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Floor patients: 

Decision that 'floors' patients

by Dr. Eugene Corea

We had several letters recently from family members and relatives of patients who are being kept on the corridors of some of the wards in the Colombo National Hospital asking as to why the authorities cannot do something about it? We know the hardships and agony of being a floor patient, and we spoke on this subject to Dr. Eugene Corea a committee member of the Sri Lanka Medical Association, who had studied this problem and written an article about it in the Sri Lanka Family Physician suggesting a few remedial measures.

Excerpts from Dr. Eugene Corea's article.

Patients on the floor of a hospital corridor

Almost everyday young doctors and the nursing staff working in public sector hospital wards are forced to take the most degrading decision to allocate patients to the floor. Medical students are taught about rational decision-making in the face of limited resources. However, they are not told about how to manage beds.

It is likely that you would find sick doctors as floor patients in a ward? Would you encounter a priest, an engineer, an architect, a businessman or even a 'channel' patient on the floor? What is suggested is not that there should be provision on the floor for a meeting of the Organisation of Professional Associations (OPA). But if these categories of individuals are not seen on the floor then why should anybody else be there? We should not force our medical and nursing professionals to take decisions on a issue like this.

Why has society taken this sordid situation for granted? The patient - adult or child, male or female, is perhaps the most vulnerable of all human beings. Human dignity, care and compassion as very clearly indicated in the Unvirsal Declaration of Human Rights, the guiding principles of the Commonwealth Medical Association and, in the SLMA Declaration on Health, are surely the right of every patient. It is the duty primarily of those attending on patients and indeed of society as a whole, to ensure that this right is respected. Why have we failed to do so?

Convenient explantation

The most convenient explantation would be the obvious chronic shortage of beds, hospitals etc. in the state health sector. It must be admitted that there is justification in such response. We are after all still a developing country.

Smallest budgetary allocations

In spite of, or perhaps as a result of our much vaunted achievements in health care on a shoe string budget, we remain one of those nations who seems to be setting aside one of the smallest budgetary allocations for health care. For well over a decade Sri Lanka has disgraced herself as being one of the worst offenders in the world, when the percentage of national income set aside for health by a country is considered. The results of this parsimonious expenditure have all too evident and our health system is gradually coming apart.

Drastic increase

We do need a drastic and immediate increase in budgetary allocation for health. However, it would be ridiculous to think that building better and bigger hospitals and providing more beds would solve the problem of the floor patient.

The issue of resource allocation in the health sector itself needs to be addressed carefully. Rational use of national health resources too would have to be reviewed.

We do need a much higher level of competency in management of patient turnover in our hospitals with the objective of ensuring a bed for every patient who is admitted. Are we adopting a 'safe policy' of admitting most patients who present themselves to the casualty officer?

Management of patients adequately in the community should be one of our objectives. Responsible referral by general practitioners and primary care providers must be inculcated.

Even in utilising secure resources in specialities such as Oncology, a fresh approach should be worked out to make adequate care available to the patient at home. All this would be possible only if a change in attitude and policy towards the human indignity of the floor patient is brought about by society.

We must decide that for every patient admitted, respect for human dignity and compassion will be given the highest priority. Every patient who is admitted to hospital must be given a bed. Every patient who presents at the casualty department however does not have to be admitted. Politicians and legislators of all hues, must be made to understand and accept this. The people must be made aware of the need to carry out this policy.

The scene

When you enter the ward of a hospital you will see neat rows of beds with patients on them.

The floors are clean and bare. Further down come the toilets and round the corner are the corridors. It is here that you meet the patients on the floor. Some of these patients will be seated on benches and others will be on mats with their belongings beside them. You may resist the temptation to drop a coin into the empty mugs or jugs that rest in their hands.

Even their 'bed' head tickets (BHTs) have relegated to a single 'floor file' kept on the table of the nurse on duty. The BHTs of the patients on beds are invariably kept on the beds.

For many patients the main concern on admission is securing a bed for the duration of stay in hospital.

The ward staff, doctors, office staff of the hospital and even their acquaintances are frantically lobbied to ensure that the patient is inducted into the bed hugging elite in the ward. If this effort fails the patient will have to join the slum in the sick places. On days when casualty admissions are anticipated to a ward, the nursing staff walk round clearing the beds. Those who are not very ill and those with little clout will have to leave their beds and join the floor to make room for new admissions. A few lucky patients may be sent home from the floor.

Apart from the misery of being on the floor, these sick people and their medical attendants have to contend with the ever present hazards of overcrowding in hospital wards.

A few patients on the floor in teaching hospitals who constitute 'interesting cases" may be afforded a temporary luxury of a bed, while hordes of medical students prod and probe their floor hardened bodies.

"People have the right when ill, to be treated always with care and compassion". Stated the SLMA Declaration on Health of 1995-96.

Health professionals should show respect at all times and in all circumstances to persons that they are attending".

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suggestions for no more floor patients

* Highest priority for human dignity and compassionate health care.

* Drastically increased budgetary allocation for health.

* Every patient who is admitted should be given a bed.

* But every patient who presents at casualty does not have to be admitted.

* Implement a credible referral system.

* Make provision for care in the community.

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On orthopaedics : Is the schoolbag ruining your child's back?

by Dr Mandeep S Dhillon

Modern day academics are usually associated with the concept that as many books as possible have to be read in the shortest possible time. Also prevalent is the fact that huge amounts of homework are carted home, and then back to school, everyday. The question thus asked by many medical observers is- Is your child carrying too heavy a load to school?

Your child's backpack may seem harmless if you only look at the course books; many more things add to the weight, like football shoes, water bottles, and whatever the child will choose to carry. The children usually don't complain, and as they find that all their peers have a similar sized bag, carry on regardless.

However if the bag is overloaded, a cumulative insult to the spine occurs overtime, and your child may experience painful back and neck problems. Talk to the child and notice if she mentions headaches, neck aches, achy strained muscles, low back pain, muscle spasm, or tingling hands? The next thing to do is to put your child's backpack on the weighing scale and see how much weight your child is carrying back and forth each day!

What is really going on? An overweight backpack causes the body to compensate for the extra weight. If your child leans forward to compensate, it reduces his or her balance, thus making it easier to fall. The extra weight distorts the natural curve of the middle and lower back, causing muscle strain. As this has to go on for many years, this may ultimately have permanent structural damage.

In the western world concern for child safety has lead to wide discussion at fora consisting of parents and teachers, while here this problem is just being realized. There are no definite scientific guidelines, but many healthcare providers are suggesting some guidelines. US based orthopaedic specialist Stuart Weinstein, has suggested that children carry no more than 10 to 15 percent of their weight in a backpack.

The calculations are rather simple; if your child weighs 20kg, he or she should carry no more than 2-3kgs in a backpack; 30 kg children should carry no more than 4 kgs; slightly older kids have stouter spines and more robust muscles (especially boys in adolescence) and hence the percentage of body weight that they can carry becomes slightly more.

Keeping these factors in mind, I suggest some tips about purchasing schoolbags as well as how they should be used. Buying the right kind of bag is an important first step for your child, and a backpack is perhaps the ideal one, especially one with a standard two-strap pack, which we must realize is designed for light loads. For heavier loads, it is better to purchase a backpack that has a hip or waist belt. This takes some of the weight off the shoulders and distributes it to the hips.

Nowadays, several new breeds of backpacks are available. These have wide padded straps, padded waist belts, a molded plastic panel inside the pack to support the spine, and more costly ones even have internal shelving to help properly distribute weight. Here are some dos and don'ts that both the child and the parent should ensure. When packing the bag, distribute the weight evenly. Put heavier items on the bottom as this will keep the weight off the shoulders.

Advise your child to use both shoulder straps. Habitually carrying a load over one shoulder strains muscles as the spine tilts and overcompensates to the opposite side; this severely stresses back muscles. If the bag seems heavy, ensure that the child uses the waist belt of the bag, as this helps to help stabilize the pack.

If you can find one, always purchase a backpack with padded or air-filled straps which helps prevent the straps from digging into the shoulders. Teach the child to take the pack off when they are waiting, for say the school bus, or in queues, and even when they sit in the buses.

And, most importantly, take only what is needed at school.

The writer is Senior Consultant Orthopaedics, Apollo Hospitals, Colombo

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Action committee on justice for patients

The action committee on Justice for Patients which comprises several groups working for the rights and welfare of patients is setting up a National Association for the Rights of Patients (NARP). While doctors, nurses and others in the health sector have powerful unions working for them, patients have no such support and thus a National Association is seen as an urgent need.

The objectives of this association would include:

* Empowerment of patients - giving them awareness and insight on how to live a healthy life under the guidance of a family physician.

* Working out a patients' charter.

* Taking steps towards the restoration of a health service model where top priority is given to the welfare of the patients.

* Providing quality drugs at affordable prices, so that any patient who needs an essential drug could obtain it irrespective of whether he or she could afford it.

* Legal aid with medical advice to be given to patients in cases where there is substantial evidence of medical negligence.

* Take steps to pressurise the government to effectively monitor the quality of health care and the pricing at private hospitals.

More details could be had from Louis Benedict convenor No. 15, Quarry Road, Dehiwala.

******

Steam-inhalation will help ward off SARS virus infection

by Dr. P. A. C. de Silva

All the deadly viruses, including SARS and AIDS are known to be very sensitive to heat and changes in the pH of the medium. The effect of steam-inhalation to ward off the common cold (Coryza) virus was known for centuries and is still encouraged and practised by senior experienced doctors and Ayurvedic physicians. The relief that one gets after washing the face with hot water and steam-inhalation, or drinking hot water when one has a sore-throat is proof of the beneficial effects of heat to destroy these viruses which are very sensitive to heat.

Steam-inhalation to ward off the coryza virus and infections of the respiratory-tract is still practised in the UK and many developed countries. The steam-tent for the treatment of respiratory tract infections in infants and children is widely used in many childrens' hospitals in the UK.

Boots Drug Co. of the UK manufacturers steam-inhalers which are often used by the British public and a few Sri Lankans who have purchased the inhaler abroad. State Pharmaceutical Corporation (SPC) must import this from the UK or manufacture it locally for use by the Sri Lankan public.

So unfortunately, this age-old inexpensive but very effective simple treatment is not encouraged by physicians of today, who bank on expensive antibiotics and other pharmaceuticals.

I demonstrate to my patients how to inhale steam using a jug of water and an electric immersion heater with the head covered with a towel and recommend that steam be inhaled for 3 mins, 2-3 times per day at the slightest discomfort in the nose or throat. In SARS patients, steam-inhalation combined with other medicaments will accelerate recovery & prevent death. Steam-inhalation will also delay frequency & severity of attacks of asthma. If LPG, kerosene or firewood is used to boil water, the flame should be turned off to prevent inhalation of toxic fumes.

A bit of Siddhalepa balm which contains the herbal ingredients, Eucalyptus oil, Citronella oil, Cinnamon oil, Pinene oil, Camphor and Menthol, applied to each nostril during the steam inhalation will be beneficial to ward off SARS and other respiratory tract infections.

A piece of ginger in the mouth is an age-old remedy for sore-throat and spread of infection to the lungs.

In ancient Lanka, the Sinhala Kings functioned as Directors of Hospitals. The Kings directed that all patients be given a piece of ginger about the size of the thumb daily, for the prevention and treatment of throat infections and improve their general health. If the hospitals did not have sufficient stocks of ginger, the authorities were taken to task. It was for this reason that the Sinhala Kings said "Rajakama nethnam Veda kama". (If you cannot be a king, be a Veda).

Thus steam-inhalation, Siddhalepa and ginger taken early will help prevent SARS virus infections.

Dr. de Silva is a Rtd. Specialist Medical Officer, Dept. of Health Services.

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A reader from Kegalle Martins Perera has written to us wanting verification as to whether the Specialist Consultation allowed by the Government when it introduced Channelled Consultation practice in 1977 was Rs. 25.

Reply:

We went through our health cuttings file for the relevant year and found that the Specialist Consultation fee Rs. 25 you mentioned is correct. in the news report we carried in the Daily News on 18.08.1977, the day channelled consultation was introduced with regard to fees we have stated...

New channelled scheme begins today

by Edward Arambawela

The Health Ministry announced yesterday the details of the revised Channelled Consultation Scheme drawn up in consultation with the GMOA and the AMS.

Phase 1 of the scheme for Specialist Medical Officers comes into operation today in Co-operative hospitals, dispensaries, private nursing homes and in consultation rooms of private practitioners.

The details of the scheme were worked out by a special Committee of Ministry officials appointed by the Health Minister Mr. Gamini Jayasuriya last Friday. A member each from the GMOA and AMS was also included in this Committee.

Some of the details of the scheme are:

* Doctors on leave are debarred from practising during the normal working hours.

* Two categories of doctors those in administrative service and the Intern medical officers are kept out of the scheme altogether.

* Details also lay down that while doctors could practise during the permitted hours (12 noon to 3 p.m. and 5 p.m. to 6 a.m.) precedence should be given to any call from a government hospital even during these times.

* Penalty for violation of these regulations is the removal of the particular doctor from the Channelled Consultation list.

A fee of Rs. 25 per consultation call is allowed under the scheme with a travelling allowance of Rs. 5.00 per return mile for calls outside a radius of 5 miles from the place of work or the residence of the doctor. Rs. 5.00 of the fee is to be retained by the channelling institution.

* The maximum fee chargeable for a surgical operation is limited to Rs. 800.00 and for a minor operation the stipulated fee is Rs. 80.00. The Anaesthetists' fees are also laid down from a maximum of Rs. 250 to a minimum of Rs. 50.00 for a minor operation.

* The Channelling Institutions are ordered to record details of calls in triplicate, including the fee charged. One copy of which is to be given to the doctor and the other to the patient. The Institution is liable under the scheme to furnish monthly returns of channelled calls to the SHS of the area.

* Phase two of the scheme for Grade Medical Officers comes into operation on August 25. The fee chargeable by them is Rs. 15.00 per consultation out of which Rs. 5.00 is to be given to the channelling institution.

*****

The characteristics of a profession

Prof. Colvin Goonaratna, General President of the Sri Lanka Association for the Advancement of Science (SLAAS) who was the chief guest at the Sri Lanka Optometric Association's awards ceremony held in Colombo last week enumerating the characteristics of a profession from the community point of view, said it would be appropriate to consider briefly what is meant by "profession" and who a professional might be.

"I know that several groups are falling over each other to call themselves professionals. But in the end, the community will decide. I believe that a profession must have the following characteristics.

Firstly, a profession has to have a code of ethics. I place this first because I think it is the most important one.

Secondly a profession ought to have a distinctive body of knowledge, skills and attitude that is being continuously updated - that is constantly evolving. Thirdly, a profession must have an objective, reliable and valid system for assessing competence and providing certification of competence, that is recognised by an appropriate licensing authority.

Next, professionals must have in their dealings with the community, the concept of service. They must understand that they are not mere traders or merchants. However, professionals are entitled to attract a fee for their services from a state or private institution, or directly from the clients they serve.

Professionals must respect each other and must not openly criticise each other to the detriment of the profession. They must form and foster a strong and respected professional asociation, that has a clear mission and specific objectives. If the SLOA does not have these, I urge you to now develop them.

The next point is that professionals must ensure the continuing professional development (CPD) of its membership.

Now this refers not only to knoweldge but also to skills, including managerial and communication skills, and attitudes that will bring honour to the profession. There may be many other characteristics that mark a profession, but I believe tht I have told you the most important ones.

As you know, I am now, in addition my appointment as Genreal Presidnet of the SLAAS and consultant to the PGIM, I am also Registrar of the Ceylon Medical College Council that gives certificates of efficiency and competence to Optometrists as well as 14 other categories of professionals, such as pharmacists, radiographers, medical laboratory technicians, physiotherapists and so on.

In my capacity as Registrar of the Ceylon Medical College Council, I can promise to help you all to advance your professional status in every way that is open to me. For example, I can help you to formulate a mission statement, objectives of the association and continuing professional development programmes.

I ask you to keep your Diploma Course alive. This country needs many more qualified and competent optometrists. We need to update existing optometrists about new developments in the speciality.

I am privileged to be in your midst today.

I hope that I contributed a message to inspire you all to greater achievement. As an experienced teacher and speaker I know the golden rules of speech-making. Those are to stand up, speak up and shut up.

Thank you ladies and gentlemen for your attention.

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