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: http://www.kaishahealthcare.com/
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
Kaisha
Another typical scene in Kabul
Why we don't speed in uparmored humvees
Approaching Massoud circle
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