With only 6 days left in Cambodia everything has become about 'lasts'. Today was my last visit to a CPA 1 Hospital near my base work place where we go to follow up TB in children screening & Severe acute malnutrition (SAM) training. The hospital has less resources than others because is has no health equity fund. I'm told that it was left without a health insurance programme so that it could act as a control to compare with other similar sized hospitals in the area that had equity funds introduced.
Although they don't have a lot the staff especially the younger nurses try really hard to following any change in practice that training advocates. On my last visit I hoped to follow up TB screening there but instead I got a stark reminder that there is still a lot more work that needs to be done here before health care is even half decent.
J & R were visiting to do nursing process follow up so went over to the emergency ward to talk to the nurse there who had attended training, whilst L & I went over to OPD. There were no staff in OPD & a few patients waiting but no children so instead we wondered over to the TB ward but that was empty, finally we ended up at the paediatric ward. Every child had been screened &had a TB contact history documented, one child had been diagnosed & transferred with SAM but that wasn't what caught my focus of attention. Sat on the bench next to the nurses table was a woman with her baby in her arms. The older male nurse told me that the child had a reaction to recent immunization. Further questioning revealed that vaccination had been 11 days ago & the child had been unwell since. The nurse was actually sat 3 metres away from the child & mother and clearly had not examined the baby as if he had we wouldn't have been chatting about whether the child at 9 months old was too young to have the immunisation. I went to check on the baby & found that it had an obstructed airway, was pale & completely unresponsive. L has no medical training but could see the little girl was in serious trouble.
I opened the airway & after the very briefest of assessments I told the male nurse that the patient was in coma & needed urgent treatment - where was customary to resuscitate severely unwell children at this hospital? I queried, having only ever done follow up & no ER work here before.
"Reanimation" he shrugged - still making no attempt to get up to see the child or even do a basic set of observations on the comatosed child. Sometimes the inaction & lassitude of health workers needs to be circumvented in a non-culturally sensitive way & this I judged was one such occasion so I took the child's uncompleted notes & their yellow book from the mother & instructed her to "follow me".
We walked the length of the hospital grounds to the emergency ward which as its only asset is a cylinder of oxygen I will refrain from calling a ER. On arrival J & R looked surprised to see that our TB follow up had led me to present to the emergency ward with a pale, obstructed airway, shocked, comatosed 9 month old girl.
The first thing that became apparent to me was that the emergency ward had one oxygen cylinder connected to one dirty nasal prongs & tubing and that was pretty much what distinguished it from any other ward of the hospital. The child was so unconscious that her breathing was far from adequate - did they have anything to assist ventilation? I begged, whilst R suggested that nasal oxygen through dirty tubing at 2 litres a minutes was probably better than nothing at all.
A midwife went off in search of a bag valve mask that they keep on the maternity ward. The on duty medical assistant (MA) arrived at the same time as the box with the mask & a stethoscope in it. He, the midwife & nurse all stood staring helplessly at the child. I looked at R & wordlessly asked for permission to lead this resuscitation, he nodded his encouragement.
R placed a towel under the childs shoulders & explained to the staff that even if you didn't have airway adjuncts you could still do manoeuvers to open the airway. They gave oxygen. I listened to the chest & asked the MA what he could hear. I felt the femoral pulse whilst R suggested a temperature.
The child was pale, cold & tachycardic - shocked. R rolled up his shirt sleeves & then suggested they put in an IV whilst trying really hard not to do it himself. I think its fair to say that we both miss emergency clinical work & getting our hands metaphorically dirty.
Trying to get a clear history from the mother was challenging - she seemed to think the child had been deeply unconscious for 11 days yet the child had been still breast feeding & eating until the previous day. She could really tell me when the child stopped feeding, when she last passed urine or about the seizures she had. She was of course obviously very upset but this inability to give a clear history is a commonly recurring theme here.
It became clear to me that MA didn't know what to do so I talked through the ABCs of resuscitation & started to suggest a fluid bolus, some dextrose & antibiotics. After the dextrose the girl started to groan & whimper, she remained flaccid & floppy on the right but had increased tone & neck stiffness. The MA & I agreed on meningoencephalitis as a most probable differential diagnosis.
We reviewed the ABCD approach, I reinforced that good, correct management had been given & then we went on to discuss transfer to a higher level Hospital. R wanted me to explain to the Mother what was wrong with her child but I thought that it would be more appropriate if the MA could do this. After some discussion R turned round to me & told me that the MA didn't know what to tell the mother. I draw the line at thinking I am better than a Cambodian at talking to a parent in khmer about their seriously ill child. The MA was persuaded to do this whilst the nurse organized an ambulance to transfer the child.
The Hospital has no triage system or way to prioritize patients hence the child lay unconscious on her mother lap for an hour before I noticed how sick she was.
The Hospital has limited equipment & resources to properly deliver the care it needs to the poor rural community it serves.
The health workers have low knowledge & are poorly trained, they are on meager salaries. But when they have someone to lead & advise then they have the technical skills to good deliver care
The patients are mainly illiterate & uneducated and can barely give an account of themselves. Health education is not poor but absent.
So many times it has been demonstrated to me over the last 33 months that what is missing here is confident clinical leadership. On the job training with Cambodian health workers to help sick patients receive better care & build their confidence is absolutely what I love to do but sometimes the enormity of the deficit here is overwhelming and as a finisher completer it is clear to me that my work here is definitely not now, nor will it ever be, done.
Although they don't have a lot the staff especially the younger nurses try really hard to following any change in practice that training advocates. On my last visit I hoped to follow up TB screening there but instead I got a stark reminder that there is still a lot more work that needs to be done here before health care is even half decent.
J & R were visiting to do nursing process follow up so went over to the emergency ward to talk to the nurse there who had attended training, whilst L & I went over to OPD. There were no staff in OPD & a few patients waiting but no children so instead we wondered over to the TB ward but that was empty, finally we ended up at the paediatric ward. Every child had been screened &had a TB contact history documented, one child had been diagnosed & transferred with SAM but that wasn't what caught my focus of attention. Sat on the bench next to the nurses table was a woman with her baby in her arms. The older male nurse told me that the child had a reaction to recent immunization. Further questioning revealed that vaccination had been 11 days ago & the child had been unwell since. The nurse was actually sat 3 metres away from the child & mother and clearly had not examined the baby as if he had we wouldn't have been chatting about whether the child at 9 months old was too young to have the immunisation. I went to check on the baby & found that it had an obstructed airway, was pale & completely unresponsive. L has no medical training but could see the little girl was in serious trouble.
I opened the airway & after the very briefest of assessments I told the male nurse that the patient was in coma & needed urgent treatment - where was customary to resuscitate severely unwell children at this hospital? I queried, having only ever done follow up & no ER work here before.
"Reanimation" he shrugged - still making no attempt to get up to see the child or even do a basic set of observations on the comatosed child. Sometimes the inaction & lassitude of health workers needs to be circumvented in a non-culturally sensitive way & this I judged was one such occasion so I took the child's uncompleted notes & their yellow book from the mother & instructed her to "follow me".
We walked the length of the hospital grounds to the emergency ward which as its only asset is a cylinder of oxygen I will refrain from calling a ER. On arrival J & R looked surprised to see that our TB follow up had led me to present to the emergency ward with a pale, obstructed airway, shocked, comatosed 9 month old girl.
The first thing that became apparent to me was that the emergency ward had one oxygen cylinder connected to one dirty nasal prongs & tubing and that was pretty much what distinguished it from any other ward of the hospital. The child was so unconscious that her breathing was far from adequate - did they have anything to assist ventilation? I begged, whilst R suggested that nasal oxygen through dirty tubing at 2 litres a minutes was probably better than nothing at all.
A midwife went off in search of a bag valve mask that they keep on the maternity ward. The on duty medical assistant (MA) arrived at the same time as the box with the mask & a stethoscope in it. He, the midwife & nurse all stood staring helplessly at the child. I looked at R & wordlessly asked for permission to lead this resuscitation, he nodded his encouragement.
R placed a towel under the childs shoulders & explained to the staff that even if you didn't have airway adjuncts you could still do manoeuvers to open the airway. They gave oxygen. I listened to the chest & asked the MA what he could hear. I felt the femoral pulse whilst R suggested a temperature.
The child was pale, cold & tachycardic - shocked. R rolled up his shirt sleeves & then suggested they put in an IV whilst trying really hard not to do it himself. I think its fair to say that we both miss emergency clinical work & getting our hands metaphorically dirty.
Trying to get a clear history from the mother was challenging - she seemed to think the child had been deeply unconscious for 11 days yet the child had been still breast feeding & eating until the previous day. She could really tell me when the child stopped feeding, when she last passed urine or about the seizures she had. She was of course obviously very upset but this inability to give a clear history is a commonly recurring theme here.
It became clear to me that MA didn't know what to do so I talked through the ABCs of resuscitation & started to suggest a fluid bolus, some dextrose & antibiotics. After the dextrose the girl started to groan & whimper, she remained flaccid & floppy on the right but had increased tone & neck stiffness. The MA & I agreed on meningoencephalitis as a most probable differential diagnosis.
We reviewed the ABCD approach, I reinforced that good, correct management had been given & then we went on to discuss transfer to a higher level Hospital. R wanted me to explain to the Mother what was wrong with her child but I thought that it would be more appropriate if the MA could do this. After some discussion R turned round to me & told me that the MA didn't know what to tell the mother. I draw the line at thinking I am better than a Cambodian at talking to a parent in khmer about their seriously ill child. The MA was persuaded to do this whilst the nurse organized an ambulance to transfer the child.
The Hospital has no triage system or way to prioritize patients hence the child lay unconscious on her mother lap for an hour before I noticed how sick she was.
The Hospital has limited equipment & resources to properly deliver the care it needs to the poor rural community it serves.
The health workers have low knowledge & are poorly trained, they are on meager salaries. But when they have someone to lead & advise then they have the technical skills to good deliver care
The patients are mainly illiterate & uneducated and can barely give an account of themselves. Health education is not poor but absent.
So many times it has been demonstrated to me over the last 33 months that what is missing here is confident clinical leadership. On the job training with Cambodian health workers to help sick patients receive better care & build their confidence is absolutely what I love to do but sometimes the enormity of the deficit here is overwhelming and as a finisher completer it is clear to me that my work here is definitely not now, nor will it ever be, done.
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