The Birth Pangs of a Modern Medical Ward

Sun up on the Nile

Dave:  It was some time ago now since we had the consultants workshop and many changes are taking place. We thought we would talk you through some of the highlights of a meeting just over two weeks ago, between the doctors of JTH and the Ministry of Health.

The meeting went rather well.  About fifty doctors were present and many issues were discussed, such as contracts, lack of equipment, drugs, discipline and professionalism.  We both felt that it was good that the Ministry of Health had taken time out from their lives to listen directly to the problems of people working on the front line.  We have never even met the CEO of our last hospital and I know nothing of the staff who work for the Secretary of State for Health in the UK.  Clare was designated the role of “minute taker” and they managed to talk for 4 hours.  She took home 16 pages of A4 paper to type up – not the best way to spend the rest of your weekend!

One of the key issues raised was one of the doctors contracts.  At the moment, many are employed by the Ministry as “locums”.  They are not entitled to study leave, annual leave, sick leave, a study budget and they aren’t allowed to be funded by the Ministry for Postgraduate Medicine.  Their contracts can be terminated at any time.  As well as creating staffing issues for the hospital when the contracts are ended, it does nothing for their motivation and self esteem.  That day in the meeting, a lovely thing happened.  The medical officers all stated that they would not sign any more contracts but would continue working (and not strike) until a new system of employment was created.  The Minister replied by promising to end the contract system.  It was a good day for the junior doctors and a good day for medical ethics and professional behaviour.  However, it was not stated what system would replace the locum set up.  The senior doctors have been working hard behind the scenes to support their junior colleagues and letters have gone to the Ministry.  A deal should be arrived at next week.  A deal has yet to be forthcoming and the junior doctors are now unemployed, working, but considering strike action.

Life is moving along at a rapid pace on the Emergency Medical Ward.  Last week, we brought back the long lost emergency drugs that the department so desperately needed.  This week, we brought back the equipment.  Much of the old equipment from 2008, which was covered in dust was re-conditioned.  Today a “high care” trolley was created that contained the following items:

  • Airways (courtesy of the last St Mary’s Juba Link visit)
  • An ambubag (the one way seal is broken but as long as you have two people operating it, it should work).
  • A few litres of normal saline and dextrose
  • Cannula’s giving sets and blood bottles
  • Adrenaline
  • A blood glucometer
  • Our old cardiac monitor from 2008

I spent my lunch break with a nurse called Laku cleaning the dust from the cardiac monitor, the suction machine, the nebuliser, and the oxygen concentrator. As a result of our efforts, we now have made a “Level 1” intensive care bed… until the power goes off.

Our head nurse on EMW, Laku, is beavering away cleaning the dust from our monitor. LAter on that day, myself, Sister Mary Angela, and a House Officer cleared the dust from a box with 16 draws in it. As there are 16 beds on the female side, we thought it would make an excellent drugs trolley.

However, the biggest difference on the ward has been due to the House Officers. Following on from our meeting with the doctors two Thursdays ago, they are faithfully clerking in patients. We now have dedicated admission sheets for each patient and when they arrive, they are re-clerked by our juniors. The standard of history taking, examinations, diagnoses and plans has improved dramatically.  This simple act has gone a long way to bridging the “24 hour blackspot” in our acute care service. Anecdotally, I can’t remember the last time I lost a patient because of malaria. In the coming days we will be having meetings with the doctors and nurses to check on levels of satisfaction. Now that we have the equipment, we need to build on this with the structures. More on this in the next blog, but for now I will pass you over to my better half…

Clare: Sadly, things have not be quite so progressive in the Anaesthetic Department.  We are running critically low on drugs and equipment and elective work all but stopped last week.  Although a request for emergency funding has been submitted (and chased), the money has sadly been slow in coming.  A lot of the elective work has been postponed, but some of the work can’t be postponed for long.  As a result, we have been undertaking semi-elective and emergency cases as best we can.  Who needs Ephedrine when you can dilute Adrenaline?!  I am repeatedly astounded by the ability of the staff to use the best use of the resources that they have.  I have followed suit:  see the photo below.

Two (very different sized) suction machines were dismantled and used to form one functional machine.... along with a lot of tape!

On the plus side, courtesy of TALC (Teaching Aids at Low Cost), I have been the proud recipient of over 40 textbooks from the UK, mostly written especially with the developing world in mind.  There are no textbooks in the department and most of the anaesthetists do not own any books of their own.  When I first arrived, the thing that they said that they most wanted were books, to improve their knowledge and practice.  Imagine working for years and years with no source of additional advice (no doctors, no books and no internet) and using only your current knowledge and trial and error in your day-to-day practice!  No wonder some of the staff’s airway skills are a little rusty – if your main work has been Ketamine based for 20 years, you’re going to forget how to do the rest.  Two of the books looked very relevant to JTH and I managed a copy of each of these books for every anaesthetist.  The rest are reference books for the department.  I am currently in their good books!

Teaching the nurses (triage), the consultants (postgraduate medical education) and the anaesthetists is ongoing.  I especially enjoy teaching the anaesthetists, but I think I learn more in return.  I may have taught them needle cricothroidotomy (for emergencies when you can’t intubate or ventilate a patient) using a water bottle and a plastic bag (and it worked!), but undertaking a general anaesthetic for an eclamptic (fitting and very swollen airway) patient (emergency caesarean section is the only cure) during a power cut (no oxygen and no electricity) would have left me stumped and rather panicked!  However, Catherin explained that she sat the patient up, gave one dose of Thiopentone, some jaw thrust and a guedel airway and asked the surgeon to be quick!  This may not be conventional, but it worked and the patient and baby survived.  Similarly, I was working in one theatre yesterday and when my (I thought dramatic – full uterine prolapse associated with large haemorrhage) case finished I went next door.  I found a patient having a bowel resection following obstruction, with an NG tube sited and self-ventilating under Ketamine anaesthesia (no tracheal tube and mechanical ventilation).  Again, not conventional, but when your anaesthetic machine is broken and the oxygen cannisters have almost run out, its a viable option.  We did have a chat about the “unprotected” airway (technically stomach contents could come up the oesophagus and go down into the lungs), but that’s why the NG tube was there…..!  Yet another hour long (pretty short by JTH standards) power cut ensued and the anaesthetist carried on working, cool as a cucumber, in the dark!

Everything proceeds, illuminated by torches and the lights from mobile phones.

We thought that we would end on an amusing note. Everyday, when having breakfast, we stare out upon glorious views of the Nile.

To this date we are still uncertain as to why this huge lump of metal ended up at this angle. The only possible explanation is that is was originally an aeroplane and flew into the Nile!

Take it easy everyone. We will try to blog sooner next time.

D+C xxx

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One Response to The Birth Pangs of a Modern Medical Ward

  1. Paul Mercer says:

    Dave, you dads friend George has asked me to get in touch as he would like to help. Could you please contact me via my email address below.
    Thank you

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