24 hours after the shocking start to the week I was having meetings with chief of ward, head of ITU medicine, head nurse and then deputy directors and finally the hospital director. The common theme is "slowly, slowly", "be patient' and "this is Cambodia - that won't work here". In fact my favourite quote is from the Director who told me "I'm not sure VSO is any good here, you have no money, you can't buy us equipment, you are no use." A motivational speech if ever I've heard one.
So with herculean strength I am attempting patience, smiling through gritted teeth and trying not to take each patients death as a personal insult and, hardest of all to achieve, my responsibility.
48 hours after the shocking Monday, Gary & I went to the ward to find a strange and beautiful sight. The bays were single sex, the nursing staff were out of the back room, leaving their embroidery behind, to supervise the student nurses. The chief of ward was proudly spraying ICU on to two new oxygen cylinder holders and the observation charts had all been filled out for that day. The last one really threw me, I've been so used to observation charts (which also act as drug charts here) not being up to date that I was asking why drugs hadn't been given until Gary pointed out that the charts had todays date on them.
A new patient had been admitted overnight with a diagnosis of hypocalcaemia - its a common default diagnosis which drives me a little crazy - so I thought I'd have a chat (via VA) to the patient, to find out what had led the admitting doctor to come up with this over used diagnosis.
The man had been getting chest pain if he did too much lifting for a while, he'd had a transient loss of vision in his right eye 3 months ago, he had left leg weakness the week before and then 2 days previously he had collapsed and been breathless and sick with upper abdominal pain. He lives 60 km away from the Hospital and the local health centre couldn't help, so the local community had had a whip round for a taxi fare and after a day he was able to get a taxi. He was still complaining of epigastric pain and some pleuritic chest pain and breathless on exertion. His observation chart showed he was bradycardic (slow pulse). He smoked heavily, was an ex-drinker and his father had died of a stroke.
Bloods on admission had been done but were limited to white blood cell count only from the FBC, Haemoglobin is rarely done - maybe because everyone is anaemic so they think why bother. His triglyceride had been requested and was elevated and he didn't have hepatitis B or C.
Now perhaps even the non-medical readers among you will be thinking - "hmm- this is sounding very cardiovascular", well I certainly was so I began searching the notes for an ECG (heart tracing). There was to my surprise an ECG but it had creatively been stapled into the back of the notes in such a way that it was completely impossible to read. It had been triple folded with the ECG facing in and then double stapled under a sheet of blood test results.
To the horror and irritation of the nursing staff I completely dissembled the notes to get to the mystery ECG. It was worth my troubles. The ECG was a perfect example of an inferior myocardial infarction. Unless hypocalcaemia is a code word for heart attack I suggested to the staff that they revise the diagnosis.
Then it happened; Dr L asked me what medications I thought we should start this man on?!!! Little old me - VSO medical advisor - was being asked for advice.
Gingerly, aware that rejection could just be around the corner, I suggested Aspirin, a ß-blocker, ACE inhibitor & a statin, and blow me down they only went and prescribed it. So perhaps, I suggested, we could use this patient for a case review to revise how to manage ischaemic heart disease? Steady on Est, don't run before you can walk. Remember the advice "slowly, slowly", "be patient", and "this is Cambodia - that won't work here."
I'm off to do my deep breathing exercises and positive affirmations - its been a very long week.
So with herculean strength I am attempting patience, smiling through gritted teeth and trying not to take each patients death as a personal insult and, hardest of all to achieve, my responsibility.
48 hours after the shocking Monday, Gary & I went to the ward to find a strange and beautiful sight. The bays were single sex, the nursing staff were out of the back room, leaving their embroidery behind, to supervise the student nurses. The chief of ward was proudly spraying ICU on to two new oxygen cylinder holders and the observation charts had all been filled out for that day. The last one really threw me, I've been so used to observation charts (which also act as drug charts here) not being up to date that I was asking why drugs hadn't been given until Gary pointed out that the charts had todays date on them.
A new patient had been admitted overnight with a diagnosis of hypocalcaemia - its a common default diagnosis which drives me a little crazy - so I thought I'd have a chat (via VA) to the patient, to find out what had led the admitting doctor to come up with this over used diagnosis.
The man had been getting chest pain if he did too much lifting for a while, he'd had a transient loss of vision in his right eye 3 months ago, he had left leg weakness the week before and then 2 days previously he had collapsed and been breathless and sick with upper abdominal pain. He lives 60 km away from the Hospital and the local health centre couldn't help, so the local community had had a whip round for a taxi fare and after a day he was able to get a taxi. He was still complaining of epigastric pain and some pleuritic chest pain and breathless on exertion. His observation chart showed he was bradycardic (slow pulse). He smoked heavily, was an ex-drinker and his father had died of a stroke.
Bloods on admission had been done but were limited to white blood cell count only from the FBC, Haemoglobin is rarely done - maybe because everyone is anaemic so they think why bother. His triglyceride had been requested and was elevated and he didn't have hepatitis B or C.
Now perhaps even the non-medical readers among you will be thinking - "hmm- this is sounding very cardiovascular", well I certainly was so I began searching the notes for an ECG (heart tracing). There was to my surprise an ECG but it had creatively been stapled into the back of the notes in such a way that it was completely impossible to read. It had been triple folded with the ECG facing in and then double stapled under a sheet of blood test results.
To the horror and irritation of the nursing staff I completely dissembled the notes to get to the mystery ECG. It was worth my troubles. The ECG was a perfect example of an inferior myocardial infarction. Unless hypocalcaemia is a code word for heart attack I suggested to the staff that they revise the diagnosis.
Then it happened; Dr L asked me what medications I thought we should start this man on?!!! Little old me - VSO medical advisor - was being asked for advice.
Gingerly, aware that rejection could just be around the corner, I suggested Aspirin, a ß-blocker, ACE inhibitor & a statin, and blow me down they only went and prescribed it. So perhaps, I suggested, we could use this patient for a case review to revise how to manage ischaemic heart disease? Steady on Est, don't run before you can walk. Remember the advice "slowly, slowly", "be patient", and "this is Cambodia - that won't work here."
I'm off to do my deep breathing exercises and positive affirmations - its been a very long week.
Do any of your fellow VSO volunteers keep a blog? What sort of a time are they having?
ReplyDeleteIf you go to the VSO website there is a section with blogs - I'm not on it though as I am trying to keep below the radar! If you read them I think you will pretty much see that there is a generic frustration to capacity building in developing countries - it is slow & challenging work.
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