Last week I went to another town to do some training & arranged to have lunch with a health volunteer there. I went to meet him in his office in the local emergency department & to marvel at an emergency nurse volunteer actually placed in an real Emergency department. My ER remains mid construction - 31 months now & still counting.
Jm had dengue recently & as a result has started smoking so wanted to sneak outside for a quick fag before going out to lunch with my boss who for some reason he didn't want her to know that he smokes. As we walked through his department - which has an odd lay out so all patient care is delivered in the main corridor because the rooms have all been renovated & are hence too nice to put patients in - we couldn't help notice an unconscious man being given chest compressions by his relative in the middle of the entrance to the ER.
A man, who I assumed to be the head nurse because he asked Jm to intubate the man, was ventilating the man with a bag valve mask whilst the relative delivered reasonably effective chest compressions. Jm explained he couldn't but perhaps I could. So I found myself at the head end asking for suction & some gloves with my scarf posing its own infection control hazard.
Jm disappeared briefly to return with an automatic defibrillator, he has singlehandedly by donations equipped his ER to the level of a 1980s NHS casualty department. It's really quite impressive, the staff with emergency skills is still a work in progress.
So whilst he attached the pads I intubated the patient & started doing one of my favorite things - running a cardiac arrest in a second langauge, and when I say second there's a hell of a long drop off from my first one.
The AED revealed that the man was in a non-shockable rhythm so off Jm trotted to get an ECG monitor. I was very impressed by the Hewitt Packard monitor - it's been a while since I've seen one in use. It not only showed that the man was in asystole but that our attempts at CPR had produced an oxygen saturation above 95%. Or it could have been the limb massaging that that family were performing.
We discussed with the nurses & family that the history - he had cardiac arrested 20 minutes before arriving at the ER & the rhythm meant we should withdraw resuscitation & with their agreement we stopped.
I washed my hands & removed my by this time contaminated scarf then thanked the head nurse for letting me help to resuscitate this patient. It turns out he was a senior doctor, so although I had failed to capacity build him I had however successfully convinced myself I haven't de-skilled as I often fear I may.
Once again it was demonstrated to me that what staff here need in an emergency is someone confident enough to lead them but few have these skills. My job has been to try & capacity build these skills but there are two common outcomes. The first is they just refuse to listen to me & ignore my advice completely or the second, like this instance, is that they step back & disengage to save face. There simply isn't the organisational culture in government hospitals for on the job training which is consequently seen as demeaning & belittling to the 'highly qualified' doctors here.
In the UK the general public are well aware that doctors train on the job & there is a system of supervision & seniority. Here in Cambodia doctors train in medical school for 7 years & then are fully qualified. Referring to a text book, guidelines & protocols or doing an internet search are all seen as weaknesses. Doctors are all knowing but can not be questioned, especially by their patients.
A few years ago there was a paper published about doctors use of google. Radio 4's Today programme interviewed the author & was particularly sniffy & derisive that doctors should already know 'everything' & it was 'shocking' that they had to use google - what did they do at medical school? the interviewer scoffed.
I personally would prefer to see a doctor that can say - I don't know- & who asks for help beyond their training & skill set. I am a generalist so have always been comfortable referring on to 'experts'. If you prefer to be treated by doctors with the blind arrogance that they know everything & need not ask for help or refer to the literature than I suggest one seeks out medical advice in Cambodia.
Meanwhile I patiently wait to be asked for help & listened to whilst Jm the next day went outside for a sneaky cigarette & inadvertently bumped in to my boss.
That's life.
Jm had dengue recently & as a result has started smoking so wanted to sneak outside for a quick fag before going out to lunch with my boss who for some reason he didn't want her to know that he smokes. As we walked through his department - which has an odd lay out so all patient care is delivered in the main corridor because the rooms have all been renovated & are hence too nice to put patients in - we couldn't help notice an unconscious man being given chest compressions by his relative in the middle of the entrance to the ER.
A man, who I assumed to be the head nurse because he asked Jm to intubate the man, was ventilating the man with a bag valve mask whilst the relative delivered reasonably effective chest compressions. Jm explained he couldn't but perhaps I could. So I found myself at the head end asking for suction & some gloves with my scarf posing its own infection control hazard.
Jm disappeared briefly to return with an automatic defibrillator, he has singlehandedly by donations equipped his ER to the level of a 1980s NHS casualty department. It's really quite impressive, the staff with emergency skills is still a work in progress.
So whilst he attached the pads I intubated the patient & started doing one of my favorite things - running a cardiac arrest in a second langauge, and when I say second there's a hell of a long drop off from my first one.
The AED revealed that the man was in a non-shockable rhythm so off Jm trotted to get an ECG monitor. I was very impressed by the Hewitt Packard monitor - it's been a while since I've seen one in use. It not only showed that the man was in asystole but that our attempts at CPR had produced an oxygen saturation above 95%. Or it could have been the limb massaging that that family were performing.
We discussed with the nurses & family that the history - he had cardiac arrested 20 minutes before arriving at the ER & the rhythm meant we should withdraw resuscitation & with their agreement we stopped.
I washed my hands & removed my by this time contaminated scarf then thanked the head nurse for letting me help to resuscitate this patient. It turns out he was a senior doctor, so although I had failed to capacity build him I had however successfully convinced myself I haven't de-skilled as I often fear I may.
Once again it was demonstrated to me that what staff here need in an emergency is someone confident enough to lead them but few have these skills. My job has been to try & capacity build these skills but there are two common outcomes. The first is they just refuse to listen to me & ignore my advice completely or the second, like this instance, is that they step back & disengage to save face. There simply isn't the organisational culture in government hospitals for on the job training which is consequently seen as demeaning & belittling to the 'highly qualified' doctors here.
In the UK the general public are well aware that doctors train on the job & there is a system of supervision & seniority. Here in Cambodia doctors train in medical school for 7 years & then are fully qualified. Referring to a text book, guidelines & protocols or doing an internet search are all seen as weaknesses. Doctors are all knowing but can not be questioned, especially by their patients.
A few years ago there was a paper published about doctors use of google. Radio 4's Today programme interviewed the author & was particularly sniffy & derisive that doctors should already know 'everything' & it was 'shocking' that they had to use google - what did they do at medical school? the interviewer scoffed.
I personally would prefer to see a doctor that can say - I don't know- & who asks for help beyond their training & skill set. I am a generalist so have always been comfortable referring on to 'experts'. If you prefer to be treated by doctors with the blind arrogance that they know everything & need not ask for help or refer to the literature than I suggest one seeks out medical advice in Cambodia.
Meanwhile I patiently wait to be asked for help & listened to whilst Jm the next day went outside for a sneaky cigarette & inadvertently bumped in to my boss.
That's life.
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