Botswana-upenn handbook [13. 13]

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Call and Admissions

Rounds

Work Rounds begin shortly after the morning intake report is completed (around 8:30-9). Residents lead work rounds with the team. The specialists rounds with the team start later in the morning (depending on the specialist) or in the afternoon (depending on the day). Most teams gather the pending laboratory data prior to beginning rounds. Rounds usually start in the ICU or private ward and continue onto the main medical ward. Each patient on the service is seen in turn and the daily plan established and or carried out. Each patient has a “file” or chart on which it should be clearly stated to which medical team he or she belongs (i.e. pink, blue or green). Each file is comprised of a drug/med sheet (yellow), doctor’s notes section, and nurse’s notes section. In addition, each file contains the “Out patient or OPD cards” for that particular person. These cards are the patient’s permanent medical record and during each encounter with a health professional a note of some sort is written. They carry these cards with them and can be a very valuable asset when trying to establish past medical history and/or the course of a patient’s present illness.
The doctor’s notes section is the area of the file where the daily progress notes are written. Unlike those in the USA notes at Marina are written entirely for communication and patient care. We do not have to “buff” the charts with medically extraneous information that is required for billing; so make the notes short, pertinent, and of course legible. Also, unlike the hospital systems you are likely used to in the USA doctors’ notes also include all non-pharmacy orders (e.g. nursing orders, transfusion orders, diet orders, IVF orders, etc.). Just write what you want in your note clearly and the nurse caring for the patient will hopefully read it, understand it and then take care of it. (It also helps to review it with the nurse). All drug orders need to be completed on the “yellow sheets” which usually are found at the front of the file. The names, dosages and availability of many medications are quite different than what you may be accustomed to in the United States but you will quickly catch on as you become more accustomed to PMH.
All laboratory orders and procedures are taken care of by the medical team. The nursing staff is usually willing to assist you with any procedures but you are responsible for doing them, ordering the appropriate tests, and cleaning up after yourself. Botswana has a national computerized healthcare system called Meditech. It is accessible in the larger hospitals and most government clinics. All labs are ordered and retrieved through this system. Instructions for its use are in the “Guide”. It has only worked intermittently lately so there will likely be times when labs will have to be ordered in the old written style on special forms.
Rounds continue until 1200 - 1300. At 1300 visiting hours begin, and the ward is flooded by families and relatives, making it virtually impossible to continue work. Usually this is an excellent time to get some lunch or work on discharges. If the work for the day is not complete the team will reconvene at 1400 or some other designated time to complete the work rounds and procedures. We also schedule the many family meetings (“counseling”) for between 1400-1500. This is done by just asking the nurses to arrange it.

Call and Admissions

Every day there are at least two medical officers taking call on the medical wards and they are responsible for seeing and “clerking” all new admissions to the ward. These admissions come through the A+E department (ER), from the clinics, or referrals from other primary hospitals. There is no system in place for “doc-to-doc” or handoffs! To date we have been unsuccessful in changing this. The patients will show up on the ward with some or no information and the MO’s will be informed of their presence on the ward.
We have just instituted a true cultural change at PMH. People now take call the day their firm is admitting. Each firm takes admissions about twice a week. The exceptions are that readmissions (any patient who has ever been admitted to a medical firm) always go back to their originally assigned firm and patients admitted at night are redistributed to the admitting firm in the morning (night float). Specialists take call (2^nd call) when their team is admitting. The specialist on call handles all transfers from other hospitals and does the consultations for other departments. Specialists are also the only persons who can put in PD catheters (don’t ask me why since MO’s and students can do all other procedures).
Penn students and residents have not officially been in the call schedule, but are expected to take call until 2100 when the firms they have been assigned to are admitting. This works out to 1–2 times a week. Be aggressive or you will not get the admissions. When you take call you should find the MO scheduled to be on call for that day-evening and let that person know you are there to take the admissions until 2100. It’s also advisable to make the nursing staff aware of this as well so that you can be notified of new patients and their location. The admission process is similar to what you are used to. An admission database needs to be completed, any labs or urgent procedures ordered and carried out and orders placed. A Penn resident will primarily function in a supervisory capacity for interns and MO’s, but should take admissions when there are several waiting.
If there are any problems, a patient is extremely ill and or needs an urgent CT scan or any other complex procedure there is always a Specialist on call for that particular day. Checking the on-call roster located on the ward can identify this individual. In addition, if any problems are encountered you can always page or call a Penn specialist, whether he or she is on call or not.
Make note of your admissions, your evaluation and your impressions, you will be presenting them the next morning at Intake Conference.
Needle Stick Exposure and PEP

The risk of needle stick exposure is very small. One of the benefits of learning procedures in an environment where HIV is very prevalent is that you will be take excellent technique. In the unlikely event of a potential exposure immediately notify a Penn specialist. We keep the first dose of PEP in the cupboard in our lab on the male medical ward and we have additional medication at Mallach house should it be needed.

Other Responsibilities for Residents (and occasionally students)

Penn has created a number of conferences at PMH and NGWE (see below and supplement). These include a didactic series on the management of basic medical problems, a case-based management conference, and a journal club (jointly with pediatrics). Residents will be responsible for preparing presentations for some of these conferences after consultation with the Penn faculty.

Weekly Conference Schedule (Princess Marina)

Monday