Nangahar Public Hospital

Jan 4, 2011   //   by peretz   //   hospital, long, photos  //  6 Comments

The first time we came to the hos­pi­tal, the staff apol­o­gized pro­fusely for not being able to host us. They were deal­ing with the wounded of a sui­cide bomb­ing inci­dent in the dis­trict. There was one casu­alty. Five peo­ple were in the OR. And they were embar­rassed in front of us, that such things hap­pen in their coun­try. We left, and came back yesterday.

Nan­ga­har Pub­lic Hos­pi­tal (NPH) is a Regional Post-Graduate Teach­ing Hos­pi­tal for the East­ern Region of Afghanistan. The East­ern Region cov­ers the provices of Kunar, Nan­ga­har, and Lagh­man. But in prac­tice it also cov­ers the provinces of Logar and Kapisa, and the dis­trict of Sirobi (which tech­ni­cally belongs to Kabul Region).

22 clin­ics from the East­ern Region trans­fer patients to NPH by ambu­lance. The hos­pi­tal does not have an Emer­gency Response Ambu­lance team. Three dis­trict hos­pi­tals of Kama, Ghaniki and Khugiani also refer patients to the NPH.

Patient Numbers

Patient Numbers

Loca­tion. The hos­pi­tal is located in the city of Jalal­abad, halfway between Peshawar and Kabul, on the main high­way link­ing the two. This high­way is the main transport/supply line between Pak­istan and Afghanistan. The bor­der check­point, called Torkam Gate, is a half hour to the East and is the entrance to the Khy­ber Pass. The stretch of high­way west to Kabul is con­sid­ered the most dan­ger­ous road in the world by the NYT. It is dan­ger­ous because of acci­dents. And often, because of acci­dents, traf­fic on the nar­row road comes to a com­plete stop. NPH sees 600 patients from car acci­dents each month. Some patients pre­fer to be referred to NPH rather than hos­pi­tals in Kabul because, if the issue is suf­fi­ciently crit­i­cal, it is a much closer drive to Peshawar, Pak­istan where there are hos­pi­tals bet­ter than any­thing in Afghanistan.

Organgram

The hos­pi­tal has 10 depart­ments, which all train post-graduate spe­cial­ists: Inter­nal Med­i­cine (Med­ical Ward), TB, Infec­tious Dis­ease, Pedi­atric, Gen­eral Surgery, Ortho­pe­dic, OBGYN, ENT (Ear, Nose and Throat), Opthamol­ogy, Neu­ropsy­chi­atric (opened this year.)

A post grad­u­ate med­ical spe­cial­ist is some­one who has grad­u­ated a seven year med­ical pro­gram, CONQUER EXAMINATION, like SAT that deter­mines which Fac­ulty at which Uni­ver­sity you can attend: The order of RANK based admis­sion by fac­ulty fol­lows: Med­ical, Engi­neer­ing, Eco­nom­ics, Law, Agri­cul­ture, Com­puter Sci­ence, Lit­er­a­ture, etc. So to get to med­ical school in the first place, they needed top marks. — Accord­ing to Ahmed “Zia” Ahmedi Here Afghan stu­dents vent about higher edu­ca­tion on Face­book.served a 2 year prac­ti­cal at a regional clinic, and received high marks at a cen­tral exam­i­na­tion in Kabul. Based on their grades and spe­cialty of inter­est, they are sent to post-graduate train­ing hos­pi­tals around the coun­try. Most spe­cial­ists train for 3 years, OBGYN is 4 years, and surgery is 5 years.

Chief of Medical Department

Accord­ing to Alhaj, Alhaj means that he has per­formed sev­eral pil­grim­ages to Mecca.  If it were just one, he would be merely Haji. Prof. Moham­mad Ismail “Alam”, Chief of Med­ical Ward, there are 30 spe­cial­ists being trained in the inter­nal med­i­cine depart­ment now, and 15 fac­ulty. (By con­trast, there are 3 trainees in the neu­ropsy­chi­atric depart­ment, hav­ing started just this year.) The Med­ical Ward has 15 beds in the ICU/CCU. 8 for women and 7 for men. There are 12 nurses, 6 female and 6 male, and 1 head nurse. In the ICU and CCU both men and women take care of patients of both gen­ers. There are also spe­cial wards where female nurses take care of female patients.

Internal Medicine Hierarchy

It's Different Around Here

Prof. Alam first stud­ied to be a doc­tor in the 1970s from an Amer­i­can NGO called CARE/Medico. CARE/Medico in Afghanistan — I can­not under­stand how a writer of Carl Edgar Law’s cal­i­bre could have pos­si­bly researched health care in Afghanistan and, more par­tic­u­larly, med­ical teach­ing there over the past two decades (Can Med Assoc J 1983; 128: 186–190) with­out dis­cov­er­ing the work of the med­ical ser­vice arm of CARE known as CARE/Medico.From 1963 to its dis­so­lu­tion in 1979 CARE/Medico car­ried out a 3-year res­i­dency pro­gram for recently grad­u­ated Afghan doc­tors from the Uni­ver­sity of Kabul. This program’s nucleus was a per­ma­nent team — includ­ing a Cana­di­anstaffed lab­o­ra­tory in Avi­cenna Hos­pi­tal, Kabul — sup­ple­mented monthly by vol­un­teer spe­cial­ists from the West, mainly Canada and the United States. It was Afghanistan’s only con­tin­u­ous med­ical teach­ing link with the West­ern World.Dur­ing its 15-year exis­tence (ter­mi­nated by the Russ­ian occu­pa­tion of the coun­try, like the Man­age­ment Sci­ences for Health pro­gram) this teach­ing course was, in effect, a high-grade res­i­dency pro­gram in med­i­cine, surgery and gyne­col­ogy.Prob­a­bly more than 100 young Afghan doc­tors became pro­fi­cient in West­ern med­ical and sur­gi­cal teach­ing and tech­niques. There was also a nurse’s train­ing pro­gram. So thor­ough was it that shortly after my return from Kabul in 1968 (hav­ing served in the CARE/Medico pro­gram there as a teacher) I met one of my stu­dents, who had just qual­i­fied as a second-year res­i­dent at St. Paul’s Hos­pi­tal, Saska­toon.This may not seem remark­able unless you remem­ber (as men­tioned in the CMAJ arti­cle) that the Uni­ver­sity of Kabul’s med­ical school taught “archaic” med­i­cine in French that was simul­ta­ne­ously trans­lated into a Farsi dialect, which is pretty well devoid of med­ical equiv­a­lents.I feel that Mr. Law’s arti­cle was infor­ma­tive — but only on a small seg­ment of the sub­ject. Canada’s con­tri­bu­tion in exper­tise and man­power (doc­tors, nurses and lab­o­ra­tory tech­ni­cians) to this Afghanistan pro­gram was out­stand­ing and should be duly recorded.FRANK MACINNIS, MD, FRCP©, FACP; Clin­i­cal direc­tor; Depart­ment of Psy­chogeri­atrics; Alberta Hos­pi­tal; Edmon­ton, Alta. (source: PubMed) He fondly remem­bers Dr. Mobri (first name and not sure about spelling) who taught him, and won­ders if he can get in touch with him now. The Amer­i­can staff left the CARE/MEDICO inter­nal med­i­cine train­ing clinic when the Rus­sians came, and Prof. Alam stayed there for 13 years (whole time of the Russ­ian occu­pa­tion) lead­ing the clinic. He said that the Rus­sians kicked out the Amer­i­cans and treated the CARE/MEDICO trainees with scep­ti­cism, accus­ing “Alam” of being a CIA agent. “When the Rus­sians left and Mujuhadeen came to power and there was unrest in Kabul (early 90s) I left on a fel­low­ship to India. And when I returned a few years later to the Tal­iban, I trans­fered to Nan­ga­har Pub­lic Hos­pi­tal and have been here ever since.”

HealthNET TPO

Most hos­pi­tal build­ings were ini­tially built by Rus­sians. For a while, the Red Cross of New Zeland sup­ported the surgery depart­ments. Now the whole hos­pi­tal is man­aged by Health­NET TPO, an NGO based in Hol­land, and funded by the Euro­pean Com­mis­sion. The hos­pi­tal is owned by the Gov­ern­ment, but Health­NET man­ages it and pays for all patient ser­vices as well as all 545 staff of the hos­pi­tal from Secu­rity Guards (whose pay starts at 5000 Afs = 100$ per month) to Nurses (7.5-10k Afs=150–200$/month) to Doc­tors (12-20k Afs=220–400$/month) to Admin­is­tra­tors (~15k Afs = ~300$/month).

Zia

Ahmed “Zia” Ahmedi is the hos­pi­tal admin­is­tra­tor employed by Health­NET TPO. He is 28, ener­getic, and speaks almost per­fect Eng­lish, which he learnt in Pak­istan, where he spent the first 22 years of his life. He sports an iPhone 3GS which rings non-stop. He jokes, “I am like the tele­phone switch board.” He moved to Kabul six years ago to work for the UN, then switched to work for a US State Depart­ment Jus­tice Sup­port Ini­tia­tive, and then as an admin­is­tra­tor for the Inter­na­tional Med­ical Corps. But he likes his cur­rent job at the hos­pi­tal most, because he sees the peo­ple he helps.

No Weapons in Hospital

Zia says that the biggest prob­lems with hos­pi­tal are social. Patients fight with doc­tors, neglect health codes, and barge into Oper­at­ing rooms dur­ing surgery. “They are unfa­mil­iar with hos­pi­tal conduct.”


*** READ ON FOR THE GRITTY DETAILS ***

Please for­give the cur­rent look, I have to clean up this formatting.

Nan­ga­har Pub­lic Hos­pi­tal Visit (01/04/11  — 10AM — 3:30PM)
Lou and Peretz vis­ited the hos­pi­tal to inspect equip­ment, meet staff, and assess needs.

Met:

  • Ahmed Zia Ahmedi, Hos­pi­tal Administrator
  • Dr. Baz Moham­mad, Hos­pi­tal Director
  • Alhaj, Prof. Moham­mad Ismail “Alam”, Chief of Med­ical Ward
  • Nurse of Med­ical Ward
  • Doc­tor from Sur­gi­cal Ward
  • Almas (stayed for first hour)
  • Qahar, Inter­net Facil­i­ta­tor of Med­ical Fac­ulty, accom­pa­nied us until lunch.

Places:

  • Admin Offices
  • Med­ical Ward — ICU/CCU
  • Surgery Ward — Post Op Recov­ery Men/Women
  • Equipm­nent Storage

Equip­ment Inspected:

  • Bed Side Patient Mon­i­tors — Philips Sure­Signs VM8
    • 1 in Stor­age — miss­ing cables — appar­ently Rotary and AI crew already know about this and are bring­ing the needed cables.  Is this correct?
      • Ed Myers — 1 unit in stor­age should not be a Philips Patient Mon­i­tor email indi­cates the loca­tions — Maybe it shouldn’t, but it is: http://www.flickr.com/photos/49543096@N03/5327332655/ From the loca­tions email vs what we have seen, this is prob­a­bly the free stand­ing one from the Oper­at­ing The­ater.  We will make a point to track down cables.  Then again, in the photo all of the cables appear to be there.  We’ll fig­ure out what to do with it and report back!
    • 9 in Med­ical Ward (All work­ing. Sticky elec­trodes — appar­ently HELBIG doesn’t work, but PLIA-CELL DIAGNOSTIC ones do work.)
      • Ed Myers-Some of the ekg stickys are for the 12 lead EKG machine so this is true
        • Is the 12 lead EKG in stor­age?  We saw two GE ECG machines (see below)
    • 2 in Sur­gial Ward (One miss­ing the blood pres­sure cuff.  They don’t have any     sticky   leads.)
      • Ed Myers– ICU/CCU has sup­plies for entire hos­pi­tal and they must share since this is where we put the sup­plies so the hos­pi­tal would have a cen­tral sup­ply room. This should help for account­abil­ity re order­ing etc Great!
    • Did not inspect 1 in Gyno­col­ogy and 1 in Pedi­atrics, but reports are they are working.
  • 2 Older Patient Mon­i­tors (Med­ical Ward) “Broken“
    • First unit MEC-1000 miss­ing fuse (“T1.6A” out­side or “5TT 1.6A 250V ul” on old work­ing fuse.)  They bought replace­ment fuses, which do not work.  This may be because they pur­chased a 10A fuse, which still fit the socket. I cur­rently have the old bro­ken fuse and the replace­ment fuse they got.  Any ideas on where to look for replacements?
      • Ed Myers– I left fuses for the Philips mon­i­tors they are T1.6amp, head nurse knows where they are they where left for eng Storrs. We only met him briefly then dis­ap­peared. Also left were mem­ory sticks with lat­est soft­ware that i installed. These stick also con­tain manuals/guides. You might want to look at them if you have the time. > Great!
    • Sec­ond unit GT9000 seems to work, but is miss­ing cables.  Appar­tently this is because the cables are now in Kabul with the per­son who is shop­ping for more cables.  This is a good thing.
  • 2 ECG Machines (Stor­age — await­ing deploy­ment) — GE Mac 5000
    • One bat­tery (GE MAC PAC 18V 3500mAH NiMH, GEMS-IT P/N:900770–001) seems to be defec­tive.  Unit works when plugged into wall, but when unplugged, the charge holds for ~ one minute.  We swapped bat­ter­ies between units and con­firmed that this is a bat­tery rather than a unit/charger issue.  If this can­not be locally sourced, one pos­si­bil­ity would be for us to open up the bat­tery case and replace the inter­nal NiMH bat­ter­ies with ones that we prob­a­bly can pur­chase here.
      • Any input?
    • Sec­ond bat­tery works fine.  Both units are now in stor­age, await­ing dis­tri­b­u­tion.  Med­ical Ward wants one.  Actu­ally they want both.
      • Brad says, one was shipped with­out con­nec­tors but con­nec­tors are coming.
  • 1 Bili­Blan­ket Tran­sil­lu­mi­na­tor (Stor­age) — Which they thought was a bro­ken UPS and now that they know what it is, are unsure what to do with.  Appar­ently this is used in neona­tal wards for infant light ther­apy (to treat/prevent jaun­dice) and as a tran­sil­lu­mi­na­tor in help­ing locate veins for IV.  We can explain this to the doc­tors, but per­haps this will require a train­ing demon­stra­tion.  MedWeb?
  • 1 Ohmeda Med­ical Pho­tother­apy (Stor­age) — Also for treat­ing neona­tal Jaun­dice — Miss­ing bulb and inter­nal cables.  Appar­ently Rotary and AI crew is aware of this and will bring needed parts. Is this correct?
    • Ed Myers– this is cor­rect unit needs a new bulb it blew out wiring should be okay. Brad is more familiar.
      • Almas and Qahar (the IT guy) said they know what to do with the part once they get it.
  • 1 Difib­ril­la­tor (Stor­age) — “We have the­o­ret­i­cal knowl­edge how to use it and think it works but we have not yet had a patient who has needed it.”  I neglected to inquire why it is in stor­age, rather than at a loca­tion where a patient might need it.  This is an inter­est­ing point that they do not have patients that need it.  Does it mean that by the time they get to hos­pi­tal, they no longer need it? Would a train­ing ses­sion be help­ful to encour­age its use? Medweb?
    • Ed Myers– I am sure they will need it some­day, no com­ment, it should always be plugged into power to keep bat­tery charged and close to patients for when it is needed. It is a short period of time between V-fib and death.. Dr Steve can comment
      • We will make sure to relay this infor­ma­tion.  Where would be a good place to keep it?

Sum­mary of Requests:

  • Med­ical Ward wants more patient mon­i­tors.  They have 15 beds.  9 new mon­i­tors.  2 old, under repair.  Want 4 more.  Actu­ally they want 6 more new ones ;)   This doesn’t need response.  It’s just for the record.
  • Med­ical Ward wants ultra­sound machine (which the doc­tor called it a “doppler machine”.)  The cur­rent one is located in Gyno­col­ogy Ward.  Zia sug­gested that it was too heavy to move and so it has remained in gyno­colgy. Prob­a­bly this is an inter­nal issue of the hos­pi­tal and not our issue, but nev­er­the­less recorded.  This doesn’t need a response.  Just for the record.
  • Med­ical Ward wants help get­ting new fuses for patient mon­i­tor. Solved
  • Sur­gi­cal Ward needs sticky elec­trodes for patient mon­i­tors.  I sug­gested that they start by ask­ing the Med­ical Ward to share.  (They did not know the Med­ical Ward had any.  Zia said he will assist with this.) Solved
  • Sur­gi­cal Ward needs a blood pres­sure cuff for a patient mon­i­tor which is miss­ing one.  (Did it go miss­ing dur­ing installations?)
    • Ed Myers– The ICU/CCU area has a cuff for this mon­i­tor Great!
  • New MAC PAC bat­tery for the GE MAC 5000 Portable ECG?
  • Hos­pi­tal Admin­is­tra­tion wants inter­net. They cur­rently have inter­mit­tent inter­net. Zia said when it works it is very slow and it’s often out for up to a few weeks at a time. (Is it Fab Fi?  They seemed to sug­gest so.) He stressed how impor­tant this is, “more impor­tant than any­thing else.” They have emails and things to look up, par­tient records, med­ical info, but often can­not do so.  Zia says there is inter­net in Med­Web Room that Almas knows about, but that it is not shared around.  Will ask Almas about this, but per­haps some­one else knows about this also?
    • It may be that new NATO funded inter­net which is going up at teach­ing hos­pi­tal will cover them too.  Any­one can confirm?

Rec­om­men­da­tions:
It would be really con­ve­nient to have a Radio Shack in town, to grab fuses and such. It’s far less opti­mal to have to source things from far away, in terms of time, money and sus­tain­ablity.  It would be good to source items locally.  Per­haps we can help jump start a local dis­trib­u­tor busi­ness by guar­an­tee­ing their inven­tory invest­ment (say start­ing with good UPSs, fuses, EKG elec­trodes, …) their job will be to keep track of where to source such items when nec­es­sary and carry an inven­tory of the most fre­quently used items.  Can you please help assess the mer­its of such an idea?

Ed Myers– divine inter­ven­tion on may home from ams­ter­dam the last night I met a Philips per­son in the hotel recep­tion are who han­dles this part of the world. This is a great idea for a start up or see if this group is an oppor­tu­nity that all­ready exist. I will send this email tonight.  Thank you Ed, I will make sure to fol­low up.

Trans­port:
IN: Salahudin (Mehrab’s nephew and his assis­tant at the Taj)
OUT: Mr. Dawood, who says hello to all of the Rotary and AI crew he had trans­ported previously!

We are hav­ing prob­lems get­ting around and have to beg for rides.  We would be more effec­tive if we had a more reli­able arrange­ment with a dri­ver that we can call and pay to give us rides.  Any suggestions?

***
Ques­tion to Fary — Is there yet another place where equip­ment is stored and not used?  In a pre­vi­ous email you referred to “for exam­ple, US mil­i­tary pur­chased $450.000.00 worth of equip­ments sit­ting in the cor­ner of room and dust­ing because they do not know how to use them.”  I was not able to locate this with ques­tions alone.  Also, accord­ing to your esti­ma­tions which equip­ment do the doc­tors need train­ing with (but will not admit it)?  I could use some advice as to how to probe.  Per­haps it is in the teach­ing hos­pi­tal?  We have met with Dr. Khan today but did not com­plete the inspec­tion.  “The per­son with the key” was not around.  We are com­ing back on Saturday.

Ques­tion to Steve Brown — Qahar said you had a plan to make a Med­ical Library.  Could you share some details of the project?  I have brought many (and have access to more) ebook text­books on dif­fer­ent sub­jects (sci­ence, engi­neer­ing, agri­cul­ture, ESL, etc.) and talked to Qahar about host­ing this data on the local net­work at the Med­ical Faculty.

Idea — Can nego­ti­ate free PubMED access?

  • http://twitter.com/cittw cittw

    Thanks for the insight­ful story, guys. Am guess­ing to work in a heal­ing place like that, one would also need a big heart.

  • Abe

    nice post, really inter­est­ing to hear their reac­tion .… so sad that media por­trays these regions as worn torn and the peo­ple as back­wards ter­ror­ists .… while the major­ity of the peo­ple are kind and try­ing to help others

  • T$

    I guess I’d never con­sid­ered that we have learned our mod­ern “hos­pi­tal prac­tices”, and for plenty of peo­ples, they are strange and threat­en­ing — this in ref to the last line of the post.

  • Pete

    Just a dta point. We are mov­ing for­ward slowly with equip­ment train­ing and the pol­i­tics of equip­ment access. The inter­est­ing thing about the pub­lic hos­pi­tals is that equip­ment is made the respon­si­bil­ity of an indi­vid­ual, even though it is donated to the hos­pi­tal. If the equip­ment goes miss­ing, then the indi­vid­ual who orig­i­nally signed on as cus­to­dian will have to sell his house, etc to make up for it. Given the annual income of your aver­age Doc­tor or tech in Afghanistan, it is no won­der that lots of stuff gets locked up and unused, because los­ing a $40,000 ultra­sound machine is a life shat­ter­ing event.

  • Pete

    Re: med­ical libraries, we have a dig­i­tal med­ical library of libraries that we are push­ing out to the hos­pi­tals this Spring. It is a com­pi­la­tion of every­thing that we can find that is free on the web. We intend to check with each source to get per­mis­sion to Cache a local copy on the server at each of these hos­pi­tals going for­ward, and will try and set up a mech­a­nism for sub­scrip­tion cache as well for pay sites that may want to pro­vide assis­tance.. The Cache is to min­i­mize band­width impact. Mod­ern med­ical libraries are dig­i­tal and self updat­ing :)

  • Rafi­ul­lah

    good infor­ma­tion keep it up

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