Dean Shocket Goes To Ghana With Project Hope (II)
After completing morning rounds in the red area, I moved on to orange. This area by far has been the most frustrating for me. During my first week I have seen patients that are held in this area for up to five days after being treated for basic stabilization.
First week in Kumasi Ghana at the Komfo Anokye Teaching Hospital (KATH)
Neil Shocket, MD
My wife Lori and I arrived in Accra in anticipation of catching a connecting flight to Kumasi. Unfortunately the airport in Kumasi had closed due to repairs so we had to find a hotel and arrange for car transportation the following day. The drive was 5 hours and the roads were sometimes in disrepair. We passed through many very small towns and stopped a few times to stretch and use the washroom.
Our accommodations at the Catering Guest House were basic but roomy and had all the necessities one would need for the month. There is a small refrigerator in the room and a place to eat on the premises. The restaurant was fine for the morning breakfast, but for an evening meal, Lori and I ventured out to find a few nice restaurants in town to relax and have a good meal.
The Komfo Anokye Teaching Hospital (KATH) is a new building and from the outside can easily be compared to any hospital in the US. The Emergency/Accident department, which was to be our home for the next 4-weeks was large and very busy. We were introduced to the director of the department, Dr. George Oduro who gave us a thorough tour of the entire hospital and introduced us to the ED residents and charge nurses. We discussed some of the challenges that the department was facing and well as many of their successes with the residency program. Dr. Oduro was kind enough to give us a key to his office to use his private washroom as well as a key to an empty office where we could safely store our belongings and have a place to take a break for lunch. There are no food facilities in the hospital so it is advisable for future volunteers to pack their own lunch or snacks for the day.
All patients enter through the triage room, where each one is evaluated using the “South African Triage System”. The emergency department is split into three treatment areas; yellow, orange and red. After patients go through triage they are taken to one of these areas based on the seriousness of their illness. Patients who go to yellow are to be seen within 4 hours, patients who go to orange are seen within 30 minutes and those who go to red are critical cases that are seen immediately. During my first week, I spent most of my time going from department to department rounding and reviewing challenging cases with the residents.
I began each day by going to morning pass-on rounds in the red area. There is usually only one resident in the department working the morning shift, but the other residents do a good job of cross covering that area if it is busy or when a critical patient arrives. I found that aside from the ED critical cases, many patients remained in this area for several days awaiting an available ICU bed. It was frustrating to see that one resident had to manage the constant flow of critical patients while still being responsible for the ongoing care of those ICU patients who were still waiting to be admitted.
The residents are very well trained. They were appropriate with their treatment and were able to assess and treat patients with ease and confidence.
I did find that some residents were not as open to discussion, instruction or treatment suggestions and I wondered if they had been given details about my presence and my role as attending before I arrived. On the other hand, the majority of the residents were quite welcoming, coming to me with questions andeager to consider a new perspective or alternative options for their differentials and treatment. I think that the role of the volunteer/visiting attending for the Ghana Collaborative will become more effective as the residents become comfortable with having us around and eventually be more receptive to instruction and alternative points of view.
After completing morning rounds in the red area, I moved on to orange. This area by far has been the most frustrating for me. During my first week I have seen patients that are held in this area for up to five days after being treated for basic stabilization. It appears that the delays in disposition are caused by either waiting for a specialist to arrive to evaluate a case, waiting for an O.R. (Theater) or simply waiting for an X-ray or lab test. I saw numerous trauma cases where open fractures, degloving injuries, maxofacial injuries and eye injuries remained in the orange area for days without their injuries being adequately addressed by the consultants, thus adding the burden to the ED resident’s workload to chase down the consultant.
This clearly increases the morbidity of these patients, i.e., loosing a limb or loosing an eye. These are young healthy people that come to the ED after an accident and leave being permanently debilitated because they were not receiving specialty care in a timely manner.
The residents do all they can, but it often appeared as if once the specialist is called, there was little else that was done for the patient until the specialist finally arrived. I would like to address this issue with the residents as a discussion topic in our meetings. Perhaps we can come up with some alternatives that can better serve the patient while working within a challenging system.
After rounds in orange, I would go to the yellow area. This department is probably the busiest and most crowded, but seems to run well. Whenever possible, I would jump in and help out with the suturing and evaluation of a serious patient. During the first week, Lori(graduating medical school next month) and I did a plastic closure on large laceration of a young woman’s cheek and eyelid, and complex repair of a deep hand wound on a 30-year old workman. The senior resident expressed her appreciation of my hands-on approach to helping in the busy department in addition to my teaching responsibilities. I spent a lot of time reviewing x-rays with the medical students as well as instructing them while performing any procedures. The residents are pretty busy and I never really had the opportunity to round in the yellow area. Again, I think that the residents are pretty self sufficient and are notquite sure of the role I play in their in their day-to-day responsibilities. They are all excellent physicians, but from the few cases that I reviewed in this area, I can see that there are learning opportunities that are often missed.
Resident educational conferences are held on Tuesday and Thursday mornings. On Thursday morning I gave my first lecture on Food Bourn Illnesses. I think it went well and the residents were receptive. For my remaining 3 weeks, I am going to try a different approach. On days I do not give my planned lectures, I am going to have a round-table session/discussion with the residents to discuss some concerns they or I have about the “human element” of medicine as well as the challenges I mentioned earlier.
Goals for the remainder of my time at KATH
- I would like to get help the residents to expand their differential and to take a bit more time to explore the “why” before settling on a quick diagnosis based upon a single positive result.
- Have the residents “re-assess” each patient for changes in their status over time and adjust the treatment accordingly.
- Instill the importance of patient respect and dignity. I would like to see the residents introduce themselves to patients when rounding each shift. They should imagine seeing patients as they might have been before being injured. Nurses and doctors should be more aware of covering up the patients and more frequent use of portable screens to protect their privacy.
- The human element – I would like to see the residents over come a general sense of apathy. Take the time to address the emotional concerns of the patient and family toward their illness, prognosis, death & dying, etc.
- Increase the practice of hand washing BEFORE examining each patient, to decrease transmission of infection.
So far I have found this to be an excellent experience and I am excited to be part of the emergency medicine residency training at KATH. I am confident that the quality of emergency medical training that the ED residents receive is of high quality. They definitely know the principles of patient evaluation and stabilization. The majority of the residents are compassionate, caring physicians and are open to improving their skills and insight into emergency patient care. I can’t to begin again on Monday!
Neil Shocket, MD