Word of Guidance Med Interns

8/12/2019 Word of Guidance Med Interns

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A WORD OF GUIDANCE TO

MEDICAL INTERNS

Dr. S. Terrence G. R. De Silva,

(MBBS, DPS, DFM, DLSHTM, M.Sc. (Lond), MD)

Deputy Director General (Medical Services) I

(Former Director of the National Hospital of

Sri Lanka, Colombo)

2009


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Copyright 2009 Ministry of Healthcare & Nutrition,Sri Lanka

Published by Medical Services Division

ISBN 000-000-0000-00-0

Contributors:

Dr. S. Terrence G. R. De SilvaDr. Lakshman Senanayaka

Dr. Deepthi Samarage

.. (Blood Bank)

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Content Page

You and Your Patients 08

Principals governing provision of medical care .. 21

Eight points concept to enhance positive attitudes towards

patients 22

Avoiding Medical Errors 28

A message from Blood Bank .. 40

Communication skills for Doctors .. 50

Guidance in issuing medical certificates . 56


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Message from the Hon. Minister of Healthcare and

Nutrition

At the outset let me congratulate you for selecting a nobleprofession as your vocation and successfully completing your

university degree.

You are about to start the mandatory training period which

would give you the necessary experience and skill which is a

prerequisite to heal the sick with responsibility.

Sri Lanka is proud of its achievements in the field of health

care, which is amply substantiated by our health indicators

which are comparable to those in the developed world.

One of the important factors that contributed to this success

story is the commitment and dedication of all the health care

workers functioning at different levels in the Ministry of Healthand peripheral institutions. I am happy that the majority of our

staff working towards providing Quality Health Care to all SriLankan without any discrimination.

Brief but valuable information in this booklet would guide you

to be a worthy professional to whom the Sri Lankan publiccould truly be grateful for.

Nimal Siripala De Silva

Minister of Healthcare and Nutrition

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Message from the Secretary, Ministry of Healthcare andNutrition

I wish to welcome you to the Ministry of Healthcare and

Nutrition.

I am very happy that the Ministry of Health was able to provide

you with this opportunity of training as a medical intern to

improve your knowledge and also gain the necessary

understanding and skills to treat the sick.

It is indeed a challenge to be able to fulfill the ever increasing

expectations of the public who seek care, within a rapidly

enlarging horizon of technological improvements and access to

information.

You as a House officer would be playing an important role at

the interphase between the care seekers and the care providers,

which would indicate the responsiveness of the Health Serviceand ultimately the fulfillment of the expectations of the patients.

The Guidance gained from this booklet will assist you to

achieve this difficult but essential part of your training.

Dr. Athula KahandaliyanageSecretary

Ministry of Healthcare and Nutrition


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Message from the Director General, Ministry of Healthcareand Nutrition

While greeting you as young members of the medical

profession, I am glad that you would have the advantage ofmeeting, examining and treating the large number of patients

attending the Ministry of Health Hospitals which eventually

will transform into a vast deposit of clinical experience for your

future guidance.

At the commencement of your internship I whish to emphasizethat it is very important to recognize that you are expected to

treat all your patients with dignity, respect and kindness, to

which they are rightfully entitled to.

This publication summarizes some of the key issues that wouldguide you to look after these patients in a manner that you could

be proud of.

Dr. Ajith Mendis

Director GeneralMinistry of Healthcare and Nutrition

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You and Your Patients

By Dr. S. Terrence G.R. De Silva,

MBBS, DPS, DFM, DLSHTM, MSc, (Lond), MD

Deputy Director General (Medical Services) I(Former Director of the National Hospital of Sri Lanka,

Colombo)

A time tested system of providing medical care existed for a

long period. The history taking, the physical examination and afew basic investigations were done to arrive at the diagnosis of

ailments. However, some of the recent advances in medical

science, the technological innovations and the different teachingmethods followed in various medical schools specially, outside

Sri Lanka, have threatened the existing low cost patient care

system. The young doctors today, tend to bypass the historytaking & physical examination and try to rely mainly on thelaboratory & radiological investigations which are very

expensive and at times beyond the capacity of our hospitals.

In addition, there are increasing public expectations and

demands for high quality service. Many of the patients haveaccess to medical information via the improved information

technology and they show an increased desire to involve with

the decisions related to their healthcare.

As far as the health indicators are concerned the health serviceof this country is almost in par with those in the developed

countries. People of this country are generally satisfied with the

health service and they have placed their trust and confidence in

this system. Nevertheless, in recent times, the attitudes of those

in the sphere of health towards their patients have left much to

be desired. Perhaps this is part and parcel of the situation in thesociety at large. It is the duty of everyone to protect our health


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system. For this it is necessary to strengthen the positiveattitudes and qualities among the health care staff. This booklet

A Word of Guidance to Medical Interns was prepared withthe aim of making an attitudinal change among the young

doctors.

What Your Vision & Mission should be?

Having successfully completed your school education, you

made up your mind, sometimes against many odds, to become a

successful medical professional in this country. Sometimes itmay have been an aspiration you have had over a number of

years. Becoming a successful medical professional was your

deep rooted vision and by this time you have been partly

successful in realizing this vision.

As a medical professional it is your duty to care for and treat

with kindness, love and empathy, your fellow human beings

who are ill and incapacitated. This is your mission as a medicalprofessional. In order to make your vision a complete success

you must ensure that you carry out your mission withdedication and commitment.

The Ministry of Health respects your vision and values your

desire and decision to carry out your mission. Recognizing yourvision and the mission stated above, the Ministry of Health

extends you a warm welcome to the Ministry. Our Ministry isthe prime healthcare provider of this country.

You are today commencing a journey with a small step but a

giant leap forward. Let me emphasize at this stage that there is

no red carpet for you to tread on, but a long and yet satisfyingand meritorious path ahead, if you would only dedicate

yourselves.

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Those medical professionals who are already serving theMinistry of Health and the Professorial Units attached to the

Faculties of Medicine are always ready to help you to carry outyour mission and to realize the goals you aspired to achieve in

your life.

The Internship Appointment

I am sure from the day your name appeared in the list of

students who have passed the final MBBS examination on the

Medical Faculty notice board you have been eagerly waiting forthe internship appointment. You would have been extremely

thrilled on this day over your success at the examination and

realization that henceforth you will be addressed as Doctor.

We have no doubt that you and all your family members would

have enjoyed this happy moment.

Going through your life, the day you assume duties as an intern

house officer is going to be another memorable day. However,internship is not plain sailing. Only once you commence the

internship you would realize the challenges that come with it.You will have to spend long sleepless hours, attend to virtually

never ending ward work and face criticism and sometimes theblame from your superiors including the Consultants & the

Senior Registrars (who actually have gone through the samehardships before you). You may feel like a slave, a laborer, a

prisoner, and at times be in a confused emotional state. Do notget disheartened about this, but think in terms of perseverance

and endurance. The Internship period is a compulsory training

and I should say that to most of us, it is really a hard time.

During the Internship you will feel the taste of what is available

for you, sometimes sweet, sometimes sour, sometimes bitterand all blended with ingredients of hard work, personal

sacrifices, mental fatigue frustration, and of course the


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satisfaction realizing that you have helped a human being toalleviate his suffering.

In the midst of all this you might even question yourself as to

your choice of the medical profession. You might even blamethose who encouraged you to become a medical doctor. I have

seen some interns comparing their lives with those of their

schoolmates who are serving in different fields, with much free

time and the ability to spend to enjoy life.

You must not be discouraged at this stage and must develop apositive attitude and gain strength to face all these situations.

Accept your internship as an opportunity to become a

successful medical professional in future. Many years later

when you walk down the memory lane, you will recall the sadand happy moments, the lessons you learnt from your superiors

and also from the patients, the skills you were able to develop

and the superiors who were there to guide you and all otherthings that made you richer in experience. Most of the Senior

Registrars and Consultants who trained you and sometimesblamed you would become lifelong friends. Later on you will

realize that most of them are with you at times of distress andneed, throughout the rest of your life. This is the beauty of the

strenuous training.

At present you may be at the bottom rung of the professionalladder, and you have to climb step by step and one day you will

reach the top rung. I must emphasize that you may have to

continue to struggle during the rest of your career too, but am

sure will improve as you go along.

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What is Special about Your Work in the Health Sector?

The Healthcare Service is saddled with the responsibility of

caring for and pursuing human life. First of all, think of thecrucial role you play in such an esteemed noble service and

come to terms with the importance of the task you are calledupon to perform.

Naturally, the position you hold in the Health Care Service

provides you with a livelihood. Yet, in this noble service, youhave to accept your position, as more of a calling than a job,

giving you an opportunity for a meritorious service.

The Specific Nature of Your Work

The Health Care Service has its own share of public liaisonactivities. The hospital is a busier place than a government

office which serves a limited clientele. Work at a hospital is of a

more arduous and one may face diverse problems. It is often

difficult to provide a service to please everyone and to meet theexpectation of people from all walks of life and holding varied

requirements. It is more so, since the people who come to a

hospital for treatment are patients ailing from various illnesses.

As an intern and thereafter as a medical officer you may havecertain specific difficulties. These include the restrictions in

obtaining leave even for an urgent personal matter, obligation toreport for work even on Sundays and public holidays which is a

facility enjoyed by the other state employees, to work on nightshifts and the need to report for work during such crisis as

disrupted transport services and being called upon to work onunexpected work shifts in emergencies.

The medical professionals like anybody else have to face

personal or family problems. Despite all these, you are expected


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to work in a spirit of dedication. Whatever your personalconstraints are, when you are on duty at the hospital, your mind

and heart should go out to the patients. This is the nature of thework of a medical professional.

Communicating with the Patients

One of the important and challenging part of providing care

during the internship and thereafter as a medical officer or a

specialist is establishing a good rapport with patients and their

relations, and communicate with them in such a way to makethem recognize your commitment and ability to provide care

using your skills and knowledge.

The first impression of any person coming into contact with you

is governed by the way you appear and the way you carry andpresent yourself.

You have to be neat, clean and tidy and with your hair wellcombed and also face well shaven or beard trimmed. It is

important that you conduct yourself like a professional. Theway you talk, the way you smile, the way you walk and the way

you behave in front of your patients, relations, superiors etc.should generate respect not fear or disgust. The patients

generally have a perception about how a doctor would look like.Therefore to start with your appearance and behavior should be

like a doctor.

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Bestow Compassion on Patients

Compassion is a must you should have. Your smile costs younothing, but it makes you a pleasant and comfort person to the

patient. Go about your work with a smile on your face. Whatgood will be done by blaming the patient instead of using kind

simple words when you want to advice, which will be of more

effective. In patient care, flexibility is of vital importance.

Always try to accommodate the requests of patients as far as

possible, because then only they will be able to comply.

When you talk about such matters as personal cleanliness, or in

instances of giving medical advice, do so after calming your

mind and without anger. When you explain the matters related

to an illness to the patient or to his relations, use the simplest

language possible, the common, conversational languageunderstandable to layman. Not only is the medical terminology

may be beyond their grasp, they may be further confused by

such words, which may be misunderstood in a way totallydifferent from the way you meant them to be.

It is necessary to address the patients with due respect and it is

always better to address the patient by name, and ensure that hisdignity and self-respect remains unsullied. The words that make

the patient pleased can be used. To cite examples, addressing apatient as Mr. or Madam may go a long way to win the

confidence of patients and their relations. Using polite words asplease, help to make patients conduct themselves well during

their stay at the hospital. Similarly, in case of an inadvertency

on your part, do not hesitate to say sorry with an explanation.

Making an apology is not something to be ashamed of when

you have done a mistake.


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Who is the VIP at the Hospital?

The VIP at the hospital is the patient and no one else. A hospitalcould be considered as a sacred place. In the days gone past,

patient care and cure were associated with temples andchurches.

A patient enters the hospital in a physically weak and mentally

depressed state. Your patient expects from you the same

affection, kindness, compassion, attachment and love that a

child expects from his mother, If you can ensure that thisexpectation is fulfilled, the patient will think of you as having

divine qualities. If he or she feels so, it will give you a

satisfaction of being special among others. The blessings the

patient invoke will surely fall on you and your loved ones.

See whether the meaning of the adaptation of this poem taken

from a Sinhala didactic work is relevant to you.

we; ; ak e; ; amr f , dj i qo f k k suy ;y f


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Do unto the patients what you like others do unto you, insimilar situations. Keep in mind the fact that one kind word

from you gives the patient more relief, than a drug worththousands of rupees.

Soothe the Pain

In the story of Mother Theresa it is stated that one day she

found a dying woman half infested with maggots and bitten by

rats. Mother Theresa sat besides her stroking her head gently

till her death. Did you take to medicine to act in the same spirit?Of course Mother Theresa later on in her life became a willing

companion for the dying; washing their wounds, soothing their

sores and preparing them for death with dignity.

Patients like to know about their condition. Thanks to the freeand compulsory educational policies of the government of Sri

Lanka 98 % of people are literate. Patients know something

about illness and want to know what is wrong with them,why it happened, what more will happen and most

importantly what we are going to do with them and whetherany further problems will happen because of what we do. We

should not assume that simply because we are doctors orbecause we are providing free medicine they would accept our

word without questions.

As doctors we are obliged to spend adequate time to explainthese matters and put their minds at ease. On the other hand the

best antidote to fear is providing correct information. Once the

patient realizes the actual condition of his illness (which is often

less than he would have imagined) and the balanced view of the

advantages and disadvantages of the treatment offered to them,it would be his wish that we should respect. This ability to

communicate you would have developed over the last few years

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of training. Additional guidance would be available in thisbooklet.

Patient is also a Member of a Family

When a patient is hospitalized, the patient as well as his family

members faces a variety of difficulties. Think of a situation at

your own home if the mother is hospitalized! Those at home

may be deprived of the person who did the cooking and other

essential household activities. If the father is hospitalized, the

family may miss the sole breadwinner. When you deal withpatients such factors should also be taken into consideration.

Dont forget the patient is a member of a family. Give a kind

and sympathetic hearing not only to the patients, but their

relatives as well.

Although the state provides free medicines and the services,

they also contribute the same in spending for transport and

other expenses out of pocket. Dont forget that every citizen ofthis country has contributed to the government coffers by some

way or other.

Take Pride of What You Have Done to Relieve the Sufferingof the Sick

Do your duty not merely because of the earnings you make

from the job. Yours is a worthy service the value of whichcannot be measured in financial terms. Undoubtedly, one needs

an income for a living. Yet real happiness of life can never be

bought.

Go about your work in a way, that you achieve a sense ofcontentment in caring for patients. Dont let the patient feel it,

even if you are facing inconveniences. Learn to enjoy the

satisfaction of seeing your patient recover from his suffering


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due to your efforts. Thus you achieve nobility in life asexpounded by the following lines from a famous sinhala song

based on religious teachings.

What other happiness in theworld than health,

What other wealth in the world

than happiness

Most professionals take great pride in their professions and

always strive to maintain high standards and a sense of greatfulfillment in what they are doing. Similarly we who are in the

health sector providing care should take pride and comfort

ourselves from what we have done to help to alleviate the pain

and suffering of fellow human beings.

A Better Future for Our Children

Today we have to play our role properly; if not therepercussions would not only on us but also fall on future

generations.

One day when you finally leave your stethoscope aside, if youhave acted in a way that will make you contented that you have

led a fruitful life, you are a person who has done your best forthe country. It is certain that one day you will really enjoy

that spiritual solace you desire.

A few words from the song Heal the World by internationally

renowned pop-singer Michael Jackson are relevant here.

Heal the world

Make it a better place

For you and for me

And the entire human race

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There are people dyingIf you care enough

For the living

Make a better place

For you and for me

I wish to conclude this bit of advice, with a quotation of Albert

Einstein. Only a life lived for others, is a life worthwhile.


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Principals governing provision of medical care

o Each patient shall be treated as a whole, irreplaceable,unique, and worthy person

o The patients safety, health, or welfare shall be protectedand shall not be subordinated to organizational, staff,educational, or research interests or to any other end.

o The privacy of the patient and the confidentiality ofevery case and record shall be maintained.

o Behavior reflecting the dignity, responsibility, andservice orientation of health care professionals, worthy

of the publics respect and confidence, shall be practiced

by all individuals.

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EIGHT POINTS CONCEPT TO ENHANCE POSITIVE

ATTITUDES TOWARDS PATIENTS

01. SmileThe smile costs you nothing but would give much, by way ofa comforting and a pleasant feeling in your patients. Thepatients would be on the road to recovery even before youtalk to him\her.

02. GreetGreet them with a word such as "Ayubowan" and follow upby addressing him with the name. This will generate a warmfeeling which would break the ice and make obtaining thehistory so much easier.

03. CourteousnessBeing polite and speaking to patients with due respectwithout any discrimination is very important in publicservice. It is necessary to answer their queries with courtesybecause patients have a need and a right to know abouttheir condition as well as about the treatment you offer.

04. AffectionThe patients will be pleased with you only if the treatmentyou offer is tempered with a feeling of goodwill and kindnessthat emanate from the bottom of the heart.

05. ListeningThe art of being a good listener is to create the space withinwhich the patients could air their own feelings and thoughtswithout fear. A good listening response is often all that isneeded to help patients to divulge their inner concerns andfeelings.


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06. SensitiveBeing sensitive to patients needs is an affirmation made tothe patient by the health care staff that indicates "Yes, youare sick and I understand that you are not able to do thethings you would like to do, or have done in the past." We

should at all times help when we can and understand thatpatients are the ones who have been inconvenienced by theillness.

07. Be SmartBeing presentable, smartly dressed and a having pleasingpersonality is important to positively impress your patientsand will increase the patients compliance towardsrecommended treatment.

08. Be Prompt.Patients need an answer for their suffering and will not wait

till the formalities and investigations are completed. Beingquick in providing treatment, even to provide temporaryrelief, is the expectation of all patients.

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Avoiding Medical Errors

Dr. Lakshman SenanayakeFRCOG, FSLCOG, MA

Consultant Obstetrician & GynaecologistConsultant Hospital Efficiency & Quality, SLHSDP

What are Medical Errors?

A medical error is an adverse event that could have been

prevented if adequate care had been taken by the care

provider, considering the current state of medical

knowledge.(1)

These do not include some adverse events due to treatment

such as side effects of cytotoxic drugs which are undesirable

though not entirely unexpected.

Are they Common?

In November 1999 the report of the Institute of Medicine (IOM)

of USA by Lucian Leape and David Bates entitled To Err Is

Human: Building a Safer Health System, focused a great deal

of attention on the issue of medical errors and patient safety.

The report indicated that as many as 44,000 to 98,000

people die in hospitals in the United States of America,

each year as the result of medical errors.(2)


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98000

43458

600050

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

Medical

Errors

Traffic

Acci dents

Accid ents

at work

Plane

Crashes

Deaths

Surprisingly in Canada 60 people die due to airplane accidents

every year where as 24,000 die from medical errors.National statistics on medical errors are not available in Sri

Lanka, but each of us would know at least of a few instances

either among our relations, friends or patients who had suffered

on account of a medical error.

I can think of one of my batch mates who had a cautery burnafter a minor operation which prevented from going for work

for more than two months and a relation who suffered from awrist drop due to nuropraxia because of the wrong positioning

at surgery.

Recent Media reports of shocking instances of amputation ofthe wrong leg or accidental cutting off of a finger is still fresh in

our minds

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Can they be prevented?

An Australian Study on Adverse Events in hospitals of New

South Wales found that adverse events were preventable in

more than 50% of cases.

A study in U.K. on Adverse Events in Obstetrics andGynaecology found that more than 50% are preventable.

(3)

Therefore it is important to learn from them and take

measures to prevent them rather than Blame or Shameothers

Why do Medical Errors happen?Medical Errors are mostly due to a combination of factors rather

than one single factor.

All medical Errors are preventable To err is Human.

To cover up is unforgivable.

To fail to learn is inexcusable.


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Human FactorHuman Error is the aspect which is often highlighted and you

and I as care providers are directly responsible for theiroccurrence and we have to individually face the consequences.

Although every one knows that health care providers do not

cause harm to patients intentionally, the grief reaction of thevictim and his or her relations usually results in blaming and

shaming the care providers and sometimes even physically

assaulting them.

Human Errors can be considered underthree headings

Slips and lapses (unintentional)

Mistakes (intentional incorrect action)

Violations (intentional deviation from safe practice)

Slips and LapsesThese are unintentional and may happen because of:Failure to recognize:

A sign, investigation finding or a change in thecondition of the patient.

E.g. Not recognizing that the patient is pale indicatinginternal hemorrhage one may loose the patient brought

to the hospital after a fall from a height. Result is

Patient is lost.

Failure to pay attention to a finding:

Findings such as tachycardia, or tachypnoea may have

been recognized but due attention such as informing theconsultant, starting a transfusion or correcting the

hydration may not have been done Result is Patient is

lost.

Failure in Memory:An important action may not be done as it has escaped

your memory. Giving a blood transfusion to a postoperative patient to compensate the blood loss at surgery

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in the post op ward. The next call you may get may bethat the patient has collapsed and bad.

Mistakes

These are intentional and occur when a course of action that is

incorrect is decided on, and therefore does not have the desiredresult or even a harmful result.

Rule based:

For example, syntometrine is given for active

management of the third stage in a woman with

hypertension and she subsequently has a fit. A good rulehas been used in but in the wrong situation.

Knowledge based:

There is a lack of knowledge. Treatment is decided on

without being certain or asking a senior person .It doesnot have the desired effect. Or worse a harmful effect

Some times a colleague or a nursing officer may point

out the error but the person may not pay attention due tohis ego or ignorance.

Violations

These are intentional deviation from safe and accepted practiceor given instructions

Routine:Cutting corners or taking short cuts, e.g. Not entering

the instructions in the BHT but verbally asking theNursing Officer to do it.

Reasoned

Interne considers that he can do a forceps for fetal

bradycardia in the delivery room without informing the

senior because the FHS is low or he withholds givingblood to a patient with a PPH as the blood pressure is

normal although the loss is more than 1000 mls and has

a tachycardia.


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Reckless:Harm is foreseeable but not intended, e.g. Going on

making multiple attempts at a procedure such as LiverBiopsy without calling for help or imaging assistance or

Going on with uterine massage or Oxytocics for PPH

without calling the Seniors or the Consultant.

What can you do to prevent them Happen?

Communication errors

Communications include not only the verbal discussionsbut the written communications via the entries in the BHT.

Your notes on the BHT are vital not only for the safety of the

patient but for your safety as well, in the event of a complaint or

litigation.

The entries on the BHT mustbe clear, legible and in complete

sentences.The comments on surgical decisions and other invasive

procedures should indicate:

Justification on what grounds the decision is made

What the decision is

Any instructions others need to follow

Wishes of the patients regarding this decision

Coordinating with other departmentsThe welfare of the patient depends on the Team Effort .Thougha patient is under one Consultant, he may desire opinions and

advice from other specialists. Therefore coordinating thecommunications between different specialists and departments

is vital and is the responsibility of the house officer.This should be attempted promptly politely and personally by

yourself.

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Other Important Issues

The prescriptions should be written clearly with the Genericname of the drug in capitals and the dose and the frequencyof administering clearly indicated. One patient in USA died

because the cytotoxic drugs were administered four times a

day when the instructions meant that the dose to be givenover a four day period. Lack of clarity in the entry causedthe death.

Names of the drugs may look and sound similar. E.g.Ergometrine used in the past for PPH. and Ergotamine for

Migraine, Zantac (ranitidine) for heartburn, Zyrtec

(cetirizine) for allergies, Celebrex (celecoxib) for arthritisand Celexa (citalopram) for depression.

Do not assume that that other person would do somethingbut clearly indicate and specifically on the BHT requesting

him to do it. If informing another care provider is urgent, do it then and

there. You may forget it later.

Keep a check list or a record of things you have to do andtick them off as you complete.

Labeling Errors

Always check the name of the drug on the vial/bottle beforeadministering the drug. Do not assume that it is the drug

because it is in the same cupboard or the same container.

Check the details on the label of the blood packs beforestarting the Transfusions of blood and blood products. Do

not assume that it was checked by some one else. One who

starts the transfusion is responsible.

Check the name and the identification on laboratory report,the X-ray or other reports before acting on them.

Address the patient by his name as given in the BHT.Whenever you communicate with him.


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Avoiding Medical Errors in Surgery

Source Ref 4

A mistake made in performing surgery on the wrong side of theleg could be disastrous not only to the patient but to the surgeon

as well. Though this kind of errors is rare, it continues tohappen in different parts of the world. A hospital in USA

reported that three patients had surgery done on the wrong side

of the head within one year.(5)

The points at which errors may happen in surgical procedures

is given in the chart which analyzed errors in USA

Higher Risk of Medical Errors

Patients undergoing multiple surgery Multiple surgeons taking part

Rushed to finish the surgery

Basic principles in preventing wrong site, wrong

procedure, wrong person surgeryo Avoid relying on memory alone.o Use a Check List to keep track of essential items that

needs to be done before surgery.

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o Talk to the patient by name and check with him/her inthe verification process.

o Discuss with other members of the surgical team.o Adhere to the protocol of.

the Unit or the instructions of your Consultant.o If there is a deviation from this, inform the Consultant

immediately.

o Mark the site of the Surgery accordingly.

The following steps are recommended to be taken at every

surgery.

Verification (To be done in the ward)

Purpose: To ensure all required documents and requisites

are complete.o Confirm identity of the patient with the surgical

procedure

o Pre operative Investigationso Other Requirement s Blood X match Prosthesis etco Informed Consent mentioning the site and side of the

surgery

Marking the site of the Surgery (To be done in the ward)

Purpose: To specifically identify the site of surgery in order

to clearly indicate the site of Surgery

o For procedures involving:o Rt/Lt distinction, the side Right/Left must be clearly

marked

o Multiple structures such as fingers should be identifiedo Intended site must be marked so that it would be visible

after covering the patient with towels. E.g. Label on theforehead


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Final Verification Immediately before starting the operationin operating theater Time Out

Purpose: To conduct a final verification before starting the

surgery

Check the name of the patient from him/her and confirm thesurgery/site/side preferably with the participation of another

member of the team.

Procedure must be started after this had been done. If there is

any doubt the consultant should be informed immediatelybefore starting the surgery.

Getting Consent for a surgical or other procedures

Informed Consent includes the following three parts and isthe responsibility of a medical officer who is, often the

intern house officer. The first part is the explanation to the patient,

in a language that the patient can understand, of the nature of a proposed procedure or

treatment,

its potential risks and benefits,

reasonable alternatives which may be available.

The second part is ensuring that

patient understands what has been explained (tothe best of the patient's intellectual capacity);

the patient accepting the risks;The patient giving his or her consent to undergo the

procedure or treatment

Finally, the process must be documented clearly in alanguage that could be understood by the patient

38

References:1 Encyclopedia of Surgery: A Guide for Patients and

Caregivershttp://www.surgeryencyclopedia.com/La-Pa/Medical-

Errors.html

2 http://www.ahrq.gov/qual/errback.htmMedical Errors Scope of the Problem

Agency for Health care Research and quality

3 Risk management in obstetrics; Current Obstetrics &Gynaecology (2005) 15, 237243

4 Sandra Strickland Preventing Medical Error WrongSurgery Preventive Action Vol 17 No 12004

http://www.firstprofessionals.com/newsletter-pdf/Phys-

winter-04.pdf

5 http://www.msnbc.msn.com/id/21981965/


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39 40

Blood Bank...,

Director, National Blood Transfusion Service

All Intern House Officers must report to the Blood Bank of

their institution as early as possible for an orientation

programme.

Instructions on basic Blood Bank procedures are given belowfor easy reference.

ABO & Rh-D Grouping of Patients & Antenatal Mothers

Materials Required

Specimens: Clotted blood sample or EDTA blood sample.

Reagents: Anti A, Anti B, Anti AB, Anti A1Anti D - monoclonal IgM Anti D

Reagent red cells A1 cells, B cells, O cells

N. Saline/PBS (Phosphate Buffered Saline)

Test tubes, Pipettes,

Metal tube stand

Table top centrifuge

Report forms

Registers for recording results

Procedure

1. Check the sample and request form to ensure that thepatient identification is correct.

2. Label the sample and request form.3. Centrifuge the sample at 1000- 3000 rpm for 3 min to

separate serum.


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4. Prepare a 5% cell suspension (can be prepared byadding 19 drops of saline to 1 drop of patients red cells

5. Arrange 8 test tubes on a test tube rack and label withpatient & test identification as following.

E.g.: Pt 1 1 1 1 1 1 1

5% cell Anti Anti Anti A1c Bc Oc

Suspension

A B AB D

Add one drop of anti A, anti B, anti AB & anti D to first

four tubes. Add one drop of 2- 5% cell suspension of red cells to be

tested.

Add two drop of patient serum/plasma to test tubes labeledas A1c, Bc, Oc.

Add one drop of A1reagent red cells to tube labeled as. A1cAdd one drop of B reagent red cells to tube labeled as Bc.Add one drop of O reagent red cells to tube labeled as Oc.

Mix the contents of the tubes and centrifuge at 1000rpm 20seconds or keep at room temperature for 5 min.

First take the cell grouping tubes and gently resuspend thecell buttons and examine for agglutination Grade and record

the results on worksheet

Take the serum grouping tubes and first examine the serumoverlying the cell button for evidence of haemolysis.

Gently resuspend the cell button and examine foragglutination.

Grade and record the results on work sheet.

42

Compare and confirm the cell grouping results with theserum grouping results.

Gently resuspend the cell button of the Rh D typing tubeand look for agglutination.

If no agglutination seen, repeat the test with 2 drops of sameAnti D.

Test for detecting weak D is unnecessary for patients whenusing monoclonal IgM antiserum.

Interpretation

Agglutination of any cell grouping tube and haemolysis oragglutination on serum tests constitutes a positive result.

The expected agglutination reaction for positive tests is 3+or 4+ in cell tubes.

Agglutination in serum tubes is often weaker. The reactioncan be enhanced if incubated at room temperature for 15

min.

A smooth suspension of red cells after resuspension of thecell button is a negative result.

In serum grouping tubes, if the supernatant (beforeresuspension) is pink/red and if the size of the cell button is

smaller or no cell button is seen it indicates lysis and is a

positive result.

ABO Grouping

Anti

A

Anti

B

Anti

ABA1c Bc Oc Interpretation

0 0 0 C/L C/L 0 Group O

3/4+ 0 3/4+ 0 C/L 0 Group A

0 3/4+ 3/4+ C/L 0 0 Group B

3/4+ 3/4+ 3/4+ 0 0 0 Group AB

C = clumps L = lysis


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Rh D Type

Anti D (not detecting Dvi variant) Interpretation

+ Positive

0 Negative

After interpretation, the blood group must be compared withprevious records, if available.

If any discrepancy between present group and previousgroup is encountered, request for a second sample andconfirm.

If any discrepancy between serum and cell grouping isencountered, repeat the test using washed cells.

If the discrepancy persists, consider the previous history ofTransfusions

If there is no discrepancy, record the blood group of thepatient.

Documentation

Enter the results of the patients grouping in the PreTransfusion Testing Register.

Complete and counter sign a Blood Report.

Pre Transfusion compatibility testing

Material RequiredEquipment. Refrigerator to store samples and reagent at +2C to

+6C

. Table top centrifuge

44

. Microscope

. 37C water bathSpecimen. Clotted blood sample of patient. 5% suspension of red cells prepared forms a selected

donor unit.

Reagents

. 0.9% saline

. 22% Bovine Albumin

. Anti human globulin (AHG)

. LISS Additive. PBS

Glassware. Glass test tubes. Glass slide. Pipettes

Miscellaneous

. Disposal box

. 2 plastic beakersTest tube racks

Procedure

1. Give a serial number to the testing sample and the requestform before commencing the procedure.

2. Group patients sample for ABO and Rh D as per REF/ SOP/02..and accordingly select a group specific blood unit/s

for cross matching.

3. If the presence of an antibody is confirmed, select relevantantigen negative blood unit/s and/or if patients phenotype

is known select blood units according to the phenotype.


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4. Label test tubes as D1, D2 .according to the number ofdonor blood units requested for the patient. Add one drop of

donor cells to each labeled test tubes.

NISS Method

5. Add three/two drops of patients serum to all test tubes.

6. Add one drop of 5% suspension of cells from donors to therelevant test tubes

7. Mix the contents and incubate all test tubes at 37 oc for 45minutes.

8. Take out and centrifuge at 250g for 20 seconds.9. Look for haemolysis and then gently disturb the cell button

to note agglutination of cells.

10.Grade and record the results.11.Add PBS to fill 2/3 of all test tubes.12.Centrifuge at1000g for 1 min.13.Decant the supernatant PBS.14.Repeat the same washing steps twice.15.After the last wash, add two drops of poly specific AHG to

all the dry cell buttons in each test tube.16.Gently disturb the cell button to note any agglutination of

cells. Record results in the work sheet

Saline Albumin Cross match1. Take two test tubes each for each Donor pack & label them

as Saline (S) & Albumin (A).2. Add three/two drops of patients serum to all test tubes.

3. Add one drop of 5% suspension of cells from donors to therelevant test tubes4. Add 1 drop of 22% bovine albumin into the tube labelled as

albumin mix the content & incubate at 37oc water bath for

30 - 45 minutes.

5. After incubation period take the tubes from the water bath &centrifuge at 250g for 20 seconds.

6. Look for haemolysis & or agglutination microscopically.7. Grade & record results on the request form.

46

8. If there is no agglutination or haemolysis in both tubes-proceed to AHG test on Albumin tube.

4.1.Shake the Albumin tube gently to disturb the cells atthe bottom.

4.2.Fill he tube with normal saline.

4.3.Centrifuge at 1000g for 1 minutes4.4.Decant the supernatant completely to get a dry cell

button.

4.5.Repeat above steps two more times4.6.After the last wash, disturb the cell button 7 add poly-

specific AHG reagent4.7.Centrifuge the tube at 250g for 15sec.4.8.Look for macroscopic/microscopic agglutination4.9.If there is no agglutination the cross match is

compatible.

(Negative IAT results should be validated with Coombs control

cells, if available.)

LISS Method

1. Take a test tube each for each donor pack.2. Add two drops of patients serum to all tubes.3. Add one drop of 5% suspension of cells from donors to the

relevant test tubes.

4. Add 2 drops of LISS Additive into the tube mix the contentwell & incubate at 37oc water bath for 15 - 20 minutes.

5. After incubation period take the tubes from the water bath &centrifuge at 250g for 20 seconds.6. Look for haemolysis & or agglutination microscopically.7. Grade & record results on the request form.8. If there is no agglutination do the indirect AHG test

mentioned in saline Albumin method & interpret the results.9. For all the washing steps use fresh normal saline or PBS

solution.

10.If there is no agglutination the cross match is compatible.


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Interpretation

6.1. If cross match is compatible

6.1.1. Write a Compatibility report6.1.2. Attach a reservation tag to the blood pack & keep

the blood pack in the correct refrigerator

6.1.3. Preserve the tested sample for 7 days in the

refrigerator.

6.2. If the cross match is incompatible

6.2.1. Recheck the patients blood group & donor unit

6.2.2. Do cross match with another unit of blood

6.2.3. If still incompatible contact MO on duty atImmunohaematology Reference Lab, NBTC.

Documentation

Enter the results in the pre-transfusion compatibility testing

work sheet and register.

If the cross match is compatible,

. Write a compatibility report and sign.

. Attach a compatibility label to the blood unit.

48

Pre Transfusion Compatibility Testing for Infants

Procedure

01.Wash the babies blood sample 3 times with fresh 0.9%

saline or PBS02. Prepare a 5% suspension of red cells after the final wash

02.Using the suspension, carry out the ABO and Rh groupingas above.

03.Carry out the ABO and Rh grouping of the mother as above.04.Select blood for crossmatch as follows,

. Select blood compatible with the ABO and Rh groupingof the baby and the mother (refer table annexed).

. Otherwise use group O Rh compatible units

. Select blood within 5 days of collection

. Avoid using blood donated by blood relatives

05.Perform the cross match using mothers Serum and donorcells as per SOP/REF/09

Infant

Group

A

Group B Group

AB

Group

O

GroupA

Bloodunit A,O

Bloodunit ,O

Bloodunit A,O

Bloodunit, O

Group

B

Blood

unit O

Blood

unitB,O

Blood

unit B,O

Blood

unit O

Group

AB

Blood

unit A,O

Blood

unit B,O

Blood

unitAB,O

Blood

unit O

Mother

Group

O

Bloodunit O

Bloodunit O

Bloodunit O

Bloodunit O


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Documentation

Enter the results in the Pre-transfusion Compatibilitywork sheet.

Write a compatibility report and a reservation tag.

50

Communication skills for Doctors

Dr. Deepthi Samarage,

Head of Dept. of Medical Education / Faculty of Medical

Sciences,

University of Sri Jayawardanapura

Introduction

Good doctors communicate effectively with patients. They

identify patients' problems more accurately, and patients are

more

satisfied with the care they receive. Doctors do

not

communicate with their patients as well as they should.

When doctors use communication skills effectively, both theyand their patients benefit.

Doctors identify their patients'problems more accurately.

Patients are more satisfied with their care and can better understandtheir problems,

investigations, and treatment options.

Patients are more likely to adhere to treatment and to follow advice onbehaviour

change.

Patients' distress and their vulnerability to anxiety and depression arelessened.

Doctors' own

wellbeing is improved. Doctors with good communicationskills have greater job satisfaction and less work stress

Key tasks in communication with patients

Eliciting the patient's main problems, the patient's perceptions of

these and the physical, emotional, and social impact of the patient's

problems on the patient and family


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Tailoring information to what the patient wants to know; checking his

or her understanding

Eliciting the patient's reactions to the information given and his or

her main concerns

Determining how much the patient wants to participate in decision

making

(when treatment options are available)

Discussing treatment options so that the patient understands the

implications

Unfortunately, doctors often fail in these tasks. Evidence shows

that only half of the complaints and concerns of patients are

likely to be elicited. Often doctors obtain little information

about patients' perceptions of their problems or about the

physical, emotional, and social impact of the problems. When

doctors provide information they do so in an inflexible way and

tend to ignore what individual patients wish to know. They pay

little attention to checking how well patients have understood

what they have been told. Less than half of psychological

morbidity in patients is recognized. Often patients do not adhere

to the treatment and advice that the doctor offers, and levels of

patient satisfaction are variable.

Blocking behavior of doctors

offering advice and reassurance before the main problems

have been identified

explaining away distress as normal

52

attending to physical aspects only

switching the topic

"jollying" patients along

Reasons for patients not disclosing problems

belief that nothing can be done

reluctance to burden the doctor

desire not to seem pathetic or ungrateful

concern that it is not legitimate to mention them

doctors' blocking behaviour

worry that their fears of what is wrong with them will be

confirmed

Each of us has our own unique way of relating with others andit is important to become aware of the impact that our style

has on our relationships. As a doctor you have a particularresponsibility to develop an interpersonal style that will

enhance the effectiveness of your relationships and facilitateeffective communication with your clients/ colleagues. We

believe that a meaningful relationship and effectivecommunication is a fundamental component contributing to the

well-being of the client/ colleague.

Attending: Physical and Psychologicalpresence

Attending is the process by which the doctor pays closeattention, both verbally and nonverbally, in such a way that the

client/colleague feels listened to, care about, and accepted.

Often doctors have developed ways of relating nonverbally


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which discourage clients/ colleagues from becoming engaged ininteractions with them. Certain facial expressions such as

frowns or curled lips, or other body behaviors such as yawningor squirming then to inhibit the interaction. By developing

awareness and practicing those behaviors which are perceived

by most people as signs of attention and interest, the doctordemonstrates physical presence and a willingness to become

involved in the interaction.

Physical attending includes facing the client/colleague making

eye contact, leaning forward toward the client/colleague and

having an open and relaxed posture.When the doctor pays close attention to the client/colleague

he/she demonstrates respect, interest, involvement and caring,

good attending is also a powerful reinforces as it encourages the

client/ colleague to become more involved in the

communication process.

Empathy

Empathy is the most critical element in a helping situation and

is the backbone of the responding skills. Empathy is the ability

to understand the ideas and feelings of another person.

By using empathy, the doctor can enable the clients/colleagues

to see themselves and their situation more clearly. Empathythen enables the client/colleague to feel understood. As a doctor

who is skillful with empathy, you are able to stand in shoes of

another. You can see and hear how clients/colleagues feel andthink, and are able to show the client/colleague that you

understand their feelings and situation.

ListeningListening is the key to understanding the meaning of anothers

experience. Why is it then, that messages are not heardaccurately and miscommunication abounds?

Factors that interfere with listening.

54

Listed below are some common factors that could interfere withyour listening ability.

Preoccupation

Often we are distracted from listening by thinking about

other things. We allow our minds to focus on ourconcerns rather than the person we are listening to.

Speaking vs. listening

At times we are more intent on speaking that listening.

We are so anxious to tell things the way we see themthat we dont truly hear what the other person is saying.

Judging vs. listening

There are many daily situations which encourage us to

judge what people are saying. To be helpful in asituation demands an ability to be accepting. Thats

difficult to do if you are used to being critical.

In every conversation there are two components to listen for:

Content: what the client/colleague is talking about

Feelings: how the client/colleague feels about the situation.

Respect

Respect, in essence, refers to a belief in the value and potential

of the other person. Respect is communicated more by attitude

than by specific response. The respect the doctor shows for the

client/colleague will enable him to share his concerns more

openly and easily.

Warmth

Warmth is a physical expression of empathy and respect. It is

generally communicated nonverbally in such ways as: eyecontact, facial expression, touching, tone of voice, posture and


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gesture. Ordinarily, nonverbal behaviors, such as eye contact,facial expressions, tone of voice, etc., are not consciously

exhibited. However, under conditions of attention and practice,you can increase your awareness of your own nonverbal

expressions and modify your nonverbal behaviors in the

direction of increased warmth.

Clarification

In interactions with a doctor, the client or colleague presents

many concerns, ideas and feelings. This is often done in an

implied way, perhaps through humour or deliberate vagueness.Clarification is a method of making the other persons message

explicit.

Clarification is also a method of confirming the accuracy of

your perceptions about the other persons message. As doctors,

we often make the assumption that understanding is occurringwithout validating our perceptions. This can lead us to making

assessments based on inaccurate information. Clarification can

serve to correct misperceptions before they becomemisunderstandings.

Summarizing

In interactions with clients, the doctor may find that many ideasand feelings are presented. Summarizing involves a process of

tying together relevant core materials that have been presentedin a fragmented way. The main purpose of summarizing is to

systematically highlight the critical aspects of the clientsstatements and behavior.

We have attempted to provide you with some concepts that we

think are necessary for effective communication. How you use

these tools will depend on your personal beliefs and values as

you respond in a helping relationship.We cannot make you communicate more effectively, the desire

has to come from within. Its now up to you!

56

Guidance in issuing medical certificates

For detailed information on issuing medical certificates, please

refer the following circulars.

General Circular No. 1006 issued by director of health services

on 20thJune 1979

General Circular No. 1086 issued by director of health services

on 7th

May 1980

General Circular No. 1481 issued by Director General of health

services on 21stOctober 1986

General Circular No. 1481 A issued by Director General ofhealth services on 12

thNovember 1986 (Maternity leaves)

Public administration circular 4 / 2005 ministry of publicadministration and home affaires 3

rdFebruary 2005

Given below are few salient points regarding issue of medical

certificates

Those authorised to issue medical certificates in Teaching,Provincial General, District General and Base Hospital are;

(I) Wards: Physicians, Surgeons, Paediatricians,Obstetricians, all the other specialists and House

Officers under the direction of their respective

consultants.

(II) Clinics: Specialist Officers(III) O.P.D: Physician and Surgeon between the hours

fixed by M.O.I/C, O.P.D. for those who attend the

O.P.D genuinely and primarily for treatment.

Medical Officers O.P.D. only in case of medical

and surgical emergencies, at all hours.


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1) Confirming the Identity of the patient to whomcertificate is issued;

2) Medical Certificates on Form Medical 170 and 331 areissued free;

3) The Medical Officer should be satisfied, before issuingthe Medical Certificate that the incapacitation resulting

from illness or injury is such that the officer/ employee

is unable to perform his/her normal duties;

4) The leave granted should be in keeping with theincapacitation;

5) Medical officers shall not recommend leave in excess ofa month at a time and extension of a leave shall not berecommended for more than a month in the first

instances and more than two weeks in the second and

third instances. Medical leave beyond the period of 3months would necessitate the individual being sent

before a Medical Board;

6) Medical Certificates issued by private MedicalPractitioners as well as those issued by Ayurvedic

Medical Practitioners should not be endorsed byGovernment Medical Officers;

7) The Medical Certificate should not cover more than fivedays past absence under any circumstances, except in

the case of an in-door patient to cover a period of stay in

hospital;

8) When officers / employees are on transfer orders utmostcare should be exercise before a decision is made to

recommend sick leave;

58

9) All cases in the Medical Certificate must be completed

in full;

(IV)(V)10)A Medical Certificate whether on Form 170 or Form

331 shall be promptly dispatched direct to theimmediate Superior of the applicant and, under no

circumstances shall a M.C. be handed over to an

applicant;

11)Medical Officers of Health may issue Medical Certi-ficate only to the following;

(a)Maternity cases,

(b)Staff working under the M.O.H., and

(c)All cases of communicable disease.

Recommending Maternity leave

Salient points from public administrative circular 4 / 2005

Government has decided to grant female public officers84 days maternity leaves with full pay, 84 days

maternity leave on half pay and 84 days maternity on nopay in respect of every child birth;

All female public officers whether permanent,temporally, casual or trainee are entitle to maternity

leave under this section.

Maternity leave with full payo Female officer is entitle to 84 working days full

pay leaves in respect of every live child birth and

they will not be allow to resume duties beforethe expiry of 4 week after the birth of the child.


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o In calculating maternity leave Public holydaysSaturdays and Sundays falling with in such

period should not be included.o In the case of a still birth or the death of a child

before the expiry of 6 weeks from the child birth,

6 weeks leave from the date of child birth shouldbe granted as special full pay leave.

Maternity leave on half payo After the exhaustion of leave mentioned in the

previous para the officer is entitled to 84 days

leave on half pay for her to look after the child.

Maternity leave on no payo After the end of leave approved under the

previous 2 paras, it is possible to grant 84 days

no pay leave only if such leave is required for the

purpose of looking after the child. However, the

approval of the leave would be by the Head of

the relevant Department.

In the case of a miscarriage the officer can avail herselfof the vacation leave she is entitled to on the production

of the medical certificate.

After the expiration of the maternity leave obtained asdescribed earlier the officer should be allowed to leave

office one hour before the normal time of departure in

order to breast feed the child provided no maternity

leave on half pay has been availed of.

Further, when the officer researches the fifth month ofpregnancy she should be allowed to attend office half an

hour later than the normal time of attendance and leaveoffice half an hour before the normal time of departure.

60

Documents

Word of Guidance Med Interns