Lush green land and open spaces, fresh air that reminds us of how artificial our all-natural room fresheners smell, and quiet nights decorated with twinklings of a starry sky and the musical buzz of crickets. That is how most would imagine a village. Few of these imaginations remain borrowable if anyone were to engage in the same exercise in regards to an ER in the village. For starters, nights aren’t as quite, color and smell changes depending on what patient you are treating that day and the space of the room shrinks in proportion to the distance you traveled to reach that village.
Two years ago, when I was posted at Beltar Primary Health Care Center (PHC), little did I know that a sparsely populated village’s abundance of space rarely follows through to the emergency room. The obvious lack of infrastructure is, of course, the major problem. In the health system of Nepal, emergency services are designed to be provided at the hospital level. However, keeping the need for emergency services in mind, health workers in the rural areas are left to run makeshift ERs. At our PHC, what was supposed to be the waiting lobby for patients was used for an ER. The lack of a four-walled room meant that the only sense of privacy was provided by the patient’s fumbling awareness owing to intense pain and the physician’s focus completely overwhelmed by trying to be resourceful amidst obvious lack of resources. Hordes of curious onlookers crowding to see what was going on is a common scene in our ER that one would start ignoring after a month or two.
After banging our heads on problems that require far more resources and policies than that within our reach, we are left to take a sensible path – focusing on one small thing at a time and changing it for the better. Today I present to you an incident that inspired us to make an effort into making one such change happen.
A 28-year-old male
Like any on-duty doctor, I found myself rushing to the ER after a call. A 28-year-old male was brought after a sudden loss of consciousness while playing football. We quickly realized that CPR was in order and jumped right at it. Quite literally so, as the arrangement of beds in the ER was such that you could only deliver quality compressions if you are on the patient’s bed.
Elephant in the room
When I asked our paramedic to start bag and mask ventilation, he looked at me in confusion – the bed was placed against the wall and he would have to jump across the patient to provide one. Our nurse had to squeeze her way through the crowd of onlookers to find the needed medication. In the end, all of us were disappointed. Exhausted physically and mentally yet pondering on things we could have done differently, like any other resuscitation team would, after an unsuccessful CPR. After ruminating on the quality of CPR, availability of better equipment, training and all other aspects of a good resuscitation, we finally addressed the elephant in the room.
Bigger space or ...
The most obvious solution of shifting our ER to a bigger space was simply not an option. What we could do was make small changes that could make things a bit better. The nature of problem-solving has to be such that the biggest constraints remain (because we rarely can do anything about them). What is it that a bigger space adds? Big space adds orderliness. As I was pondering on this question, I had an idea that felt like an epiphany. I remembered one of my toys as a kid – a Rubik’s cube. We do not expand our Rubik’s cube to make it orderly. We rearrange it – you get to manipulate the pieces but not the whole cube. Thus, we started the mission of Rubik’s cubing our ER.
Rubik's Cubing
We had four beds in our ER. We wanted a separate resuscitation bed with enough surrounding space. We moved all three beds to one side of the room; installed two privacy screens instead of both a door and a wall (sorry onlookers!). We repaired and re-stocked the crash cart, placed each medicine in separate compartments in the drawers and labelled them properly.
A few weeks later, we performed CPR in another patient. The patient was rushed to our resuscitation bed, the privacy screens were drawn and the crash cart pulled near the bed. After we resuscitated the patient, we started the age-old culture of replaying the scene in our head and trying to figure out what else could be done. We obviously came up with a lot, this time too. But in terms of using the available resources, everyone was satisfied that they did the best they could make out of the situation.
Resuscitation will never be easy, but that is the precise reason we need to make it as orderly as possible. People who develop protocols and policies are doing their part. We, at Beltar, tried to do ours.
