Field visit report (Formal and Informal)

Field Visit Place: Geriatric Unit of Dhaka Medical College Hospital

Group: E

Group supervisor: Dr. Md .Rabiul Islam

Associate Professor

Institute of Social Welfare and Research

Dhaka University

Field Visit Report

History

Dhaka medical college hospital was established as a 250 bedded general hospital in

1946.British major virgin was the first superintendent of Dhaka medical college

hospital. Since then Dhaka medical college hospital is pioneer in the under graduate

medical education and largest service providing hospital in this country. Subsequently it

has been converted into 1800 bedded tertiary level hospital .Now a days it has been

announce 2300 bedded tertiary level hospital ,100 beds is for burn unit. Everyday all

types of patients from different corner of Bangladesh are reported to this hospital to get

better management. They have all the specialty/subspecialty of medical science in this

hospital.

Picture 1: Dhaka Medical College Hospital

Organization at a glance

Name of the facility Dhaka Medical College Hospital

Name of Director Brig Gen Md. Mustafizur Rahman

Telephone no. 09677411

Fax no. 08623382

Email dmch@hospi.dghs.gov.bd

Dhaka Medical College was established some new ward such as

Bone marrow transplantation

New palliative ward

Geriatric ward

The biggest public hospital, Dhaka Medical College Hospital (DMCH), has opened a

special unit for them called ‘geriatric unit’, in what may be a model for other medical

college hospitals. Geriatric ward was the most important topic on them. It was

established in 14 August, 2014.The announcement came at a seminar in the medicine

department in 2014, 01 October. It was organized to mark the international day for the

old age persons. On that year the slogan of the international day for the old age persons

was “Leaving no one behind, Promoting a society for all”. It was good news for

thousands of poor elderly patients looking for treatment that sometimes mean taking

refuse on the floors of government hospitals. The special ward which is being

supervised by the medicine unit has 28 beds at the second floor of the hospital. Patients

aged above 65 years sufferings from multiple chronic diseases will be admitted in this

ward.

Picture 2: Geriatric Unit of Dhaka Medical College Hospital

Picture 3: Inauguration day of geriatric unit in Dhaka Medical College

Hospital.

Purpose of geriatric unit

Ageing in Bangladesh is a recent phenomenon. Though internationally accepted cut of

age is 65 years, above which peoples are considered elderly, in Bangladesh, persons

with age of 60 or above are cited as geriatric age group in different literatures.

However, in reality people in this country become older before the age of 60 because of

poverty, physical hard working and, inability and illness due to malnutrition and

geographical condition as well. Every year approximately 80,000 new elderly are

entered into the group of the older persons. The estimates and projections show that the

amount is certain to increase markedly with time.3 This trend is expected to accelerate

and by 2050 the number of persons aged 60+ are projected to be approximately 40.5

million, which is roughly 6 times higher than what it was in the year 2000.4 So it is

worth saying that the burden of old age diseases in our low income country will be

enormous.

The scenario of Bangladesh concerning the old people is quite frustrating. A full blown

geriatric policy in our country yet to be formulated. But this is a matter of hope that a

geriatric medicine unit as a wing of medicine department of Dhaka Medical College

Hospital has been launched in the late 2014.

Associate Professor of Medicine Md Titu Miah is the co-coordinator of the new unit.

He said they came up with

1. The idea of providing “decent care” to the growing number of elderly people.2

2. Citing a study, Titu Miah said a study by their medicine unit on a specific

day found one-quarter of the 332 male patients were above 65years of age.

It was more than one in 10 for female patients.“But many of them do not

even get beds in this very crowded hospital,” he said.

3. This type of special ward is new in government general hospitals including

medical colleges. The military hospital CMH has a separate unit for elderly care.

4. The number of elderly is growing by the day in Bangladesh as the

average life expectancy nears 70.As they grow old, they suffer from

multiple chronic diseases like hypertension, diabetes, heart conditions,

dementia, infections and joint pains that need special care.

“It has to be well-equipped,” Titu Miah said, adding they were seeking government’s

support to develop this unit. 65 years sufferings from multiple chronic diseases will be

admitted in this ward.

Patients aged above 65 years sufferings from multiple chronic diseases will be admitted

in this ward. The special ward which is being supervised by the medicine unit has 28

beds at the second floor of the hospital. The DMCH special unit for them will take this

special attention with proper nursing.

Committee

The biggest public hospital, Dhaka Medical College Hospital (DMCH), has opened a

special unit for them called ‘geriatric unit’, in what may be a model for other medical

college hospitals. The special ward which is being supervised by the medicine unit.

All member of the Medicine department are the committee member of geriatric unit.

The Department is divided into

1. 11 units headed by five Professors and six Associate Professors.

2. There are 10 Assistant Professors alongside to second each unit. The Units are

also armed with Registrar and Assistant Registrars along with a number of Indoor

Medical Officers and Honorary Medical Officers. The Registrars maintain the

academic activities of the unit while the Assistant Registrars are responsible for

the clinical side.

3. Proff Titu Miah is the co-coordinator of the new unit.

4. There are 5 senior staff nurse in this department. They are specially for here.They

are well trained and In charge name is Selina pervin. They do roaster duty in

three shift, those times are morning, evening and night shift. They said all time

doctors are available.

The Department of Medicine of Dhaka Medical College is one of the core disciplines of

the institution. Since its establishment in 1946 this Department has earned a reputation

that only others can envy of. Not only does it handle the bulk of non surgical

emergencies of DMCH, the Department also has a very strong teaching and research

activity. The Department is also complimented by a strong group of Allied Discipline

which brings out the strength of the Department and is considered as the auxiliary

power. They are Neurology, Cardiology, Nephrology, Hematology, Hematology,

Gastroenterology, Endocrinology, Pulmonology, Dermatology and Psychiatry

Departments.

Services of geriatric unitFrom the era of ancient medicine, physicians tried their best to alleviate the sufferings

of elderly but only a few people reached their maximum due to early death by diseases

and war. When modern medicine evolved the average life span of human increased with

time. This demographic transition started slowly but got it’s pace very soon. Now 11%

of the world population is of 65 years of age or over. Sometime around the year 2020,

For the first time ever, the number of people aged 65 and older in the world is expected

to exceed that of children under the age of 5.

1. Prof Titu Miah the coordinator of geriatric unit said they came up with the idea of

providing “decent care” to the growing number of elderly people.

2. Quality Assurance Scheme (QAS) activities ran very smoothly.

3. All activities of different phases worked satisfactorily.

4. All time doctors and sister are available.

5. They care for them with special nursing care.

6. As per patient’s requirement and by doctors referred all specialized doctors are

available for them.

7. ICU and CCU services are also present.

8. They have some chair with special toileting system for bed ridden older person.

9. Management strategy adopted in geriatric unit is also quite similar comparing the

developed countries.

Geriatric medicine unit as a wing of medicine department of Dhaka Medical College

Hospital has been launched in the late 2014. Now it is the time to flourish this small

initiative to a complete geriatric medicine department which will be a great

achievement and milestone in the history of medicine in Bangladesh.

How it is fruitful for patient

“The problem of old age is not merely medical; it is physical, mental, economical

and socio-cultural. A cumulative approach is needed to combat the problem which

should involve the medical professionals, social workers, political leaders, NGOs

and media personals. The western society has become successful to blend the above

sectors together. As a result, life expectancy and quality of living of aged people

have been improved. The most notable contribution is from medical sector. To

overcome this new situation they have established geriatric medicine department in

the hospitals targeting the aged people”, Proff Titu Miah said.

After the establishment of geriatric medicine unit in DMCH in 2014, total 561

patients have been admitted till 10 May, 2016. 300 of them are male and the rest

261 are female. Multi morbidity is common. Till 10 may, 2016 total death was

53. Mortality rate was 5.70%. Patients were treated by supportive care only due to

lack of emergency medical facilities. Patients with diseases from every

subspecialties of medicine e.g. cardiology, nephrology, neurology, endocrinology,

respiratory medicine, gastroenterology, were admitted and treated accordingly. In

male patients, the mostly encountered diseases were CVD, HTN, COPD, DM and

bronchial carcinoma. Female patients were predominantly suffering from DM with

its complications and UTI. The mean age of admission was 67.4 years & the patient

with highest age was a 108 years male. Some of them are so happy because

government took a step for them. Treatment facilities are so much expensive in

private hospital.

Satisfaction Statement of Patient

When we visited the geriatric unit there was 5 patients. They came from the outside

of Dhaka for better treatment. Most of the people don’t know about this special

unit. When we talked with them about they told us some issues about their health

and care and family, these are

1. Most of them were come from lower middle class and middle class family. For

this reason they had so much tension about cost of money.

2. Some of them had long term disease and they were taking medicine for them

such as every patients had Diabetes Mellitus, High pressure, Chronic

Obstructive Pulmonary Disease, Chronic Liver disease,Cancer,Arthritis,Urinary

tract Infection, Stroke and it is so much expensive for them.

3. They told some complain about nursing care.

4. They said that they have to purchase most of the drug. (When we asked the duty

nurse about this they told us that some medicine is not available because

government don’t supply them).

5. Most of them were telling that they had one common problem and that is

“PAIN”

6. But they tell one thing that if government did not take any step they have to

spend so much money in any private hospital and for this they are very thankful

to this hospital and government.

Doctors Statement

When we asked a question to Prof Md. Azizul Kahhar ,he share of his view with us and these are After few months of observation in our geriatric medicine unit, certain difference has been noted between the global geriatric trends and that of Bangladesh.

1. The disease pattern is more or less same but infectious disease is more prevalent here.

2. The management strategy adopted in our unit is also quite similar comparing the developed countries

3. But the most notable difference is economical rather than medical. In the western society, there is a social security service for old and health insurance policy run by government. They bear all the treatment and rehabilitation cost.

4. In our country, as old people are mostly dependant, they cannot cope with expensive investigations or treatment.

5. So they often fail to maintain the follow up schedule. As a result they come with more serious complications later on. 6.Though the victory over communicable diseases has been achieved, other non communicable diseases like CVD, IHD, DM, malignancy and neuro-degenerative disorders have become more prevalent in developed countries.

Limitations

1. The management strategy is not so much strong

2. They have no one stop service system, all the patient have to run from one

area from another area.

3. Some time they spend so much in hand of bad people for treatment

purpose.

4. Due to the majority of population belonging to the lower economical

group, our dependency on the Government Health Care system is very high.

But there is widespread public perception about the low quality of health

service delivery, be it provided by government, private or other non-state

actors in Bangladesh. Several studies and surveys published has proven that

the quality of healthcare has declined in Bangladesh with increasing cost

backed by the non-availability of certain treatments, more waiting time, lack

of cordial and caring doctors, scarcity of professional nursing staff, poor

reliability on pathological and diagnostic tests etc.

5. Absence of human touch and care from the hospital staff.

6. Absence of sense from government because this is a special unit and there

is no assisted living device.

7. Physiotherapy center is so much far from geriatric unit.

Regardless of several limitations, the geriatric medicine unit is running

successfully since its initiation. We hope that positive steps from the

government and donor organizations towards a geriatric friendly health care

system will soon be on the cards. Increase in allocation and change in policy

will see a rapidly flourishing discipline. The elderly are the people who have

fought for this nation it is time we repay them and should not forget that

pretty soon we will also be joining them.

Recommendations’1. Most of the people don’t know about this unit so awareness should spread

among people.

2. Physiotherapy unit should be available for them for removing their pain

and gait

3. Treatment should be easily accessible for older person.

4. Nurse and doctor’s ratio for all older people should be increase.

5. Ward boy and aya should be increase for them.

6. Some assisted living device should bring for their daily living

7. Government has to take some initiative to flourish this special unit.

Ageing is a natural phenomenon which cannot be stopped or altered. From

the dawn of civilization man is feared of being old. There is a German

proverb, ‘Old age is a disease that you die from’. In fact elderly suffer from

variety of diseases which make them feeble, dependant and even bed bound.

This is why, every human being wants to get rid of old age but this is

inevitable. Population trends in Bangladesh show that Bangladesh is well

into third phase of demographic transition, having shifted from a high

mortality-high fertility regime to a low mortality-low fertility one. Every

year approximately 80,000 new elderly are entered into the group of the

older persons. The estimates and projections show that the amount is certain

to increase markedly with time. This trend is expected to accelerate and by

2050 the number of persons aged 60+ are projected to be approximately 40.5

million, which is roughly 6 times higher than what it was in the year 2000.4

So it is worth saying that the burden of old age diseases in our low income

country will be enormous. The scenario of Bangladesh concerning the old

People are quite frustrating. So we should take more steps for older person

because in some days we will join them. More specialized geriatric unit

should be open in every tertiary level hospital, because sometimes it’s so

much painful for older person to travel from outside of Dhaka.

Findings of Informal case study

All of the respondents were in the young old and middle old age area

variation. Among all respondents 4 of them were women and 6 of them were

man.

In their sociodemographic situation we find varieties findings. One

respondent was poor, rest of them were in middle class higher class and well

established in society. They are Muslim by their religion and their

educational background is good. All of the respondents are living with their

children and grandchildren except one. He and his wife lives alone in a

house. He spends a very successful life .He makes all children well educated

and well established in society. Now he and his wife feels very helpless,

hopeless and lonliness.One of them is so much poor ,she lives with her

younger daughter who works in Qatar and she looks after her grandchildren.

Four women respondents were widower and 2 of them lives with their

daughter and 2 of them lives with their son. Among them 2 respondents

getting pension because their husband was government job holder. After a

long winding struggle of one and a half year through the authority they

finally got the pension fund from the government. They use this money for

their daily needs.

Six men respondents, they are happy with their wife and children and

grandchildren. Among them 2 men respondents was government job holder

and they are getting pension.

If we look on their findings about health, we will find one common thing

that is PAIN. If we categorize their physical disease then it will be easy for

us:

1. Bronchial asthma

2. Diabetes mellitus

3. Hypertension

4. Arthritis

5. Joint pain

6. Cataract

7. Gallbladder stone (operated)

8. Tumor (operated)

9. Cough

10. Urethral stone

11. Urethral stricture

12. Lung infection

13. Constipation

These are long term diseases we find among respondents and most of the

respondents are suffering from 2 or 3 diseases. All of them are taking

medicine for long time under doctors’ supervison.The respondents who have

diabetes all of them are in strict diet chart and some of them take insulin

after checking glucometer. They maintain a good health by morning walk

and doctors advice.Their diseases cost much money of their family and for

this reason sometimes they feels tension.

We get one important findings about their mental health and these are

1. Insomnia

2. Anxiety

3. Stress

4. Depression

Specially the persons whose children aren’t living with them. They feels

lonlely,helpless,hopeless.They wants stay happy and secure with all family

member, but there sons and daughters are too busy to talk with them and

hear them.

All of them a good relation with their family, friends and neighbor. They

have good contact with relatives and family member those lives in Dhaka or

outside of Dhaka. Some older persons are the head member of the cultural

committee of society. Some older person is the main decision maker of the

family and members respect the decision. In their leisure time, they do many

things.

1. Fishing

2. Gardening

3. Spend time with grandchildren

4. Paper reading

5. Gossip with friends and peer groups

6. Some helps their daughter in laws in kitchen.

They have no idea about National policy for older person and parents act law

2013.Some person heard about old allowance but they don’t know how they

can get it and some don’t want to take it. When told them about parents act

law they hear it very deeply. We told that if their sons, daughter or daughter-

in-law don’t care them they can case a file against their children then they

told us that parents can’t case file against their children.

All of them do their prayers every day. They all-time think about their death

and dying process. In everyday prayers they want some limited things from

ALLAH, her/his children happiness, and they want to die in fronts of

children and family. Some widower and single older person all time thinks

about their daughter that how they will manage when they will die. They

think who will look after them. They want to see her married in their lifetime

and want to ensure a good life for them. They want to die with respect and

dignity. They don’t want die alone.