The week before I demonstrated how not to capacity build the ICU medicine staff I actually had quite a good week. There were moments when I even felt that the staff were listening to me & altering the management of patients as a result.
Two good examples of this were on the Paediatric & ICU medicine wards respectively.
There is currently in Cambodia a Dengue epidemic & the Paediatric ward is bursting to the seams with Dengue patients - easy to identify due to the big blocks of ice on their abdomens & the characteristic look in their eyes - its the look of a child with a very bad headache & high fever. Whilst walking around the ward one day L was stopped by a concerned Mother (I may have mentioned before that having a female VA - volunteers assistant - has opened up a whole new world to me). The mother was concerned because although her son had Dengue, he also had a lump on his neck for the last month. She had asked the staff on the ward about it, who had told her that her son was in for Dengue fever & that was all they would treat him for. L called me back to talk with the mother. I asked her what she was worried about. She told me that her father, who she lived with, had been treated for TB recently & had just stopped his 6 month treatment - she was worried that her son had TB also, I thought this was a reasonable concern to have. I explained to her that the staff at the hospital didn't listen to me much either but I would try to ask them to refer her son for TB testing. I explained to her that if I wasn't successful the best thing to do would be to go to her health centre when her son was discharged, as TB was generally managed in the community here so the staff there would have training & be able to help her.
I went in search of the head of service - Dr CP - one of the paediatric all stars. He was having coffee at the hospital canteen, previously doctors left the hospital for coffee but now you know where you can go to find them - its progress of sorts. He was sat with one of the URC doctors & invited me to join them. I asked "what would you do if a child had a 1 month history of an enlarged lymph node & a close TB contact?" - he knows me well so his response was "which room is the patient in?" To which I responded "I am just talking generally!" He laughed & asked "Generally which room is the patient in?!"
We went over to see the patient together. The mother surprised me by being quite assertive when Dr CP asked her what the problem was - her response "I've already told 3 of your staff & they have ignored me". Dr CP was quite taken back - here in Cambodian patients & relatives don't speak to doctors like that. He then went on to show me the notes & the absence of his hand writing in them - "I have never seen this patient!" he exclaimed "If I had I would have organised TB testing". I laughed (in a saving face kind of way) "I know" I reassured, "and that is why I asked you as I know you will do the right thing. Perhaps now you, as head of service, need to tell the rest of the staff to behave in the same way?"
And the following week, after my first run in with ICU medicine, Dr CP with Dr M are the people who comfort me with coffee & kind words - this is why they are the paediatric all stars.
The other case from the week before was a case of Tetanus on ICU medicine. I have learnt about tetanus, I have seen videos of the spasms but I have never seen a case before. I found it hard to control the nerdy medic in me who just wanted to take videos & was very excited despite the suffering of the poor man. He was 29 years old, so when he was a baby & his immunisations for tetanus were due there was a little civil war going on in Cambodia along the border with Thailand which was the Khmer Rouge strong hold against the occupying Vietnamese & hence despite any history of a particular wound, he had developed fever & the classical symptoms of tetanus. He had been correctly diagnosed - although Dr O told me it wasn't that common in Cambodia either any more these days - and had been started on the correct antibiotics, was on a diazepam infusion (of sorts) & had been put in a separate quiet room with the shutters drawn - stimulus such as noise or light can exacerbate the spams. However despite being in for over 24 hours & having 'lock jaw' so being unable to swallow he had no IV fluids prescribed. I explained to the staff he needed IV fluids also & was told that he was on an IV already - I tried to explain that 5% glucose with 60mg of diazepam given over a 24 hour period was not IV fluids but sedation. I left thinking my message was clear but the next day when I went to check on him he still had no IV fluids up. This time I went straight to the boss, Dr L, who I was expecting the same old resistance & the usual hostility from (x-ref any medical blog involving ICU medicine) but the conversation went something like this.
Me: Dr L, I wonder if I could discuss the management of the man with Tetanus?
Dr L: Yes - what is it?
Me: I am very interested to see him as I have never seen a case of tetanus before. His medical management has been excellent, he looks like he will survive but I wonder if he might benefit from IV fluids as well - Normal saline or Ringers Lactate - as he can not swallow & the 5% dextrose used for the sedation infusion is not enough?
Dr L: Yes of course.
Me: He will need another cannula & at least 2 litres a day.
Dr L: Yes, I know, I will do that.
And the strangest thing happened, when I went back that afternoon he had!
The patient survived & went home after an uneventful recovery. Maybe this is why the following week in ICU hit me so hard - my expectations had been raised.
This week - the week after - the MoH have visited whilst I have been away, they were on an infection control (IC) inspection. When they went to ICU medicine it was scored a zero, when they tried to tell the staff about their incorrect IC practice the staff were hostile & verbally abusive. For some reason it makes me very happy that they are now in the dog house & in serious trouble, despite the fact that improving IC is part of my role here. But the MoH staff got a taste of what I get on a daily basis & they are high status, Cambodian males - so this means I can take last week less personally.
I went to ICU today & apologized to Dr V for being rude & inappropriate last week, I explained I was upset because I cared about the outcome of the patient. I knew it was wrong & I knew it was unCambodian. He accepted my apology, listened to my advice about doing an ECG on a patient who had been in for 3 days already with chest pain & shortness of breath. He listened to me whilst I went through the ECG with him (fast atrial fibrillation with ischaemia, secondary to pneumonia probably, that he then independently requested a CXR to confirm). He requested a full blood count when I begged him to, instead of the usual white blood cell count & then he meekly explained he couldn't stop the Digoxin on the pre-eclamptic women (yes, I know - why was she not in maternity & what the hell was she on Digoxin for when she had a sinus tachycardia due to sepsis & having an haemoglobin of 4?!!) because his boss started it so as he is junior/lower status, he couldn't change it.
Nurse P is not talking to me, but as she was the member of staff that was abusive & rude to MoH officials, I think perhaps she has been spoken to about her attitude.
And the woman with meningitis - she made a full recovery & went home this Thursday. Her mother told my VA to pass on her thanks to me, for all my help. That alone makes that week, the one in the middle of the week before & the week after, worth it.
Two good examples of this were on the Paediatric & ICU medicine wards respectively.
There is currently in Cambodia a Dengue epidemic & the Paediatric ward is bursting to the seams with Dengue patients - easy to identify due to the big blocks of ice on their abdomens & the characteristic look in their eyes - its the look of a child with a very bad headache & high fever. Whilst walking around the ward one day L was stopped by a concerned Mother (I may have mentioned before that having a female VA - volunteers assistant - has opened up a whole new world to me). The mother was concerned because although her son had Dengue, he also had a lump on his neck for the last month. She had asked the staff on the ward about it, who had told her that her son was in for Dengue fever & that was all they would treat him for. L called me back to talk with the mother. I asked her what she was worried about. She told me that her father, who she lived with, had been treated for TB recently & had just stopped his 6 month treatment - she was worried that her son had TB also, I thought this was a reasonable concern to have. I explained to her that the staff at the hospital didn't listen to me much either but I would try to ask them to refer her son for TB testing. I explained to her that if I wasn't successful the best thing to do would be to go to her health centre when her son was discharged, as TB was generally managed in the community here so the staff there would have training & be able to help her.
I went in search of the head of service - Dr CP - one of the paediatric all stars. He was having coffee at the hospital canteen, previously doctors left the hospital for coffee but now you know where you can go to find them - its progress of sorts. He was sat with one of the URC doctors & invited me to join them. I asked "what would you do if a child had a 1 month history of an enlarged lymph node & a close TB contact?" - he knows me well so his response was "which room is the patient in?" To which I responded "I am just talking generally!" He laughed & asked "Generally which room is the patient in?!"
We went over to see the patient together. The mother surprised me by being quite assertive when Dr CP asked her what the problem was - her response "I've already told 3 of your staff & they have ignored me". Dr CP was quite taken back - here in Cambodian patients & relatives don't speak to doctors like that. He then went on to show me the notes & the absence of his hand writing in them - "I have never seen this patient!" he exclaimed "If I had I would have organised TB testing". I laughed (in a saving face kind of way) "I know" I reassured, "and that is why I asked you as I know you will do the right thing. Perhaps now you, as head of service, need to tell the rest of the staff to behave in the same way?"
And the following week, after my first run in with ICU medicine, Dr CP with Dr M are the people who comfort me with coffee & kind words - this is why they are the paediatric all stars.
The other case from the week before was a case of Tetanus on ICU medicine. I have learnt about tetanus, I have seen videos of the spasms but I have never seen a case before. I found it hard to control the nerdy medic in me who just wanted to take videos & was very excited despite the suffering of the poor man. He was 29 years old, so when he was a baby & his immunisations for tetanus were due there was a little civil war going on in Cambodia along the border with Thailand which was the Khmer Rouge strong hold against the occupying Vietnamese & hence despite any history of a particular wound, he had developed fever & the classical symptoms of tetanus. He had been correctly diagnosed - although Dr O told me it wasn't that common in Cambodia either any more these days - and had been started on the correct antibiotics, was on a diazepam infusion (of sorts) & had been put in a separate quiet room with the shutters drawn - stimulus such as noise or light can exacerbate the spams. However despite being in for over 24 hours & having 'lock jaw' so being unable to swallow he had no IV fluids prescribed. I explained to the staff he needed IV fluids also & was told that he was on an IV already - I tried to explain that 5% glucose with 60mg of diazepam given over a 24 hour period was not IV fluids but sedation. I left thinking my message was clear but the next day when I went to check on him he still had no IV fluids up. This time I went straight to the boss, Dr L, who I was expecting the same old resistance & the usual hostility from (x-ref any medical blog involving ICU medicine) but the conversation went something like this.
Me: Dr L, I wonder if I could discuss the management of the man with Tetanus?
Dr L: Yes - what is it?
Me: I am very interested to see him as I have never seen a case of tetanus before. His medical management has been excellent, he looks like he will survive but I wonder if he might benefit from IV fluids as well - Normal saline or Ringers Lactate - as he can not swallow & the 5% dextrose used for the sedation infusion is not enough?
Dr L: Yes of course.
Me: He will need another cannula & at least 2 litres a day.
Dr L: Yes, I know, I will do that.
And the strangest thing happened, when I went back that afternoon he had!
The patient survived & went home after an uneventful recovery. Maybe this is why the following week in ICU hit me so hard - my expectations had been raised.
This week - the week after - the MoH have visited whilst I have been away, they were on an infection control (IC) inspection. When they went to ICU medicine it was scored a zero, when they tried to tell the staff about their incorrect IC practice the staff were hostile & verbally abusive. For some reason it makes me very happy that they are now in the dog house & in serious trouble, despite the fact that improving IC is part of my role here. But the MoH staff got a taste of what I get on a daily basis & they are high status, Cambodian males - so this means I can take last week less personally.
I went to ICU today & apologized to Dr V for being rude & inappropriate last week, I explained I was upset because I cared about the outcome of the patient. I knew it was wrong & I knew it was unCambodian. He accepted my apology, listened to my advice about doing an ECG on a patient who had been in for 3 days already with chest pain & shortness of breath. He listened to me whilst I went through the ECG with him (fast atrial fibrillation with ischaemia, secondary to pneumonia probably, that he then independently requested a CXR to confirm). He requested a full blood count when I begged him to, instead of the usual white blood cell count & then he meekly explained he couldn't stop the Digoxin on the pre-eclamptic women (yes, I know - why was she not in maternity & what the hell was she on Digoxin for when she had a sinus tachycardia due to sepsis & having an haemoglobin of 4?!!) because his boss started it so as he is junior/lower status, he couldn't change it.
Nurse P is not talking to me, but as she was the member of staff that was abusive & rude to MoH officials, I think perhaps she has been spoken to about her attitude.
And the woman with meningitis - she made a full recovery & went home this Thursday. Her mother told my VA to pass on her thanks to me, for all my help. That alone makes that week, the one in the middle of the week before & the week after, worth it.
That made me, however many hundreds of kilometres away, all warm and fuzzy. I can't imagine how frustrating it is day to day but when those break throughs come, do you not just walk about with a grin and a little bit of a 'look at me, changing the world and saving some lives' swing in your step? Happy days.
ReplyDeletelittle baby steps... :)
ReplyDeleteHi Est, just read your recent blog entry. wo! Talk about diplomacy on your part. It matters that you are there doing what you are doing. It reminds me of the story of the thousands of starfish stranded on the beach. A little boy was throwing them back in, one at a time. A passer by asked him why he was bothering, the task was so big. The little boy replied, "It mattered to that one" and carried on. One starfish at a time x
ReplyDeletespoke with Dr CP & the boy did have TB & is now on treatment
ReplyDelete