More Emergency Anecdotes

Dr Magdi (Consultant Physician) and Sister Anna on Emergency Medical Ward

Hello again everyone.

Much has happened in the four days since the creation of the medical emergency ward and I thought it was about time to update you all. You will recall I predicted bedlam. My prediction was correct - the first four days have witnessed the chaotic birth pangs of a new system in evolution. Here are some highlights:

Friday: Day 2 of the Emergency Ward
Why Bed Managers Are Important

At 8 am I walked into a ward that was simply heaving. I have never seen anything like it- the patients were two to a bed, there were patients outside, patients on the floor, and in the corridors. The first order of the day was to move all relatives outside so that we could see who the patients were. Then we spent the morning with all nurses transferring patients.

At 10 am the male patients we were transferring started arriving back because there were no male beds (the wards are male medical or female medical). In fact there are about 70 female medical beds and 22 male medical beds. This problem was finally ironed out today when Matron Susan (the Head of Nursing, a good friend, a powerful ally and a Pastor for the Catholic Church) re-designated some of the wards.

Saturday: Day 3 of the Emergency Ward
The Nurses Show Their Worth

At 11 am I was dealing with a very unwell patient and saw the nurses taking the suction machine out of the Emergency Cupboard (for you non-medics this is not a good sign - it means there is a sick patient lurking on the wards).

At 11.05 am I was asked to see a patient by the nurses. The patient was unconscious and without any help they had done a full ABCDE assessment on the patient, which included:

1) Sucking secretions from the airway
2) Measuring observations (temp, respiratory rate, pulse, BP and conscious level)
3) Inserting a cannula and starting a drip
4) Taking basic bloods to the labs
5) Diagnosing low blood glucose levels

I want you to appreciate the magnitude of this in Juba Teaching Hospital. Three months ago, nurses couldn’t do ABCDE and were deemed too stupid to do observations. Three days ago, the nurses wouldn’t have had any life-saving equipment on the ward to help them. Today I walked in whilst they were giving the glucose to the patient and my heart melted as the patient woke up. Six hours later the patient was discharged. Four days ago that same patient would probably have died.

Sunday:

I took my first day off in four weeks

Monday:

Day 5 of the Emergency Ward- the birth of the “High Care Bed.”
We had a patient admitted who was horribly, horribly ill (to the medical folk out there, she was severely malnourished, septic and febrile, oedematous and had a BP of 50/23 with a Haemoglobin of 24g/L- and no this is not a misprint, it was actually 24g/L). However, our ward had a few tricks up it’s sleeve:

1) She received 1-2-1 nursing with 20 minutes observations, including hourly urines
2) She became the first patient to receive pulse oximetry and non-invasive automated BP monitoring on our funky monitor (and the first patient in a ward to receive this)
3) She had oxygen! (Nasal cannulae only but it’s a start)
4) Her family were too poor to buy any medical treatments so we opened the emergency drugs cabinet and gave her drugs that our hospital had run out of
5) We gave her some blood to increase her haemoglobin levels

This means that our “High Care Bed” was functioning almost to the standard of an ordinary UK hospital bed.

Now blood is in very short supply out here - if you need it the relatives have to donate it. The only person she had was her husband and a 12 year old granddaughter. So, as a doctor my duty of care went a little bit further:


Thanks to the screening, I also learned that I do not have malaria, hepatitis B or C, syphilis or HIV. When I left her, she had received the first pint of blood and had two units waiting for her. She seemed to be turning a corner- certainly the vital signs were looking better. The technician had a bit of trouble siting the (large) blood taking needle but luckily James was on hand and only too glad to ram it home, so all was good. Bearing in mind the important “3-1 rule” of replacing blood loss with fluids, we went to the pub on the way home to round things off.

So it’s all fun here in Juba!

David & James



PS:
In an unrelated note, this little monstrosity is what is often seen around the hospital cutting the grass. In a land where we've often witnessed car wheels come flying off their axels down the road, you can understand why being anywhere near one of these little bad boys in action makes us very nervous...

James

More Emergency Anecdotes

Dr Magdi (Consultant Physician) and Sister Anna on Emergency Medical Ward

Hello again everyone.

Much has happened in the four days since the creation of the medical emergency ward and I thought it was about time to update you all. You will recall I predicted bedlam. My prediction was correct - the first four days have witnessed the chaotic birth pangs of a new system in evolution. Here are some highlights:

Friday: Day 2 of the Emergency Ward
Why Bed Managers Are Important

At 8 am I walked into a ward that was simply heaving. I have never seen anything like it- the patients were two to a bed, there were patients outside, patients on the floor, and in the corridors. The first order of the day was to move all relatives outside so that we could see who the patients were. Then we spent the morning with all nurses transferring patients.

At 10 am the male patients we were transferring started arriving back because there were no male beds (the wards are male medical or female medical). In fact there are about 70 female medical beds and 22 male medical beds. This problem was finally ironed out today when Matron Susan (the Head of Nursing, a good friend, a powerful ally and a Pastor for the Catholic Church) re-designated some of the wards.

Saturday: Day 3 of the Emergency Ward
The Nurses Show Their Worth

At 11 am I was dealing with a very unwell patient and saw the nurses taking the suction machine out of the Emergency Cupboard (for you non-medics this is not a good sign - it means there is a sick patient lurking on the wards).

At 11.05 am I was asked to see a patient by the nurses. The patient was unconscious and without any help they had done a full ABCDE assessment on the patient, which included:

1) Sucking secretions from the airway
2) Measuring observations (temp, respiratory rate, pulse, BP and conscious level)
3) Inserting a cannula and starting a drip
4) Taking basic bloods to the labs
5) Diagnosing low blood glucose levels

I want you to appreciate the magnitude of this in Juba Teaching Hospital. Three months ago, nurses couldn’t do ABCDE and were deemed too stupid to do observations. Three days ago, the nurses wouldn’t have had any life-saving equipment on the ward to help them. Today I walked in whilst they were giving the glucose to the patient and my heart melted as the patient woke up. Six hours later the patient was discharged. Four days ago that same patient would probably have died.

Sunday:

I took my first day off in four weeks

Monday:

Day 5 of the Emergency Ward- the birth of the “High Care Bed.”
We had a patient admitted who was horribly, horribly ill (to the medical folk out there, she was severely malnourished, septic and febrile, oedematous and had a BP of 50/23 with a Haemoglobin of 24g/L- and no this is not a misprint, it was actually 24g/L). However, our ward had a few tricks up it’s sleeve:

1) She received 1-2-1 nursing with 20 minutes observations, including hourly urines
2) She became the first patient to receive pulse oximetry and non-invasive automated BP monitoring on our funky monitor (and the first patient in a ward to receive this)
3) She had oxygen! (Nasal cannulae only but it’s a start)
4) Her family were too poor to buy any medical treatments so we opened the emergency drugs cabinet and gave her drugs that our hospital had run out of
5) We gave her some blood to increase her haemoglobin levels

This means that our “High Care Bed” was functioning almost to the standard of an ordinary UK hospital bed.

Now blood is in very short supply out here - if you need it the relatives have to donate it. The only person she had was her husband and a 12 year old granddaughter. So, as a doctor my duty of care went a little bit further:


Thanks to the screening, I also learned that I do not have malaria, hepatitis B or C, syphilis or HIV. When I left her, she had received the first pint of blood and had two units waiting for her. She seemed to be turning a corner- certainly the vital signs were looking better. The technician had a bit of trouble siting the (large) blood taking needle but luckily James was on hand and only too glad to ram it home, so all was good. Bearing in mind the important “3-1 rule” of replacing blood loss with fluids, we went to the pub on the way home to round things off.

So it’s all fun here in Juba!

David & James



PS:
In an unrelated note, this little monstrosity is what is often seen around the hospital cutting the grass. In a land where we've often witnessed car wheels come flying off their axels down the road, you can understand why being anywhere near one of these little bad boys in action makes us very nervous...

James

Progress

James has never been a fan of inserting exclamation marks into blog posts and I agree with this approach. However the next sentence warrants three...

After 8 weeks of preparation, training, enlisting support, and a few courtesy steps backwards, we have done it:

The new emergency ward is up and running!!!

We have a dream team of nurses and they seem to be loving it. The work is hard but one of them said to me today "I do not mind hard work if we are making a difference."

James ducked out of surgery today to help in medicine

The impact has been immediate and absolute. In the past, there would have been no in-ward medical cover from the time the patient was admitted until the next day. The mortality figures amply demonstrated this with >50% of all medical mortalities occurring during this time.

Now there is medical cover and most importantly, nurses trained in the basics of acute care. Today was a first for many things:
1) The first time an emergency cupboard was opened to save a patients life
2) The first time a ward performed obs on all patient admissions
3) The first time a prescription chart, fluid chart, observation chart and acute care pathway were used
4) The first time that the doctors and nurses were working together as a team

Today was another first for me- it was the first time I saved an asthmatic patients life with the power of creative thought. We had a very unwell asthmatic (who was also very dehydrated and had a chest infection) brought in today. We had no medicine for this at JTH so I sent his grandson who was only about 10 to the Pharmacy to buy some asthma medicines (I needed 3) and some antibiotics. He had spent what little money he had- he could only afford a salbutamol inhaler and the antibiotic. He looked at me with tears in his eyes.

An idea dawned. A salbutamol inhaler can be made more effective if you attach something called a "spacer" which a well made static-free container (we don't have these either). In fact it is as good as a machine that we use in the UK for our severe asthmatics (called a nebuliser). So I took a large mineral water bottle, cut out a hole in the bottom and covered it with tape. Then I made a smaller hole in the tape and put the inhaler in that end. I got the patient to put their mouth at the other end and breath. After 10 puffs on this, 3 litres of fluid and some antibiotics, there was a massive improvement. This chap would have almost certainly died if it was not for this new ward.

The improvised salbutamol spacer

At 5 pm, one of the patients relatives came to me. "Khwaja (means white man), I want to thank you for the work you are doing. That child was crying because he thought his grandfather would die. I have just left the man- he is sat up and talking to my husband."

The nurses were amazing. They seemed to be enjoying themselves and (with the exception of a few minor hiccups) they slotted into the new system like a glove. The day was much less chaotic than I anticipated and I left at 6pm physically exhausted but mentally exhilarated. I am certain that two people would have needlessly died today if it was not for the nurses and the New Emergency Ward. However, anecdotal evidence in Medicine is of no value, which is why we are going to monitor all deaths and see if there is a noticeable reduction.

See you all soon,

David

Progress

James has never been a fan of inserting exclamation marks into blog posts and I agree with this approach. However the next sentence warrants three...

After 8 weeks of preparation, training, enlisting support, and a few courtesy steps backwards, we have done it:

The new emergency ward is up and running!!!

We have a dream team of nurses and they seem to be loving it. The work is hard but one of them said to me today "I do not mind hard work if we are making a difference."

James ducked out of surgery today to help in medicine

The impact has been immediate and absolute. In the past, there would have been no in-ward medical cover from the time the patient was admitted until the next day. The mortality figures amply demonstrated this with >50% of all medical mortalities occurring during this time.

Now there is medical cover and most importantly, nurses trained in the basics of acute care. Today was a first for many things:
1) The first time an emergency cupboard was opened to save a patients life
2) The first time a ward performed obs on all patient admissions
3) The first time a prescription chart, fluid chart, observation chart and acute care pathway were used
4) The first time that the doctors and nurses were working together as a team

Today was another first for me- it was the first time I saved an asthmatic patients life with the power of creative thought. We had a very unwell asthmatic (who was also very dehydrated and had a chest infection) brought in today. We had no medicine for this at JTH so I sent his grandson who was only about 10 to the Pharmacy to buy some asthma medicines (I needed 3) and some antibiotics. He had spent what little money he had- he could only afford a salbutamol inhaler and the antibiotic. He looked at me with tears in his eyes.

An idea dawned. A salbutamol inhaler can be made more effective if you attach something called a "spacer" which a well made static-free container (we don't have these either). In fact it is as good as a machine that we use in the UK for our severe asthmatics (called a nebuliser). So I took a large mineral water bottle, cut out a hole in the bottom and covered it with tape. Then I made a smaller hole in the tape and put the inhaler in that end. I got the patient to put their mouth at the other end and breath. After 10 puffs on this, 3 litres of fluid and some antibiotics, there was a massive improvement. This chap would have almost certainly died if it was not for this new ward.

The improvised salbutamol spacer

At 5 pm, one of the patients relatives came to me. "Khwaja (means white man), I want to thank you for the work you are doing. That child was crying because he thought his grandfather would die. I have just left the man- he is sat up and talking to my husband."

The nurses were amazing. They seemed to be enjoying themselves and (with the exception of a few minor hiccups) they slotted into the new system like a glove. The day was much less chaotic than I anticipated and I left at 6pm physically exhausted but mentally exhilarated. I am certain that two people would have needlessly died today if it was not for the nurses and the New Emergency Ward. However, anecdotal evidence in Medicine is of no value, which is why we are going to monitor all deaths and see if there is a noticeable reduction.

See you all soon,

David

Emergency Medical Unit

The enthusiasic new EMU staff

Two steps back...

“Your teaching has been cancelled today,” said William the Director of Admin and Finance “ We have an Indian delegation arriving with the Undersecretary for the Ministry of Health.” We are very good friends and he didn’t mean it to sound rude. It’s just he doesn’t speak English very well so it comes out rather brusquely.

I had planned this teaching for three weeks and it was designed specifically for nurses who would be working in the Emergency Ward. However, in Africa you have to adapt. We moved the teaching to the next day and moved back the opening of the ward. It now opens on Thursday (assuming there are no further delegations.)

...and one priceless step forward

Today, however, we took the necessary step forward. They learnt the principles and delivery of oxygen, how to write in prescription charts, how to write in fluid charts, and how to work medical machinery like nebulisers and suction machines. What they loved most was a special present I saved for them- a monitor that shows oxygen concentration in the blood (oxygen saturations), pulse, and blood pressure. All they had to do was press a button and the blood pressure cuff inflates and deflates automatically and gives you a reading.

Dr Magdi, Lead Consultant in Emergency Medicine demonstrating and teaching the monitor

We have 8 of these monitors and they are in storage because no trained in their operation. Today was:

1. The first time this was brought out of its (rather dusty) box
2. The first time certificate nurses in JTH were trained in its use

And they absolutely loved it! They were amazed that it cost $6,000 and were more amazed that one of the adaptors alone cost $400. For me, I see these things on the wards in NHS hospitals all the times. The ability to measure the concentration of oxygen in your blood (and indeed have oxygen therapy to give at every bed) is second nature in our hospitals. I found myself thinking fondly of the NHS, then feeling gutted that these people had so little to work with when we have so much, then thinking “Stop thinking useless thoughts and do something productive like training these nurses. Come on boy!” This cycle all took place within 10 seconds.

The day was a good one. They were all excited about being the first nurses to work in a ward with basic life-saving equipment and medicines (something completely taken for granted in the UK). However, today I saw something else. They were actually proud of themselves. In a land where nursing is the most downtrodden profession and the nurses self-esteem esteem is low, seeing this was a priceless experience.

The ward opens on Thursday - I shall keep you informed but my prediction is one of chaos that turns to order as the dust settles over the first week. The long term strategy for acute care is very much a step-wise one. We're aiming to get medicine running first, and then the model can be rolled out to Paeds and the other specialities. It's tempting to do try and do everything at once (particularly as time is running short) but we feel the wisest thing is to just get a small(ish) thing right first and then leave the Jubans with the tools to press ahead with the rest.

Ta for now,

David & James

Emergency Medical Unit

The enthusiasic new EMU staff

Two steps back...

“Your teaching has been cancelled today,” said William the Director of Admin and Finance “ We have an Indian delegation arriving with the Undersecretary for the Ministry of Health.” We are very good friends and he didn’t mean it to sound rude. It’s just he doesn’t speak English very well so it comes out rather brusquely.

I had planned this teaching for three weeks and it was designed specifically for nurses who would be working in the Emergency Ward. However, in Africa you have to adapt. We moved the teaching to the next day and moved back the opening of the ward. It now opens on Thursday (assuming there are no further delegations.)

...and one priceless step forward

Today, however, we took the necessary step forward. They learnt the principles and delivery of oxygen, how to write in prescription charts, how to write in fluid charts, and how to work medical machinery like nebulisers and suction machines. What they loved most was a special present I saved for them- a monitor that shows oxygen concentration in the blood (oxygen saturations), pulse, and blood pressure. All they had to do was press a button and the blood pressure cuff inflates and deflates automatically and gives you a reading.

Dr Magdi, Lead Consultant in Emergency Medicine demonstrating and teaching the monitor

We have 8 of these monitors and they are in storage because no trained in their operation. Today was:

1. The first time this was brought out of its (rather dusty) box
2. The first time certificate nurses in JTH were trained in its use

And they absolutely loved it! They were amazed that it cost $6,000 and were more amazed that one of the adaptors alone cost $400. For me, I see these things on the wards in NHS hospitals all the times. The ability to measure the concentration of oxygen in your blood (and indeed have oxygen therapy to give at every bed) is second nature in our hospitals. I found myself thinking fondly of the NHS, then feeling gutted that these people had so little to work with when we have so much, then thinking “Stop thinking useless thoughts and do something productive like training these nurses. Come on boy!” This cycle all took place within 10 seconds.

The day was a good one. They were all excited about being the first nurses to work in a ward with basic life-saving equipment and medicines (something completely taken for granted in the UK). However, today I saw something else. They were actually proud of themselves. In a land where nursing is the most downtrodden profession and the nurses self-esteem esteem is low, seeing this was a priceless experience.

The ward opens on Thursday - I shall keep you informed but my prediction is one of chaos that turns to order as the dust settles over the first week. The long term strategy for acute care is very much a step-wise one. We're aiming to get medicine running first, and then the model can be rolled out to Paeds and the other specialities. It's tempting to do try and do everything at once (particularly as time is running short) but we feel the wisest thing is to just get a small(ish) thing right first and then leave the Jubans with the tools to press ahead with the rest.

Ta for now,

David & James

Acute Care

Hello

I justed wanted mention a few points of progress regarding the improvement of acute care services in Juba. There's been some good consequences from my presentation to the Ministry of Health at GOSSHA2 (see previous blog entry) recently. Amongst other things, we clearly demonstrated in a mortality distribution study that 60% of inpatient mortalities (and 70% of paediatric mortalities) in JTH occur within the first 24 hours of admission. We concluded from this that in order to reduce hospital mortality, attention would be best spent on improving the acute care delivery services.

What's been really great is that people are actually taking this seriously. Dr Dario (my Consultant and Director General of JTH) has created a new permanent post in Juba: Director of Emergency Services, and appointed Dr Thomas to the task to coordinate it all. This is really encouraging and improving acute care is now high on the hospital's agenda.

Another good outcome from GOSSHA2 has been that Dr Dario managed to put forward as an official recommendation to the ministry that the current procurement system for hospital supply should be revised. Consistent supply of life-saving drugs and equipment, whilst we take it for granted back at home, is a huge issue here. There's few things more frustrating and upsetting as a clinician than seeing delays in, or worse still no treatment at all for a sick patient because there just are no, for example, venflons in the hospital. So in the old system we got what we were given by MoH rather than what we said we needed. Hopefully this will change and the hospital will have more autonomy in procuring supplies.

Enough from me - a few words from David now.


James

The new emergency drugs cupboard on the Emergency Medical Ward.
It may not look much but you wouldn't believe the amount of effort required...

“How was your day?” the Comboni’s often ask me at supper.
“Same as usual,” I often reply “Everyday we move two steps forward, one step backward and one step sideways. But always, we move one step forward!”

Yesterday we took three huge strides:

The purpose of the cupboard is to provide medicines at night time when there are no pharmacists and to allow access to life-saving medicines that you need within seconds. Currently, if a patient needed urgent treatment I would have to send a nurse to pharmacy. More likely than not the nurse would get side-tracked in vigorous hand-shaking and salutations, the Pharmacy would probably be shut, the Pharmacist would be out, or there would be no drugs. This lamentably slow process would take 15 minutes at best. At worst the word “Bukra,” would be given which is a word I hear rather frequently (it means “tomorrow”).

We have selected the Male Emergency Ward as our new Emergency Ward because it has two separate wings. One wing can be for females, the other for males. Handover and the drugs cupboard is in the middle. Today we have been moving the patients out of the Male Emergency Ward and redistributing them.

I am holding out high hopes. We have enough staff, they are all trained, we have the medicines and equipment we need. In the future, we will see if it impacts on mortality.

David