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Internship Report

Social Work in Lady Reading


Hospital
From 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

Summery
By: Imran Ahmad
Contents Internship Report 17-sep to 18-
oct-07

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.

Table of contents

By: Imran Ahmad


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

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, Baitulmal fund, Endowment fund, Prime
Admin Setup, Source of fund, Zakat fund, Minister Programme fund, Hepatitis “C”,
Unclaimed Cases,

4. Accident and Emergency………………………………………………………11-15


Introduction, History, Departmental Layout, Purchee Counter, Mass Emergency Hall,
Staff Setup, Nomenclature, the process in Trauma Room
A&E, COW, CSW, CMW, Minor OT, COT,

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

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

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

8. Case Histories………………………………………………………………….22-28
Four 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 5


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

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

By: Imran Ahmad, M.A. Final 6


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

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)

By: Imran Ahmad, M.A. Final 7


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

MS is the head of hospital administrative machinery. He is also given a 20 grade. His main
duty is to implement the policy formulated by the chief executive. The MS has divided the
hospital into 6 zones. Every zone has a deputy medical superintendent (DMS).

Deputy Medical Superintendent (DMS)

DMS is the head of each zone. There are 6 DMS of the different Zones and one DMS Admin.
Therefore there are seven 7 DMS in LRH. But the A&E department has two heads; one DMS
and one Director.

Staff Hierarchy in Wards

The hierarchical structure of any department is like the following;

1. Professor
2. Associate Professor
3. Assistant Professor
4. Senior Registrar
5. Registrar

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

OUT PATIENT DEPARTMENT


Lady Reading Hospital
1
Jahangir Khan ”Social Medical Officer” Zakat Cell. LRH Peshawar
By: Imran Ahmad, M.A. Final 8
Internship Report LRH 17-sep to 18-
oct-07

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 • Laboratory

• Record Room • Pharmacy department

• X-Rays department • Social guides, Ardalees

• Eye department • 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.

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

3. X-Rays department
X-rays department is a big place and it is a large department. The x-ray fee is 35/ RS each.
Ultrasound section is also included in x-rays department. There are two ultrasound rooms;
One for in-patients and the other for out patients. The timing of x-rays department for opd
cases is till 2:00 PM.

4. Eye OPD
It is a separate section from the general eye opd. Three eye specialists are being hired for this
section.

5. Laboratory
There is an attached lab in OPD which charges very minor costs for different types of tests.
The lab timing is till 12:00 AM.

6. Pharmacy department
It seems to me as a separate and not related to the OPD. Because this department provides
free medicines to all the units of the hospital. Free medicines are provided to the in-patients.

7. Social guides
The social guides are to provide help to the helpless patients. Their duty is to provide
stretcher facility to the severe ill patient.

8. Doctors
There is a variety of physicians and surgeons available in OPD. The OPD doctors include
both lower and senior. I found the following major types of health specialties;
Medical Eye Cardiovascular Skin
Surgical Nephrology Neurosurgeons Urology
Dental Cardiology Neurology Pediatricians

2000-3000 patients daily visit the opd.2

OPD Administrative Setup

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

1. RMO  The head of Out patient Department in LRH


2. Additional RMO  He is to assist RMO
3. Senior Social Medical Officer
4. Social Medical Officer
5. Steno Typist
6. Computer Operator
7. social guides
8. Ardalee

2
Mr. Innam, LDC, Zakat Cell, LRH Peshawar
By: Imran Ahmad, M.A. Final 10
Internship Report LRH 17-sep to 18-
oct-07

SOCIAL SERVICES UNIT


The first social services unit in LRH was established in 1967. Before that year there was no
system of providing social services to the patients. But the question here is that why this unit
was established? This was due to the unclaimed patients and dead bodies—Lawaris. The
social services unit was established to deal with such cases.

The first social medical officer, on the other hand, was appointed in 1982 who was Sir. Ibrar
Anjum. The social services unit is headed by RMO—Resident Medical Officer.

Major objectives

• To financially assist the poor patients through Zakat & other funds, during treatment
• To deal with unclaimed patients & dead bodies –Lawaris Patients
• Administration of the OPD
• Revenue collection

Zakat cell
The section in which the social medical officer is working is called Zakat and social welfare
cell.
Total Zakat fund for the year is 82, 50,000 /Rs. This is a fixed fund, neither increases nor
decreases. The fund is provided in two installments per year.

Administrative setup

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


Social medical officers 3
LDC ---lower divisional clerk 1
Social guides 2
Ardali 4

Major areas for funds delivery are

• ENT  Appliances, e.g. hearing device


• Eye  Lenses
• Orthopedic  Rods & screws, all the operation cost
• Peads surgery  GIA (an implement worth 30, 000/ Rs
• Neoro-Surgery  VP shirts

What are the sources of funds to the patients?


By: Imran Ahmad, M.A. Final 11
Internship Report LRH 17-sep to 18-
oct-07

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.

By: Imran Ahmad, M.A. Final 12


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

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.

By: Imran Ahmad, M.A. Final 13


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

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

3
Abrar Anjum, Senior Social Medical Officer LRH, 26-sep-07
By: Imran Ahmad, M.A. Final 14
Internship Report LRH 17-sep to 18-
oct-07

where they keep the body safe for 10 days or may be a few days more. After that time if no
one claims for the dead body, then the students of the medical college are free to make their
experiments and practices on the dead body.

Accident and emergency


Department
The emergency department (ED), sometimes termed the emergency room (ER), emergency
ward (EW), accident & emergency (A&E) department or casualty department is a hospital or
primary care department that provides initial treatment to patients with a broad spectrum of
illnesses and injuries, some of which may be life-threatening and requiring immediate

By: Imran Ahmad, M.A. Final 15


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

attention. Emergency departments developed during the 20th century in response to an


increased need for rapid assessment and management of critical illnesses
Upon arrival in the ED, people typically undergo a brief triage, or sorting, interview to help
determine the nature and severity of their illness. Individuals with serious illnesses are then
seen by a physician more 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;
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;

1 Registration room (purchee counter) 8 Medicine corner


2 Waiting lounge 9 ECG room
3 CMO office 10 DMS office
4 Registrar office 11 X-rays room
5 Female examination hall 12 Casualty Lab
6 Casualty Medical Ward Male 13 Trauma room
7 Casualty Medical Ward Female 14 Casualty Cardiac Unit

By: Imran Ahmad, M.A. Final 16


Acknowledgments

The first flour setup is somewhat like the following;


1 Director A & E office 6 Plaster room
2 Casualty Operation theater 7 Casualty Surgical ward male
3 Waiting lounge 8 Nursing room
4 Casualty orthopedic ward male 9 Casualty surgical ward female
5 Casualty orthopedic ward female
The setup of the trauma room
1 Nursing counter 4 Doctor’s office computer office
2 Nursing supervisor office 5 Store room
3 Oxygen supply room

Staff setup
• Director A&E 1
• DMS—Deputy Medical Superintendent 1
• Senior Registrar 1
• CMO 3
• TMO 4
• MO 5
• Cardiologists 3
• House officers not confirmed

Nursing staff
NURSING STAFF SUMMERY
SPR H/N C/N N/A S/N SPR Supervisor 1
H/N Head Nurses 2
Medicine 4 1 C/N Charge Nurses 32
counter
N/A/ Nursing 3
CMW/ male 4 1 5 Attendant
CMW/ female 5 5 S/N Student Nurses 19
CSW + COW 1 7 5 TOTAL 57
COT 1 4
Trauma Room 1 4 1 4
CCU 4

By: Imran Ahmad


Acknowledgments

Other staff
Total Ardalees in mornig shift 28
Sweepers 15
Police Men 10 all shifts

Flying Squad
Supervisor 1
Dispensers 3
Drivers 2

Beds and other stuff


BEDS Stretchers 14
CMW/m 9 Wheel chairs 5
Ambulances 2
CMW/f 9
COW/m 10
COW/f 4
CSW/m 10
CSW/f 10
TOTAL 52

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 A & E -LRH
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.
4
Dr. Muslim Khan “DMS A&E” LRH

By: Imran Ahmad


Acknowledgments

The NEP on the other hand are guided first to the Casualty Medical Officer- CMO, who, after
initial interview and checkup, refers the patient to the concerned casualty ward, e.g. medical,
surgical, orthopedic etc. These wards provide one day care to these patients. Next they are
transferred to the main wards if necessary.

Casualty Orthopedic Ward

The patients with bone injury or broken bone are treated in orthopedic ward. The initial
treatment is given in casualty orthopedic ward. This ward is divided into to sections; male
and female. This ward consists of fourteen beds. Often the RTA cases visit this department.

Casualty Surgical Ward

This ward is on the first flour of the A & E department in LRH. The patients who need some
kind of operation or surgery are treated in surgical ward. The casualty surgical ward consists
of twenty beds; ten male and ten female. The patients stayed only for some hours in this
ward.

Casualty Medical Ward

The casualty medical ward is on the ground flour in & E department in LRH. This ward
consists of twenty beds; ten male and ten female.

Minor OT

Minor OT means, Minor Operation Theater. This section is to do minor kind of operations
like stitching a wound, heeling the injuries etc.

COT
COT means Casualty Operation Theater. The patients who need immediate operations in the
department are operated in this operation theater. The operation theater is on the first flour of
the department.

Purchee Counter

Here the purchee counter is similar to the purchee counter of opd. The computerized purchees
are issued to every new patient. The purchee counter is the first place of interaction for the
patient in A&E.

Mass Emergency Hall

This hall consists of more then one hundred beds and sub-beds. This is on the ground flour of
the department. All the casualty facilities are available here. This hall is very busy when there
is a bomb blast or some kind of fire or flood make casualties. During this internship time, one
bomb blast happen in Peshawar at Nishtar Abad. It causes two persons to death and twenty
eight injured5.

5
Daily Express, 9-oct-2007

By: Imran Ahmad


Acknowledgments

What is trauma room for?


Trauma room is an important section in any emergency department where the trauma team is
ready to deal with any traumatic situation e.g. bomb blast, RTA—Road and traffic accidents,
burnt cases, severe injuries etc. First aid and other emergency treatment are provided at this
place to the AEP. Two neurosurgeons consultants, two orthopedic consultants, and two
general surgeons are present in trauma room.
In the A&E all the treatment expenditure is met by the Government. the medicine and other
stuff is provided free of cost to the patient. 1500-1800 patients are daily registered in A&E
LRH. When the patient enters the trauma room in a traumatic situation, within 5-10 minutes
he is given treatment of 500-1500 /Rs.

By: Imran Ahmad


Acknowledgments

What is Triage?

Triage is a system of sorting patients according to need when resources are insufficient for all
to be treated. It is a system of response to a major incident. The term comes from the French
tri (meaning sort). There are two kinds of triage:
• Triage sieve &

• Triage sort

Triage Sieve6
The primary triage of patients has been called the “triage sieve” and is based on the Simple
Triage and Rapid Treatment method of “START”. This technique can be used at the scene of
the accident and also subsequently, e.g. on arrival at the Casualty Clearing Station (CCS).
This method can be used effectively and reliably by appropriately trained laypersons.
Casualties who can walk are assigned to the Delayed category. The remaining patients are
sorted following an ABC (Airway, Breathing, Circulation) assessment.
The patency of the airway is then assessed. If the airway is not patent it is opened using a
simple airway manoeuvre (chin lift of jaw thrust). Those patients who are found to be not
breathing following this procedure should be declared dead (remember this is a mass casualty
situation).
The respiratory rate is now assessed. If the respiratory rate is low (less than or equal to 10) or
high (greater than or equal to 30) the casualty is triaged to the Immediate category.
If the rate is between 11 and 29 breaths per minute the circulation is assessed by determining
the capillary refill time. This is done by squeezing the casualty’s fingertip for five seconds.
On release of this pressure the normal response is for the nail bed to relish within two
seconds. If the capillary refill is less than two seconds the patient is assigned to the Urgent
category. If the capillary refill is more than two seconds (indicating the presence of shock)
the patient is put in the Immediate category.
The capillary refill time may be prolonged in conditions of low ambient temperature or be
difficult to assess because of poor lighting. In such 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 incident
E: Exact Location
T: Type of incident
H: Hazard, present and potential
A: Access in emergency
N: Number of casualties
E: Emergency services required 7

Social work in casualty

The patients and family don’t know where to go and get help. For example where is
ultrasound, where to go for ECG etc. We social workers have to direct the patients and
families to there concerned spot of help. We have to provide guidance to them. Social worker
has to deal with the social aspects of the casualty. For example if a patient is severely injured
due to fighting with someone, now what the social worker has to do here is to find out the
causes of fighting. Social workers have to rehabilitate the patient back in their community8.

First Aid
First Aid is an emergency care for a victim of sudden illness or injury until more skillful
medical treatment is available. First aid is provided in those conditions when you have no
treatment apparatus and any other helping thing.

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

7
Fazl-E-Hakeem, “Nursing Supervisor” LRH Peshawar
8
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.

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

By: Imran Ahmad


Acknowledgments

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.

Case no. 1
Department/ Ward: A&E
Case type: Orthopedic

By: Imran Ahmad


Acknowledgments

Name: Riaz Ali


Age: 37
Resident: Serchina Sawabi
Educational qualifications: M.A. B.Ed
Occupation: principle of a school in sawabi
Major problem: an injury in right foot

History of the patient


The social worker meet with the patient in palaster room of the casualty orthopedic ward. the
doctor prescribed him injection and an X-ray. He himself was facing difficulty in moving.
Mr. Riaz was all alone and he had no respondent at that time. He was guided by the training
social worker to the nursing room for injection. When the injection was given to him by nurse
then he was guided next to the Casualty X-Ray room. The X-Ray technician has an X-Ray
just within few minutes.
Now the training social worker show and guide him to an easy way to get back to the doctor.
When the patient reached to the doctors room, he was busy in bandage of a child. So we wait
for some time.
During this time the social worker interviewed him and took a complete history of Riaz.

How the injury occurred?


(In the words of Riaz) I am a principle of a public school in sawabi. Today I came to
Peshawar to the high court due to some case. While coming down via the stares in high court,
my leg slipped at a stare and I feel extreme pain in my leg. My lawyer arranged a Riksha for
me which brought me to A & E. I got the purchee from the counter and then come to the
orthopedic doctor up here.

Diagnoses of the doctor


Dr. Gherat after assessing his x-rays said that the injury is not severe and the joint of the leg
has got some pressure. He prescribed him some medicines and a crack bandage.
During this time he called a friend on cell phone. His friend Mr. Maqsood arrived after some
time to A & E. but he was unable to find palaster room. So the social worker went out and
searches him and brought him to his patient. Mr. Maqsood fetches the crack bandage and
other medicine. Riaz’s leg was bandaged. And they both move to their home back to sawabi.

The role played by social worker


The patient Mr. Riaz was helpless and all alone. He really needs someone’s assistance to
guide him. So the social worker provides him guidance. He needs someone’s company and
counseling. So that he can pass the time of stress and anxiety in an easy way. The social
worker provides him company and has tried to divert his attention from the illness so as to
reduce his tension and anxiety. The social worker also makes the situation more clear to him
and his respondent.

By: Imran Ahmad


Acknowledgments

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

History of the patient

By: Imran Ahmad


Acknowledgments

The social worker met the patient in casualty surgical ward. The doctor prescribed him
injection, an X-ray, and urine test. Although the patient was an aged person but he was all
alone and he had no respondent. He was guided by the training social worker to injection.
When the injection was given to him by nurse then he was guided next to the Casualty X-Ray
room. The X-Ray technician has an X-Ray just within few minutes. Next the patient was
guided to the casualty lab where his urine sample was analyzed by the lab assistant within 15
minutes.
Now the training social worker show and guide him to an easy way to get back to the doctor.

Why the help was sought?


According to patient he feel some swelling in his urine but sometimes it become intense and
severe, and sometime he became normal.

Diagnoses of the doctor


Dr. Ayub after assessing his x-rays and lab report said that the case is not so severe. The
doctor prescribed some medication and said that he should drink water in large amount.

The role played by social worker


The patient was an aged person and all alone. He was really in need of assistance and help.
So the social worker provided him guidance. He needed someone’s company and counseling.
So that he can pass the time of stress and anxiety in an easy way. The social worker provides
him company and has tried to divert his attention from the illness so as to reduce his tension
and anxiety. The social worker also makes the situation more clear to him.

Effect of social work


The patient was very much amazed of the guidance and assistance of social worker. He was
very happy and thankful to social worker. He asked social worker that why he is helping him
in a situation when his children have left him alone. It was due to the social worker that the
time and energy of the patient was saved. He prayed for the social worker’s success. The
patient prayed that such social workers may be available to all the patients.

Case no. 3
Identification

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


Name: Niat Meer
Age: 75
Nature of the case: Neoro-Surgical
Ward: Trauma Room
Family system: joint
Respondent: Abad Meer = brother
Zubair =
Hassan = step son
Marital status: he has a second wife who is also near death
No. of siblings: 1 son who has died 14 years ago in the age of
25, 2 step sons
Financial position: independent
Resident: Pir Qala, Shabqadar Dheree
Educational qualifications: nil

By: Imran Ahmad


Acknowledgments

Chief Complaint: severe Head injury


___________________

Present History
According to all the respondents, the baba has been beaten on the head by the brother of his
Bahoo whose name is Bilal / 20y. he was beaten when he was taking care of his cow. The
patient him self don’t know that who beat him

Past History
His son was fired down by mafroors 14 years ago. Due to this trauma he has got a severe
shock. Bcz he was his only son. This traumatic event makes him irritable minded. The baba
has distributed the property among the stakeholders. He has a house as a property on his
name. the bahoo want to sell the house but the baba is not ready to do so. The relationship
between them are very constraint.
According to the respondents they have a quarrel just few days ago. The reason was that the
bahoo has stayed in someone’s home for 20 days without the permission of the baba.

Financial Position
The baba took his care and meet all his expense by him self. He has 15 goats and a milk cow,
which is his major source of earnings. He has also poultry hens in home.

Socio-cultural situation
This is a very complex case. Pir qala is the are of pukhtoons near mohmand agency. Socio-
economically the area is very backward and less developed. There is mass illiteracy and lack
of educational facilities and other services. The people are very poor though they have their
own properties.

Diagnoses
Why a poor baba who is near his medical death has bean beaten by his bahoo’s brother?
There can be many reasons for this case. One major reason is the property distribution. The
second is the generation gap. The third can be that the character of the bahoo may not be
normal, which has caused the incident.

Hospital history and social worker’s role


The baba was brought to the A & E by his brother Abad Mir on 23-sep. The patient was
given some initial treatment in trauma room. The patient was transferred to the neurosurgical
ward on 24-sep. the social worker has interviewed them on the same date in trauma room. All
the social history has been given in the above lines. The social worker has visited him in the
ward on 25-sep. the baba was conscious and talking in a good mood. He provided the
information that he has 15 goats and some hens and one milk cow. He was talking about them
only.

But when the social worker visited him on 26 of sep, he was discharge by the incharge of the
ward. The doctor has discharged him just by examining his physical conditions. The social
situation of the patient in his community and family is still not in his favour. He has to live
with the same Bahoo who is responsible for his being here in the hospital. Now the baba can
again come to the casualty in the emergency situation.

Recommendation

By: Imran Ahmad


Acknowledgments

We have to develop a system for the rehabilitation of such patients whose family
environment is against them. The bahoo of the baba haven’t been contacted by any one, this
is just bcz there is no social worker or counselor in any ward. The social worker has just tried
to contact her but during this the patient was discharged. So the social worker has lost the
case. There should be at least one social worker appointed for each ward or department, who
can make some rehabilitation processes for such patients.

Case no. 4
Identification

Purchee no. LRH0907-091797


Name: Hameed Khan
Age: 25
Nature of the case: Neoro-Surgical
Ward: Trauma Room
Family system: joint 25 members live in one house
Respondent: Farzullah Khan = brother
Fazal Dad = brother
Rahmat = nephew
Marital status: unmarried
No. of siblings: 5 brothers and 7 sisters
His position: he is the youngest of all
Occupation: zamidari
Resident: Bela Neko Khan, Dalazak Road, Peshawar
Educational qualifications: nil

By: Imran Ahmad


Acknowledgments

Chief Complaint: severe Head injury


___________________

Present History
According to all the respondents, the patient has been beaten on the head by three persons.
There names are Haider, Gohar, and Awal Gul. The main stakeholder is Gohar. They have
beaten him at 8:00 am when the people were busy in saying their prayers.

Past History
Mr. Hameed has a joint family system. They are 25 members living in one house. They have
enough manpower to maintain and to threat others in the village. But this time the other party
was more strong then them. About half of the village belongs to the other party. The
reputation of the Hameed’s family is not good in this regard.

This time the dispute begin, according to the respondents, bcz Gohar and Hameed have an
agreement of zamindari and mazdoori. But Gohar refused to work with him just a night
before the work has to begun. Now it was due to this refusal they have a little bit quarrels at
that time. But Gohar plan after this and beat him with the help of his brother and friend.

Socio-cultural situation
Bela Neko Khan is situated on Dalazak road. It is a typical rural area. This area is included in
Khalisa, which is famous for its greenery and Sugar Cane production. Most of the people
belongs to agriculture. Agricultural disputes are the daily routine of the area. So the above
case is. Similarly an agricultural dispute. The people of the area are generally less developed
and illiterate.

Diagnoses
Mr. Hameed has a family background which is full of such incidents, quarrels and disputes.
His family is not in a mood to resolve the current dispute. Although they have a jirga system
in their area but it is not so much effective. The current incident is due to the cultural pattern
of the area.
Hospital history and social worker’s role
The patient was brought to the hospital on 24 of September. He was given the first aid in the
trauma room of A&E. when the social worker met him he was laying unconsciously on the
bed. So the interview was taken from the respondents. As they have a joint family system so
there was a number of respondents available on the spot.
Next day the social worker visited him in the neurosurgical ward. The family was busy in
taking care of him. There were at least ten respondents available at that time. So it was
difficult to interview them in this crises situation. So the visit was made again on the next
day. When the social worker met him he was unconscious. But the social worker was amazed
to here that the hospital concerns have discharged him.

Remarks
Now this is the case where the real social work is needed. The disputes of Hameed are still
present. No jirga has still been conducted. The environment of his community is not
favourable to him. But he was discharged. --- now it could happen again that he may come in
the same condition to the hospital.
We have to develop a system for rehabilitation of such patients. There is an urgent need of
professional social workers in hospitals.

By: Imran Ahmad


Acknowledgments

Voluntary blood donors

A collection by Imran Ahmad Sajid

There are some situations in our life when we are completely helpless and in a very crucial
condition. In this situation we need the help of other people. One such situation is when
somebody gets a life threatening illness. The other such situation is a sudden casualty such as
bomb blast, traffic accident. In these incidents some people go to death while some are
extremely injured. These people can be saved if they are given the necessary treatment
immediately. The injured people need immediate blood. But sometimes the blood group of
the case is not available in the blood bank. So therefore we have collected some of the
voluntary blood donors who are ready at anytime to donate their blood for the needy people.
You just call them and they will be available. Some of the donors name and their contacts are
being given below;

Blood Contact
S. No Name F/Name Address
Group No.

By: Imran Ahmad


Acknowledgments

0332-
1 A+ Bilal Siddiqee M. Siddique Garhi Baloach Peshawar
9124774
0345-
2 A+ M. Yousuf Gul Rehman Garhi Baloach Peshawar
539592
0321-
3 AB+ Bilal Ahmad Sajid Khaista Gul Garhi Baloach Peshawar
9021277
Department of
0333-
4 B+ Asim Nawab Nawab Khan Environmental
9317506
Sciences UOP
Syed Haroon Ali 0300-
5 B+ Syed Yousuf Shah Garhi Baloach Peshawar
Shah 5955868
0334-
6 B+ Momin Khan Abdul Qayum Thandee Khoee Peshawar
9204705
345-
7 O+ M. Mustafa Sajid Khaista Gul Garhi Baloach Peshawar
9163441
Department of
0346-
8 O+ M. Tariq Environmental
9810631
Sciences UOP
0321-
9 O+ Younus Javed Gul Rehman Garhi Baloach Peshawar
9056048
0334-
10 Amaanullah Abdul Qayum Thandee Khoee Peshawar
9204704
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

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

By: Imran Ahmad


Acknowledgments

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

NEWS PAPER

1. Daily Express, 9-oct-2007

INTERNET
1. Emergency Department, wikipedia the free encyclopedia,
http://en.wikipedia.org/wiki/Emergency_department

2. Triage, wikipedia the free encyclopedia,


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

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


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

LRH WEBSITE
4. Dr. Jahanbaz Afridi, “History of Lady Reading Hospital”, Lady Reading Hospital
Peshawar
http://www.lrh.gon.pk/ohms/frmhistory.aspx

5. Dr. Jahanbaz Afridi, “Out Patient Facilities”, Lady Reading Hospital Peshawar
http://www.lrh.gon.pk/ohms/frmoutpatient.aspx

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


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

7. Dr. Jahanbaz Afridi, “Accident & Emergency”, Lady Reading Hospital Peshawar
http://www.lrh.gon.pk/ohms/frmaccidentemergency.aspx

By: Imran Ahmad


Acknowledgments

Map of lady reading hospital

By: Imran Ahmad


Acknowledgments

By: Imran Ahmad