Friday, September 25, 2009

Eid Mobarak 2009

As far as mentoring goes, it has been an easy week since I last posted to this blog. Ramadan ended on Sunday, with three days of Eid that started on Sunday. I have included some pictures from the Eid celebration at NMH on Sunday. My team of mentors met up with leadership of NMH, MPRI mentors, and a select few of the ANA leadership. After meeting up at NMH and congratulating everyone (Eid Mobarak is Dari for “congratulations on Eid”), we formed up to see the ANA Chief of Staff review the honor guard, before meeting and shaking hands with all present. He then visited the wounded ANA soldiers and police throughout the hospital. We went to the top of the hospital to the flower room for chai and cookies.

Monday and Tuesday was the continuation of Eid, so we didn’t go to NMH to mentor. It was only a duty crew and our interpreters also had the time off. On Tuesday, our nurse mentors met with Rick the senior nurse for MPRI and discussed the current state of nursing at NMH. The nurses are understaffed and underpaid, but that is like all other nurses throughout the world including the US. We are trying to help NMH restaff some of their wards to help with the nursing shortage. We are also offering suggestions on how to staff some wards with shift nursing, but that is a hard sell. Some hospitals here in Kabul do shifts, but not at NMH yet.

Wednesday was back to NMH for mentoring, but it was similar to Eid. Most of the staff came into the hospital, but left early. I am working with the OT director on how to schedule cases for each day. We are trying to incorporate a new scheduling tool, which is an excel spreadsheet to better manage the individual rooms. It hasn’t taken effect yet, but he and I continue to work on it. We are going to ask the surgeons to start booking their cases 2 days in advance so we can put out a schedule 1 day prior to surgery. This way we will have better time management in the OT and can block out time inbetween each case to give the staff time to turnover the room and properly clean it. Hopefully, we can implement this schedule starting on Saturday. We will brief the surgeons during morning report.

Thursday was another short day of mentoring. Our 3 nurse mentors went to a meeting with the Senior Nurse from NMH and the OTSG (Office of the Surgeon General) so we could discuss the current nursing shortage at NMH. NMH is a 400 bed hospital, but we only have 86 nurses. Try staffing that big of a hospital with 86 nurses. We calculate that NMH needs a little over 250 nurses to provide safe and effective nursing care to the patients. We discussed ways to increase staffing, but it will take time to increase their manning document (Tashkiel). In the meantime, we hope to hire some contract nurses locally here in Kabul to help bridge the nursing shortage.

Today, jumma, (Friday) is the regular day off. I use the day to get caught up on admin and to update the blog. Tomorrow, it is back to full work days at NMH. Here are the pictures from Eid:

US Navy Medical Embedded Training Team Mentors at Eid Celebration

Dennis, myself, Joe and MG Yaftali, the ANA Surgeon General

US Nurses, Rick, and ANA Nursing Leadership

ANA Chief of Staff reviewing the Honor Guard

Saturday, September 19, 2009

Bloggin' catch-up

Trading covers...

This will be a long-winded catch-up blog because it has been 2 weeks since my last entry. So much has happened yet I have been seriously slacking on updating this blog. Let me recap since I posted last…

My first trip was to the Annex Hospital which is part of NMH but approximately 7 or 8 klicks away. It consists of a psych ward, a medical hold ward, and a TB ward. After our visit, we determined that it is mostly a redundant hospital and it would be better to transfer the majority of the staff back to NMH. NMH only has 1/3 of the nurses it needs to provide adequate care to the patients.

Tuesday, 08 Sep began as a regular mentoring day at NMH until a SVBIED detonated at KAIA (Kabul Airport). I was in the OR when we got the word. We didn’t know how many patients were wounded so we made preparations for mass casualties. I had to use my outside voice to stop the surgeons from starting their scheduled elective cases. We had some heated discussions, but they finally understood when I had the General, who is the Surgical Director, come into the OR to stop the surgeons. It wasn’t a long delay because we only received 3 patients in the OR. We treated those patients, then started the day’s elective cases.

The next day was Massoud Day, which was a holiday. Because the holiday was on a Wednesday, it became a 3-day holiday. When a holiday is near jumma (Friday), the government will usually give the holiday off, then give Thursday off because Jumma is already end of the week and a non-work day. Because of the holiday, I did not go to NMH, but worked on admin all day in the office on NKC.

Thursday was my moving day. I moved out of the basement room on the A-block into a room on the second floor of the B-block with a member of my team, Dennis. The room even has a window (not one that opens) but it does allow some sunlight into the room. It is the simple things like a window that makes the deployment so much better. I can’t complain about the room accommodations. The barracks on NKC are nice. It can always be worse on a deployment…

Then I had another travel day in Kabul. I got to be the CC or Convoy Commander for this trip. We left early in the morning to drop of some folks at KAIA, then drove over to Camp Phoenix. It was September 11th, 8 years later. We attended a memorial service in the DFAC. I will always remember where I was and what I was doing when the Twin Towers were attacked and destroyed. I hope you too will always remember this day… It is one of many reasons why I am here in Afghanistan now.

After the ceremony, we spent most of the day at Phoenix waiting for our vehicles to be serviced. It is just like dropping off a vehicle at the dealer for service. We had to make an appointment, then wait around all day for the service to be completed. We made it back to NKC in the late afternoon and then attended a memorial service on our compound.

The next few days were regular mentoring days at NMH. I have many projects going at once. The Ministry of Public Health, MoPH, has developed some guidelines for all of the hospitals in Afghanistan. They are based on WHO guidelines. We are working to implement them in the OR and CSD (Central Sterilization Dept). I am also helping develop a simple spreadsheet to manage the OR schedule. We are going to try and have the surgeons book their cases 2 days prior, so the day before surgery we can put out a schedule showing the actual times of surgery. Currently, they put out a schedule the day before with only the cases booked, not the time needed. We are trying to prevent over-booking of the rooms and to force the surgeons to give us enough time between cases to properly clean the rooms and set up for the next case. This will also allow for a proper turnover of the patient for recovery. We have to slow things down inbetween cases, which in the long run will allow better patient care.

Over the weekend in the afternoon, we had to move our offices around. We had to give up 3 offices to the engineers. Since we arrived here, we have gone from 8 offices to 4. We are crammed into each office. Eventually, we will move out of the admin building into new temporary spaces once they are built on the compound.

On Tuesday, 4 of us went on a field trip to KMTC (Kabul Military Training Center) to help with physicals. The Afghans were starting a new class of recruits for their Special Forces and we went to help one of the US Mentors do physicals. They came and picked us up and brought us back. After we finished the physicals, we got a tour around KMTC. It is good to do something different for a day and see more of Kabul.

Wednesday was the Chief’s Pinning Ceremonies. Two of the folks I trained with in Fort Riley were promoted to Chief. We attended the first ceremony in the morning at Camp Eggers for one, and then the second ceremony was at NKC after lunch for the other. These are very special ceremonies and an extremely proud moment for the Chief’s who were promoted. We made sure we took the time off to attend their ceremonies. On Saturday night, we will have a dinner for the 2 Chiefs to celebrate their promotions. Chiefs all over the world are promoted on the same day. Only the Navy has the special promotion from E6 to E7.

Yesterday started out as another regular day of mentoring. We went up to NMH in the morning and returned to NKC by lunch. We were eating lunch in the office when a SVBIED went off on the road outside our compound, a little to the north. Our building actually shook. You can read all the news reports online. An Italian convoy was attacked. The last report I read online reported a total of 6 Italian soldiers killed and 10 Afghans killed with an additional 58 afghans wounded. We were not immediately allowed to go to NMH after the explosion, but did make it up there within a couple of hours. I went straight to the OR. I spent several hours there until the last person left the OR. A total of 40 patients were treated in the OR. The Taliban has claimed responsibility for the attack. Another senseless attack by the Taliban on both Coalition Forces and the local Afghan’s.

Today, Jumma, is a day to get caught up on everything including sleep and relaxation. I will try and post to this blog a little more regular…

Soviet tank graveyard near KMTC

Friday, September 4, 2009

Traveling Sailors...

Another week has passed and on top of the normal everyday mentoring at NMH, I have been back to NDS hospital and visited a new hospital, Kaisha. Kashia can be found on the web at:

The trip to NDS was both good and bad. Good in that I finally got to observe a surgery and bad because I did observe a surgery. NDS is a new hospital, but much needs to be done to improve their nursing practices to bring up their standards of care. Surgery is done in the same manner as NMH. Nursing is both an art and a science, both of which need to be taught here in Kabul. In my opinion, nurses don’t “see” the patients, all they see is what is going on with the patient. If you ask a nurse here what the patient’s name is, they wouldn’t be able to answer, but if you ask the nurse what is wrong with the patient, I think they could give the main diagnosis. For example, I observed an open cholecystectomy (open gallbladder removal) at NDS. DJ (anes) and I showed the surgical team at NDS how we would work together in bringing the patient into the room and putting the patient to sleep. The Afghans still need to learn “team concepts”. I don’t think an OR nurse has ever assisted anesthesia in an Afghan OR. The surgical team did a good job in performing the surgery, but they need work on doing it while maintaining sterile technique. After the case, I went with the assistant surgeon to transfer the patient to Recovery (PACU) which is a nursing job but not done here. That was eye-opening. I had to prompt the nurse to put the patient on O2, which should be the automatic first step in recovery. I then worked with the nurse on assessing pain in patients and what to do. There was another patient in PACU who had ENT surgery on his nose. He was moaning in pain and I had to get Anesthesia to give the patient something for pain. We also need to teach the nurses to talk to their patients, to reassure them and let them know what is going on. When a patient wakes up from surgery, they are disoriented and it is the nurse who helps to reorient. What we take for granted in US healthcare…

As I mentioned earlier, we as a team went to visit Kaisha hospital. I was lucky enough to drive the lead vehicle again. It was a 20 minute drive to western Kabul. Mostly, it was a fact-finding mission to see how a for-profit hospital is run here. I do not know the history of the hospital, but it hasn’t been open for too long. It was a fairly nice facility and very busy. I did get to tour the OR but it wasn’t any different from NMH or NDS. All 3 hospitals use similar equipment, with NDS having the best and NMH a close second. One huge advantage Kaisha has though is a modern lab and an angio suite. Most of the doctors and nurses that we met were trained outside of Afghanistan in places such as Turkey, Pakistan and India. Another big plus is that the patients had great charts including H&P (History & Physical), progress notes, nursing notes and a MAR (Medication Administration Record). We are working hard to incorporate better charting at NMH.

We are also beginning to establish many new projects at NMH. In the OR, I helped the OT director translate a document that we have passed out to all the doctors who enter the OR, some basic guidelines. I did the “tough” part of typing the English and he had the even tougher part of translating to Dari. It ended up being 11 pages long on how to enter the OT, hand scrubbing, gowning & gloving, universal precautions and surgical conscience. Hopefully, it will help to change some of the bad habits that have been going on for years.

Another project is trying to establish a preop holding area. This includes anesthesia and the surgeons. We will bring the patients to the preop area so anesthesia and the surgeon can check the patient prior to surgery, and it gives the OT nurses time to make sure the room is ready with all the correct gear. In addition, we are trying to incorporate a preoperative checklist that reminds everyone of the steps needed to ensure a safe surgery. I borrow heavily from the World Health Organization (WHO) website. Afghanistan is a member state of WHO and we as a team are trying to incorporate the WHO standards of care into NMH. The Afghans at NMH do many of the steps already. Now, we want them to use the checklist and document all of the steps to help ensure patient safety.

Other than what I have already mentioned, it was a typical mentoring week. The OR is doing more cases everyday now that the elections have passed. Eventhough NMH is on reduced working hours for Ramazan, the OT is busy, scheduling 8 to 12 cases a day. I can only imagine how busy it will be in another few weeks…

I guess I have rambled on enough for this entry. I have also included some pictures:

The surgery I observed at NDS

The "expert" lead driver


Another typical scene in Kabul

Why we don't speed in uparmored humvees

Typical pedestrians and traffic thoughout Kabul

Approaching Massoud circle