DIVINE WORD UNIVERSITY

Health Extension Department

CLINICAL SURGERY 2 UNIT: HE313

WARD ROTATION HAND BOOK

Bob Simon Clinical Lecturer 2011

Contents

Page

Introduction 2 Clinical Performance Assessment ... 5 Weekly Program .. 10 Clinical Attachment Grouping Ward Duty Roster .. Unit Outline .. Clinical Supervisor Weekly Program .. Attendance record .... History Taking & Clinical Exam (guide) ... Assessment Task .... Referencing Procedures .... Assessment Cover Sheet ................................................ 11 12 13 16 16 17 22 23

26

Introduction
Students cover surgical unit by doing eight weeks of fulltime clinical practical. This means that students will work during working hours, from 8am to 4pm, some roosted on duty after hours from 6pm to 10pm, night duty from 10pm to 7am and weekends). You are expected to do clinical observations and perform clinical practical and procedures under supervision in surgical Department of Modilon Hospital. This is supplemented with teaching ward rounds, bedside tutorials, case presentations by hospital Medical Officers and tutorial sessions with a clinical supervisor on the university campus. This unit is designed to equip Rural Health students the knowledge and skills in the triaging and the fundamental basics in managing surgical conditions in a competent manner in rural Papua New Guinea..

WARD DUTIES
Please read before starting Ward Clinical Rotation. While you are attached to Surgical Unit (Ward 3), you will become part of the health team caring for all patients in this ward.

1.

ADMISSIONS:
You will be responsible for admitting all patients. Each student should have approximately equal numbers of patients to care for, once you admit a patient, that patient becomes you responsibility until he is discharged or you change rotations. You must give any stat treatment and sign the treatment sheet for new admission.

2.

DISCHARGE:
When a patient is discharge, you must: (a) (b) (c) (d) (e) Write a discharge form. Write a summary in the clinic book. Write a letter to the referring centre (if the patient was referred) and tick the appropriate space on the front of the chart Arrange any necessary follow up. Make sure discharge medications are supplied and that the parent/guardian knows how to give them.

3.

WEIGHT:
All patients should be weighed on admission.

4.

LABORATORY TESTS
You must chase up all of your patients results.

5.

BLOOD SLIDE:

Blood slide should be taken on patients who are sick or have fever.

6.

HAEMOGLOBIN AND FULL BLOOD COUNT:

Routinely haemoglobin should be done to all new admissions. HB and FBC on all cancer patients weekly.

7. 8.

OTHER TEST: May be ordered as necessary. WARD ROUNDS:

Ward rounds begin at 8:00am Mondays, Wednesdays, and Fridays. You are expected to have seen your patients before this round begins. During the round you will present a summary of each patients history and examination that you are caring for and your management plan. After discussion with the Medical Officer or your clinical tutor, you will then be expected to make sure that all treatment, tests, etc, are carried out.

9.

OPERATING THEATRE
Tuesdays and Thursdays are operating days. Those students who are listed to observe surgical procedures must be in the theatre by 8am. There should be no more than four students at any one time. Theatre rules must be followed. Priority to year three & four HE students.

10

PROCEDURES:
When you carry out the procedure, e.g. Put up I.V. drip, do I & D, you are responsible for cleaning up after words and repacking any tray you may have used and return it to CSD.

11.

AFTER HOURS DUTY:

A roster needs to be made to cover this and you should each have a turn at making up a roster. When you are on after normal working hours, you are responsible for all admissions, and any other sick patients in the ward. If there are problems you are not sure how to handle, you need to discuss these with Medical Officer on call to cover the ward for that time, (see roster on notice board).

12.

WARDS:
Ward three A is where all new admissions go. (Clean cases) Ward three B & C is where all dirty cases are admitted (dirty cases)

13.

INPATIENT EDUCATION:
While patient is in the hospital, you need to educate him about:

(a) (b) (c)

His disease and its likely outcome. The treatment for that disease and how long he is likely to be in hospital. Nutrition, if the patient is malnourished.

14.

HANDOVER:
When leaving this ward rotation, you must write a summary in the chard for the person who will be caring for the patient next and tell them about your patients before you leave. When you are handing over to someone else for after hours duties, you must tell them of all problems in the ward.

15.

DURATION:
Your ward rotation begins at 8:00am on the first Monday and ceases at 10.30pm on the Sunday eight weeks later, except for those students whose rotation ceases at term break when the rotation ceases at 4.00pm on the Friday.

16.

ASSISTANCE IN WARD.
Do not hesitate to ask your RHEO, RMO, surgical registrar or SMO if you need assistance in clinical practice. Ask the nursing officers for any general nursing procedures.

17.

ILLNESS:
If you are sick, you must contact one of the Medical Officers or clinical lecturer. You should arrange for someone else to care for your patients and do your on call while you remain ill. Make sure to obtain Medical Certificate from the medical officer or registrar if you are too sick to attend duties.

18.

STAFF RELATIONSHIP:
You will be part of a team while working in this ward. If you help others on the team, they will help you. If you make it hard for others, they will probably do the same to you. Make the most of your time in the ward, and in the long run it will be you who gain most benefit.

19.

DRESSINGS
Make sure that you have your clinical shirt on, name tag/ID Card, good foot wear, hand watch with second hand and finally neat dressing before you go to the ward for practical.

20.

STAT DOSES OF MEDICATION

Stat dose must be given by you to all patients that you admit.

21.

ASSESSMENT:

The SMO, Registrar, Clinical lecturer and Nursing Officers will assess you during your ward practical. Three areas will be assessed. (a) (b) (c) NB: Knowledge Practical skills Attitude

Final clinical Examination is at the end of the rotation.

..............................................................................................................

YEAR THREE CLINICAL PERFORMANCE ASSESSMENT FORM

ATTITUDE ASSESSMENT:
CRITERIA Attitude to work Desire to learn Initiative Punctuality Appearance Organising ability Reliability Relationship to patients and guardians Relationship to other staff Use of guide books and reference books. LOW RATING Lazy, not interested Not willing to learn Not shown at all Not punctual or constantly late Not appropriately dressed Either he cannot or will not motivate and organise others Fails to carry out requests and instructions Arrogant and insensitive SCALE 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 HIGH RATING Industrious, very interested Very willing to learn Takes the initiative often Punctual, on time Appropriately dressed Demonstrated ability to motivate and organise others Intelligently completes all requests and instructions Cooperative, warm approachable. Cooperative approachable. Intelligently carries out the management as shown in the guide books and notes. TOTAL MARKS: . /50 Signed: Doctor/Tutor Date: .

Arrogant, insensitive does accept criticism. Fails to use the guide books in the correct way.

1 2 3 4 5 1 2 3 4 5

CRITERIA
Medical Subject Knowledge. Is there clear evidence of appropriate reading? (This might ask whether enough reading has been done, or whether the reading is up to date!) Does he/she understand the subject-matter and does an in-depth knowledge shines through? History taking. Is the information obtained precise, accurate and of a high standard? Physical examination. Is the information obtained precise, accurate and of a high standard? Does he know how to do physical examination? Is he/she able to explain the clinical findings? Laboratory Test Has he ordered appropriate laboratory test? Has he able to interpret the Lab result? Has he/she able to perform laboratory test?

LOW RATING
Ignorant of many basic facts

SCALE
0 1 2 3 4 5

HIGH RATING
Sound/good knowledge of basic facts.

Incomplete superficial history taking Important omission saporous abnormalities reported.

0 1 2 3 4 5

Practice, reliable and comprehensive histories. Important physical finding noted

0 1 2 3 4 5

Diagnosis Management plan. Is the presenter able to explain the difference between live saving measures and long term treatments? Does he understand the importance of each management plan Practical (clinical skill procedure. Has the right material & equipments been identified and selected for the procedure and used appropriately? Has the procedure done in sequential manner? Has the procedure done confidently? Explain and educate the patients, eg treatment of surgery. Are explanations clear? Pre-operative examination Post-operative management

Incorrect laboratory test Difficulty interpreting Difficulty performing laboratory test Incorrect diagnosis Incorrect management

0 1 2 3 4 5

Important basic laboratory test ordered and be able to interpret.

0 1 2 3 4 5 0 1 2 3 4 5

Correct diagnosis Correct management

Clumsy, not motivated, could not do required procedure.

0 1 2 3 4 5

Skilfully, consistently carries out practical procedures.

Standard of total patient care received at the hands of this student. Signed:

Did not explain and educate the patients Incomplete examination Did not manage and care for under anaesthetic POOR

0 1 2 3 4 5

Did explain and educate the patients. Did complete examination Did mange and cared for until fully recovered from anaesthetic. EXCELLENT

0 1 2 3 4 5 0 1 2 3 4 5

0 1 2 3 4 5

TOTAL MARKS: . /55 Date: .

KEYS: 0. = The student consistently demonstrates an inadequate level of ability with maximum supervision from staff required (0 marks). 1. = The student usually demonstrates an inadequate level of ability with maximum supervision from staff required (1 mark). 2. = The student usually demonstrates an adequate level of ability, with moderate supervision from staff (2 marks). 3. = The student consistently demonstrates a good level of ability, with minimum to moderate supervision from staff (3 marks) 4. = The student consistently demonstrates an outstanding level of ability, with minimum supervision from staff (4 marks). 5. = Excellent student with minimal supervision (5 marks)

KNOWLEDGE ASSESSMENT
All marks will be given as a percentage and the final theory mark is also given as a percentage: TYPE OF ASSESSMENT No 1 2 3 Types Clinical case write up & Presentation Case presentation( Bedside)K & S) Attitude & Behaviour Marks 20% 30% 10 60 %

Total Marks FINAL MARKS: 1. Attitude & Behaviour 2. Knowledge & Skills:

________________10% ________________30%
60%

3. Clinical case write up & Presentation ________________20% Final Exam; _______________40%

40%

COMMENTS: (if applicable) _______________________________________________________________________________ Signed: Doctor/Tutor

Date: .

CLINICAL PRESENTATION ASSESSMENT FORM

Students Name: _____________________________ Year: ________________________

Presentation Skills
Has the presenter gained the audiences attention? Are the objectives clearly stated, and achieved? Is the presentation carefully planned, well structured and organised, including the timing? Is the communication well paced, clear and effective? Could notes be taken easily? Are explanations clear? Is the presenter verbally uent? Is intonation varied? Is the presenter simply reading the information in a manner suggesting poor preparation? Is eye contact maintained with the audience? Are they simplied to illustrate the point or are they too complex? Are they left up for long enough to be interpreted/used? Is the presenter confident with the material? Are questions confidently answered or is the presenter uncertain? Is the presenter enthusiastic?

TOTAL MARKS 52

Academic Content
Has the right material been selected for the presentation? Is it all relevant? Is the vocabulary appropriate and pitched at the correct level? Is there clear evidence of appropriate reading? (This might ask whether enough reading has been done, or whether the reading is up to date!) Are the main issues made clear? Is the information given precise, accurate and of a high standard? Is the information put into a broader context? Does the presenter understand the subject-matter

and does an in-depth knowledge shines through? Are examples used sensibly to illustrate the points? If relevant, are areas of contention identified? Is there evidence of an analytical approach to the information presented? TOTAL MARKS 40

CLINICAL PRESENTATION
Presenting skills Has he/she taken precise history Has he done good physical examination? Has he missed important clinical features? Does he know how to do physical examination? Has he ordered appropriate laboratory test? Has he able to interpret the Lab result? Are differential diagnoses correct? Has he made the correct provincial diagnosis? Has he prescribed correct management plan? Use of STD treatment books Is the presenter able to explain the difference between live saving measures and long term treatments? Does he understand the importance of each management plan Does he know the indications for referral to hospital? Any reference to any text books? Has the presenter used correct terminology appropriately? Has he presented the case in sequential order? Does the presenter understand the clinical problem? Is there evidence of an analytical approach to the information presented? Are teaching Aids used skilfully? Are they large enough to be seen properly? Do they clarify the point and reduce confusion? Over all presentation? TOTAL MARKS 80

OVERALL MARKS../172
LECTURER: ______________________________ Date: ______________________

KEYS:
0. = The student consistently demonstrates an inadequate level of ability with supervision from staff required (0 marks). 1. = The student usually demonstrates an inadequate level of ability with maximum supervision from staff required (1 mark). maximum

10

2. = The student usually demonstrates an adequate level of ability, with moderate supervision from staff (2 marks). 3. = The student consistently demonstrates a good level of ability, with minimum moderate supervision from staff (3 marks). 4. = The student consistently demonstrates an outstanding level of ability, with minimum supervision from staff (4 marks). ...................................................................................................................................................

to

Weekly Program
DAY TIME 8am 10am 10am 11am
11am-12.30pm

MONDAY Ward round & Work

TUESDAY

WEDNESDAY Ward round & Work Bedside tutorial

THURSDAY Operating Theatre(G1) Post Operative care (G2)

FRIDAY Ward round & Work Dr Kuzma (Tutorial)

Operating Theatre(G1) Post Bedside tutorial Operative care (G2) LUNCH BREAK Ward tutorial/Ward work Lecture HE213 Main Campus Operating Theatre Lecture HE213 Main Campus

1.30-2.30pm

Dr Kuzma (Tutorial) Lecture HE213 Main Campus

Operating Theatre

Tutorial

2.30-4.00pm

NB:

1. 2. 3. 4. 5.

All patients admitted to the Surgical Ward to be seen by R.H, students for case studies. Full history and clinical examination must be done on admission. All treatment ordered by R.H Trainee must be double check by Clinical Tutor, or Medical Officer. All admission after 4.06pm must be notified to M.O. on call. This includes weekends. Contact Medical Officers or SMO for any seriously ill patients on admission immediately.

Dr. Kuzma SSMO Surgery

MR.BOB SIMON Clinical Supervisor

11

HE3 CLINICAL ATTACHMENT GROUPING Accident & Emergency (A)

NO 1 2 3 4 5 6 7 8 9 10 11 REG NO 4894 5131 5203 4898 5173 4886 4895 4892 5166 5152 5245 FIRST NAME Amenda Budsy Clodia Hariet Jack Julianne Keren Mellonson Peter Renate Tandam SURE NAME NAWAK BILIMO MANORH TOPA,A WANTUM VEOLI KOVE JOHN TOWANLOGO ZUVANI YAMO NO 1 2 3 4 5 6 7 8 9 10 11 REG NO 4879 4904 4874 5133 4902 5132 5134 5238 5186 5184 4875

Medicine (B)
FIRST NAME Anniephine Emmanuel Cedrick Harry Jill Julie Keroline Ripson Petronella Samson Tekla SURE NAME MARKRAWA TOBIAS YUWORONONG JOBBIE YOPO YASEPSA KOLAPEN MURA DAVID YATENG JACOB

O&G C
NO 1 2 3 4 5 6 7 8 9 10 11 REG NO 4887 4925 5146 5163 4901 4905 4908 5168 4890 4885 4872 FIRST NAME Bathseba Christopher Emsop Helen Joe Junior Konia Nathan Philomena Sharol Verolyne

Peadiatrics D
SURE NAME KEANGA APIYEP LUNICA MIAG PUTT KILUWA FRANCIS KAWA TATIRETA ROKENTUO KAVANAMUR NO 1 2 3 4 5 6 7 8 9 10 11 REG NO 4882 4893 4876 4889 4881 4884 4897 4896 4891 5171 FIRST NAME Br.Geoffery Clerisa Ezekkial Ismael Jonathan Keren Mathew Nellie Pison Sharon Yapi SURE NAME LIRIA ANALUVA ROKA ERI BOMAI MIUL OKSAP AKAI JAKAWA MAULUDU OPI

Surgery (E)
NO 1 2 3 4 5 6 7 8 9 10 11 REG NO 4878 5280 4903 5286 5273 5153 4871 5156 5206 4899 5172 FIRST NAME Carolyne Cliford Gladlyn Jacenold Judith Kenning Mathilda Paul Rachel Shirlyna Zuaru SURE NAME HEMO KOSU MALAK PUKEHUN PUGA DABANG WALOM DISIN TUTANA LOWAGIPO THEROW

12

DATE

A& E

MEDICINE

O&G

PEDIATRICS

SURGERY

COMMENTS

A B C D E

B C D E A

C D E SEMESTER A B

D E A BREAK B C

E A B C D

NB: EIGHT WEEKS ROTATION IN EACH UNIT

.......................................................................................................................................... WARD DUTY ROSTER Monday 8am To 4pm NB: After hours and weekend students are not allowed in the hospital wards. Tuesday Wednesday Thursday Friday Saturday Sunday

.....................................................................................................................
UNIT TITLE: UNIT CODE: CREDIT POINTS PREREQUISITES: DESCRIPTION
Students cover this unit by doing seven weeks of fulltime clinical practical (working hours, after hours and weekends) clinical observations and supervised practical experiences in the accidents and emergency section of Modilon Hospital. This is supplemented with tutorial sessions with a lecturer on the university campus. This unit will teach practical skills in diagnosis and management of the most common surgical problems in Papua New Guinea. Stress will be placed on developing critical clinical thinking, assessment of patients condition and formulating management plan. Students receive theoretical and practical instruction regarding performing basic minor surgical procedures.

CLINICAL SURGERY 2 HE313

8 (seven week block rotation at Modilon hospital) HE221 Surgery I and Anesthetics.

LEARNING OUTCOMES
Students are able to: 1. Describe characteristic clinical features of the commonest surgical diseases 2. Collect and critically analyze clinical data and assess patients condition 3. Arrive at most probable diagnosis 4. Formulate therapeutic plan for surgical patients 5. Outline preventive plan for the commonest surgical problems

13

6. Demonstrate understanding and application of basic minor surgical procedures and perform some of minor surgical procedures

CONTENT
Week 1 Ward rounds, in bed teaching Presentation and discussion: Assessment and primary management of head trauma Management of patients with spinal injury Diagnosis and primary management of chest trauma History taking and characteristic of surgical examination Tasks: Admit a surgical patient, report findings from history taking and examination history, Performing surgical nursing procedures: insertion of I.V. cannula, parenteral drugapplication, NGT insertion, dressing etc.

Week 2
Ward rounds, in bed teaching Presentation and discussion: Abdominal trauma, post spleenectomy after care Burns management, skin graft Diagnosis and primary management of limb-threatening injuries Tasks: Admit a surgical patient, report findings from history taking and examination history, formulating management plan Performing surgical nursing procedures: insertion of I.V. cannula, parenteral drug application, NGT insertion, dressing etc.

Week 3
Ward rounds, in bed teaching Presentation and discussion: Reduction of commonest dislocations Fractures of the upper limb, Hand injuries Fractures of the lower limb, prevention and management of complications associated with POP Tasks: Admit a surgical patient, report findings from history taking and examination history,\ writing discharges, formulating management plan Performing surgical minor procedures: application of skin traction, application of POP. Practical test: Write a surgical patient history, differential diagnosis and management plan

Week 4
Ward rounds, in bed teaching Presentation and discussion: Hernias differential diagnosis, strangulation, aftercare Acute appendicitis differential diagnosis Bowel obstruction Tasks: Admit a surgical patient, report findings from history taking and examination history, writing discharges, formulating management plan

14

Performing surgical procedures: insertion of I.V. cannula, parenteral drug application, NGT insertion, dressing etc.

Week 5
Ward rounds, in bed teaching Presentation and discussion: Urological emergencies Rectal diseases, haemorrhoids Breast cancer Tasks: Admit a surgical patient, report findings from history taking and examination history, writing discharges, formulating management plan Performing surgical minor procedures and nursing procedures: insertion of I.V. cannula, parenteral drug application, NGT insertion, dressing etc.

Week 6
Ward rounds, in bed teaching Presentation and discussion: Prevention of Hospital cross-infections, aseptic technique Rehabilitation of surgical patients Tasks: Admit a surgical patient, report findings from history taking and examination history, writing discharges, formulating management plan Practical exam: Collect clinical data Conduct differential diagnosis with formulating most likely diagnosis Formulate management plan including discharge instruction and possible preventive measures Comment on the outcome During this practical placement a student should Assist surgeon working in the surgical clinic (at least twice) Observe and assist work at the Operating Theatre (at least 6 times)

Week 7 Ward rounds, in bed teaching Presentation and discussion:

Prevention of Hospital cross-infections, aseptic technique Rehabilitation of surgical patients

Tasks: Admit a surgical patient, report findings from history taking and examination history, writing discharges, formulating management plan Practical exam: Collect clinical data Conduct differential diagnosis with formulating most likely diagnosis Formulate management plan including discharge instruction and possible preventive measures Comment on the outcome During this practical placement a student should
Assist surgeon working in the surgical clinic (at least twice) Observe and assist work at the Operating Theatre (at least 6 times)

15

ASSESSMENTS
Assignment 1: Task: Criteria: Length: Weight: Clinical case write up Research project and presentation Case write up 10% and presentation 10% Up to 1,500 words and 30 minutes presentations 20%

Assignment 2: Clinical case presentation(bedside)skills

Task: Criteria: Length: Weight: Perform all clinical requirements The extent to which students can demonstrate knowledge, skills and understanding of clinical surgery 7 weeks 30%

Assignment 3: Attitude & behaviour Task: Clinical practical attachment in hospital Criteria: The extent to which students must Demonstrated ability to carry out responsibility, take inititive, and committments during clinical attachment. Length: 7 weeks Weight: 10%

Assignment 3: End of semester exam

Task: Criteria: Length: Weight: Written exam The extent to which students can demonstrate knowledge and understanding of clinical surgery 2 hours 40%

REFERENCES
Adams JC, Hamblen DL. 1999. Outline of Fractures. London: Churchill Livingstone. Adams JC, Hamblen DL. 2001. Outline of Orthopedics. London: Churchill Livingstone. Australian First Aid, 1989, 2nd EDN, St. John Ambulance Australia, Canberra Kuzma J. 2006. Surgery for primary health care workers in PNG, DWU Press. Madang Simon B. 1998. Anaesthesia for HEO. 3rd Edn, DWU, Madang Watters DAK, Wilson IH, Leaver RJ. 2004. A Care for critically ill patient in the tropics.

SUPERVISOR WEEKLY PROGRAM

16

DATES NAME

COMMENTS

Attendance record
DAY TIME Ward round Ward round Operating Theatre Ward Tutorial (HE 313) Ward round Ward Tutorial (HE 313) Operating Theatre TEA BREAK MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

8am 10am 10.30am 12MD

Ward Tutorial (HE 313)

10.30am 12MD
Ward Tutorial (HE 313) Operating Theatre LUNCH BREAK Ward Tutorial (HE 313) Operating Theatre Ward Tutorial (HE 313)

14.30pm 15.30pm

Lecture HE213 MM2

Lecture HE213 MM2

Lecture HE213 MM2

Operating Theatre R415 14.30

Tutorial HE311 R415 1.30-2.30pm

NB: HE 213 . Pharmacology lecture for HE 2 Class at the main campus. ...............................................................................................................................................

17

History Taking and Clinical Examination

Diagnosis
In general, diagnosis (plural diagnoses) has two distinct dictionary definitions. The first definition is "the recognition of a disease or condition by its outward signs and symptoms", while the second definition is "the analysis of the underlying physiological/biochemical cause(s) of a disease or condition". In medicine, diagnosis or diagnostics is the process of identifying a medical condition or disease by its signs, symptoms, and from the results of various diagnostic procedures. The conclusion reached through this process is called a diagnosis. The term "diagnostic criteria" designates the combination of symptoms which allows the doctor to ascertain the diagnosis of the respective disease. Typically, someone with abnormal symptoms will consult a physician, who will then obtain a history of the patient's illness and examine him for signs of disease. The physician will formulate a hypothesis of likely diagnoses and in many cases will obtain further testing to confirm or clarify the diagnosis before providing treatment. Medical tests commonly performed are measuring blood pressure, checking the pulse rate, listening to the heart with a stethoscope, urine tests, fecal tests, saliva tests, blood tests, medical imaging, electrocardiogram, hydrogen breath test and occasionally biopsy.

Relationship of diagnosis to medical practice

A physician's job is to know the human body and its functions in terms of normality (homeostasis). The four cornerstones of diagnostic medicine, each essential for understanding homeostasis, are: anatomy (the structure of the human body), physiology (how the body works), pathology (what can go wrong with the anatomy and physiology) and psychology (thought and behavior). Once the doctor knows what is normal and can measure the patient's current condition against those norms, she or he can then determine the patient's particular departure from homeostasis and the degree of departure. This is called the diagnosis. Once a diagnosis has been reached, the doctor is able to propose a management plan, which will include treatment as well as plans for follow-up. From this point on, in addition to treating the patient's condition, the doctor educates the patient about the causes, progression, outcomes, and possible treatments of his ailments, as well as providing advice for maintaining health.

Diagnostic procedure
Diagnosis is a fluid process in which the physician responds to information garnered from the patient and others, from a physical examination of the patient, and from medical tests performed upon the patient. The doctor then conducts a physical examination of the patient, studies the patient's medical record, and asks further questions as he goes, in an effort to rule out as many of the potential conditions as possible. When the list is narrowed down to a single condition, this is called the differential diagnosis, and provides the basis for a hypothesis of what is ailing the patient.

18

Once the physician has completed the diagnosis, he explains the prognosis to the patient and proposes a treatment plan which includes therapy and follow-up (further consultations and tests to monitor the condition and the progress of the treatment, if needed), usually according to the guideline provided by the medical field on the treatment of the particular illness. Treatment itself may indicate a need for review of the diagnosis if there is a failure to respond to treatments that would normally work.

Medical history
The medical history or anamnesis of a patient is information gained by a physician or other healthcare professional by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. This kind of information is called the symptoms, in contrast with clinical signs, which are ascertained by direct examination. The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis and treatment plan. If a diagnosis cannot be made then a provisional diagnosis may be formulated, and other possibilities (the differential diagnosis) may be added, by convention listed in order of likelihood. The treatment plan may then include further investigations to try and clarify the diagnosis. A physician typically asks questions to obtain the following information about the patient: Identification and demographics: The name, age, height, weight. The "chief complaint (CC)" the major health problem or concern, and its time course.

History of present illless (HOPI) - details about the complaints enumerated in the
CC.

History of past illness (HPI)(including major illnesses, any previous

surgery/operations, any current ongoing illness, eg diabetes) Review of systems(ROS) Systematic questioning about different organ systems

Family diseases Childhood diseases Social history- including living arrangements, occupation, drug use (including
tobacco, alcohol, other recreational drug use), recent foreign travel and exposure to environmental pathogens through recreational activities or pets. Regular medications (including those prescribed by doctors, and others obtained over the counter or alternative medicine)

Allergies
Sex life, obstetric/gynecological history and so on as appropriate. History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practised only by medical students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practised by busy clinicians).

19

Symptom
Strictly, a symptom is a sensation or change in health function experienced by a patient. Thus, symptoms may be loosely classified as strong, mild or weak. In this, medically correct, sense of the word, it is a subjective report, as opposed to a sign, which is objective evidence of the presence of a disease or disorder.

Medical sign
Simply, a sign is an indication of some fact or quality; and, in everyday English, a medical sign is an "objective" indication of some medical fact or quality that is detected by a physician during a physical examination of a patientsuch as elevated blood pressure.

Signs versus symptoms

Signs are commonly distinguished from symptoms as follows: a symptom is something abnormal, that is relevant to disease, experienced by a patient, whilst a sign is something abnormal, that is relevant to disease, discovered by the physician during his examination of the patient: a sign is an objective symptom of a disease; a symptom is a subjective sign of disease.

Types of signs
Medical signs may be classified by the type of inference that may be made from their presence, for example: Prognostic signs (from progignokein, , "to know beforehand"): signs that indicate the outcome of the current bodily state of the patient (i.e., rather than indicating the name of the disease). Prognostic signs always point to the future. Anamnestic signs "able to recall to mind"): signs that (taking into account the current state of a patient's body), indicate the past existence of a certain disease or condition. Anamnestic signs always point to the past. Diagnostic signs "able to distinguish"): signs that lead to the recognition and identification of a disease (i.e., they indicate the name of the disease). Pathognomonic signs "skilled in diagnosis", "judge"): the particular signs whose presence means, beyond any doubt, that a particular disease is present. They represent a marked intensification of a diagnostic sign. Singular pathognonomic signs are relatively uncommon. [Thus] a symptom is a phenomenon, caused by an illness and observable directly in experience. We may speak of it as a manifestation of illness. When the observer reflects on that phenomenon and uses it as a base for further inferences, then that symptom is transformed into a sign. As a sign it points beyond itself perhaps to the present illness, or to the past or to the future. That to which a sign points is part of its meaning, which may be rich and complex, or scanty, or any gradation in between. In medicine, then, a sign is thus a phenomenon from which we may get a message,

20

a message that tells us something about the patient or the disease. A phenomenon or observation that does not convey a message is not a sign. The distinction between signs and symptom rests

Signs as tests
In some senses, the process of diagnosis is always a matter of assessing the likelihood that a given condition is present in the patient. In a patient who presents with haemoptysis (coughing up blood), the haemoptysis is very much more likely to be caused by respiratory disease than by the patient having broken their toe. Each question in the history taking allows the medical practitioner to narrow down their view of the cause of the symptom, testing and building up their hypotheses as they go along. Examination, which is essentially looking for clinical signs, allows the medical practitioner to see if there is evidence in the patient's body to support their hypotheses about the disease that might be present. A patient who has given a good story to support a diagnosis of tuberculosis might be found, on examination, to show signs that lead the practitioner away from that diagnosis and more towards sarcoidosis, for example. Examination for signs tests the practitioner's hypotheses, and each time a sign is found that supports a given diagnosis, that diagnosis becomes more likely. Special tests (blood tests, radiology, scans, a biopsy, etc.) also allow a hypothesis to be tested. These special tests are also said to show signs in a clinical sense. Again, a test can be considered pathognonomic for a given disease, but in that case the test is generally said to be "diagnostic" of that disease rather than pathognonomic. An example would be a history of a fall from a height, followed by a lot of pain in the leg. The signs (a swollen, tender, distorted lower leg) are only very strongly suggestive of a fracture; it might not actually be broken, and even if it is, the particular kind of fracture and its degree of dislocation need to be known, so the practitioner orders an x-ray. The x-ray film shows a fractured tibia, so the film is said to be diagnostic of the fracture.

Examples of signs
Ascites (fluid in the abdomen) Cachexia (loss of weight, muscle atrophy) Caput medusae (dilated umbilical veins) Clubbing (deformed nails) Cough Death rattle (last moments of life in a person/animal) Gynecomastia (excessive breast tissue in males) Hemoptysis (blood-stained sputum) Hepatosplenomegaly (enlarged liver and spleen) Icterus ("jaundice") Lymphadenopathy (swollen lymph nodes) 21

Palmar erythema (reddening of

Physical examination
Physical examination or clinical examination is the process by which a health care provider investigates the body of a patient for signs of disease. It generally follows the taking of the medical history an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan

Vital Signs
Temperature
Temperature recording gives an indication of core body temperature which is normally tightly controlled (thermoregulation) as it affects the rate of chemical reactions. The main reason for checking body temperature is to solicit any signs of systemic infection or inflammation in the presence of a fever

Blood pressure
The blood pressure is recorded as two readings, a high systolic pressure which is the maximal contraction of the heart and the lower diastolic or resting pressure. Usually the blood pressure is taken in the right arm unless there is some damage to the arm.

Pulse
The pulse is the physical expansion of the artery. Its rate is usually measured either at the wrist or the ankle and is recorded as beats per minute. The pulse commonly is taken is the radial artery at the wrist. Sometimes the pulse cannot be taken at the wrist and is taken at the elbow (brachial artery), at the neck against the carotid artery (carotid pulse), behind the knee (popliteal artery), or in the foot dorsalis pedis or posterior tibial arteries. The pulse rate can also be measured by listening directly to the heartbeat using a stethoscope. The pulse varies with age. A newborn or infant can have a heart rate of about 130-150 beats per minute. A toddler's heart will beat about 100-120 times per minute, an older child's heartbeat is around 90-110 beats per minute, adolescents around 80-100 beats per minute, and adults pulse rate is anywhere between 50 and 80 beats per minute.

Respiratory rate
Varies with age, but the normal reference range is 16-20 breaths/minute.

General appearance
Obvious apparent features as the patient enters the consulting room and in the course of taking the history (e.g. mobility problem or deafness) JACCOL, a mnemonic for Jaundice, suggestion of Anaemia (pale colour of skin or conjunctiva), Cyanosis (blue coloration of lips or extremities), Clubbing

22

Inspection (medicine)
In medicine, inspection (Latin word "Inspectio" or the act of beholding) is the thorough and unhurried visualization of the client. This requires the use of the naked eye. During inspection, the examiner observes: External signs: Body features and symmetry appearance Nutritional state or weight Skin color Frequency and volume of breaths during respiration Movement of the abdomen and each side of the chest during respiration Hair distribution divercation of recti muscle umbilicus (site-shape-color- infiltration) Gait and manner of speaking

Gross Deviation:
Abnormal contour Scars and striae Visible masses Discoloration Swelling Tremor In medical practice, inspection is however not limited to visual information alone. Inspection also involves: Listening to any sounds emanating from the client Odors that may be present

Palpation
Palpation is a method of examination in which the examiner feels an object to determine its size, shape, firmness, or location. Medical doctors, for example, may palpate body parts to check for swelling or disease.

Percussion (medicine)
Percussion is a method used by a clinican to find out about the changes in the thorax or abdomen. It is done by tapping on a surface to determine the underlying structure. It is one of the four methods of clinical examination: inspection, palpation, percussion and auscultation. It is done with the middle finger of right hand tapping on the middle finger of the left hand, which is positioned with the whole palm on the body.

Auscultation
Auscultation is the technical term for listening to the internal sounds of the body, usually using a stethoscope. Auscultation is normally performed for the purposes of examining the circulatory system and respiratory system (heart sounds and breath sounds), as well as the gastrointestinal system (bowel sounds). Auscultation is a skill that requires substantial clinical experience, and good listening skills.

..

23

Assessment Task(Case presentation)

Presentation format.
Comprehensive format headed with;

Definition (Topic) Epidemiology

The epidemiology describes the incidence and prevalence of disease.

( 5 marks)

(5 marks)

Pathology
The pathology relates to the Aetiology and pathogenesis of disease.

(5 marks)

Scope of disease (complications)

Disease can present as primary condition or as a result of a secondary complication.

(5 marks) Clinical features (5 marks)

This relates mainly to symptoms and examination features of disease and any other associated complications.

investigations,Lab Test

(5 marks)

Further investigations refer to investigations not usually performed for all patients with clinical features suggestive of the underlying disease, as well as more invasive or specific investigations for patients with specific indications or associated complications.

Initial management (5 marks) Initial management provides information and instruction on simple first line measures on the management of disease or the important first step of emergency management. Medical management (5 marks)

Medical management refers to all non surgical management and usually describes risk-factor modification and drug treatment, although it may include any other intervention performed by physician.

Surgical management

(5 marks)

Surgical management describes the surgical management, procedure, result and complications, usually in sufficient detail to obtain informed consent.

Indication for referral (5 marks) What are the indications for referral from Health centre/District hospital Prognosis (5 marks)

The prognosis is used to describe the natural history of untreated disease as well as the result of treatment.

References.

(5 marks)

24

.................................................................................................................

REFERENCING PROCEDURES
Introductory comments
In academic writing, an author almost always gets information from the writings of others. It is essential that these sources be acknowledged. These acknowledgements provide evidence of professional reading and give support to the points being made. University students are expected to demonstrate this practice. There is no one simple internationally used set of referencing procedures. This can be seen as you look at referencing styles in different academic publications. The style being described in these notes uses the author-date format from the Style Manual (Australian Government Publishing Service 1994). This is used by public servants and also by many publishers, authors, editors, businesses, private individuals and educational and other institutions in Australia. Consistency in how you apply a referencing style is important. You may use a recognised style other than the one in the AGPS Style Manual but the important thing is to use it consistently.

A. Reference list at end of text

List in alphabetical order by the surname of the author. If typing, use italics for titles of books and journals. Do not underline as this covers the down strokes of letters and slows down reading comprehension. Only in hand-written work is underlining used to indicate book and journal titles. 1.1 One author Marsh, C.J. 1992, Key Concepts for Understanding Curriculum, The Falmer Press, London. 1.2 Two or more authors Huling, L., Hall, G., Hord, S. & Rutherford, W. 1983, A Multi-Dimensional Approach for Assessing Implementation Success, Southwest Educational Development Laboratory, Austin, Texas. 1.3 Edition of a book Barry, K. & King, L. 1998, Beginning Teaching and Beyond, 3rd edn, Social Science Press, Australia. 1.4 One editor Guthrie, G. (ed.) 1987, Basic Research Techniques, Report No. 55 Educational Research Unit, University of Papua New Guinea.

1.5 Two editors Pigdon, K. & Woolley, M. (eds) 1992, The Big Picture: Integrating Childrens Learning, Eleanor Curtain, Armadale.

1.6 Chapter or article in a collection

Smith, Geoffrey 1972, Education, history and development, in Encyclopaedia of Papua New Guinea, Peter Ryan (ed.), Melbourne University Press, Australia, pp. 315-330.

\25

1.7 Article from a journal

NDrawii, J. 2003, Social problems faced by female student teachers at Madang Teachers College, MTC Search, vol. 6, no. 4, pp. 6-10.

1.8 Article from a newspaper with known author

Kapigeno, J. 2004, Schools warned against sending children home, Weekend National, 13-15 February, p. 6. 1.9 Article from a newspaper, author not indicated Weekend National, 13-15 February 2004, Lae tax officer charged with K26,000 fraud, p. 7. 1.10 Paper presented at a meeting, seminar or conference Tivinarlik, A. & Nongkas, C. 2002, Catholic leadership in Papua New Guinea secondary schools, paper presented at the Australian Catholic University conference on leadership. 1.11 Unpublished thesis Tivinarlik, A. 2000, Leadership styles of New Ireland high school administrators: a Papua New Guinea study, PhD thesis, University of Iowa, USA. 1.12 Dictionary, thesaurus, atlas. Bible etc The Macquarie Dictionary 1991, 2nd edn, Macquarie University, Australia. 1.13 Two or more publication by same author in same year Department of Education 2000a, National Education Plan 1995-2004 Update 1, Waigani, Papua New Guinea. Department of Education 2000b, Primary Education Handbook, 2nd edn, Waigani, Papua New Guinea. 1.14 Films and video recordings title, format, date First Contact (video recording) 1981. Haus and Home (television production) 2 March 2004, EMTV. 1.15 author, date, title, www address Curriculum Reform Implementation Project 2004, Upper primary student resources for PNG Department of Education, www.pngcurriculumreform.ac.pg, accessed 12 June 2007. B. In-text references 2.1 author-date, and sometimes page Matane (1986) was the first to suggest a philosophical change. Matane (1986, p. 4) stressed the importance of integral human development. Research into leadership styles (Tivinarlik & Nongkas 2002) found Several studies (Dorrow & ONeal 1979, Mullaney 1978, Talpers 1981) found 2.2 et al (and others) for three or more authors The concerns-based adoption model (Huling, et al. 1983) was trialled widely.

\26

2.3 Quotation less than three lines single quotation marks The Ministerial Committee argued that education should not be considered as a passport to a paid job (Matane 1986, p. 1) and described how attitudes of educators, parents and young people must change. 2.4 Citation in text more than three lines indent, block, no quotation marks Josephs (2000, p. 29) argued that: The greatest single factor affecting quality is the teacher. Pre-service and in-service opportunities for teachers are important indicators, but for some children the presence of a teacher in the classroom would be a welcome bonus. It is common knowledge that some teachers absent themselves from classrooms regularly and without authority. C. Some other points concerning academic writing 3.1 Abbreviations contain the initial letter and other letters of a word or words but not the final letter. vol. no. p. pp. i.e. e.g. ed. Abbreviations using capital letters are written without full stops. PhD PNG UPNG PO UNESCO 3.2 A contraction has at least the first and last letter of a word. It is written without a full stop eds (editors), edn (edition), Dept (Department), Mr (Mister), Dr (Doctor) 3.3 Non-discriminatory and inclusive language is to be used. Avoid using man in a generic sense and use alternatives such as headteacher, police officer, chairperson etc. Avoid the awkward use of he/she, him/her by rewriting the sentence in the plural. 3.4 Use full stops at the end of sentences but not headings and sub-headings. Use single quotation marks to enclose exact words of a writer or speaker. Do not hyphenate words at the ends of lines, put the whole word on the next line. 3.5 Lists. A colon is used to introduce a list. Punctuation is not needed at the ends of items in a list. The last listed item is followed by a full stop. Avoid unnecessary numbering in lists unless it is needed to show order, e.g. to make something. 3.6 Use headings and sub-headings to organize your text. Avoid creating sub-subheadings. 3.7 The first time an acronym is used, give the words in full followed by the letters in parentheses, e.g. Divine Word University (DWU). After that, the acronym can be used by itself. Approved by DWU Academ

\27

ASSESSMENT COVER-SHEET

DIVINE WORD UNVIVERSITY Degree Rural Health

ASSESSMENT COVER-SHEET

STUDENT NAME: UNIT TITLE: ASSESSMENT TITLE: LECTURER:

DUE DATE UNIT CODE:

Your assessment should meet the following requirements. Please confirm by ticking boxes before submitting your assessment. Assessment presentation is your responsibility.

\28

Your name and the essay title as footer on each page Assessment is presented on A4 paper Printed single sided, page numbers on bottom right corner Pages firmly stapled together Top & bottom margins 2cms minimum Left margin 4cm & right margin 3cm

Double or 1 line spacing Text left justified Typed, spell checked and paginated Referencing is consistent and thorough Declaration below is completed Copy retained by student

Declaration:
This essay / assessment is all my own work, except where duly acknowledged. Ideas taken from other sources are indicated with footnotes; words or passages taken from other sources are marked with quotation marks, citations and appropriate references. Signed: Date:

.................................................................................................

OPERATION NOTES
Name: Age/SexAdmission No..... Date: .

Operative Diagnosis: Indications: ... Operation: SURGEON: .. ANAESTHETIST:

Incision/Approach: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Finding: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

\29

Procedure: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Post operative instruction: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ...............................................................................................................................

REFERRAL FORM
Bundi Health Centre P.O.Box 10 BUNDI Madang Province 20th February 2011 To: ________________________ ________________________ ________________________ ________________________

Dear Sir, We are referring you age of 20 years for your help and attention. Clinical Details: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

\30

We should be grateful if you would kindly take over the management of this patient, and let us know in due course of the patients progress. Yours sincerely,

______________________ Health Extension Officer (OIC)

..............................................................................

CODE OF ETHICS The following code of ethics has been approved by the Health Extension Officers Association. It is an attempt to help members of the association with common ethical problems which may be expected to arise in the course of our members professional practice. Members who may be confronted with ethical problems requiring individual consideration, or if he/she is in doubt about the course of action to take in any professional difficulty, he/she should seek proper assistance through the Secretary, Papua New Guinea H.E.O. Association. Disciplinary matters over registration of H.E.O.s is the responsibility of the P.N.G. Medical Board. The H.E.O. Association has the responsibility of informing its members about their duties and the ethical demands placed upon them by the H.E.O. profession. Professional misconduct should be interpreted as follows: An H.E.O. who, in the course of professional practice, has done something which will be reasonably regarded as disgraceful by other members of the H.E.O. profession with a high standard of behavior shall be regarded as having committed professional misconduct. GENERAL PRINCIPLE Members of the H.E.O. profession accept the following principles for which they strive: To observe truth and non-violence at all times and to be dedicated to the well being of his/her country and fellow citizens.

To actively support moves to change policies that will improve the health status of people of Papua New Guinea, especially those living in the rural areas. To render service in activities other than health, that may be carried out within communities from time to time to establish a society where justice and equality shall prevail. To realize and work towards the ideal that maximum well being and happiness of humanity can only be achieved when within communities people are non-violently

\31

organized as self-reliant rural and urban communities where scientific and other values are harmoniously combined for the welfare of all.

1.

DUTIES OF H.E.O.s IN GENERAL 1.1. An H.E.O. must maintain the highest stand and of professional conduct towards individuals and society An H.E.O. must regard his/her profession as a service to individuals and society and not simply a profit making organization. To this end, an H.E.O must not allow himself/herself to be influenced by how much he/she can get, but rather, how much and what he/she can give. It is unethical for an H.E.O. to receive or demand to be given in connection with services he/she give to a patient or community other than paid to him/her by the employing agency. Under no circumstances is an H.E.O. to do anything that would weaken the mental or physical resistance of a human being except from strictly therapeutic or prophylactic indications imposed in the interest of the patient. When an H.E.O. is called upon to give evidence or a certificate, he/she should only state the facts that can be proved. It is the responsibility of the H.E.O. to assure himself/herself of the competence of nurses, C.H.Ws and other auxiliary staff. An H.E.O. must not exercise favoritism to any one individual on the staff when dealing with disciplinary matters.

1.2.

1.3.

1.4.

1.5.

1.6.

1.7.

2.

DUTIES OF H.E.O.s TO THE SICK 2.1 2.2 An H.E.O. must always remember the importance of preserving life from the foetus until death. No matter who the patient is, or how sick he is, an H.E.O. must give his/her best care and attention to his/her patient. An H.E.O. must never discriminate on the basis of race, religion, tribe, social position, political party or ability to pay, suffer from pain of body and mind when he is under the care of an H.E.O. An H.E.O. must keep in mind that patients may change their attitudes because of diseases he may acquire, becoming too demanding, mentally unstable and un-cooperative. In all these circumstances, and H.E.O. must always keep calm and be polite and friendly to the patient. An H.E.O. must accept consequences of his/her professional judgment or practice and report to the appropriate authority at once when mistakes are being made. An H.E.O. owes to his/her patient complete loyalty and all the resources of his /her knowledge. It only appropriate therefore when an examination or treatment is beyond his/her capacity, that he/she should consult another H.E.O. who may have the necessary ability, seek the opinion of a doctor or transfer the patient to the hospital where a doctor could take over the responsibility of caring of the patient.

2.3

2.4

2.5

\32

2.6

An H.E.O. because he/she owes his/her knowledge to the patient, must keep all information which has been disclosed to him/her by the patient absolutely confidential. An H.E.O. must never betray the confidence entrusted to him/her by the patient. Occasionally, an H.E.O. will be permitted to break the bond of secrecy without the specific consent of the patient. In the interest of the patient, his spouse and H.E.O. An H.E.O. may discuss with a wife or a husband the condition of a marriage partner. This is a day to day occurrence. The H.E.O.s common sense tells him/her what information can be disclosed.

2.7

a:

b:

Statutory requirements There are certain cases where an H.E.O. is required by law to disclose confidential information about a patient. These cases are few and clearly defined. For instance, H.E.O.s are required by law to notify the Department of Health in cases of certain diseases, mainly the communicable diseases.

c:

d:

The medical witness An H.E.O. may be required by law to disclose confidential information concerning his/her patients on the direction of a court of law. However, the H.E.O. may express reluctance to divulge certain information. He would be guided by the decision of the judge. Danger to society The H.E.O. may feel duty bound to disclose confidential information about a patient who is in danger to a society. Such occasions are rare and are necessitated only by the public safety. For example, the uncontrolled epileptic who refuses to surrender his/her driving license cannot be expected to be entitled to the confidence enjoyed by other patients. The H.E.O. may then pass the necessary information on to the appropriate authorities.

e:

Cruelty to a child When cruelty to a child is discovered during course of professional practice, the H.E.O. should not hesitate to bring the information to the attention of the appropriate authorities. Criminal cases No H.E.O. must withhold knowledge of marked crime. Secrecy is certainly not desirable where a patient appears to die of a criminal act (e.g. poisoning, maltreatment). A death certificate should not be signed in these cases until permission to do so has been given by the coroner. On the other hand, an H.E.O. should not b agent of the police, or a private detective. An H.E.O. should be guided by his/her conscience as to when it is essential that he/she reveal information obtained in confidence from a patient.

f:

2.8 a:

Consent of examination and treatment No one is obliged to submit himself/herself to examination or treatment except in a few obvious cases where the law requires it. an H.E.O. should

\33

remember that it is the patients consent which makes it lawful for the H.E.O. to examine or treat him/her. b: On most occasions, consent for treatment and examination is implied. This is when the patient does not express his/her consent, but it is implied by his/her action in submitting to examination or treatment. Expressed consent Occasionally, it is desirable that the patient gives consent in more positive terms. This is required when procedures requiring loss of the patients consciousness are indicated. On all these occasions, patients consent can be expressed verbally or in writing. An H.E.O. is advised to seek written authority from the patient as this carries more authority and permanence. A verbal consent, if appropriate, must be given in the presence of a reliable witness who can be called upon to confirm it. a consent should always be obtained before pre-medication is given. Before an H.E.O. examines a female patient, he must always have a second female person present. d: The injured, unconscious patient whatever his age, the unconscious patient should be treated immediately in whatever way is necessary, without wasting time in seeking the consent of relatives, which in any event would probably have no legal validity. e: The mentally incapable A mental patient legally detained has been deprived of his/her rights to decide for himself/herself and the H.E.O. in whose care he/she has been placed, may authorize procedures he/she thinks necessary for the patients welfare. f: The young Only in the very young, thus incapable of providing their own consent, has the consent of the parents or guardians real validity and this should obtained if possible. At the age of 16 years, a person of normal intelligence should make his/her own decisions in regard to treatment or examination should be carried out on the basis of the young persons consent alone. g: Blood transfusion if an adult adamantly refuses his consent to blood transfusion (e.g. on the grounds of religious conviction), even if his/her life would be imperiled if transfusion were withheld, such an adult should have his/her beliefs respected. The H.E.O. should refer the matter to a doctor who will decide appropriate courses of action. In the case of a child under 16 years whose legal guardian objects to blood transfusion of the child and transfusion is definitely indicated for the child (e.g. following an accident to the child), then transfusion should not be withheld. h: Contraception The introduction of an IUCD into a married woman without her husbands consent, unless done for the health and safety of the wife, is unwise. The

c:

\34

husband may thus be deprived of the opportunity of procreation by an action of which he neither knows nor approves, and there is the possibility of action for damages being taken against the H.E.O. in such a case. With regard to pills, the final act in contraception is taken by the wife in swallowing them, and the H.E.O. is thus a more remote agent. However, unless it is undesirable for medical reasons that she become pregnant, to provide the pill to the wife of a disapproving husband is unwise. In regard to the provision of contraception to an unmarried female of 16 years or more, known by the H.E.O. to be having sexual intercourse, the H.E.O. will by guided by the principles that he/she will do what is best for the welfare of his/her patient. He/she is certainly breaking no law in providing contraception to such a patient. 2.9 Informing the patient A patient has the right to know the facts and opinion about his case. In serious illness, especially where likelihood of recovery is slight or absent, the H.E.O. should use great care in deciding what he/she tells the patient and how he/she tells him, bearing in mind that he/she must act on the patients best interests. It should perfectly ethical to inform near and responsible relatives of the true state of affairs in such a case and to discuss how far he/she the H.E.O, should go in giving his /her opinion when the patient demands it. 2.10 2.11 An H.E.O must give the necessary treatment in emergency. An H.E.O. may cease attending a case if he/she feels that the professional relationship is unsatisfactory due to the conduct of the patient or the patients guardians or where confidence has been lost, or when the case is beyond his/her ability, provided: the fullest allowance has been made for the patients unsatisfactory conduct. arrangements for the transfer of the patient have been adequately made. withdrawal of attendance does not interfere with the patients welfare or treatment. Sexual intercourse with a patient or relatives of a patient is forbidden. Every family and every community has the right to expect their special relationship with the H.E.O. to be guaranteed against abuse. An H.E.O. while on duty, if incapable of looking after his/her patients properly because of drunkenness or drug abuse, is guilty of serious professional misconduct.

a: b: c:

2.12

2.13

3.

DUTIES OF H.E.Os TO THE COMMUNITY 3.1 An H.E.O. must provide his/her services equally to all individuals in a community regardless of race, tribe, political beliefs, or where an individual comes from. An H.E.O. must never exercise the wantok system when providing his/her service to the community. An H.E.O. must respect the integrity of the community.

3.2

\35

3.3 3.4

An H.E.O. must also get involved in community heath related activities. An H.E.O. must show courtesy, respect for or the village elders, and community when dealing with the village community feelings when conducting public health programs and other community health orientated activities. An H.E.O. must not undermine the traditional cultures of the village communities. An H.E.O. must not abuse a member of the opposite sex when carrying out public health programs within a village. For instance, it would be improper for an H.E.O. to have a sexual intercourse with a village girl or a woman when he/she carrying out a patrol. An H.E.O. must have sympathetic attitudes towards the need of the community. He/she must not use bulldozing tactics in getting a village community to participation in the delivery of health services, (e.g. if there is a traditional ceremony being held by the village community coinciding with the H.E.O. program the H.E.O. should not interfere with these ceremonies). An H.E.O. must not use his/her status to influence the community (e.g. when campaigning for election to Parliament). An H.E.O. must be helpful to the community by example rather than by telling (e.g. an H.E.O. should take part in projects like digging of toilets, water supply, instead of telling people to do the work. An H.E.O. must not behave in a drunken manner towards an individual member of the community. An H.E.O. must not be involved in drunken brawls within the community.

3.5

3.6

3.7

3.8

3.9

3.10

3.11

4.

DUTIES OF H.E.Os TO THE NATION 4.1 4.2 An H.E.O. must be loyal to the government of the day. An H.E.O must never ask what the nation should do for him/her, but rather he/she must ask him/herself what he/she can do for the nation.

5. 5.1 5.2

DUTIES OF H.E.Os TO THE EMPLOYER An H.E.O. must abide by the rules and regulations set down by his/her employer in the interest of the nation. An H.E.O. must be loyal to his/her employer, (e.g. he/she must never criticism made by the H.E.O. against his/her employer must be constructive and must be made in confidence). An H.E.O. must obey instructions given to him/her by his/her employer within reason, (e.g. if an H.E.O. is posted to serve in an area where his/her employers consider to have a greater need, the H.E.O. must be willing to go). An H.E.O. must be cautious in the utilization of available resources, in the persuit of his/her employers aim (e.g. an H.E.O. must not misuse funds allocated to him/her, the H.E.O. must not misuse his employers properties under his/her care.

5.3

5.4

\36

5.5 5.6

An H.E.O. must use drugs wisely; he/she must discourage wastage of drugs. An H.E.O. must never allow wastage through inefficiency or lack of concern for maintenance of health center supplies and equipment, (e.g. he/she must never allow a refrigerator to run out of kerosene which could ultimately lead to the wastage vaccines). DUTIES OF H.E.Os TO THE PROFESSION An H.E.O. must be loyal to his/her profession. For instance, an H.E.O, must carry out all his/her duties to the best of his/her ability. An H.E.O. must strive to maintain a high standard of professional conduct. An H.E.O. must set a good example in the maintenance of good health, and maintaining a high standard of health as required by his/her profession, (e.g. maintain a clean environment of health centre, maintain a high standard of cleanliness in his/her personal appearance. DUTIES OF H.E.Os TO OTHERS An H.E.O. must behave towards others as he/she would have them behave towards him/her.

6. 6.1

6.2

7.

a:

Doctors An H.E.O. must give due respect to a doctor, regardless of personal differences. An H.E.O. must never allow professional jealousy between him/her and a doctor to over ride the H.E.Os concern for his/her patients or the community he/she serves.

b:

Supervisors An H.E.O. must carry out instructions given to him/her by his/her supervisors. If an H.E.O. has good reasons to disagree with his/her supervisors instructions, he/she should communicate his/her disagreement in a polite and respectful manner.

c:

Nurses An H.E.O. must establish and maintain effective co-operation between him/her and the nurses. He/she must never allow him/herself to think of nurses as having and inferior status to this own.

d:

Environment Health Officer (E.H.Os) An H.E.O. must never regard him/herself as superior to Environmental Health Officers. An H.E.O. must ensure a high standard of working relationship between him/herself and the Environment Health Officer in the interest of their communities and the nation as a whole.

e:

Dental Therapist An H.E.O. must observe similar relationships applicable to the H.E.O. and the E.H.Os and nurses.

f:

Malaria Eradication Officers

\37

An H.E.O. must maintain relationships with the malaria eradication officers similar to the type of relationship he/she maintains with E.H.Os, nurses and dental therapist. 8. 8.1 DUTIES OF H.E.Os TO EACH OTHER An H.E.O has a moral obligation to his/her patients. If he/she lacks the necessary ability to examine or to treat a patient, he/she must consult with another H.E.O. to seek advice and assistance in the treatment of the patient. An H.E.O. must never think that asking his/her fellow H.E.O. is below his/her dignity. It is unethical for an H.E.O. to gossip about a fellow H.E.O. to others. In the interest of the H.E.O. profession, H.E.Os are expected to discuss problems affection each other directly instead of resorting to malicious gossip. As colleagues, H.E.Os must support each other morally and professionally. It is unethical for a H.E.O. to criticize the inability and inefficiency of another H.E.O. in front of a patient or individual of a community. Criticism of a colleague must be done courteously with professional interest being the aim. H.E.Os should never be offended when criticisms against them are made by a colleague on the basis of professional practice. DUTIES OF H.E.Os TO HIMSELF/HERSELF An H.E.O. must continually seek to better him/herself professionally. This implies that H.E.Os learning does not end once he/she graduates from the college. An H.E.O. must continue to keep up with the latest development in the field of H.E.O. education and must accept personal responsibility to keep him/herself informed of educational development in the H.E.O. profession. An H.E.O. must actively seek to better him/herself by developing responsible attitudes towards him/herself, (e.g. an H.E.O. must avoid excessive consumption of alcohol. This could lead to personal disaster). He/she must have the welfare of him/herself and his/her family safe-guided against undesirable consequences. An H.E.O. must protect him/herself from diseases that may lead to possible bad effect on his/her professional efficiency.

8.2

8.3

9. 9.1

9.2

9.3

\38

HUMANITY This criterion requires all who are concerned with the delivery of health care to treat those whom they service as fellow human being, entitled to respect, understanding and sympathy. Entitled also to be treated in a manner free from arrogance or disc

\39