet, no suction, no bag valve mask. These things were each asked for slowly, in turn, whilst the baby continued not to breath, losing heat from his wet skin in the aggressively air conditioned room.The Paediatrician in me itched to go over to cover & dry him with a towel whilst the OR staff were struggling to move one of the operating lights to act as a warming light.
The young male nurses & my work colleague continued to play with the machine, adjusting alarm parameters & fiddling with the humidifier. "Ermmm,"I tentatively asked, "Should we go & help the midwife?"
R shrugged & told me that they have had plenty of training on helping babies breath. In a sense he was right as the suction & rescue breathes, as well as towel, all did eventually arrive but just not as the rate that I would have carried it out at.
I agitated. "Be patient Dr Esther!"- I was instructed.
It puzzles me how in the same room for the same clinical case the quality of care can be so varied. The anaesthetic & surgical team were completely prepared for the case - medication, oxygen, monitoring, suction, surgical equipment all at the ready and yet when the baby was delivered there wasn't even a prepared area to resuscitate him. No towel, no warming light, no suction, no bag-valve mask, yet they were all available in the hospital. The midwife knew what to do, my collegue was right she had plenty of training but there was no preparedness, no forward planning, no sense of emergency.
If you had come to this hospital a year ago the ER had only just opened - it was brimming with newly purchased emergency equipment that no one really knew how to use. Today you would see that there is extension building work to accommodate for the increase in patient numbers, often there are patients sleeping on the ER veranda as the 2 trolleys inside are occupied by sicker patients requiring oxygen & monitoring. Nurses will do 'ABCs', they will monitor & record vital signs, the drug cabinet is neat & organised - checked & restocked very day, the whole area (apart from the building work) is clean & well maintained. This has been an excellent demonstration of how basic resources, space & preparedness has resulted in better patient care, which in turn increased patient attendance which improves Hospital income due to the user fee increase.
Whilst feeding back to the Hospital that afternoon on their yearly assessment R brought up the issue of preparedness - what I had witnessed with the neonatal resuscitation & how being ready for emergency cases will improve patient outcomes. Because he is Cambodian he failed to also feedback how impressed I was with the organisation of the anaesthetic & surgical team and how the development of their ER has been exemplary but he remembered to name & directly quote me for the less than positive feedback.
Today I went to see the mother & her baby boy - the first patient to ever have a ventilator used on them in the history of the hospital. She was a bit sore but the baby was doing well.
Today is my last day at this hospital. Words can't really describe how sad I feel about this, leaving just as improvement in patient care & positive change are gaining momentum here. The tail end of Tropical cyclone Haiylan's blustery, grey cloud laden skies & cold, persistent drizzle is a perfect match for my current mood.
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