Let’s insist on the possible by Valerie Douglas

Many things in life are complicated, require great debate and despite huge resources are not guaranteed to be successful in practice. There are other things which are simple to understand, can easily be implemented and immediately make a difference to improve lives or in some cases save lives. You only have to think of the meaningful campaign to change the care of people with a diagnosis of dementia led by Tommy Whitelaw (Tommy Whitelaw @tommyNTour). It makes sense and it hits you in the heart. As a professional you cannot listen to Tommy talk about caring for his mum and withhold your support for this campaign. His mum is your mum.

Another example is Kate Grainger’s inspirational campaign (#hellomynameis). This focuses right in on the doctor/patient relationship. It goes further than just making us think more about face to face contact with patients who may feel vulnerable, distressed and in alien surroundings. It asks us to look at our practice on a basic level, to say our name aloud, on every contact. At one point this patient was Kate Grainger but the patient could be any one of us.

Last November an important, widely supported campaign for the mandatory teaching of Cardiopulminory Resuscitation (CPR) to schoolchildren was unsuccessful. This Emergency Bill was opposed despite irrefutable evidence that it saves lives. In Norway it has been compulsory for schoolchildren to be taught CPR since 1961 and survival rates are double what they are in the UK. As out-of-hospital cardiac arrest is the commonest life-threatening emergency in the UK so I thought this campaign was bound to be fully supported and unchallenged. You can imagine my disappointment.

I felt at a loss about what to do next, yet felt there had to be a ‘next’. To increase survival rates of cardiac arrest the immediate action of bystanders is crucial. Personally I have carried out CPR three times, twice in a hospital setting and once at a family event. A day of laughter and pleasure turned into tragedy. Event though, as a nurse, I’m aware that the outcome from CPR is variable for a myriad of reasons, I was left affected by this last experience. Then a doctor said to me, “If I had a cardiac arrest I would want someone to have a go.” I am glad I have been taught CPR and am able to ‘have a go’, otherwise the most I could have done that night would have been to phone an ambulance instead of giving a friend a chance of life.

What could I do now? I decided to put together a resolution to RCN Congress 2016 calling on governments to mandate the teaching of CPR to schoolchildren (the remit of the Emergency Bill had been wider, encompassing all kinds of First Aid). The resolution was accepted and I presented this in June this year.

There were wide ranging contributions to the debate. Personal stories were shared about children delivering CPR successfully. A delegate told us about a situation where his 27 year old teammate collapsed during a game of football. 23 players including the referee were there and nobody knew how to do CPR; this man died. He went on to describe a more recent experience when an instructor was brought in to teach CPR to the junior football team. Within 10 minutes they were doing it perfectly.
Some delegates expressed concern about the effect on children if they delivered CPR and it was unsuccessful. Others answered this by saying: remove the fear, teach them young. The evidence is there. Someone else highlighted again that encouraging CPR lessons in schools as an add option is not enough; teaching needs to be a requirement so that there is no national disparity. Kate Ashton made a very acute observation at Congress:
“If we can educate youngsters in schools about sex education and creating life then surely we can educate them about saving lives.”

Every year an estimated 60 000 out of hospital cardiac arrests occur in the UK (BMJ 2013;347:f4800) It could happen to any one of us. What can you do?
Write to your local MP and express your support for the campaign to mandate teaching of CPR.
Become a local First Responder.
Find out if your town/village has a defibrillator and where it is kept.
Ask your school if the teaching of CPR is on the curriculum.
Let’s insist on the possible.

Valerie Douglas is a Staff Nurse in Mental Health at Midpark Hospital, NHS Dumfries and Galloway

Fork Handles!!! by Helen Moores

helen-m-1“The single biggest problem with communication is the illusion that it has taken place” George Bernard Shaw

What is the reading age of the most popular newspaper in Scotland, The Sun?

If you were to categorise it and place it on a shelf where would you put it? 8-10 yrs? 12-14? 14-16 yrs? The answer is 8 years old.

In terms of language level, vocabulary, grammar etc. The Sun is written at the same level as a school reading book for an eight year old child. According to The Literacy Trust the average reading age in Scotland is only 9 years old. This sort of information has massive implications for the way we communicate with our patients, carers, their friends and family.  If we are producing written material or talking in a way that is too technical, medical or wordy we lose, bewilder and alienate our audience whilst thinking we have been clear. It is referred to as health literacy –  the gap between what we as professionals think we have said and what our patients have actually heard or understood or are able to access. It brings to mind the confusion in the classic Two Ronnie’s sketch where a man walks into a hardware shop and asks for Fork Handles and receives 4 candles!

helen-m-2October is World Health Literacy Month and the aim is to raise awareness of this gap in communication. The Health Literacy Place is a website attached to The Knowledge Network and details the Making It Easy action plan to improve Health Literacy here in Scotland. It contains some frightening statistics:

  • 43% of English working age adults will struggle to understand the instructions to calculate a childhood paracetamol dose
  • 26% of people in Scotland have occasional difficulties with day to day reading and numeracy
  • People with lower health literacy have increased rates of emergency admissions, wait until they are sicker before visiting their GP and are less likely to engage with public health programmes eg breast screening and vaccination
  • In general people remember and understand less than half of what we discuss with them

The implications for patient experience, safety and access to services are clear. This is not just a welfare or financial obligation, but a legal one. The Patient Rights (Scotland) Act 2011 states that “people should be communicated with in a way that they can understand and that healthcare staff should make sure that the patient has understood the information given.” Our skill as healthcare professionals is not only to diagnose and treat but to communicate those findings in a culturally appropriate, meaningful and memorable way.

helen-m-3Here in D&G it has never been more timely for us to think about these issues as we plan our own Big Move, thinking about clear signage, systems for patient appointments, e-records etc in our new home. In addition our English neighbours in Cumbria are getting to grips with the Accessible Information Standards. These legal standards were introduced into NHS England on 31st July this year and go one step further in addressing communication needs. They stipulate that a person with a disability, impairment or sensory loss should be provided with information that they can easily read or understand with support. The Standards also state that these needs should be identified and recorded prior to a patient accessing a service.

The good news is that because of the introduction of these standards in England there are lots of resources to help us look at our practice here in Scotland. So where do we start? As a communication specialist, it’s a subject close to my heart.

If you are looking at a service audit or improvements, some handy hints include:

  • to never be without a pen and paper
  • to download a profession specific app or animated sequence for your phone or tablet
  • sit down or be at eye level for all conversations, where possible
  • order a name tag and say..”Hellomynameis…”helen-m-4
  • attend one of the specialist workshops in the Education Centre

but also…….

“Tell me your story…”

Asking this initial interview question allows you time to tune in like a radio to the person’s wavelength. By asking this I can assess fluency, coherence, intelligibility, cognitive ability, word finding skills, language level and most importantly adjust mine accordingly .. but also assess the patient’s accuracy as a historian, their interpretation of events, what they believe the doctor said, if there’s an outstanding or unresolved issue or complaint, their mood and motivation for engaging with therapy, what is important to them, their family, goals, hobbies and start to identify any hooks that I can hang my therapy on to make it personal and meaningful and therefore increase its success. Not bad for one simple question!

 

Perform the SMOG!

The simplified measure of gobbledygook – yes it’s a real thing. Created in 1969, take any piece of written material your service routinely supplies and apply the formula to calculate a reading age. If it’s higher than 9, think again. http://prevention.sph.sc.edu/tools/SMOG.pdf

 

Access The Health Literacy Place

This NES website gives some really great tailored resources for GPs and medics, AHPs and nurses including simple techniques like Teachback, but also online courses, training and templates to re-evaluate and improve your communication personally and within your service. http://www.healthliteracyplace.org.uk/media/1360/health-literacy-month-eflyer-2.pdf

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Chat to a friendly Speech & Language Therapist

But then I would say that! The Royal College has a new position paper and website to support Health Literacy or Inclusive Communication as it’s sometimes known.

And Finally……

…for a chortle and a lighter look at Health Literacy as seen from the perspective of the doctor we all love to hate, click or paste the link below…. If you can’t see it you may need to upgrade your version of Internet Explorer to 11. http://www.youtube.com/watch?v=zG2DVoRP86g

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Happy Friday and happy Health Literacy Month!

#healthlitmonth

Helen Moores is a Specialist Speech and Language Therapist for Adult Service & The IDEAS Team (Interventions for Dementia, Education, Assessment & Support) at NHS D&G

helen-m-7Follow us @SLT_DG

Find us at NHS D&G SLT Adult

 

Health Literacy Month logo and Health Literacy Heroes illustration are reprinted with permission of Helen Osborne, founder of Health Literacy Month

“Going that extra mile” by Sharon Shaw

Patient Centred Care

Being caring and compassionate is an unique talent and sometimes sadly often gets forgotten about and falls by the wayside. We are all human beings and sometimes we all need to take a step back and grasp how valuable our lives are and that of loved ones.

I want to share my story. This is the first time I have written a blog, so please be “patient” with me.

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In November 2015 I started my new job in clinical education. I was excited and yet in a way I wanted to prove to myself and others how valuable education is in this forever changing healthcare environment.

Approximately 3 weeks into my new role, the Respiratory Team contacted me concerning a patient with a complex condition. It was a 59 year old male who had severe emphysema and required an Under Water Sealed Drain (UWSD) to try and reinflate his left lung. The damage was so severe it became evident that the UWSD could not be removed or his lung would continually, spontaneously collapse.

“IT WAS HIS LIFE LINE”.

I walked into the side room in Ward 12 to introduce myself. With hos blue eyes he gazed up at me looking slightly anxious. Giving him a good firm handshake, I smiled and said

“Hello John, my name is Sharon”

I’m a great believer in “non-verbals” as it delivers communication and initially builds upon a trusting relationship. And indeed it did as from then on it had a huge impact.

As my father always said…

“Sharon a good solid handshake goes a long way”.

John was palliative. He had not long retired and to get devastating news about his diagnosis and outcome was so sad. His ultimate wish was to get back home to spend the rest of his short life left with his beloved family.

sharon-2I made a point of seeing John everyday in Dumfries and Galloway Royal Infirmary. It was essential to build up that relationship. During the 2 weeks I delivered education on how to care for a patient with an UWSD. Approximately 30 nurses received education, Kirkcudbright Hospital Staff, District Nurses and Rapid Response Team. As you can imagine there was a lot of anxiety, fear and uncertainty amongst the nurses. This was actually the first patient to get discharged to Kirkcudbright Hospital with a UWSD. John was fully aware of my role and was updated.

The time had come, John was ready for discharge. Understandably so, he was very anxious. I took the decision to actually go in the back of the ambulance with him to Kirkcudbright Hospital. Holding his hand and bantering away we both arrived to our destination. We were pleasantly greeted by the nursing staff. They knew John as he was a local from the town and had received care from them in the past.

His family were so supportive especially his daughter Michelle, whom I have now made a lifelong friend.

John managed to continue life for 7 months in Kirkcudbright Hospital. Unfortunately he did not get his wish to go home but in all fairness the care he received from the hospital staff made his last few months comfortable and to have that precious time with his family. He managed to celebrate his 60th birthday with his family. It was an emotional, uplifting day.

I guess what I’m trying to say folks….

“Going that extra mile” was so successful and beneficial. I would certainly do it all again.

Thanks for taking time to read this.

Sharon Shaw is Clinical Educator for NHS Dumfries and Galloway

 

 

 

Do you want free dental treatment? by Kim Jakobsen

#hellomynameis Kim and I am encouraging the people of Dumfries to consider self referral to a dental student at Dumfries Dental Centre for free dental treatment.

There has been a dramatic improvement in access to NHS dental care in the region over the last 6-8 years. The Dumfries Dental Centre opened January 2008 to provide an outreach / training programme for student dentists and student dental therapists, aimed at supporting the future growth of these professionals across Scotland, while continuing to provide secondary care dental services, emergency dental services and routine NHS dental services which moved from Nithbank. The plan was to provide additional access to NHS dental registration at the centre, but on opening, access to Independent Dental Contractor practices for NHS dental registration had increased. Following a review of the Health Board’s managed dental service, recognising the increased access available for patients to NHS dental registration, routine NHS dental services at Dumfries Dental Centre were withdrawn in 2015.

With the goal of improving oral health while modernising dental care, prevention has played a key role in the dental care being provided by dental professionals for some time. This means that patients who are registered and regularly seeing a dentist, dental therapist, dental hygienist or extended duty dental nurse are getting orally fit.

This combination of increased access to NHS dental registration and patients getting orally fit is great news but it does mean finding suitable patients who require routine treatment to support our dental student outreach programme is becoming more challenging each year.

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image2Outreach programme aims

David J. Watson, Senior Clinical University Teacher at Glasgow Dental Hospital and School explains that ‘The Outreach experience is intended to enable the student who has already attained basic competence in a range of areas to grasp the concept of the provision of holistic oral health care in the primary care setting and to gain an appreciation of integrated multisectoral involvement in health care delivery. The aim of the entire experience is to aid transition from the dental school to the practice environment by replicating the primary care experience as closely as possible.’

Who makes a suitable patient?

A broad base of patients with differing needs is desirable for the Outreach programme. Patients receiving emergency dental care provision and who are unregistered with a GDP may happily return for a course of treatment. Patients who self-refer can be screened for suitability at the initial examination, as can other healthcare professional referrals.’

Please note the following;

Appointments can last 1-2 hours and sometimes a bit longer.
Patients won’t always be able to see the same dental student, as they attend Dumfries Dental Centre from Glasgow Dental Hospital and School one week at a time.
Patients should have realistic treatment expectations.
Patients who are, for example, extremely nervous of dental treatment or requiring specialist intervention should be suitably referred.
Patients with special care requirements would be assessed for their ability to cope with routine dental care.
Patients with health preclusions would not be excluded automatically unless they would impede routine treatment provision or necessitate specialist intervention.

How and where do we find patients for our students?

The answer is from You. Please spread the word about our student dental outreach programme. Come and see us for yourself if you are unsure about us and/or happy to refer people to us. The facilities at the Dumfries Dental Centre are quite something. The staff and the students are all friendly and good at what they do; believe me they get lots of praise from their patients.

Are you interested yet?  I really hope you are.

Further information and self referral application form is available at: http://www.nhsdg.scot.nhs.uk/Departments_and_Services/Dental_Services/Dental_Student

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In summary;

Dumfries Dental Centre has a student dental outreach programme operating August to May.
The student dental outreach programme needs dental patients requiring routine dental treatment; this could be you, your family, a friend, your neighbour or a member of the public that you come into contact with.
Student dentists are in their final fifth year of studies.
Student dentists are supervised which includes their work being checked.
If accepted to the programme, treatment is free from a student.

Kim Jakobsen is Dental Services Manager for the Public Dental Service

Cutting the Sugar…. by Fiona Green

Over the last 2 years NHS DG have been offering a structured programme of work experience to young people in their final years at school thinking about a career in medicine. This has been very well received by the young people who attend and the success of the programme is largely down to excellent organisation and communication skills of Anne-Marie Coxon and her team in the education centre who arrange tasters in various areas of medicine including medical admissions, theatre, surgery and A&E along with some time with me in the diabetes centre

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Linocut by Hugh Bryden Crichton Hall- home to the Dumfries Galloway Diabetes centre

As a clinician it has been really interesting to spend time with these young people who have yet to develop preconceived ideas about healthcare and for me to try and understand what it is that excites them about spending a lifetime in medicine and to try and remember what it was that motivated me to apply for medicine and ultimately what made me move into Diabetes and Endocrinology.

For those of you who know me you will have heard me say that it is diabetes that excites me rather than the rare and esoteric conditions that I deal with in the endocrine service but I recognise that despite my real enthusiasm and commitment to improving care in diabetes that when these young work experience students come to diabetes clinic I sometimes find myself apologising to them that I don’t have any exciting procedures to show them, or new diagnoses to make; in fact in diabetes clinic I rarely examine people and I spend my time just listening to things that seem unrelated to sugar levels and talking…..

Just Listening and Talking…

The fact that I feel the need to apologise about the nature of diabetes clinic being  “just listening and talking” has made me realise  how little value we as hospital healthcare professionals place on these core skills that we all use every day. We are required to do mandatory training in many important areas such managing the deteriorating patient, infection control, awareness and fairness to name a few- yet it is possible for a healthcare professional to go through their in working career without any update, assessment or post graduate training in the core communication skills that we use every day. This lack of post graduate training in clinical communication skills is particularly apparent in the acute hospital setting compared to our colleagues in general practice and psychiatry where advanced post graduate training in consultation skills is the norm. Despite the seemingly acute nature of a hospital environment many of us spend a large part of our working week in clinics working with people to try and improve their health and wellbeing but what are we doing to ensure that these interactions are effective and meet the patient’s agenda?  Do we find it easier and quicker to pursue our own agendas and default into education mode rather that hearing about what is really important?  Several research studies have shown that by exploring a person’s background, worries and their understanding of their condition can help to avoid unnecessary investigations or anxiety for the patient as well as reduce the strain on resources[i][ii]

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The success of the late Dr Kate Granger’s “Hello my name is …” movement and the “What Matters to Me” campaign show that in acute setting healthcare teams are beginning to contemplate a change to a more patient centred rather than the traditional paternalistic, didactic approach to our interactions with patients but this change is slow and these important initiatives are only an entry level to improving our communication with the people we see in clinic and reaching a shared agenda.

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Locally Jean Robson and her colleagues from psychology, human resources and other interested clinicians have recently worked hard to put together a directory of diverse courses and programmes which are delivered locally by NHS Dumfries and Galloway aimed at improving advanced communication skills including sessions on communication skills which allow individuals to film and review their performance in real life clinic setting (been there and done that -daunting but very helpful), communicating with people with existing communication difficulties, human factors training and sessions on communicating with colleagues in meetings to name a few

So, back to the title of “cutting the sugar”. The discovery of insulin almost 100 years ago is one of medicine’s most remarkable discoveries changing the outcomes for people diagnosed with type 1 immeasurably as the before and after pictures below poignantly demonstrate

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December 1922

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February 1923

 

 

 

 

 

 

 

 

 

“Child 3” before and 3 months after insulin treatment

There is of course a but; insulin is not a cure for type 1 diabetes just a treatment and Insulin treatment brings with it a huge burden for the person with type 1 diabetes- blood testing more than 4 times a day, injecting insulin at least 5 times a day, assessing the carbohydrate content of foods are all required to achieve the tight blood sugar targets required to maintain health and wellbeing. This all needs to be balanced against activity levels and avoidance of hypoglycaemia. People with diabetes can never have a day off.  They become experts in managing their blood sugar levels and this brings me to the “just listening and talking bit”. Listening to what’s important to people when I’m clinic seemed more time-consuming in the beginning but by encouraging this shared understanding I have come to recognise that almost universally people with type 1 diabetes want to be healthy and that they fully understand the importance of controlling blood glucose but what I also now appreciate more clearly is that there are many other things that get in the way of achieving this goal. Some of these barriers to change seem obvious e.g. fear of hypoglycaemia, fear of injections but others may take gentle probing to identify e.g. the young woman who removed her insulin pump because she had a new boyfriend who didn’t know she had diabetes, the young mum on her own putting her own health after the needs of her family. Through training, practice and reflection I have come to learn is that each person is different and whilst a particular solution may work for one person it might not work for the next and whilst the temptation is for me to offer the solutions that I think will work by practicing the skills I have learnt at various communication skills sessions I now recognise that solutions generated by the person with diabetes are far more likely to be successful that anything that I may suggest. Of course very few consultations are perfect and like every skill we use practice, reflection and additional training can help us to improve which is why I believe that consultation and communication skills shouldn’t be seen as just “the icing on the cake” but more of the “meat on the bones” of our daily work.

Dr Fiona Green is a Consultant in Diabetes and Endocrinology at NHS Dumfries and Galloway

[i] Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”. J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.

[ii] eisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”. J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.

The Dietetic Detectives by the DGRI Dietetic Team

As Dietitians’………………….. we are Detectives
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The patient in front of us has a nutritional problem –they are underweight, they have lost weight and they are struggling to eat – but why? It’s a mystery! Could the mystery be they are malabsorbing due to chronic bowel inflammation, bowel obstruction, or pancreatitis? Or do they have difficulty swallowing due to stroke, neurological disorders or head and neck cancer? And the list goes on…

Cue the acute Dietitian!
To get to the bottom of this, we need to look for clues. Clues come in all forms;
anthropometry
biochemistry
presenting medical problem
current symptoms
past medical history
current medications
environment and the patient’s own beliefs
psychological factors
As Dietitians we gather this information and put it together to solve the mystery.

But then what?

We then need to work with the patient, carers and family as well as the multidisciplinary teams to translate our gathered finding (clues). We use our clues to calculate nutritional requirements, this allows us to individualise patients needs – their calorie, protein and fluid needs. We then draw from the evidence base and our own experience, incorporating the tools of our trade some of which are:
Oral nutrition – Fortified diet, nourishing drinks, snacks and oral nutritional supplements.
Enteral (tube) Feeding – Into the gastrointestinal tract
Parenteral (intravenous) Feeding – Into the blood stream via venflons or central lines

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Here in Dumfries and Galloway Royal Infirmary our focus is on malnutrition.  People may think malnutrition is a thing of the past in this country, but according to a recent publication by the British Association of Parenteral and Enteral Nutrition (BAPEN) 25-34% of patients admitted to hospital in the UK are at risk of malnutrition (under nutrition).  Malnutrition is associated with less favourable outcomes such as increased length of hospital stay, impaired wound healing and reduced ability to fight infection. It is therefore important to identify and treat malnutrition as soon as possible.
Elsewhere in the other areas there are different patient groups receiving expert nutritional advice, projects being carried out and contributions to national research going on.
The evidence base regarding diet and health continues to grow; treating and preventing malnutrition in the hospital and community setting, gastroenterology, paediatrics, weight management, diabetes, renal, catering and mental health to name a few.

A few myths about dietitians:-
We never eat chocolate
We never drink alcohol
We judge you when we meet you in the local takeaway
Detox diets are good for you
Superfoods exist and are recommended
All we give is weight loss advice
Dietitians will inspect your poo (although we will ask about it)

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So hopefully you see there is more to dietetics than the common misconceptions – that we’ll be spying on your trolley at the supermarket, and of course we never eat cake, we always have our five a day and we do in fact we always have the perfect diet!
We hope this gives you a small insight into our profession.

And so this morning we’re off to the wards again,

NG tubes, Fortisips and TPN,

We’ll calculate needs, and make sure they’re met,

We won’t stop until food charts are used, you can bet.

Ensuring good nutrition, we can’t get enough,

Though we know sometimes it’s gonna be tough,

So we’ll chat, and we’ll laugh but we’ll work till we’re blue,

So when the cake comes out remember, we’ll have some too!

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This weeks blog was a joint effort by the Dietetic Team at Dumfries and Galloway Royal Infirmary

A Journey to Africa by Dave Christie (@bagheera79)

At a little half past eight in the morning on the 25th of November last year I started on the ICU ward round with the team of residents, at the Black Lion Hospital in central Addis Ababa – the capital of Ethiopia. There were sixteen patients to see, with a high proportion of trauma – especially brain injury – and severe life-threatening infections. It looked so different from the unit here in Dumfries. It had big wide windows allowing in daylight, for a start. In a UK hospital, windows at this height would be securely fixed so as to avoid the kind of unfortunate incident that makes the headlines. Here, in Addis, one of the nurses was leaning right out of the window and yelling cheerfully to a colleague in the carpark over a hundred feet below.

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As I looked around I took in more differences. The beds were quite close together, with a low wall separating the heads of beds between the divided area. Instead of uniform ranks of identical equipment all bought at the same time, the pumps and ventilators were a mishmash of ancient and relatively modern kit. Huge, head height tanks of oxygen sat beside each ventilator, as there was no built in oxygen supply in the walls. Beside most beds sat a big bottle of caramel liquid – it took me a moment to work out that this was nasogastric feed. Of course! – they don’t have the pumps to delivery a trickle of feed continuously, so they have a supply for the day and administer it at intervals. Each patient’s bedsheets were different, brightly coloured, and obviously donated or brought in from home. Nobody was wearing aprons, or gloves – the bright smurf blue and purple hands of healthcare that are so ubiquitous in UK ICU were nowhere to be seen. I could imagine our own infection control team spontaneously combusting at the sight. Of course, they would likely have already lost consciousness at the sight of an entire team of doctors standing around the bedside in long-sleeved white coats – something which has been verboten in the UK for years.

But then, I looked closer and readjusted. Put into context, they were doing the same stuff we do. Airways were protected. Patients were being rolled, washed, and cleaned every day, with a change of sheets. Physiological parameters were being diligently recorded on big charts in close detail. Because pumps were usually either broken or in very short supply, sedation and analgesia were given by injection at regular intervals. They were being fed – one way or another. Patients were receiving regular chest physiotherapy to try to shift stubborn sputum and prevent pneumonias. Blood tests. The nurses still laughed and joked and teased each other. It’s the same stuff that we do, but in a much simpler, less precise way. And, a lot of the time, it worked. Which, to be brutally honest, is just as true of our own, ‘modern’ intensive care.

I turned my attention to the lady in the bed. Clearly profoundly affected by a severe head injury as a result of trauma, she also had signs of a severe chest infection. Here in the UK, it would be standard practice to send sputum samples off to the lab to identify the offending organism, certain specific blood tests might be done, and a chest x-ray would be a routine investigation in order to see the extent of the infection. I asked if they could do any of those things. Dr. Woubadel looked at me with a wry, slightly sheepish smile. “Well, we can. But we only have two antibiotics and our microbiologists have refused to analyse our sputum samples. And the lifts are out at the moment.”

Right. Wait, what? “You only have two antibiotics?”

“Yes, ceftriaxone and ceftazidime.”

If you don’t speak antibiotic, that’s a little like going to the supermarket and discovering that the only two cleaning products available are napalm and a hydrogen bomb. Given that antibiotic resistance is a real and growing threat, this is a disaster for the future.

And the lifts…. ah. The building of the Black Lion is definitely a little bit past its best, and was undergoing a phase of refurbishment. Almost all of the lifts were removed and in true, relaxed Ethiopian style, there was occasionally a warning sign. I had had a look at one of the lift shafts and it really was an open door onto a seven storey drop. Later that day, I watched a patient being taken urgently to theatre from one of the wards on the floor above the theatre complex. Four orderlies and a nurse were carrying the entire bed – with the patient lying on it – down a flight of stairs. Another nurse was carrying the drip. That morning, if they really wanted a chest x-ray, they’d have to do the same thing if the lift was out as there was no portable facility to take x-rays on the unit. And if need be, they’d have done it.

Dave C 1So why was I there? It’s worth pointing out that the Black Lion is a large teaching hospital in the city centre. It’s one of the lucky ones, as the facilities it has are relatively modern. They can even do cardiac bypass – provided there’s a visiting perfusionist from overseas to work the machinery. This definitely wasn’t one of the small hospitals out in the country. I was there along with Fanus Dreyer, a consultant in General Surgery here in Dumfries, to teach on a critical care course that he organises. The College of Surgeons of East, Central and Southern Africa overseas the training of surgeons in that part of the world, and the critical care course is part of the mandatory requirements of their training. It is a charity – the aim is to make the course (along with the others which deal with surgical skills, and research) self-sustaining in each of the involved countries. The idea behind all of this is to try to improve the healthcare in that part of the world, by standardising surgical training, ensuring basic competencies etc, in an area where healthcare is sporadic and frequently poor or non-existent. Peri-operative and critical care is a vital part of that – being able to competently do an emergency bowel operation is nothing if the patient dies post-operatively from a lack of care.

Being out there and teaching on the course was an extraordinary experience. Having had the chance to spend some time in the actual clinical areas, to see how they worked on a day-to-day basis, helped hugely as it helped give me direction on what the course attendants needed. The junior surgeons on the course had excellent clinical knowledge and ability – the real difference was the approach. They have the same knowledge as our junior surgeons – medicine is universal, fundamentally – but what they needed was guidance on how to organise the approach to sick patients, and how to structure their management. They were highly motivated, and very keen to learn. But as I knew, they would often be working in facilities that had next to zero resources, hundreds of miles from Addis. There’s no value in teaching about the potential uses of dialysis in critical care in that sort of scenario – but there is enormous benefit in teaching about the approach to sepsis. Being able to manage a patient with a critically endangered airway with simple techniques would be life-saving – even in the most rural surgical facilities there will be some sort of scalpel.

David C 3And over the two days of the course, in the four days that I spent there, I realised that the simplicity of approach is something that we are still striving to teach here, even with the advanced facilities available to us. Their ICU looked primitive in comparison to the UK, but it was still striving to provide the basics of critical care. I realised I was teaching the same things that I teach here – sort out the basics and communicate well. Recognise illness, recognise dying, and treat each thing in turn, with compassion. These things are universal – and we shouldn’t allow a distraction with technology to cost us our humanity.

 Dave Christie is a Consultant Anaesthetist at NHS Dumfries and Galloway