The Temburong One Week Duty
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I’m back! Phew… just got back from Temburong duty last week and still recovering haha… not from the travelling but from catching up with my post-poned outpatient appointments in RIPAS. I thought I might write something about Temburong viagra cialis online pharmacy pharmacy for the benefit of future doctors who will be posted there, unfortunately I could not dig out much information from the web, so had to do a bit of research. The information provided below is based on the 2007 Temburong hospital statistics and my observation during my one-week stay there. Enjoy…

Introduction:

The Pengiran Isteri Hajah Mariam Temburong (PIHM) Hospital is one of the smallest district general hospitals in Brunei Darussalam and supposedly houses no more than 50 beds with two main wards (Male + Children & Female), 1 isolation ward (converted into doctors on-call room and a multi-function area) and a newly furbished day-care renal dialysis ward. The hospital provides general medical services to a population of around 9,000 people in its district.

On average Temburong hospital sees around 123.5 patients per day in it’s Out patient Department (General & Specialists). The ratio of doctors to population in Temburong is approximately 1: 3000 with only 3 permanent doctors to serve the whole district.

Amongst the services that it is able to provide includes Outpatient & Inpatient services, Outpatient specialists clinics, Pharmacy & dispensary, X-ray, Accident & Emergency, Dental Care, Physiotherapy, Laboratory services and until recently a Day care Dialysis centre for 11 of it’s patients requiring Haemodialysis. 3 permanent medical officers have been dedicated to this hospital; one of them is a female doctor with experience in Obstetrics & Gynaecology. There are no local doctors posted permanently here as yet.

Doctors’ duties in Temburong

During a regular working day, the doctor who has been on-call for 24 hours the night before will be responsible to do a ward round in the morning before going Off Duty for the rest of the day. This leaves the other 2 doctors to run the general outpatient clinic, which regularly sees around 85 patients a day, and admits around 2-3 patients per day during their on-call period. Majority of the cases they see in clinic are mainly cases you would see in a typical General Practice, and for those requiring admission to hospital 70% are medically related, 13.3% Paediatrics, 11.8% Obstetrics & Gynaecology and only 4.7% Surgically related.

Since March 2008 the Department of Medical Services through RIPAS Hospital initiated a new move to support the medical services in Temburong. It offers a separate paediatric service every working day and sends one local medical officer from RIPAS hospital to spend 1 week working in PIHM Temburong Hospital. These extra doctors were incorporated into the on-call rota and will also be doing clinic sessions during their time in the hospital.

With the new initiative Temburong Hospital Medical Service can now operate with a 1 in 5 rota and relieves some of the burden in managing paediatric cases in the outpatient. However if a paediatrician is doing the on-call, there will be no next day paediatric cover, and if a RIPAS junior medical officer is on-call, there should be a senior person to be 2nd on call as well.



After completing a week’s duty in Temburong hospital, several observations has been made and are as follows:

1) The majority of the cases seen in the outpatient are very much cases you will see in a general practice.
E.g. Cough & Cold, Headache, General Obstetrics & Gynaecology, Management of Diabetes & Hypertension.

2) Despite Paediatric Cover, there will be a day in the week when the Paediatric On Call will be off the next day, leaving you and the other doctor to deal with Paediatric Cases. (NB Paediatric admissions accounts for 13.3% of total admissions, the majority are medically related adult admissions).

3) Hesitation in management of Paediatric & Medical Emergencies for the surgeons and expecting a paediatrician/medic to handle an Adult trauma case is sometimes a concern.

4) Certain important drugs are not available and some were found to be out of date
E.g. Intravenous Phenytoin for management of prolonged seizure (not available during one of the RIPAS doctors week of duty)

5) There were actually only 27 beds available & functioning (instead of 50 beds)


6) The person On-Call is supposed to do the next day Ward Round alone. The problem arises because the M.O. is sometimes quite junior and inexperience in certain specialty cases like Gynaecology and Paediatrics, but most importantly there is an issue of Continuity of Care.

7) No CME Activity listed or planned for the month

However there are some positive feedbacks about this hospital service

1) There is 24 hour Lab Service & X-ray Service
2) All round pharmacy service
3) The On-Call Room is decent & Clean
4) Good food provided by the hospital (apparently this is not a common phenomenon, if you are nice to the nurses and attendants you might get it I guess)
5) Dr Elangovan, the Senior medical officer is very helpful
6) Small Hospital, therefore very friendly environment
7) Hospital Drivers are helpful in transporting us to wherever needed (very useful when you need to get some food for dinner when you are on-call)
8) Helicopter transportation is prompt and almost 24hrs weather permitting


Taking into consideration that it is a small and fairly remote hospital, it is quite impressive that this hospital is still able to provide a fairly good all round medical service.

Suprisingly although the doctors’ population ratio is huge (5x of Singapore) the in-patient activity only accounts for 2.85% of its total activity, the majority of which is medically related. Below are several issues that have been highlighted and followed by suggested recommendations.

Suggested Recommendations:

1) To incorporate Local General Practitioners into the Temburong Hospital Initiative. This would definitely be beneficial for the population of Temburong. Not only it fulfils the objective of exposing our local doctors to Temburong, but also the added benefit that the majority of illness treated are very familiar to their expertise.

2) Incorporate a period of 1-2 month compulsory placement to Temburong Hospital for all Basic Specialty Trainee (GPs, Surgeon’s and Medics) during their A&E placement, perhaps the last 2 months of their rotation in A&E. However a permanent senior A&E staff (specialist preferably) should be placed in Temburong to ensure training continues for the trainees.

3) To give a Special Allowances for any Health Staff working in remote areas, especially in Temburong district in this case. This is to act as an incentive and appreciate the hardship our staffs have to go through to work at remote places where many facilities are limited, and to recognize that some of them have to leave their family behind to work at these places. Not only will this promote good morale but may even attract health professionals to work in the rural community. The allowances should be awarded to temporary, visiting and permanent staffs at the particular hospital/health centre. The ministry of health can help ratify the rates, so that it is appropriate and always-in line with the standard of living.

4) Provide a simple guideline handbook to management of common Paediatric, Medical & Surgical outpatient & Emergencies.

5) The morning ward rounds should be led by the Temburong doctors every day, to ensure good continuity of care and provide a potential teaching session for the junior MOs. It also promotes the sense of teamwork amongst the Temburong doctors. A timetable should be set to do ward rounds and all MOs should make an effort to come to the ward rounds.

6) Regular update of important emergency drugs.

7) The more experienced visiting MOs can do teaching sessions during their week stay for the Temburong health professionals. This not only gives the opportunity for the permanent staff to score CME points, but also encourages a teaching & learning environment for every health professional.



Conclusion:

In general approximately 97% of the activities in Temburong Hospital are outpatient based and only 2.85% are inpatient work, of which the majority of the cases are medically related followed by O&G and paediatrics.

This raises two important issues, firstly is the proportion big enough to justify having a hospital in Temburong. If it is, then should we allocate more money to ensure that it has adequate expertise, facilities, drugs and equipments. Perhaps we can start by placing a A&E specialist there. I could suggest Dr I.... from RIPAS for a start. Alternatively if it’s not, then we should concentrate on making it a better equipped health centre, with the current facilities that it already has.

However I think the general picture is quite clear from the figures mentioned earlier (derived from Temburong Hospital Statistics 2007) Temburong hospital would benefit from having more generalist clinician around to support the population’s demand of healthcare provisions.

The one-week experience of working in Temburong Hospital has highlighted several issues on how we can better improve the quality of medical services to a small population district general hospital like Temburong. It has also given us the 1st hand experience of working in a hospital environment where facilities, manpower, and expertise are sometimes of limited supply.

The objective to expose our local doctors to our people is most probably a very good step forward not just enriching the doctor’s experience as an individual but also in identifying & highlighting issues for improving our medical services in the future as a whole. After all it is our own people that we are looking after and it is our Health Service that we want to better. My last comment would be, the choice of doctors sent could be better.. ahem.


Btw .. Don't forget to:

1) Be at the RIPAS Jetty by 7.00am for a boat to go to Temburong
2) See the Temburong CEO (Pg Sabtu) on your last day there and ask for the overnight form to claim for your allowances working there

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Accountable Palliative Care Organizations (APCOs)
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Accountable Palliative Care Organizations (APCOs)

From time to time, clients inquire if there is a single factor which keeps communities, in general, and hospital/health systems, specifically, from realizing the full potential of palliative care. Our analyses of the Dartmouth Medical Atlas suggests to us that HOW communities are ORGANIZED to deliver and distribute palliative care may be the single most important determinant of success.

Drawing a composite picture of a hospital’s (and community's) palliative care performance from palliative outcome indicators can reveal lots about performance in meeting the needs of those with advanced illness. Our study of better-performing communities identifies several attributes shared by these exemplar palliative care communities (much has been written recently about one of these Exemplars - LaCrosse, Wisconsin). These shared attributes are:
• Multiple Points of Patient Access
• Multiple Sources of Reimbursement and Mechanisms to Enable Internal Pricing and Transfers
• Chief Palliative Care Officer
• Protocols/Tools Span Settings of Care
• Relentless Collection of Data and Focus on Accumulating and Disseminating Knowledge of Best Practices.

We refer to virtual structures possessing these attributes as Accountable Palliative Care Organizations (APCOs). In coming posts, I'll offer more detail on why these attributes matter, and why APCOs are so difficult to develop. In the meantime, I'm curious to learn your thoughts, and how your assessment of current late-life care practices in your communities confirms or refutes this organizational model.

Três pessoas são presas e 11 farmácias interditadas em Carpina e Ipojuca
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Três pessoas foram presas e 25 farmácias, notificadas, em uma operação da Agência Pernambucana de Vigilância Sanitária (Apevisa), nas cidades de Ipojuca, no litoral sul, e Carpina, na zona da mata norte do estado, que resultou na apreensão de quase 5 mil caixas de medicamentos. Do total de estabelecimentos, 11 foram interditados e 15 tiveram apreensões de remédios controlados, que eram vendidos de forma inadequada, com uso de receituários irregulares, fora da validade, contrabandeados do Paraguai ou mesmo armazenados incorretamente. A polícia ainda investiga o possível envolvimento de uma médica na ação.



As autuações foram realizadas no âmbito criminal e também administrativo. Todos responderão por tráfico de drogas, como são considerados os medicamentos controlados. “Em todas as farmácias vistoriadas nessa semana foram encontradas irregularidades, mas nem todas foram fechadas. Foram 16 autuações e 6 notificações, além dos locais onde havia crime”, explica o gerente geral da Apevisa, Jaime Brito.



Se condenados, os três proprietários dos estabelecimentos onde foram verificados crimes, apenas por este crime, podem cumprir penas que variam de 5 a 15 anos de reclusão. Em Ipojuca, João Amaral de Oliveira, 65, foi flagrado vendendo o remédio para disfunção erétil cheap cialis falsificado e deve ter a pena agravada.



Já em Carpina, Everaldo Barbosa da Costa, 51 anos, ainda deve responder por crime de contra a saúde e economia públicas, mediante relação de consumo. Daxciane Coelho Silveira, 34, proprietária de duas farmácias na mesma cidade, ainda pode responder por contrabando, uma vez que comercializava o ‘Pramil’, remédio de disfunção erétil que teve a venda proibida no Brasil e que é produzido de forma ilegal no Paraguai.



As investigações começaram há dois meses, quando foram identificadas irregularidades na movimentação de produtos de seis estabelecimentos das duas cidades junto ao Sistema Nacional de Gerenciamento de Produtos Controlados. Apenas em uma farmácia de Carpina, 500 caixas de Artane, indicado para mal de Parkinson e normalmente utilizado como potencializador do efeito de drogas, foram encomendadas e repassadas à população sem o devido registro, em um prazo de apenas dois meses. A média nacional é de apenas 10 caixas por farmácia em um mês.



De acordo com a delegada Maria Helena Couto Fazio, do Departamento de Repressão ao Narcotráfico, durante a ação ainda foram encontrados talões de receituários médicos carimbados e assinados, supostamente pela médica Erivalda dos Santos Ramos. O fato também configura crime e a profissional deverá prestar depoimento para verificar se há envolvimento nos crimes ou se as receitas haviam sido falsificadas com seu nome.



Erivalda dos Santos atualmente trabalha no Hemocentro de João Pessoa, na Paraíba, e não tem registro junto ao Conselho Regional de Medicina de Pernambuco (Cremepe) e, no entanto, nos receituários, a origem indicada na prescrição seria do Hospital Belarmino Correia, em Goiana, na Mata Norte do estado. “Já verificamos que o registro é de uma pessoa ‘real’, que não foi falsificado. Resta saber se a autoria da prescrição foi, de fato, da médica em questão”, explica a delegada.



Balanço - Ao todo, foram apreendidas 4.985 caixas de medicamentos, com uma média de 20 comprimidos cada, tanto pela polícia, quanto pela Vigilância Sanitária. Entre os principais produtos estão o Rivotril, Lexotan e Diazepan e outros psicotrópicos, anticonvulsivantes e anorexígenos. A ação fez parte de uma busca pela fiscalização, por parte da Apevisa, de medicamentos controlados a exemplo do Artane e do Desobesi, um inibidor de apetite também utilizado por condutores de caminhões para manter-se acordados em longas viagens (popularmente conhecido como ‘Arrebite’).
A última operação do gênero foi deflagrada em fevereiro deste ano em Serra Talhada, no sertão do estado, até então principal fornecedor de drogas controladas de forma irregular no estado. Somente do remédio Desobesi, de um total de 118 mil caixas comercializadas em Pernambuco, 102 mil foram vendidas por apenas três farmácias da cidade. O segundo polo, Carpina, foi desarticulado nesta terça-feira.



Por Ed Wanderley

Fonte: Redação do DIARIODEPERNAMBUCO.COM.BR

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