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

Internship ReportSocial Work in Lady Reading

HospitalFrom 17-September To 18-octuber, 2007

Submitted by: Imran Ahmad Sajid

M.A Final (evening)Class No. 22

DEPARTMENT OF SOCIAL WORK UNIVERSITY OF PESHAWAR

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

Acknowledgement

First of all, greatness, sanctity and glory to Almighty & Merciful 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.

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

By: Imran Ahmad


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 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.

By: Imran Ahmad


Table of contents

Contents Pages

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 Room

5. Triage System ………………………………………………………………….16-18Triage Sieve, Triage Sort, Main Categories, Methane message, Social Work in Casualty

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

7. Recommendations …………………………………………………………….20-21 For improvement

8. Case Histories ………………………………………………………………….22-28Four case histories

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

By: Imran Ahmad

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

A collection by Imran Ahmad Sajid

10. Bibliography ……...……………………………………………………………30-31

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

By: Imran Ahmad, M.A. Final 6


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. Professor2. Associate Professor3. Assistant Professor4. Senior Registrar5. Registrar

Each professor is the incharge of his ward. All the admissions and discharges are made by him1.

OUT PATIENT DEPARTMENTLady Reading Hospital

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



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:

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 SkinSurgical Nephrology Neurosurgeons UrologyDental 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 LRH2. Additional RMO He is to assist RMO3. Senior Social Medical Officer 4. Social Medical Officer5. Steno Typist6. Computer Operator7. social guides8. Ardalee

SOCIAL SERVICES UNIT

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



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 3LDC ---lower divisional clerk 1Social guides 2Ardali 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 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.

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



Accident and emergencyDepartment

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


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

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

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

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

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

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seen by a physician more 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 corner2 Waiting lounge 9 ECG room3 CMO office 10 DMS office4 Registrar office 11 X-rays room5 Female examination hall 12 Casualty Lab6 Casualty Medical Ward Male 13 Trauma room7 Casualty Medical Ward Female 14 Casualty Cardiac Unit

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;


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

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

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

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Acknowledgments

The first flour setup is somewhat like the following;

1 Director A & E office 6 Plaster room2 Casualty Operation theater 7 Casualty Surgical ward male3 Waiting lounge 8 Nursing room4 Casualty orthopedic ward male 9 Casualty surgical ward female5 Casualty orthopedic ward female

The setup of the trauma room

1 Nursing counter 4 Doctor’s office computer office2 Nursing supervisor office 5 Store room3 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 staffTotal Ardalees in mornig shift 28Sweepers 15Police Men 10 all shifts

Flying SquadSupervisor 1Dispensers 3

By: Imran Ahmad

NURSING STAFF

SPR H/N C/N N/A S/N Medicine counter

4 1

CMW/ male 4 1 5CMW/ female 5 5CSW + COW 1 7 5COT 1 4Trauma Room 1 4 1 4CCU 4

SUMMERY

SPR Supervisor 1H/N Head Nurses 2C/N Charge Nurses 32N/A/ Nursing

Attendant3

S/N Student Nurses 19TOTAL 57

Acknowledgments

Drivers 2

Beds and other stuff

Stretchers 14Wheel chairs 5Ambulances 2

Nomenclature

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

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

4 Dr. Muslim Khan “DMS A&E” LRH

By: Imran Ahmad

BEDS

CMW/m 9

CMW/f 9

COW/m 10

COW/f 4

CSW/m 10

CSW/f 10

TOTAL 52

A & E -LRH

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

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

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

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

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

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

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

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

Acknowledgments

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.

COTCOT 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.

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.5 Daily Express, 9-oct-2007

By: Imran Ahmad

Acknowledgments

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:

By: Imran Ahmad

Acknowledgments

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 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.

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

By: Imran Ahmad

Acknowledgments

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?

By: Imran Ahmad

Acknowledgments

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 incidentE: Exact LocationT: Type of incidentH: Hazard, present and potentialA: Access in emergencyN: Number of casualtiesE: Emergency services required 7

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 AidFirst 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?

7 Fazl-E-Hakeem, “Nursing Supervisor” LRH Peshawar8 ? Dr. Muslim Khan “DMS A&E” LRH Peshawar

By: Imran Ahmad

Acknowledgments

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.

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

By: Imran Ahmad

Acknowledgments

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.

By: Imran Ahmad

Acknowledgments

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.

By: Imran Ahmad

Acknowledgments

Case no. 1Department/ Ward: A&ECase type: OrthopedicName: Riaz AliAge: 37 Resident: Serchina SawabiEducational qualifications: M.A. B.EdOccupation: principle of a school in sawabiMajor problem: an injury in right foot

History of the patientThe 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 doctorDr. 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 workerThe 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.

By: Imran Ahmad

Acknowledgments

Case no. 2Department/ Ward: A&EPurchee No: LRH0907-080970Nature of the case: surgical Name: Noor MohammadAge: 75Respondent: none Marital status: married No. of Off-springs: 6 - (3 daughters and 3 sons) Financial position: dependent upon his sonsOccupation of the supporters: drivers Resident: Pajagee Road Peshawar Educational qualifications: nil

By: Imran Ahmad

Acknowledgments

Major problem: urine problem

History of the patientThe 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 doctorDr. 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 workerThe 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. 3Identification

Purchee no. --------------------Name: Niat MeerAge: 75Nature of the case: Neoro-Surgical Ward: Trauma RoomFamily system: joint Respondent: Abad Meer = brother Zubair = Hassan = step sonMarital status: he has a second wife who is also near death

By: Imran Ahmad

Acknowledgments

No. of siblings: 1 son who has died 14 years ago in the age of 25, 2 step sons Financial position: independentResident: Pir Qala, Shabqadar Dheree Educational qualifications: nilChief Complaint: severe Head injury___________________

Present HistoryAccording 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 HistoryHis 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 PositionThe 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 situationThis 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

By: Imran Ahmad

Acknowledgments

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.

RecommendationWe 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. 4Identification

Purchee no. LRH0907-091797Name: Hameed KhanAge: 25Nature of the case: Neoro-Surgical Ward: Trauma RoomFamily system: joint 25 members live in one houseRespondent: Farzullah Khan = brother Fazal Dad = brother Rahmat = nephewMarital status: unmarried No. of siblings: 5 brothers and 7 sisters

By: Imran Ahmad

Acknowledgments

His position: he is the youngest of allOccupation: zamidari Resident: Bela Neko Khan, Dalazak Road, Peshawar Educational qualifications: nilChief Complaint: severe Head injury___________________

Present HistoryAccording 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 HistoryMr. 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 situationBela 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.

RemarksNow 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

By: Imran Ahmad

Acknowledgments

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.

By: Imran Ahmad

Acknowledgments

You just call them and they will be available. Some of the donors name and their contacts are being given below;

S. NoBlood Group

Name F/NameContact

No.Address

1 A+ Bilal Siddiqee M. Siddique0332-9124774

Garhi Baloach Peshawar

2 A+ M. Yousuf Gul Rehman0345-539592


3 AB+ Bilal Ahmad Sajid Khaista Gul0321-9021277


4 B+ Asim Nawab Nawab Khan0333-9317506

Department of Environmental Sciences UOP

5 B+Syed Haroon Ali Shah

Syed Yousuf Shah0300-5955868


6 B+ Momin Khan Abdul Qayum0334-9204705

Thandee Khoee Peshawar

7 O+ M. Mustafa Sajid Khaista Gul345-9163441


8 O+ M. Tariq0346-9810631

Department of Environmental Sciences UOP

9 O+ Younus Javed Gul Rehman0321-9056048


10 Amaanullah Abdul Qayum0334-9204704

Thandee Khoee Peshawar

11 Malak M. Bilal Malak M. Sharif Yakka Toot Peshawar

Bibliography

Social Services Unit Staff

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

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

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

A & E Staff

By: Imran Ahmad

Acknowledgments

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

INTERNET1. 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

By: Imran Ahmad

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

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

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

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

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

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

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

Acknowledgments

Map of lady reading hospital

By: Imran Ahmad

Acknowledgments

By: Imran Ahmad

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

Documents

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