The
following protocol was developed for the Paediatric Casualty at the
Johannesburg Hospital in the period 1987-1988,and should be seen against the
following background to provide some understanding of its basis and framework
:-
1. 'Children’s casualty’ as it was
colloquially known dealt with both medical emergencies and trauma.
2. It was in the ‘white’ Johannesburg
Hospital and was (at the time) staffed by ‘white’ nurses and doctors but it
took critically ill patients from all population groups.
3. The protocol was initially developed as
much for the staff as for the parents.The staff were themselves not coping with
the volume of sick and dying children; and with the types of deaths,
(often as a cause of political violence) of children in the Unit.
4. It was also obvious that the bereaved
parents and family were not being properly dealt with by the staff or indeed
the Hospital bureaucracy.There was a strong sense of “unfinished business” on
both sides, which needed to be addressed.
5. Given the clash of First and Third worlds
seen in any University hospital which also serves as a regional trauma
centre; given the marked language and cultural differences;given the changing
and rising expectations of black South Africans;and the verbal feedback that
the Unit received,it was decided to adopt an “open-door” policy.A decision was
taken to let the parents into the Resuscitation Room during the actual medical
intervention.This honest, open policy laid the foundations for a
dynamic,positive interaction between staff and patients and their family.
6. The degree of professional and
emotional honesty expected from the staff “upfront”, and implicit in
letting parents into the Resus Room,required a high degree of
self-awareness and involvement in the development of the protocol by the staff.
7. Onto this was grafted the concept of
the ‘injured family’. The idea is that the whole family needs to be cared for
within the acute care setting and situation.
For
practical purposes,a large part of the emotional/psychological/spiritual needs
of the unconscious/dying/brain dead child are transferred to the family until
the child dies or recovers.
In
the same way that in a typical ‘chronic’ Hospice setting,where the
patient is attended to by social workers,ministers and various mental
health worker so too must the acutely dying patients needs be met.
It
was expected then that with an honest and ‘open-door’ policy, that any
cultural, religious or linguistic barriers could be transcended. Everything
that is being done to, or, for the child can be “checked” against the parents
personal checklist and understanding of the situation, allowing any particular
need to be addressed.
In
most modern casualty departments, the staff are given prior warning by the
Ambulance services, telephonically or via a radio, that a particularly severe
case, a ‘resuscitation case’ is en route to them.
Generally
some basic information with regard to the age of the patient and mechanism of
injury is sent as well as the expected time of arrival of the ambulance.
At
that point the senior Nurse will notify the necessary departments such as the
Operating Theatres and Intensive Care Units, and will then page the “Resus
Team”, typically comprising of the on-call Trauma surgeon, the Emergency
Medicine Physician, (perhaps the on-call anaesthetist), radiologist, pathology
staff and the Social Worker (or Counsellor).
The
potential case is explained as fully as possible to all members of the team and
they are requested to come immediately to the Casualty Unit.
(All
the medical and nursing team members are briefed and trained in ATLS/ACLS/APLS
and know what their individual roles and responsibilities are within the
framework of the ALS protocols and they simply go to their Resus station.
For
example, “Sister One” is the Registered Nurse entrusted with the total care of
the head (including the brain), C-spine and airway.
All
of the ‘extended’ EMS ‘family’ including those in the Ambulance/Paramedic
services are trained using the same ALS protocols and language and there are
common shared expectations of how the patient will be “packaged” for transport
to the hospital and will then be managed on arrival).
The
Social Worker though is called for different reasons.
1.Firstly they will be actively looking after,
or caring for-, the relatives and friends of the child being resuscitated.
2. This practically means that the medical and
nursing staff can concentrate on the resuscitation initially.
3.Secondly they fill a bridging role between
the event/the transport/the hospital/the outcome. Ideally they will have been
informed of what happened to the child (in the pre-hospital environment) and
can explain it to the family, as representatives of the hospital.
And they should be in a position to stay with the family
until at least the resuscitation phase is complete. In fact they would ideally
stay with the family until the family leaves the hospital (if the child dies)
or they are asked directly to leave by the family.
4. Due to the high emotional stress of the
acute phase, the 'Casualty Social Worker' would not be expected to continue
working directly with the family if the child survives and moves to Intensive
Care.She will however still see the family on an ad hoc basis and will feedback
to the medical staff in casualty.
5. They also provide a bridging role between
the medical staff and the family. The staff will be “formally” dressed which
can set up barriers to communication and will probably only meet the family
some time into the Resuscitation event.
The social worker can act as facilitator, introducing
the various players in the drama and can help them to communicate with one
another, not least by acting as ‘demystifiers’.
6. They are literally asked to “translate’ the
medical jargon, explain technical terms, identify team members and explain
their role in the Resuscitation. Whilst there may be some parents who are
familiar with the technology of emergency medicine thanks to television, it
nevertheless remains a huge shock to actually see their child lying on a
stretcher surrounded by machinery and very tense strangers.
And of course with the diverse mix of cultures and
living standards and conditions, there can be no assumption that the families
have had any prior exposure to a sophisticated university hospital environment.
7. Fifthly, the Social Worker is there ‘simply’
to provide emotional support. To counsel if necessary; to pray with the family
if required; to hug them, to listen to them, to simply bear witness. But above
all, she is there next to them.
8.Lastly, and mundanely, she understands the
bureaucracy and infrastructure if the hospital. She knows where the telephones
are located; how to get a cup of tea, and where the toilets are. This seems
obvious and even frivolous but is often overlooked and the family are left
doubly stranded.
When
the child actually arrives in the Unit, obviously the first priority of the
medical team is always towards the physical resuscitation, and remains so until
the child is either stable or has died.
When
the family arrive they are taken into a suitable waiting area/relatives lounge
by one of the floor Nurses, who will stay with them until relieved.
As
soon as possible, a senior Nurse is required to go and speak to the family. The
Nurse introduces herself, and identifies the parents at the earliest
opportunity. They are asked if they are aware of what has happened to their
child and the situation explained as completely as possible.
1.The introduction is done in a friendly and
open manner. It is important to remember that firstly, the hospital is not
their environment and so it is only good manners for the Nurse (whose “house”
it is) to introduce herself.
2.Secondly, you can easily establish a climate
of professional concern, because as the authority figure, you initially have
the opportunity to set the tone of the relationship by your initial
interaction.
3.Equally it is important to identify the
parents, simply because as the parents, they should have first claim on your
attention.
4.Additionally, you need to take a brief
medical history and find out if there are any allergies, underlying conditions
and such like.
5.They will probably also need to give consent
for invasive procedures and operations.
The asking for consent has more than mere legal significance
as it starts to restore their control of their child. They understand that the
staff have done/ will do whatever is necessary to save the life of their child,
but feel isolated and powerless and this small acknowledgement pays large
dividends particularly later should the Resuscitation be unsuccessful and you
seek to harvest the organs.
6. At all times the conversation flow should be
pitched at the speed of comprehension of the relatives. People do not always
“hear” what they are being told, generally because of the stress of the event,
or because they are being swamped with information.
The
family and friends of a dying patient are travellers in a strange land. The
event itself, the hospital environment, all makes for feelings of loss of
control, of helplessness.
The
family needs to see their child, to be afforded the opportunity to touch him,
to share in the pain. They need to feel that they are part of what is happening
to him, that they have some control over what is happening.
On
an emotional level, the ‘laying on of hands’ has long been associated with
healing, and the parents need to be able to pass their energy onto their child.
The idea is to include the parents as “carers, not to make them (further)
casualties”.
There
are practical reasons for the parents to see their child.
One
Saturday afternoon we were resuscitating a young boy with massive head injuries
.I had explained to the parents that he was critically ill, and invited them
into the Resus Room to watch what we were doing.
As
I was about to cut a piece of red string with some beads on it from his wrist,
so that I could do an arterial blood gas, his father asked me to leave the
string alone for religious reasons.
The father explained that in terms of their
faith, that if the child was to die without the string and beads on his wrist,
then he would not progress to the next level of reincarnation or being.
That
was a primary consideration and concern for the parents.
They
absolutely understood that their child might die;they had absolutely no
objection to anything and everything we were doing to their son;but they didn’t
want his death to be in vain in terms of their world view.
How
easy was it for me to simply move the piece of string and still do the blood
gas? Very easy.
And
when they left a few weeks later , with their son ,they sought me out to
express their thanks that I had 'heard' their plea and was prepared to help
their child transcend if the medical interventions had failed.
It
often simply doesn’t matter what you are doing technically to the child.
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