Daktari in Casualty

The following is a summary of Dad's past 3 weeks working in the Casualty department. Now nearly halfway through our time at Tenwek Dad will be switching departments later this week. Although long, his experiences are a very worthwhile read. Our family is continually moved by the stories he brings home each day...

Daktari.

The first week was spent getting oriented to the hospital and particularly “Casualty” (ie Emerg) which is where I was posted for the first month. I was both amazed and overwhelmed at the variety and complexity of the medical conditions that presented to the hospital. It was a little scary at first. However, the first week I shared Casualty with one of the career missionaries who was able to very quickly fill me in on what I needed to know both medically and operationally.

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The Casualty, OPD (outpatient department) and CCC (Chronic Care Clinic) is staffed by 10 CO’s (Clinical Officer’s) at a time – 1 in Casualty, 6 in ODP and 3 in CCC. CO’s have had 3 years of medical training and 1 yr of internship. They are very capable, caring and competent but lack breadth and depth of knowledge.

As the Consultant for these three areas, my role is to be a resource to them for the more complex patients, and to see the more complicated and sicker patients in Casualty when needed. When consulted regarding a pt in the ODP or CCC, the CO comes to Casualty where we discuss it or sometimes go see the pt together.

There are also Nurses, nursing students and PA’s (Patient Attendants – ie LPN’s) staffing the three areas as well.

It is a very collaborative approach working together in the best interests of the patient. As such, there is no room for egos as the different professionals freely consult and cooperate with each other. I am free to ask questions of others just as often as they are free to consult me.

Emergency Casualty enterance.

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By the second week, I wasn’t quite as overwhelmed and was able to figure out the daily routine:

• 7:45 – morning report – interns from the different departments (Med, Surg, Obs and Peds) present their most interesting and challenging cases while the consultants and others ask questions, provide feedback and add relevant teaching points. There are usually 16 interns, several consultants and residents and a few medical students. This is followed by a teaching session except on Wed where someone presents a devotional instead.
• 9:00 – Casualty – this is very slow in the am with usually 0-3 patients in the department at a time. As the CO is usually able to handle the load in the am, I found there is plenty of time to do other things during this time.
• 10:30 – Chai break – Everybody takes part in this (sometimes in shifts if there are patients needing urgent attention).
• 1-2 – Lunch – What a concept! I think this is the first time I’ve routinely taken an hour lunch break since High School! Usually I go home (a 4 minute walk) but sometimes I stay for the teaching rounds done twice a week by one of the consultants.
• 2:00 – Casualty – things usually pick up in the afternoon requiring me to see some pts on my own in Casualty, as well as be available for the other CO’s. However the pace is still relatively slow in that I may see 1-2 pts an hour on my own plus occasional consultations. The most time consuming part is getting a good detailed history. About a third of the patients speak English but often the pts are so sick they are not able to talk or can only provide limited history. A lot of time is also spent deciphering previous records, reviewing labs, reading x-rays, reassessing the pt’s condition, asking further questions, and collaborating with other staff and charting.
• 5:30-6:30 – Done!

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By now I was able to see a lot of inefficiencies in the place. During the mornings, I spent some time wandering and wondering through the different departments asking questions of different staff. I delegated some basic decluttering and labelling jobs to the nurses in Casualty to work on when not busy in the am (when there were few patients, I would often find them just “relaxing” – ie sitting and chatting).

I also organized a place for the charts and designed and tested a “flag” system. They were all very appreciative of these simple changes. By the end of the week I had quite a list of changes. Fortunately, this week was a little slower as all the career missionaries were away for most of this and the following weeks.

Tenwek sign and motto.

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The past week I’ve been much more comfortable in my role here, which I realize is to see a few patients, provide some medical teaching, but mostly to facilitate and teach delivery system redesign and operational improvement.

Some of my ideas will have to wait until the career missionaries are back at work next week, but some I went ahead and implemented this week – the biggest project of the week was simply adding room and bed numbers to all of the hospital’s 300 charts (which consisted of a wooden clipboard that appeared to be 20 years old). Surprisingly (or not), most of the wards had no chart labelling system. With 50-70 pts per ward, and up to 20 pts per room, you can imagine the chaos – you would walk into a room and find a huge pile of charts on one of the desks with only the pts name on the chart!

I employed the help of the whole family as well as some of the other missionary kids to make and apply color coded labels to all the charts, and to create specific places for them. We have received much appreciation for this simple (but time consuming!) task. I also happened to find 70 brand new clipboards while exploring the hospitals supply room!

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I’m also more comfortable in managing patients in Casualty. Aside from the usual Pneumonia, Meningitis, Malaria, Fever of Unknown Origin, diarrhea, dehydration and minor trauma, some of my more interesting cases have been the following:

- 30 yo with perforated typhoid ulcer

- 50 yo with uncontrolled hypertension and major stroke

- 1 yo with prolonged seizure

- 46 yo with periodontal abscess

- 25 yo with coma from self induced poisoning (suicide method of choice here)

- 80 yo with stroke, heart failure, hypertension and diabetes

- 20 yo with acute psychosis (I’m amazed at how prevalent mental illness is here – particularly psychosis)

- 40 yo with skin cancer on the scalp that had invaded the skull – he had 15 cm diameter hole in the top of his head exposing his brain!

- 8 yo with AIDS, TB, meningitis and seizures (died the following day)

- 16 yo with heart failure due to rheumatic heart disease (RHD - not uncommon here) and accumulation of fluid around the heart which the surgeon readily aspirated – the surgeon created a window in the membrane over the heart the following day

- 13 yo with right sided paralysis from a stroke caused by atrial fibrillation secondary to heart failure from RHD

- 50 yo alcoholic with respiratory distress likely from aspiration (died the following day despite my innovative modified high flow oxygen mask)

- 40 yo who was incoherent when he came in and died while I was examining him despite a pathetic attempt at resuscitating him (it took several minutes just to get a bag, mask and oxygen for him) – when you start resuscitating someone, the nurse’s tendency is to walk away. Fortunately we have 3 excellent student nurses in casualty who are eager to learn so after every code we have a brief teaching session on what we can do better next time. I also make sure the CO’s practice their intubation skills and have reorganized the resuscitation equipment.

- 45 yo man who was DOA (dead on arrival) but I ran a code anyway both for practice and the benefit of the family – after the code I went into a little room to talk to the brother and 18 yo son. The Chaplain was also there. I asked questions to better ascertain what the probable cause of death was and then broke the news to the relatives. The Chaplain then led us all in a prayer. I again offered my condolences and when I reached out to shake their hands, I was surprised when the son jumped up and hugged me burying his head in my shoulder. He sobbed for about a minute. I just stood there embracing him until his sobbing subsided. As I walked home for lunch I reflected on what was most important – it is not the physical result as much the process of providing compassion. I was reminded of an oft quoted role of a physician that we all learned in medical school – “to cure sometimes, to relief often, to comfort always”.

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In addition to continuing to do my best (with God’s help) to provide compassionate healthcare, by goal for the coming week is to revise, simplify and organize the hospitals requisitions; and try to facilitate improvements in the registration and lab processes. I will also familiarize myself with the medical ward as I will be in charge of this area starting this Fri (instead of Casualty) when the current Internist who has been here for the past 9 months returns to the US.

We Treat, Jesus Heals,

Daktari Dad