I'm looking for some answers. I would like to know how I can motivate people, how to make them care and how to engender a sense of responsibility? Failing that I'm looking for permission to lapse on my new years resolution.
It's another clinical tale I'm afraid - but often writing it out helps me make sense of it, or at least try to, so sorry if the following bores you.
After the storming success of the PTC course I have started work on the surgical ward, observing trauma management and attempting to encourage the best practice demonstrated in PTC. This required much negotiation with the Director, deputy director and head of service (HS) but was finally agreed, people even signed a piece of paper - there were no photos or banners though.
So the first working day of 2012 I found myself with a man who had fallen from his moto 5 hours earlier. He had a large boggy haematoma on the side of his head, would only open his eyes to voice and was confused (I had to take the Cambodian staffs word for that as my khmer isn't that good yet) and was complaining of a severe headache.
Unfortunately as there is no CT scanner or neurosurgery the plan was just to wait & see. I felt it was probably quite likely that he had a intracranial bleed but in a world of hopeless cases sent home to die, 'no money - no surgery' and no specialist care I wasn't really surprised to not see him the next day. You'd think this case would be the cause of my own headache - not quite.
That same day I ventured on to the Surgical ICU ward - a hybrid of a recovery room (not like any room I'd want to even recover from a bad pedicure in) and a serious cases ward. In there was a young man in a hard neck collar. On further investigation - reading the notes, speaking with the patient and his mother, the staff are 'too busy' - it became clear he was a construction worker who 4 days previously had fallen 3m onto his head and as a result had a headache, sore neck and couldn't move his arms or legs.
I asked if he had an X-ray taken and his mother produced a solitary AP (front to back) X-ray of his neck. A surgeon popped up to point out to me the crushed 7th cervical vertebrae (its been a while but even I could spot the difference) and when I asked for the other X-rays he just looked at me puzzled and I was told that any other views can not be done here in Cambodia and it wasn't his patient anyway. Now I've learnt a thing or two in my 9 months here and one of them is never, ever question or challenge a doctor directly ESPECIALLY not in front of patients, their relatives (the patient's or the doctor's), nurses, other doctors and occasionally even my own translator (the latter can be a real challenge). So I shrugged, smiled and demurely told the family I'd be back.
I wandered outside to the front of the surgical ward with my VA in tow in search of a surgeon (he gets nervous in these situations.)
I have a new years resolution - I am trying to be good. Note the use of the word 'try' - as long as I am trying it doesn't matter if I am achieving.
Three surgeons were stood outside chatting. I approached them - much arm clasping and slapping (them), hair flicking (me) ensued. In the most non-confrontational & non-threatening way possible I asked if I could ask a question about a patient. All smiles - go ahead, they really are such a friendly bunch as long as you aren't trying to capacity build them. Mind you if I had a personal trainer I would almost certainly react as they did when I asked them who the C7# patient (forgive me but I was conversing with surgeons) was being looked after by?
After a very long conversation it was established that none of the 3 surgeons I was talking to were responsible for this young quadriplegic man's care. They then commandeered my VA and chewed his ear off for another 10 minutes about operation lists, the nurses not doing what they are told, how I had only been here 9 months imagine how they feel and if I had a problem I should speak to HS, he is responsible for all patients as head of service. At this point I had only asked who I could talk to about the patients management - I can only assume that they knew he had been mismanaged and this explained their defensive behaviour. That or their new years resolution was to be as obstructive and rude as possible - damn, I should have picked that one to, much more achievable.
When I smiled (as a good person would) and said I only wanted to log roll him (not documented as done on admission) to check he hadn't any further injuries (if you have one spinal fracture it significantly increases your chances of another) and I just wanted permission from his attending surgeon, then there was a queue to grant me consent.
The next challenge was to find people able to log roll him. Its not brain surgery (which is a good job because we can't do that here) but a log roll does require 4 people who know what they are all doing. There was a student nurse (always good log rolling fodder), a nurse who had been on the PTC course (reinforcing transportation workshop) and B from URC to take the head but we needed one more person. B and my VA being polite, respectful Cambodians didn't want to disturb the nurse writing her monthly report. I'm not Cambodian and thought it would be polite & respectful to the patient for him to have a proper log roll so called out for "Kroo Peit moie tiet!" - another nurse came.
We log rolled him, he had no other spinal tenderness but a sacral pressure sore of a size and depth that you would expect of a newly quadriplegic man who had laid on a metal bed with no mattress for 4 days without being turned.
I'm trying to be a good person so I pointed out to the nurses what HS had written in the notes that morning about 2 hourly turns, checked that they knew now how to log roll and left.
I went in search of HS, he unlike the rest of the department - who were still stood outside watching the construction of a restaurant (yes they can build a staff canteen but not complete the sodding ER building!) - was scrubbed in theatre all day.
The following day I checked on the patient - he hadn't been turned since we had done it last (a long 2 hours). I caught up with HS - he wasn't in good humour. Staying up half the night doing a laparotomy will do that to you. I suggested perhaps I could come back another day - I knew where this encounter was heading, we've been here before. Despite my best smiling & trying to be a 'good person' and even after me saying "please don't get defensive I just want to talk generally about improving trauma care" - it all went a bit defensive.
Apparently HS was not responsible for the patient with the C7#, couldn't tell the nurses what to do and certainly wasn't responsible as the head surgeon for any of the other surgeons. He thought I should not work in the surgical ward and it would be best if I waited for the ER to open (or failing that the new hospital restaurant). I may have said some things I shouldn't - maybe not quite in keeping with my new years resolution. In khmer I know how to say 'lazy', 'arrogant' and 'closed minded' but he started it off by saying all the staff here were 'blind' and I just ran with it. None of this was a problem, as these are practically the only 3 words in khmer I use in work, he has heard it all before (sticks & stones) but when I told him (in english) that I thought the staff here didn't care - that appeared to hit home.
The staff in ICU pretended they couldn't understand what I was asking when I went without my VA to see if we could turn the patient and so that afternoon when I returned with my VA there was a student nurse and some tumble weed. HS had suggested the family log roll him, when this idea was mooted with the patient he said he would prefer people who knew what they were doing. I bit my tongue - I am trying!
URC staff log rolled the patient that afternoon.
Today after lunch I went to check up on C7#, we passed HS on the way who decided to give me the cold shoulder - this was an excellent opportunity for my VA to learn another idiom and also revealed that maybe staff do care, about what remains to be seen.
No surprises that the patient had not been turned since the last time we were there. We corralled a posse of log rollers and as I observed worsening bed sores and paralysis the futility of it all suddenly hit me. What was I doing? It certainly isn't sustainable. What was best for this 24 year old man anyway? Why the hell doesn't any of the staff care about his pressure areas, potential pneumonia and progressive neurological deficit?
I went in search of a surgeon who could tell me a plan so I could believe that someone had one and did actually care. I failed but in fairness did remain 'good' throughout. Even when a surgeon I hadn't even known was in the building came up to me whilst I was deep in conversation with the duty surgeon and shouted "I am busy and don't want to talk to you" - cue serene good person's smile.
None of the staff will take responsibility for, is motivated or seems to care about this (or any) patient. I don't know how to capacity build from this starting point.
So unless you have any answers to my original question can you please give me permission to lapse - the trying to be good is most definitely the hardest part.....
It's another clinical tale I'm afraid - but often writing it out helps me make sense of it, or at least try to, so sorry if the following bores you.
After the storming success of the PTC course I have started work on the surgical ward, observing trauma management and attempting to encourage the best practice demonstrated in PTC. This required much negotiation with the Director, deputy director and head of service (HS) but was finally agreed, people even signed a piece of paper - there were no photos or banners though.
So the first working day of 2012 I found myself with a man who had fallen from his moto 5 hours earlier. He had a large boggy haematoma on the side of his head, would only open his eyes to voice and was confused (I had to take the Cambodian staffs word for that as my khmer isn't that good yet) and was complaining of a severe headache.
Unfortunately as there is no CT scanner or neurosurgery the plan was just to wait & see. I felt it was probably quite likely that he had a intracranial bleed but in a world of hopeless cases sent home to die, 'no money - no surgery' and no specialist care I wasn't really surprised to not see him the next day. You'd think this case would be the cause of my own headache - not quite.
That same day I ventured on to the Surgical ICU ward - a hybrid of a recovery room (not like any room I'd want to even recover from a bad pedicure in) and a serious cases ward. In there was a young man in a hard neck collar. On further investigation - reading the notes, speaking with the patient and his mother, the staff are 'too busy' - it became clear he was a construction worker who 4 days previously had fallen 3m onto his head and as a result had a headache, sore neck and couldn't move his arms or legs.
I asked if he had an X-ray taken and his mother produced a solitary AP (front to back) X-ray of his neck. A surgeon popped up to point out to me the crushed 7th cervical vertebrae (its been a while but even I could spot the difference) and when I asked for the other X-rays he just looked at me puzzled and I was told that any other views can not be done here in Cambodia and it wasn't his patient anyway. Now I've learnt a thing or two in my 9 months here and one of them is never, ever question or challenge a doctor directly ESPECIALLY not in front of patients, their relatives (the patient's or the doctor's), nurses, other doctors and occasionally even my own translator (the latter can be a real challenge). So I shrugged, smiled and demurely told the family I'd be back.
I wandered outside to the front of the surgical ward with my VA in tow in search of a surgeon (he gets nervous in these situations.)
I have a new years resolution - I am trying to be good. Note the use of the word 'try' - as long as I am trying it doesn't matter if I am achieving.
Three surgeons were stood outside chatting. I approached them - much arm clasping and slapping (them), hair flicking (me) ensued. In the most non-confrontational & non-threatening way possible I asked if I could ask a question about a patient. All smiles - go ahead, they really are such a friendly bunch as long as you aren't trying to capacity build them. Mind you if I had a personal trainer I would almost certainly react as they did when I asked them who the C7# patient (forgive me but I was conversing with surgeons) was being looked after by?
After a very long conversation it was established that none of the 3 surgeons I was talking to were responsible for this young quadriplegic man's care. They then commandeered my VA and chewed his ear off for another 10 minutes about operation lists, the nurses not doing what they are told, how I had only been here 9 months imagine how they feel and if I had a problem I should speak to HS, he is responsible for all patients as head of service. At this point I had only asked who I could talk to about the patients management - I can only assume that they knew he had been mismanaged and this explained their defensive behaviour. That or their new years resolution was to be as obstructive and rude as possible - damn, I should have picked that one to, much more achievable.
When I smiled (as a good person would) and said I only wanted to log roll him (not documented as done on admission) to check he hadn't any further injuries (if you have one spinal fracture it significantly increases your chances of another) and I just wanted permission from his attending surgeon, then there was a queue to grant me consent.
The next challenge was to find people able to log roll him. Its not brain surgery (which is a good job because we can't do that here) but a log roll does require 4 people who know what they are all doing. There was a student nurse (always good log rolling fodder), a nurse who had been on the PTC course (reinforcing transportation workshop) and B from URC to take the head but we needed one more person. B and my VA being polite, respectful Cambodians didn't want to disturb the nurse writing her monthly report. I'm not Cambodian and thought it would be polite & respectful to the patient for him to have a proper log roll so called out for "Kroo Peit moie tiet!" - another nurse came.
We log rolled him, he had no other spinal tenderness but a sacral pressure sore of a size and depth that you would expect of a newly quadriplegic man who had laid on a metal bed with no mattress for 4 days without being turned.
I'm trying to be a good person so I pointed out to the nurses what HS had written in the notes that morning about 2 hourly turns, checked that they knew now how to log roll and left.
I went in search of HS, he unlike the rest of the department - who were still stood outside watching the construction of a restaurant (yes they can build a staff canteen but not complete the sodding ER building!) - was scrubbed in theatre all day.
The following day I checked on the patient - he hadn't been turned since we had done it last (a long 2 hours). I caught up with HS - he wasn't in good humour. Staying up half the night doing a laparotomy will do that to you. I suggested perhaps I could come back another day - I knew where this encounter was heading, we've been here before. Despite my best smiling & trying to be a 'good person' and even after me saying "please don't get defensive I just want to talk generally about improving trauma care" - it all went a bit defensive.
Apparently HS was not responsible for the patient with the C7#, couldn't tell the nurses what to do and certainly wasn't responsible as the head surgeon for any of the other surgeons. He thought I should not work in the surgical ward and it would be best if I waited for the ER to open (or failing that the new hospital restaurant). I may have said some things I shouldn't - maybe not quite in keeping with my new years resolution. In khmer I know how to say 'lazy', 'arrogant' and 'closed minded' but he started it off by saying all the staff here were 'blind' and I just ran with it. None of this was a problem, as these are practically the only 3 words in khmer I use in work, he has heard it all before (sticks & stones) but when I told him (in english) that I thought the staff here didn't care - that appeared to hit home.
The staff in ICU pretended they couldn't understand what I was asking when I went without my VA to see if we could turn the patient and so that afternoon when I returned with my VA there was a student nurse and some tumble weed. HS had suggested the family log roll him, when this idea was mooted with the patient he said he would prefer people who knew what they were doing. I bit my tongue - I am trying!
URC staff log rolled the patient that afternoon.
Today after lunch I went to check up on C7#, we passed HS on the way who decided to give me the cold shoulder - this was an excellent opportunity for my VA to learn another idiom and also revealed that maybe staff do care, about what remains to be seen.
No surprises that the patient had not been turned since the last time we were there. We corralled a posse of log rollers and as I observed worsening bed sores and paralysis the futility of it all suddenly hit me. What was I doing? It certainly isn't sustainable. What was best for this 24 year old man anyway? Why the hell doesn't any of the staff care about his pressure areas, potential pneumonia and progressive neurological deficit?
I went in search of a surgeon who could tell me a plan so I could believe that someone had one and did actually care. I failed but in fairness did remain 'good' throughout. Even when a surgeon I hadn't even known was in the building came up to me whilst I was deep in conversation with the duty surgeon and shouted "I am busy and don't want to talk to you" - cue serene good person's smile.
None of the staff will take responsibility for, is motivated or seems to care about this (or any) patient. I don't know how to capacity build from this starting point.
So unless you have any answers to my original question can you please give me permission to lapse - the trying to be good is most definitely the hardest part.....
Sounds like you're fighting the good fight under "very trying circumstances". I find alcohol can be helpful at times like this. I've had difficult conversations with surgeons in my own country (as an EM doc) and can't imagine what it must be like in Cambodia. Was wondering if you might answer a question I have about EM and toxicology in Cambodia. mzuckerm AT gmail com
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