Imran Ahmad Sajid-Medical Social Work in Lady Reading Hospital, Peshawar, Pakistan

Contents Internship Report 17-sep to 18-oct-07

By: Imran Ahmad

Internship Report

Social Work in Lady Reading Hospital

From 17-September

To 18-octuber, 2007

Submitted by:

Imran Ahmad Sajid


By: Imran Ahmad

M.A Final (evening)

Class No. 22

DEPARTMENT OF SOCIAL WORK

UNIVERSITY OF PESHAWAR

Acknowledgement

First of all, greatness, sanctity and glory to Almighty ALLAH, who blessed

me to complete my field report

I will acknowledge the assistance, guidance and continuous feed back from

Sir. Abrar Anjum, social medical officer, Zakat cell, LRH Peshawar.

The continuous and persistent encouragement and appreciation of Jahangir

Khan has given me the energy to work hard.


By: Imran Ahmad

The outstanding efforts of Dr. Ali Haider and their professional approach in

clarifying the concept of the topic have contributed markedly in completing

this report.

It has been pleasure learning from all my group members.

Finally I will thank to all the staff members of LRH specially the Ardalees of

Zakat cell.

Imran Ahmad Sajid

Summery

Lady reading hospital is the largest hospital of the province. It was given the

status of PGMI in 1982. The specialists of every specialty are available here.

Opd is the place for initial treatment to the patients. It deals with those

patients who do not need hospitalization.

Zakat and social welfare services cell is working under RMO ad social

medical officer. It provides free treatment expenditure to the needy and

deserving people. Main objective is to handle unclaimed patients and dead

bodies.

Accident and emergency department is the busiest department of the

hospital. This department is to deal with major and minor incidents,

traumatic situations such as RTAs, bomb blast, burnt cases etc. there are


By: Imran Ahmad

two types of emergency patients. Acute emergency patients are those who

needs immediate treatment and are directed to trauma room. The normal

emergency patients are to meet the CMO first.

Triage is a system of sorting patients according to need when resources are

insufficient for all to be treated. It is a system of response to a major

incident. There are two types of triage i.e. triage sieve and triage sort.

First Aid is an emergency care for a victim of sudden illness or injury until

more skillful medical treatment is available. First aid is provided in those

conditions when you have no treatment apparatus and any other helping

thing.

A proper communication network, coordination, behavioral training, more

new hospitals, medical social workers, field work system, and a quota for the

management of unclaimed cases in each department and wards are few

recommendations for the hospital.

Some people have the spirit to help others. They are ready to donate their

blood.

The social workers have to work extremely hard and selflessly in the field of

social work in accident and emergency.

Table of contents

Contents

Pages


By: Imran Ahmad

1. Introduction to the Institution ………………………………..……………....1-3

Introduction to LRH, History of LRH, Chronological

Development, Services, Administrative Setup,

2. Out Patient Department

(OPD)…………………………….…………………4-5

3. Social Services Unit………………………………………………………………6-

10

Introduction, Main objectives,

Zakat Cell,

Admin Setup, Source of fund,

Zakat fund,

Baitulmal fund, Endowment fund,

Prime Minister Programme fund,

Hepatitis ―C‖, Unclaimed Cases,

4. Accident and Emergency………………………………………………………11-

15

Introduction, History, Departmental Layout, Staff Setup, Nomenclature, the

process in A&E, COW, CSW,

CMW, Minor OT, COT, Purchee Counter, Mass Emergency Hall, Trauma Roo

5. Triage System………………………………………………………………….16-18

Triage Sieve, Triage Sort, Main

Categories, Methane message,

Social Work in Casualty

6. First Aid…………………………………………………………………….….19

7. Recommendations…………………………………………………………….20-21


By: Imran Ahmad

For improvement

8. Case Histories………………………………………………………………….22-28

Four case histories

9. Voluntary Blood Donors List………………………………………………….29

A collection by Imran Ahmad Sajid

10. Bibliography……...……………………………………………………………30

-31

11. Map of LRH……………………………………………………..…………….32

Internship Report LRH 17-sep to 18-oct-07

By: Imran Ahmad, M.A. Final 7

Introduction to the institution

Introduction of Lady Reading Hospital

Government Lady Reading Hospital is one of the oldest and largest

Teaching Institutes of the country which provide state of Art, excellent

curative and preventive services to the ailing humanity of the Frontier

Province. It is also called loye (big) huspatal (hospital) and Gernali

Huspatal. It was established in 1924 and it is just 200 meters away in the

south of Grand Trunk Road, behind the famous historical Qila Balahisar.

Famous Masjid Muhabat Khan, Ander Shehr bazaar, Qissa Khawani bazaar

and Khyber bazaar is across the road of LRH. LRH is just outside historical

wall in the jurisdiction of cantonment board.

History of Lady Reading Hospital

The foundation stone of LRH was laid in 1928 by Miss. Lady Reading, who

was the wife of the viceroy Lord Reading (1921-1926). The anecdote of

the hospital of its coming into being is that His Excellency Mr. Lord

Reading, viceroy of the subcontinent from 1921 to 1926, happened to

visit Peshawar. He was accompanied by his spouse Lady Reading. She

was fascinated by the view of the city from Balahisar where they had

lodged.



She expressed her desire to see the

city. She was provided horse in

compliance with her desire. She

visited the city. As she was

returning back to the fort the horse

took the fright causing fall of the

Lady from the horse back. This

resulted in some injuries to the Lady

Reading. Non-availability of medical

aid instantly made her unconscious.

She was rushed to Agerton Hospital

where the facilities were scanty.

Uncomforting to cater for the

requirements, she was shifted to the Royal Artillery Hospital now called

CMH Peshawar where she was given proper treatment. The immense

impact of this incidence on her made it imperative to construct a hospital.

On retirement of Lord Reading in 1926 she came to Peshawar from Delhi

and campaigned to construct a standard hospital in place of Agerton

Hospital.

Chronological Development

This new hospital was subsequently named after her as Lady Reading

Hospital. Later on the hospital was given into status of District

Headquarters hospital with 150 beds and in 1930 it was 200 bedded

hospital. In the beginning there was only medical ward working in the

hospital. Medical ward was responsible for providing all kinds of services

to all patients. The surgical and Gynea wards were added next to the

medical ward. After these three wards the emergency department was

established in LRH. It was near the Mazar in LRH



After partition in 1955 Khyber Medical College Peshawar University was

established and the hospital assumed the status of the teaching hospital.

Then it had four wards consisting of Medical, Surgical, ENT and T.B wards.

Doctor Khan Bahadur Abdul Samad Khan had been the first Medical

Superintendent of the hospital. Doctor Muhammad Ayaz Khan was

appointed the first Administrator of the hospital in 1973. This hospital

became affiliated to Khyber Medical College in 1973 with medical,

surgical, ENT, Eye & T.B wards. In 1982 LRH was raised to the status of

Post Graduate Medical Institute ----PGMI. The students of the health do

their specialization in this hospital.

O.P.D is going above 2000 patients per day and the casualty attendants

of A & E departments is more than 1000 or 1200 per day. Every machine

of this hospital is running round the clock and so are the doctors and

nurses

Services Available at Present

Now at present time every specialty of the health sector is available in

this institution. These specialties include the following;

1 ENT 11 CARDIOTHORACIC

2 Eye 12 Cardiovascular

3 Medical 13 Neuro Surgery

4 Surgical 14 Gynecology

5 Orthopedic 15 Peads surgery/ children

6 Psychiatry 16

7 Skin 17 Drug Addict

8 Chest 18 Leprosy

9 Urology 19 Nephrology

10 Cardiology 20 Neurology



Administrative Setup

Chief Executive

The chief executive is the head of the hospital. He is a scale 20 officer. He

is often a professor or a doctor. But this seat is not reserved for the

doctors. The political people can come on this seat. Since few years the

generals of army has occupied this seat. Now a days Dr. Hafizullah, the

cardiologist is the chief executive of the lady reading hospital. He is also

incharge of the cardiac unit. Initially just the MS was the head of the

hospital but now the powers has been distributed between the MS and

chief executive.

The chief function of the chief executive is to formulate policies for the

uplift and development of the hospital. He has to make planning for the

development of different departments of the hospital. It is not his duty to

run the administration but he has to make effective policies and

procedures.

Medical Superintendent (MS)

MS is the head of hospital administrative machinery. He is also given a 20

grade. His main duty is to implement the policy formulated by the chief

executive. The MS has divided the hospital into 6 zones. Every zone has a

deputy medical superintendent (DMS).

Deputy Medical Superintendent (DMS)

DMS is the head of each zone. There are 6 DMS of the different Zones

and one DMS Admin. Therefore there are seven 7 DMS in LRH. But the

A&E department has two heads; one DMS and one Director.



Staff Hierarchy in Wards

The hierarchical structure of any department is like the following;

1. Professor

2. Associate Professor

3. Assistant Professor

4. Senior Registrar

5. Registrar

Each professor is the incharge of his ward. All the admissions and

discharges are made by him1.

OUT PATIENT DEPARTMENT

Lady Reading Hospital

Patients who do not require an overnight hospital stay receive outpatient

care in out patient department or in OPD. LRH Outpatient Center is

located on the hospital's ground floor, making it easily accessible to

patients and families. A designated outpatient parking area is located just

outside the Center's entrance.

Facilities provided at Out Patient Department in Lady Reading Hospital are

as follow:

1 Jahangir Khan ”Social Medical Officer” Zakat Cell. LRH Peshawar



Experienced & highly qualified doctors are present from 8:00 a.m till

1:00 p.m in all specialties work 6 days a week.

Welfare activities to poor & unknown patients and also family

welfare services loke counseling.

Daily 2000 to 3000 patients are treated in OPD in Lady Reading

Hospital.

All the diagnostics & therapeutics & rehabilitative services like X-

rays, Ultra Sound, psychotherapy, Physiotherapy, occupational

therapy, Laboratory Services, & Orthopedic Workshop (prosthesis &

orthotics).

Provision of general medical services to out patients on scheduling

and unscheduling basis.

Provision of preventive and pro motive services like health

education, immunization,

Screening, antenatal, wallaby clinic and family planning.

Curative services like consultation, investigation, therapeutic

procedures and specialists services

Follow up services of discharged patients, chronic illnesses, and

postnatal cases and post operated cases.

Training and education of doctors, nurses and paramedics.

Let me introduces all the structure of the opd;

OPD consist of

counter

Record Room

X-Rays department

Eye department

Laboratory

Pharmacy

department

Social guides,

Ardalees

Doctor



1. Counter

The purchee counter is the place where the hospital and the patient

interact for the first time. The patient is registered through purchee which

worth 5/ Rs- the patient is referred to the concerned physician or surgeon

through the purchee e.g. ENT, eye, chest, medical or surgical etc. the

counter is divided into two parts for the convenience of the patient. One

for male and one for female but the condition seem to be not satisfactory.

Because there is a huge influx of the patients who wait for their turn to

get a purchee. They often stand in 10 meter long lines.

2. Record Room

The record room is simply to keep all the records of the OPD.

3. X-Rays department

X-rays department is a big place and it is a large department. The x-ray

fee is 35/ RS each. Ultrasound section is also included in x-rays

department. There are two ultrasound rooms; One for in-patients and the

other for out patients. The timing of x-rays department for opd cases is

till 2:00 PM.

4. Eye OPD

It is a separate section from the general eye opd. Three eye specialists

are being hired for this section.

5. Laboratory

There is an attached lab in OPD which charges very minor costs for

different types of tests. The lab timing is till 12:00 AM.

6. Pharmacy department



It seems to me as a separate and not related to the OPD. Because this

department provides free medicines to all the units of the hospital. Free

medicines are provided to the in-patients.

7. Social guides

The social guides are to provide help to the helpless patients. Their duty is

to provide stretcher facility to the severe ill patient.

8. Doctors

There is a variety of physicians and surgeons available in OPD. The OPD

doctors include both lower and senior. I found the following major types

of health specialties;

Medical Eye Cardiovascular Skin

Surgical Nephrology Neurosurgeons Urology

Dental Cardiology Neurology Pediatricians

2000-3000 patients daily visit the opd.2

OPD Administrative Setup

The administrative setup of the opd in LRH is given below;

1. RMO The head of Out patient Department in

LRH

2. Additional RMO He is to assist RMO

3. Senior Social Medical Officer

4. Social Medical Officer

5. Steno Typist

6. Computer Operator

7. social guides

2 Mr. Innam, LDC, Zakat Cell, LRH Peshawar



8. Ardalee

SOCIAL SERVICES UNIT

The first social services unit in LRH was established in 1967. Before that

year there was no system of providing social services to the patients. But

the question here is that why this unit was established? This was due to

the unclaimed patients and dead bodies—Lawaris. The social services

unit was established to deal with such cases.

The first social medical officer, on the other hand, was appointed in 1982

who was Sir. Ibrar Anjum. The social services unit is headed by RMO—

Resident Medical Officer.

Major objectives

To financially assist the poor patients through Zakat & other funds,

during treatment

To deal with unclaimed patients & dead bodies –Lawaris Patients

Administration of the OPD

Revenue collection

Zakat cell

The section in which the social medical officer is working is called Zakat

and social welfare cell.



Total Zakat fund for the year is 82, 50,000 /Rs. This is a fixed fund,

neither increases nor decreases. The fund is provided in two installments

per year.

Administrative setup

Zakat cell is headed by RMO who is also the head of OPD.

Social medical officers 3

LDC ---lower divisional clerk 1

Social guides 2

Ardali 4

Major areas for funds delivery are

ENT Appliances, e.g. hearing device

Eye Lenses

Orthopedic Rods & screws, all the operation cost

Peads surgery GIA (an implement worth 30, 000/ Rs

Neoro-Surgery VP shirts

What are the sources of funds to the patients?

There are three main sources of funds with the social welfare section.

These are

Zakat fund

Baitulmal fund

Endowment fund

Zakat Fund



Zakat fund is given by the federal Government to help poor patients for

their treatment.

Procedure for Indoor Patients

When the patient is in treatment in the ward and he is so poor that he can

not afford the treatment expenses, then he comes to the Zakat cell with a

Zakat Istehqaq form duly signed by the chairman local Zakat committee

and district Zakat committee. The photo copy of NIC is compulsory to

attach with the form. The patient shows the form to the incharge of the

concerned wards who makes a list of all necessary medicines and other

necessary implements of treatment on a pro-forma and gives it to the

patient.

Now these four forms, Zakat form + prescription pro-forma + NIC

photocopy, and Local Purchee move on to the social welfare cell of LRH.

The form is signed by

Incharge Zakat cell

Senior Social Medical officer

RMO (Resident Medical Officer)

MS (Medical Superintendent) & sometimes

Chief Executive (if necessary)

When all the documentation requirements are met by the patient then the

approved contractors for the year, who come through the tenders, take

the prescription of the doctor and gives medication to the patient. The

contractors give discount to the Government on the medicines. It can be

5%-10%.

Indoor patients can have treatment expenditure from Zakat cell up to 20,

000/ Rs. The amount can be raised in special cases.



Procedure for out-door Patients

The procedure for out door patient is the same but the doctor’s pro-forma

is not needed in these cases. The out door patients can have a treatment

expenditure of up to 1, 000/ Rs from Zakat cell.

The medicines to the long lasting diseases patients are given on monthly

bases. The dosage of one month is given to the patients. Room # 65 is

the medical store for Zakat cases.

Bait-ul-Mal Fund

The baitulmal fund is also a system developed for poor patients to have a

free treatment. This fund is given by the federal Government.

The process is somewhat the same as Zakat process. The patients who

come for baitulmal fund bring a printed pro-forma from the provincial

baitulmal office. This pro-forma is signed by the doctor of the concerned

ward. The doctor also writes the expenditure of the treatment + the type

of medicine, or device + its market price.

Social welfare unit is the next place for the form. Here in the office, the

form is signed by

MS

Senior Social Medical Officer

The form then moves on to the pharmacist in the pharmacy department

for verification of price + dosage + quantity.

The form is taken to the regional baitulmal office for the next step. The

regional baitulmal office in NWFP has its on procedure, according to which



they deal with it. The baitulmal office sends the form to Islamabad. A

cheque of national bank is issued by the name of the doctor and patient.

The cheque goes to the Almoner of the hospital. The almoner is the

person from the administration, who gives medicines for the month

according to the doctor’s prescription.

Endowment fund

This fund has been started just few years ago. This fund is also called

hospital fund. This fund is given by the provincial Government. This fund

is only given for the Hepatitis ―C‖ cases. Only the registered patients are

given the help through endowment fund.

This fund is generated through the interest of the Government funds in

the banks. The Government distributes the interest in different sectors.

So health sector is one of them.

Prime Minister Programme for Hepatitis “C” Fund

This fund is expected this year or may be the next year.

Hepatitis “C” patients

Hepatitis attacks the lever of the body. It damages it. Some of the

symptoms of the hepatitis patients are as the following;

Permanent fever 99-1000

Permanent pain in the body

Exertion, fatigue and tiredness

Swelling of lever

Digestive system is disturbed



How it is diagnosed?

The hepatitis is diagnosed initially through HBS and HCV (Hepatitis C

Virus) tests. The charges for these tests in Peshawar are 165/ Rs. But this

test is not enough. So another test which is called PCR (Polymerase Chain

Reaction) test is taken for a complete diagnose. This test shows the

severity, extent and the nature of the hepatitis, i.e. whether it is A, B, or

C.

Hepatitis is a life long disease and cant be cured completely. After

treatment the virus can attack again during lifetime.

Treatment

The complete course of the treatment of hepatitis c is for six 6 months.

This course is called INTERFERONE THERAPY. 72 injections with tablets

are injected in the body. The patient needs 12 injections per month, And

3 injections per week.

Now coming back to the social welfare side, the Zakat fund for the HCV

patients is very limited. Therefore the Zakat cell just provides them some

help in their treatment expenditure. The Zakat cell provide them half of

the treatment expenditure e.g. the patient needs 12 injection per month,

one injection worth 900-1000/ Rs. Zakat cell give them 6 injections per

week.

Other expenses can be met through the endowment fund or the prime

minister programme for HCV.

UNCLAIMED (LAWARIS) CASES



How to deal with unclaimed patients?

Before going into the details the first question is how the LAWARIS

patient reached to the hospital? It is simple that most of the road and

traffic accident—RTA- cases are unclaimed.

When an unclaimed patient is brought to the A & E department in LRH,

the DMS of the department writes a CALL letter to the social welfare unit

of the hospital. In the letter he mentions that we have an unclaimed

patient and he needs such and such medicines, food, and clothing. The

social welfare unit send a social guide to the patient. The social guide

takes care of the patient’s food, medicine, and clothing. The guide also

provide social support to the patient.

The expenditures of food and clothing are met by the welfare fund while

the medication expenditure is met through Zakat fund.

When the patient becomes conscious he is then transported to his area.

The transportation expenditures are also met by the social welfare unit.

How to dispose off an unclaimed died body?3

When a patient dies in casualty department, the deputy medical

superintendent of the department writes a CALL letter to the social

welfare unit. The social welfare unit (SWU) takes the photo of the dead

body and publish it in the news paper. Mostly the daily Mashriq and AAJ

provides free advertisement of the unclaimed dead bodies. The swu

calculates all the expenditures on the dead body e.g. food, medicine,

clothing, picture, and transportation.

If the exact address is known through some source then the body is

transported to that address. If just the district is known then the Police

3 Abrar Anjum, Senior Social Medical Officer LRH, 26-sep-07



Station of the district is informed. But when there is no address and no

source for finding the area of the dead person then the social welfare unit

have only one option. The body is transported to the Khyber Medical

College where they keep the body safe for 10 days or may be a few days

more. After that time if no one claims for the dead body, then the

students of the medical college are free to make their experiments and

practices on the dead body.

Accident and emergency

Department

The emergency department (ED), sometimes termed the emergency room

(ER), emergency ward (EW), accident & emergency (A&E) department or

casualty department is a hospital or primary care department that

provides initial treatment to patients with a broad spectrum of illnesses

and injuries, some of which may be life-threatening and requiring

immediate attention. Emergency departments developed during the 20th

century in response to an increased need for rapid assessment and

management of critical illnesses

Upon arrival in the ED, people typically undergo a brief triage, or sorting,

interview to help determine the nature and severity of their illness.

Individuals with serious illnesses are then seen by a physician more

http://en.wikipedia.org/wiki/Hospital

http://en.wikipedia.org/wiki/Primary_care

http://en.wikipedia.org/wiki/Patient

http://en.wikipedia.org/wiki/Illness

http://en.wikipedia.org/wiki/Injury

http://en.wikipedia.org/wiki/Medical_emergency

http://en.wikipedia.org/wiki/20th_century



http://en.wikipedia.org/wiki/Triage



rapidly than those with less severe symptoms or injuries. After initial

assessment and treatment, patients are either admitted to the hospital,

stabilized and transferred to another hospital for various reasons, or

discharged. The staff in emergency departments not only includes doctors

and nurses with specialized training in emergency medicine but in house

emergency medical technicians, radiology technicians, Physician

Assistants (PAs)/Healthcare Assistants (HCAs), volunteers, and other

support staff who all work as a team to treat emergency patients and

provide support to anxious family members Since a diagnosis must be

made by an attending physician, the patient is initially assigned a chief

complaint rather than a diagnosis. The chief complaint remains a primary

fact until the attending physician makes a diagnosis.

History

The first specialized trauma care center in the world was opened at the

University of Louisville Hospital in 1911 and developed by surgeon Arnold

Grishwold during the 1930s.

Department layout

A typical emergency department has several different areas; each

specialized for patients with particular severities or types of illness. The

departmental structure of the A&E in LRH is given below;

1 REGISTRATION ROOM

(PURCHEE COUNTER)

8 MEDICINE CORNER

2 Waiting lounge 9 ECG room

3 CMO office 10 DMS office

4 Registrar office 11 X-rays room

5 Female examination hall 12 Casualty Lab

http://en.wikipedia.org/wiki/Nurse

http://en.wikipedia.org/wiki/Emergency_medicine

http://en.wikipedia.org/wiki/University_of_Louisville



The A & E in LRH is a two storey building. On the ground flour the

following wards, offices, and other places are found by the social worker;

6 Casualty Medical Ward Male 13 Trauma room

7 Casualty Medical Ward Female 14 Casualty Cardiac Unit



The first flour setup is somewhat like the following;

1 DIRECTOR A & E OFFICE 6 PLASTER ROOM

2 Casualty Operation theater 7 Casualty Surgical ward

male

3 Waiting lounge 8 Nursing room

4 Casualty orthopedic ward

male

9 Casualty surgical ward

female

5 Casualty orthopedic ward

female

The setup of the trauma room

1 NURSING COUNTER 4 DOCTOR’S OFFICE

COMPUTER OFFICE

2 Nursing supervisor

office

5 Store room

3 Oxygen supply room

Staff setup

Director A&E 1

DMS—Deputy Medical Superintendent 1

Senior Registrar 1

CMO 3

TMO 4

MO 5

Cardiologists 3

House officers not confirmed

Nursing staff



Other staff

Total Ardalees in mornig shift 28

Sweepers 15

Police Men 10 all shifts

Flying Squad

Supervisor 1

Dispensers 3

Drivers 2

Beds and other stuff

NURSING STAFF

SPR H/N C/N N/A S/N

Medicine

counter

4 1

CMW/ male 4 1 5

CMW/ female 5 5

CSW + COW 1 7 5

COT 1 4

Trauma Room 1 4 1 4

CCU 4

SUMMERY

SPR Supervisor 1

H/N Head Nurses 2

C/N Charge Nurses 32

N/A/ Nursing

Attendant

3

S/N Student

Nurses

19

TOTAL 57

BEDS

CMW/m 9

CMW/f 9

COW/m 10

COW/f 4



Stretchers 14

Wheel chairs 5

Ambulances 2

No

menclature

In Australia and New Zealand, the department is usually referred to as

the emergency department. In the United Kingdom, Hong Kong,

Singapore and Ireland it is usually called the accident and emergency

department (A&E). The popular term casualty is no longer considered

appropriate by emergency physicians in Australia, the United Kingdom

and Ireland. Leading journals consistently use the term Emergency

department.

In the United States an emergency department is often referred to by

laypeople as an emergency room (ER). Medical professionals typically call

it whatever its name is within their specific hospitals, or simply

"Emergency.".

The Process in A&E4

There are two types of emergency patients

4 Dr. Muslim Khan “DMS A&E” LRH

CSW/m 10

CSW/f 10

TOTAL 52

A & E -LRH

http://en.wikipedia.org/wiki/Australia

http://en.wikipedia.org/wiki/New_Zealand

http://en.wikipedia.org/wiki/United_Kingdom

http://en.wikipedia.org/wiki/Hong_Kong

http://en.wikipedia.org/wiki/Singapore

http://en.wikipedia.org/wiki/Republic_of_Ireland

http://en.wikipedia.org/wiki/Casualty_(person)

http://en.wikipedia.org/wiki/United_States



Acute Emergency Patients

Normal Emergency Patients

First of all the patient is registered through purchee counter. AEP are

directly guided to the trauma room where the first aid treatment is

provided to the patient and then he is shifted to the concerned ward.

The NEP on the other hand are guided first to the Casualty Medical

Officer- CMO, who, after initial interview and checkup, refers the patient

to the concerned casualty ward, e.g. medical, surgical, orthopedic etc.

These wards provide one day care to these patients. Next they are

transferred to the main wards if necessary.

Casualty Orthopedic Ward

The patients with bone injury or broken bone are treated in orthopedic

ward. The initial treatment is given in casualty orthopedic ward. This ward

is divided into to sections; male and female. This ward consists of

fourteen beds. Often the RTA cases visit this department.

Casualty Surgical Ward

This ward is on the first flour of the A & E department in LRH. The

patients who need some kind of operation or surgery are treated in

surgical ward. The casualty surgical ward consists of twenty beds; ten

male and ten female. The patients stayed only for some hours in this

ward.

Casualty Medical Ward



The casualty medical ward is on the ground flour in & E department in

LRH. This ward consists of twenty beds; ten male and ten female.

Minor OT

Minor OT means, Minor Operation Theater. This section is to do minor

kind of operations like stitching a wound, heeling the injuries etc.

COT

COT means Casualty Operation Theater. The patients who need

immediate operations in the department are operated in this operation

theater. The operation theater is on the first flour of the department.

Purchee Counter

Here the purchee counter is similar to the purchee counter of opd. The

computerized purchees are issued to every new patient. The purchee

counter is the first place of interaction for the patient in A&E.

Mass Emergency Hall

This hall consists of more then one hundred beds and sub-beds. This is on

the ground flour of the department. All the casualty facilities are available

here. This hall is very busy when there is a bomb blast or some kind of

fire or flood make casualties. During this internship time, one bomb blast

happen in Peshawar at Nishtar Abad. It causes two persons to death and

twenty eight injured5.

5 Daily Express, 9-oct-2007



What is trauma room for?

Trauma room is an important section in any emergency department

where the trauma team is ready to deal with any traumatic situation e.g.

bomb blast, RTA—Road and traffic accidents, burnt cases, severe injuries

etc. First aid and other emergency treatment are provided at this place to

the AEP. Two neurosurgeons consultants, two orthopedic consultants, and

two general surgeons are present in trauma room.

In the A&E all the treatment expenditure is met by the Government. the

medicine and other stuff is provided free of cost to the patient. 1500-

1800 patients are daily registered in A&E LRH. When the patient enters

the trauma room in a traumatic situation, within 5-10 minutes he is given

treatment of 500-1500 /Rs.

What is Triage?

Triage is a system of sorting patients according to need when resources

are insufficient for all to be treated. It is a system of response to a major

incident. The term comes from the French tri (meaning sort). There are

two kinds of triage:

Triage sieve &

Triage sort



Triage Sieve6

The primary triage of patients has been called the ―triage sieve‖ and is

based on the Simple Triage and Rapid Treatment method of ―START‖. This

technique can be used at the scene of the accident and also subsequently,

e.g. on arrival at the Casualty Clearing Station (CCS). This method can be

used effectively and reliably by appropriately trained laypersons.

Casualties who can walk are assigned to the Delayed category. The

remaining patients are sorted following an ABC (Airway, Breathing,

Circulation) assessment.

The patency of the airway is then assessed. If the airway is not patent it

is opened using a simple airway manoeuvre (chin lift of jaw thrust). Those

patients who are found to be not breathing following this procedure

should be declared dead (remember this is a mass casualty situation).

The respiratory rate is now assessed. If the respiratory rate is low (less

than or equal to 10) or high (greater than or equal to 30) the casualty is

triaged to the Immediate category.

If the rate is between 11 and 29 breaths per minute the circulation is

assessed by determining the capillary refill time. This is done by

squeezing the casualty’s fingertip for five seconds. On release of this

pressure the normal response is for the nail bed to relish within two

seconds. If the capillary refill is less than two seconds the patient is

assigned to the Urgent category. If the capillary refill is more than two

seconds (indicating the presence of shock) the patient is put in the

Immediate category.

The capillary refill time may be prolonged in conditions of low ambient

temperature or be difficult to assess because of poor lighting. In such

6 Dr. Bob Mar, “Non but Ourselves” Frontier Medical Co. UK



situations the pulse should be assessed and a rate of more than 120 bpm

considered being the upper limit of normal and equivalent to a prolonged

capillary refill time.

At any stage in the triage process another first aider can be assigned to

the patient to carry out life saving measures such as keeping the airway

open or controlling external hemorrhage (extreme bleeding).

The triage category can then be displayed on the patient using a triage

label (see below). Primary triage of the patient will determine priorities for

treatment and evacuation to the

CCS.

Triage Sort

Triage sort is the secondary triage. It is more prolonged process and can

take place after initial resuscitation. It is started in trauma room.

Main triage categories

• Deceased (Black) are left where they fell, covered if necessary;

note that in S.T.A.R.T. a person is not triaged "deceased" unless they are



not breathing and an effort to reposition their airway has been

unsuccessful.

• Immediate or Priority 1 (Red) they need advanced medical care at

once or within 1 hour. These people are in critical condition and would die

without immediate assistance.

• Delayed or Priority 2 (Yellow) can have their medical evacuation

delayed until all immediate persons have been transported. These people

are in stable condition but require medical assistance.

• Minor or Priority 3 (Green) These people are able to walk, and may

only require bandages and antiseptic.

What is METHANE Message?

When you wetness to see a major incident, what will you do?

You will deliver a METHANE message to the control room. METHANE

message is a system of informing the control room about a major incident

at some place. The abbreviation stands for

M: MAJOR INCIDENT

E: Exact Location

T: Type of incident

H: Hazard, present and

potential

A: Access in emergency

N: Number of casualties

E: Emergency services

required 7

7 Fazl-E-Hakeem, “Nursing Supervisor” LRH Peshawar



Social work in casualty

The patients and family don’t know where to go and get help. For

example where is ultrasound, where to go for ECG etc. We social workers

have to direct the patients and families to there concerned spot of help.

We have to provide guidance to them. Social worker has to deal with the

social aspects of the casualty. For example if a patient is severely injured

due to fighting with someone, now what the social worker has to do here

is to find out the causes of fighting. Social workers have to rehabilitate

the patient back in their community8.

First Aid

First Aid is an emergency care for a victim of sudden illness or injury until

more skillful medical treatment is available. First aid is provided in those

conditions when you have no treatment apparatus and any other helping

thing.

When you wetness to see a road or traffic accident, what will you do with

the casualties?

First of all clean the mouth of the person if he has some thing in mouth,

e.g. a piece of cloth etc. the person can’t move him self therefore you

have to clean his mouth so that he can keep breathing continue.

8 8 Dr. Muslim Khan “DMS A&E” LRH Peshawar



If a person is unconscious, don’t hold him from the neck. We suppose that

every unconscious person in the accident situation is with a damage neck.

Always hold them from the shoulders.

In case of vessel injury, tide the body from such place so that the

bleeding could be stopped. Tide it very tightly because we have to save

the life here.

If his leg or hand, for example, is broken then give it a slab so as to keep

it straight and protect further damages.

If the patient is not breathing then place him straight on a place and hold

his leg up in the air for some time. Do not force a person to sit who is in a

state of fit. During fit don’t give any water to the patient so that he can

breathe freely9.

Recommendations

For Improvement

There is no communication system in allover the hospital between the

departments. All the departments are working at their will. First of all in

this situation, a communication network should be established between

the all the departments and sections of the hospital. So that the time and

energy could be saved.

9 Ali Haide, Neoro-Surgeon Consultant, A & E LRH Peshawar



There is a lack of coordination in all the departments of the hospital. A

proper coordinated system should be devised for all the departments.

How to bring coordination? this is the headache of the hospital

authorities.

Behavioral training should be given to all the staff members of the

hospital. This must includes the lower level members such as the ardalee.

The technicians and all the paramedical staff should be trained in

behavioral science. So that they can deal with the patients in a good

manner. For this purpose the in-service training should be arranged every

year.

As this hospital is the largest hospital of the province so there is no need

to further extend it. Now the burden of the patients visiting daily is

unbearable for the hospital. It is very difficult to ménage them

appropriately. So more and more new hospitals should be established

with all the facilities. Or the existing district hospitals should be provided

with all the necessary facilities.

The role of the Medical Social Worker is Nil in the hospital. The concept

which we have studied is not present in a minor amount here. So this is a

recommendation here that the medical social work should be applied with

its true spirit and nature. The medical social worker should be given only

the social job not that jobs which do not relate to his profession.

All the departments should have a direct contact and immediate

communication system with the casualty department because the

casualty department is the heart of the hospital. It needs more and more

reinforcement.

There is no system for the field work of the social work students. A

proper system hasn’t been devised still. So a well developed system



should be devised for the university students to have their field work

training in this institution. A separate room and a field supervisor should

be allocated for them. The existing social workers in the hospital have

more work to do, and they have very rarely sometime to give to the

students.

The number of the medical social workers are nil in the hospital. One

social worker at least is required for each ward. They are more

concerned with the socio-economic position of the patients. This has been

felt during the internship period that we need more social workers for all

the wards of the hospital. The social workers should be appointed for

those places where the staff has a direct dealing with the public.

The management of the unclaimed cases is the one of the duty of the

social welfare section of the hospital. The social welfare unit should be

given a separate place where such cases could be dealt or the quota

should be given to the social welfare unit in each ward for such cases.

Due to the non-availability of such place the unit authorities are getting

troubles in performing their duties.

Case histories

Our group in the agency consist of eleven members. The group was

divided by the authorities into three sub-groups. One group was sent to



the orthopedic ward, one to the medical –A ward, and one to the

Accidents & Emergency department. Our group was working in the A&E

department. Now therefore all the case histories given below have been

taken in the A&E department of the hospital. There is a number of the

case histories which have been collected by the group but for the sake of

our report only four of them are being presented here.

Case no. 1

Department/ Ward: A&E

Case type: Orthopedic

Name: Riaz Ali

Age: 37

Resident: Serchina Sawabi

Educational qualifications: M.A. B.Ed

Occupation: principle of a school in sawabi

Major problem: an injury in right foot

History of the patient

The social worker meet with the patient in palaster room of the casualty

orthopedic ward. the doctor prescribed him injection and an X-ray. He

himself was facing difficulty in moving. Mr. Riaz was all alone and he had

no respondent at that time. He was guided by the training social worker

to the nursing room for injection. When the injection was given to him by

nurse then he was guided next to the Casualty X-Ray room. The X-Ray

technician has an X-Ray just within few minutes.

Now the training social worker show and guide him to an easy way to get

back to the doctor. When the patient reached to the doctors room, he was

busy in bandage of a child. So we wait for some time.

During this time the social worker interviewed him and took a complete

history of Riaz.



How the injury occurred?

(In the words of Riaz) I am a principle of a public school in sawabi. Today

I came to Peshawar to the high court due to some case. While coming

down via the stares in high court, my leg slipped at a stare and I feel

extreme pain in my leg. My lawyer arranged a Riksha for me which

brought me to A & E. I got the purchee from the counter and then come

to the orthopedic doctor up here.

Diagnoses of the doctor

Dr. Gherat after assessing his x-rays said that the injury is not severe and

the joint of the leg has got some pressure. He prescribed him some

medicines and a crack bandage.

During this time he called a friend on cell phone. His friend Mr. Maqsood

arrived after some time to A & E. but he was unable to find palaster room.

So the social worker went out and searches him and brought him to his

patient. Mr. Maqsood fetches the crack bandage and other medicine.

Riaz’s leg was bandaged. And they both move to their home back to

sawabi.

The role played by social worker

The patient Mr. Riaz was helpless and all alone. He really needs

someone’s assistance to guide him. So the social worker provides him

guidance. He needs someone’s company and counseling. So that he can

pass the time of stress and anxiety in an easy way. The social worker

provides him company and has tried to divert his attention from the

illness so as to reduce his tension and anxiety. The social worker also

makes the situation more clear to him and his respondent.

Case no. 2



Department/ Ward: A&E

Purchee No: LRH0907-080970

Nature of the case: surgical

Name: Noor Mohammad

Age: 75

Respondent: none

Marital status: married

No. of Off-springs: 6 - (3 daughters and 3 sons)

Financial position: dependent upon his sons

Occupation of the supporters: drivers

Resident: Pajagee Road Peshawar

Educational qualifications: nil

Major problem: urine problem

History of the patient

The social worker met the patient in casualty surgical ward. The doctor

prescribed him injection, an X-ray, and urine test. Although the patient

was an aged person but he was all alone and he had no respondent. He

was guided by the training social worker to injection. When the injection

was given to him by nurse then he was guided next to the Casualty X-Ray

room. The X-Ray technician has an X-Ray just within few minutes. Next

the patient was guided to the casualty lab where his urine sample was

analyzed by the lab assistant within 15 minutes.

Now the training social worker show and guide him to an easy way to get

back to the doctor.

Why the help was sought?

According to patient he feel some swelling in his urine but sometimes it

become intense and severe, and sometime he became normal.

Diagnoses of the doctor



Dr. Ayub after assessing his x-rays and lab report said that the case is not

so severe. The doctor prescribed some medication and said that he should

drink water in large amount.

The role played by social worker

The patient was an aged person and all alone. He was really in need of

assistance and help. So the social worker provided him guidance. He

needed someone’s company and counseling. So that he can pass the time

of stress and anxiety in an easy way. The social worker provides him

company and has tried to divert his attention from the illness so as to

reduce his tension and anxiety. The social worker also makes the situation

more clear to him.

Effect of social work

The patient was very much amazed of the guidance and assistance of

social worker. He was very happy and thankful to social worker. He asked

social worker that why he is helping him in a situation when his children

have left him alone. It was due to the social worker that the time and

energy of the patient was saved. He prayed for the social worker’s

success. The patient prayed that such social workers may be available to

all the patients.

Case no. 3

Identification

Purchee no. --------------------

Name: Niat Meer

Age: 75

Nature of the case: Neoro-Surgical



Ward: Trauma Room

Family system: joint

Respondent: Abad Meer = brother

Zubair =

Hassan = step son

Marital status: he has a second wife who is also near

death

No. of siblings: 1 son who has died 14 years ago in

the age of 25, 2 step sons

Financial position: independent

Resident: Pir Qala, Shabqadar Dheree


Chief Complaint: severe Head injury

___________________

Present History

According to all the respondents, the baba has been beaten on the head

by the brother of his Bahoo whose name is Bilal / 20y. he was beaten

when he was taking care of his cow. The patient him self don’t know that

who beat him

Past History

His son was fired down by mafroors 14 years ago. Due to this trauma he

has got a severe shock. Bcz he was his only son. This traumatic event

makes him irritable minded. The baba has distributed the property among

the stakeholders. He has a house as a property on his name. the bahoo

want to sell the house but the baba is not ready to do so. The relationship

between them are very constraint.

According to the respondents they have a quarrel just few days ago. The

reason was that the bahoo has stayed in someone’s home for 20 days

without the permission of the baba.



Financial Position

The baba took his care and meet all his expense by him self. He has 15

goats and a milk cow, which is his major source of earnings. He has also

poultry hens in home.

Socio-cultural situation

This is a very complex case. Pir qala is the are of pukhtoons near

mohmand agency. Socio-economically the area is very backward and less

developed. There is mass illiteracy and lack of educational facilities and

other services. The people are very poor though they have their own

properties.

Diagnoses

Why a poor baba who is near his medical death has bean beaten by his

bahoo’s brother?

There can be many reasons for this case. One major reason is the

property distribution. The second is the generation gap. The third can be

that the character of the bahoo may not be normal, which has caused the

incident.

Hospital history and social worker’s role

The baba was brought to the A & E by his brother Abad Mir on 23-sep.

The patient was given some initial treatment in trauma room. The patient

was transferred to the neurosurgical ward on 24-sep. the social worker

has interviewed them on the same date in trauma room. All the social

history has been given in the above lines. The social worker has visited

him in the ward on 25-sep. the baba was conscious and talking in a good

mood. He provided the information that he has 15 goats and some hens

and one milk cow. He was talking about them only.

But when the social worker visited him on 26 of sep, he was discharge by

the incharge of the ward. The doctor has discharged him just by



examining his physical conditions. The social situation of the patient in his

community and family is still not in his favour. He has to live with the

same Bahoo who is responsible for his being here in the hospital. Now the

baba can again come to the casualty in the emergency situation.

Recommendation

We have to develop a system for the rehabilitation of such patients whose

family environment is against them. The bahoo of the baba haven’t been

contacted by any one, this is just bcz there is no social worker or

counselor in any ward. The social worker has just tried to contact her but

during this the patient was discharged. So the social worker has lost the

case. There should be at least one social worker appointed for each ward

or department, who can make some rehabilitation processes for such

patients.

Case no. 4

Identification

Purchee no. LRH0907-091797

Name: Hameed Khan

Age: 25

Nature of the case: Neoro-Surgical

Ward: Trauma Room

Family system: joint 25 members live in one house

Respondent: Farzullah Khan = brother

Fazal Dad = brother

Rahmat = nephew

Marital status: unmarried



No. of siblings: 5 brothers and 7 sisters

His position: he is the youngest of all

Occupation: zamidari

Resident: Bela Neko Khan, Dalazak Road,

Peshawar


Chief Complaint: severe Head injury

___________________

Present History

According to all the respondents, the patient has been beaten on the head

by three persons. There names are Haider, Gohar, and Awal Gul. The

main stakeholder is Gohar. They have beaten him at 8:00 am when the

people were busy in saying their prayers.

Past History

Mr. Hameed has a joint family system. They are 25 members living in one

house. They have enough manpower to maintain and to threat others in

the village. But this time the other party was more strong then them.

About half of the village belongs to the other party. The reputation of the

Hameed’s family is not good in this regard.

This time the dispute begin, according to the respondents, bcz Gohar and

Hameed have an agreement of zamindari and mazdoori. But Gohar

refused to work with him just a night before the work has to begun. Now

it was due to this refusal they have a little bit quarrels at that time. But

Gohar plan after this and beat him with the help of his brother and friend.

Socio-cultural situation

Bela Neko Khan is situated on Dalazak road. It is a typical rural area. This

area is included in Khalisa, which is famous for its greenery and Sugar

Cane production. Most of the people belongs to agriculture. Agricultural



disputes are the daily routine of the area. So the above case is. Similarly

an agricultural dispute. The people of the area are generally less

developed and illiterate.

Diagnoses

Mr. Hameed has a family background which is full of such incidents,

quarrels and disputes. His family is not in a mood to resolve the current

dispute. Although they have a jirga system in their area but it is not so

much effective. The current incident is due to the cultural pattern of the

area.

Hospital history and social worker’s role

The patient was brought to the hospital on 24 of September. He was

given the first aid in the trauma room of A&E. when the social worker met

him he was laying unconsciously on the bed. So the interview was taken

from the respondents. As they have a joint family system so there was a

number of respondents available on the spot.

Next day the social worker visited him in the neurosurgical ward. The

family was busy in taking care of him. There were at least ten

respondents available at that time. So it was difficult to interview them in

this crises situation. So the visit was made again on the next day. When

the social worker met him he was unconscious. But the social worker was

amazed to here that the hospital concerns have discharged him.

Remarks

Now this is the case where the real social work is needed. The disputes of

Hameed are still present. No jirga has still been conducted. The

environment of his community is not favourable to him. But he was

discharged. --- now it could happen again that he may come in the same

condition to the hospital.

We have to develop a system for rehabilitation of such patients. There is

an urgent need of professional social workers in hospitals.



Voluntary blood donors

A collection by Imran Ahmad Sajid

There are some situations in our life when we are completely helpless and

in a very crucial condition. In this situation we need the help of other

people. One such situation is when somebody gets a life threatening

illness. The other such situation is a sudden casualty such as bomb blast,

traffic accident. In these incidents some people go to death while some

are extremely injured. These people can be saved if they are given the

necessary treatment immediately. The injured people need immediate

blood. But sometimes the blood group of the case is not available in the

blood bank. So therefore we have collected some of the voluntary blood

donors who are ready at anytime to donate their blood for the needy

people. You just call them and they will be available. Some of the donors

name and their contacts are being given below;

S.

NO

BLOOD

GROUP NAME F/NAME

CONTACT

NO. ADDRESS

1 A+ Bilal Siddiqee M. Siddique 0332-

9124774

Garhi Baloach

Peshawar



2 A+ M. Yousuf Gul Rehman 0345-

539592

Garhi Baloach

Peshawar

3 AB+ Bilal Ahmad

Sajid Khaista Gul

0321-

9021277

Garhi Baloach

Peshawar

4 B+ Asim Nawab Nawab Khan 0333-

9317506

Department of

Environmental

Sciences UOP

5 B+ Syed Haroon Ali

Shah

Syed Yousuf

Shah

0300-

5955868

Garhi Baloach

Peshawar

6 B+ Momin Khan Abdul Qayum 0334-

9204705

Thandee Khoee

Peshawar

7 O+ M. Mustafa

Sajid Khaista Gul

345-

9163441

Garhi Baloach

Peshawar

8 O+ M. Tariq 0346-

9810631

Department of

Environmental

Sciences UOP

9 O+ Younus Javed Gul Rehman 0321-

9056048

Garhi Baloach

Peshawar

10 Amaanullah Abdul Qayum 0334-

9204704

Thandee Khoee

Peshawar

11 Malak M. Bilal Malak M.

Sharif Yakka Toot Peshawar

Bibliography

Social Services Unit Staff



1. Jahangir Khan ”Social Medical Officer” Zakat Cell. LRH Peshawar

2. Abrar Anjum, “Senior Social Medical Officer” Zakat Cell. LRH Peshawar

3. Innam Khan, “LDC”, Zakat Cell, LRH Peshawar

A & E Staff

1. Dr. Muslim Khan “DMS A&E” LRH

2. Dr. Ali Haide, “Neoro-Surgeon Consultant”, A & E LRH Peshawar

3. Fazl-E-Hakeem, “Nursing Supervisor” LRH Peshawar

4. Kifayat-ul-llah, “Chief Dispenser”, A&E, LRH Peshawar

5. Khalid, “Head Ardali”, A&E, LRH Peshawar

NEWS PAPER

1. Daily Express, 9-oct-2007

INTERNET

1. Emergency Department, wikipedia the free encyclopedia,



http://en.wikipedia.org/wiki/Emergency_department

2. Triage, wikipedia the free encyclopedia,

http://en.wikipedia.org/wiki/Triage"

3. Dr. Bob Mar, “Non but Ourselves” Frontier Medical Co. UK

http://frontiermedical.co.uk/resources/NoneButOurselves.pdf

LRH WEBSITE

4. Dr. Jahanbaz Afridi, “History of Lady Reading Hospital”, Lady Reading Hospital

Peshawar

http://www.lrh.gon.pk/ohms/frmhistory.aspx

5. Dr. Jahanbaz Afridi, “Out Patient Facilities”, Lady Reading Hospital Peshawar

http://www.lrh.gon.pk/ohms/frmoutpatient.aspx

6. Dr. Jahanbaz Afridi, “Welcome to LRH”, Lady Reading Hospital Peshawar

http://www.lrh.gon.pk/ohms/frmdefault.aspx

7. Dr. Jahanbaz Afridi, “Accident & Emergency”, Lady Reading Hospital Peshawar

http://www.lrh.gon.pk/ohms/frmaccidentemergency.aspx

http://en.wikipedia.org/wiki/Emergency_department

http://en.wikipedia.org/wiki/Triage

http://frontiermedical.co.uk/resources/NoneButOurselves.pdf

http://www.lrh.gon.pk/ohms/frmhistory.aspx

http://www.lrh.gon.pk/ohms/frmoutpatient.aspx

http://www.lrh.gon.pk/ohms/frmdefault.aspx

http://www.lrh.gon.pk/ohms/frmaccidentemergency.aspx



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Imran Ahmad Sajid-Medical Social Work in Lady Reading Hospital, Peshawar, Pakistan

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Transcript of Imran Ahmad Sajid-Medical Social Work in Lady Reading Hospital, Peshawar, Pakistan