Monday 25 November 2013

The original Johannesburg Hospital Protocol - Part One

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. 

Rather, parents want to know that everything possible was done for their child, in terms of their frame of reference, be it religious, cultural or spiritual. Perhaps for example a Jehovah Witness wants to insure that his child is not receiving any blood products. By speaking to the family and showing them their child, you can lessen their overall anxiety, and establish a good working relationship.





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