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Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen  Cletus
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Internship at Sagar Hospital Final Report 2008-09 by Rijo Stephen Cletus

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Study of Dialysis department, Pharmacy department, Biomedical Engineering department and Ambulance department at Sagar Hospitals, Jayanagar, Bangalore, by Rijo Stephen Cletus under the Guidance of Dr Mohan Reddy, the Medical Director as a partial requirement for the degree of PGDHHM from PESIT Bangalore. Internal Guides were Dr Major Madhu and Dr Jithendra Kumar.

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  • 1. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP Junior Internship At Sagar Hospitals Jayanagar, Bangalore Guides: Dr Mohan Reddy Medical Director, Sagar Hospitals Dr. Major Madhu Regional Head – South, Hosmac India Pvt. Ltd. Dr. Jithendra Kumar Senior Consultant, Hosmac India Pvt. Ltd. Presented by Rijo Stephen Cletus. B.E. PGDHHM course by HOSMAC-PESIT 1
  • 2. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP ACKNOWLEDGEMENT I wish to express my sincere gratitude to Dr. Mohan Reddy, Medical Director, administration, Sagar Hospitals, Jayanagar, Bangalore for giving me the opportunity to do my Junior Internship at his highly esteemed Organization. I am grateful to Dr. Madhu Malathi and Dr. Jithendra Kumar for their valuable guidance, advice, suggestion and encouragement rendered to me at every stage. I am also extremely thankful to Mr. Sundar (Dialysis Department), Mr. Pradeep (Pharmacy), Mr. Raja (Biomedical Engineering), Mr. Imdad Ali (Ambulance Department) for giving me information and valuable guidance during the period of internship1. Without their encouragement and guidance this project would not have materialized. The guidance and support received from all the members who contributed to this study was vital for the completion of this study. I am grateful to all of them for their constant support and guidance either directly or indirectly towards completion of my study. Rijo Stephen Cletus 2
  • 3. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP Table of Contents INTRODUCTION TO THE HOSPITAL .....................................................................................6 SAGAR GROUP .............................................................................................................................. 7 ABOUT SAGAR HOSPITALS, JAYANAGAR.................................................................................... 8 LOCATION....................................................................................................................................... 8 VISION AND MISSION .............................................................................................................9 FACILITIES .................................................................................................................................... 10 DIAGNOSTICS & TREATMENT SERVICES .................................................................................. 10 CENTRES OF EXCELLENCE ....................................................................................................... 12 QUALITY POLICY..................................................................................................................13 ACCREDITATIONS ........................................................................................................................ 13 CARE FOR INTERNATIONAL PATIENTS...................................................................................... 14 STUDY OF DIALYSIS DEPARTMENT ...................................................................................15 DIALYSIS ....................................................................................................................................... 16 PRINCIPLE OF DIALYSIS ............................................................................................................. 16 TYPES OF DIALYSIS .................................................................................................................... 17 THE PHYSICAL STRUCTURE OF THE DIALYSIS DEPARTMENT ............................................... 19 DIALYSIS MACHINES ................................................................................................................... 19 ORGANIZATIONAL STRUCTURE ................................................................................................. 20 SHIFTS .......................................................................................................................................... 21 DISTRIBUTION OF RESOURCES ................................................................................................ 21 ACTIVITIES UNDERTAKEN TO SUPERVISE................................................................................ 21 EXTERNAL CLEANING OF THE MACHINES AFTER EVERY DIALYSIS...................................... 21 REVERSE OSMOSIS (RO) PLANT ............................................................................................... 22 PREPARING THE MACHINE FOR DIALYSIS................................................................................ 24 STARTING AND CLOSING OF DIALYSIS ..................................................................................... 24 STARTING OF DIALYSIS............................................................................................................... 25 CLOSING OF DIALYSIS ................................................................................................................ 26 FIGURE – ARTERIO-VENOUS FISTULA ...................................................................................... 27 FIGURE – REPRESENTATION OF THE FLOW OF DIALYSATE AND BLOOD ............................. 28 FIGURE: VENOUS BLOOD AIR TRAP .......................................................................................... 29 MEDICAL EMERGENCY DURING DIALYSIS ................................................................................ 30 STUDY OF PHARMACY DEPARTMENT...............................................................................34 INTRODUCTION TO PHARMACY DEPARTMENT ........................................................................ 35 NEED FOR THE DEPARTMENT ................................................................................................... 36 FUNCTIONS .................................................................................................................................. 36 PHYSICAL STRUCTURE .............................................................................................................. 38 THE ORGANIZATIONAL STRUCTURE OF THE DEPARTMENT .................................................. 39 THE HUMAN RESOURCE MANAGEMENT .................................................................................. 39 ACADEMIC QUALIFICATIONS AND DESIGNATIONS .................................................................. 40 JOB RESPONSIBILITIES .............................................................................................................. 40 REGULATORY COMPLIANCE ...................................................................................................... 41 FORMULARY ................................................................................................................................ 41 STORAGE ..................................................................................................................................... 41 SALES ........................................................................................................................................... 42 3
  • 4. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP OUTPATIENT PRESCRIPTIONS ................................................................................................... 43 INPATIENT PRESCRIPTIONS ....................................................................................................... 43 SALES RETURNS ......................................................................................................................... 44 EXPIRY DRUGS RETURN ............................................................................................................ 44 STOCK CHECKING....................................................................................................................... 45 BREAKAGE ................................................................................................................................... 45 STUDY OF BIOMEDICAL ENGINEERING DEPARTMENT...................................................46 BIOMEDICAL ENGINEERING DEPARTMENT .............................................................................. 47 TECHNICIANS............................................................................................................................... 48 WORKING HOURS........................................................................................................................ 48 PHYSICAL STRUCTURE .............................................................................................................. 48 TECHNOLOGY.............................................................................................................................. 48 PROCUREMENT ........................................................................................................................... 48 PREVENTIVE MAINTENANCE...................................................................................................... 49 BREAKDOWN MAINTENANCE..................................................................................................... 49 STUDY OF AMBULANCE SERVICES DEPARTMENT .........................................................50 AMBULANCE SERVICES DEPARTMENT..................................................................................... 51 HOW THE SERVICE REQUEST PROCESSED ............................................................................ 52 WHEN IS A SERVICE REQUEST DECLINED ............................................................................... 52 PRESENT DEMAND FOR THE AMBULANCE SERVICE .............................................................. 53 THE VEHICLES AND THEIR TYPES ............................................................................................. 53 MAINTENANCE OF THE VEHICLES............................................................................................. 54 THE HUMAN RESOOURCE.......................................................................................................... 55 AMBULANCE DRIVERS ................................................................................................................ 55 SOME IMPORTANT GUIDELINES ................................................................................................ 55 DRIVERS SHIFTS ......................................................................................................................... 56 RECOMMENDATIONS...........................................................................................................57 INDEX.....................................................................................................................................58 4
  • 5. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP Page Left Bla nk Intentionally 5
  • 6. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP INTRODUCTION TO THE HOSPITAL 6
  • 7. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP SAGAR GROUP Sagar Group is a forerunner in path-breaking ventures that have been touching the chords of the populace in the city of Bangalore. Founded by Barrister Shri R. Dayananda Sagar, the group pioneered in Education more than five decades back. In memory of the Father of the Nation, Sri R. Dayananda Sagar founded the Mahatma Gandhi Vidya Peetha Trust, which today runs 22 institutions ranging from primary education to doctoral levels offering 100+courses spread over Science, Arts, Commerce, Management, IT, Engineering, Dentistry, Pharmacy, Nursing and Physiotherapy. It ventured into healthcare services in 1960 under the qualified leadership of Dr. Chandramma Sagar. The healthcare and educational activities have attained a global brand status bringing pride to Bangalore. These services together employ close to 5,000 professionals and an equal number of support staff, impacting the lives of large sections of society. The vision of this philanthropic couple is being realized through the efforts of Dr. D. Hemachandra Sagar, Chairman – Sagar Group and Dr. D. Premachandra Sagar, Vice- Chairman – Sagar Group, both qualified doctors themselves. Their dynamic leadership is carrying the legacy of the founders of the group forward with a mission to add value to life and make healthcare affordable to everyone. 7
  • 8. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP ABOUT SAGAR HOSPITALS, JAYANAGAR Sagar Hospitals is a comprehensive healthcare provider in Bangalore with two multi-specialty hospitals, four clinics and a chain of pharmacies. The 665 beds facility spread across two locations in South of Bangalore is equipped with the latest medical technology offering affordable medical treatment with personalized care. Apart from the world’s latest 128 slice cardiac CT, the hospital has some of the path breaking diagnostics and surgical equipments. This combined with highly skilled medical, nursing, administration and paramedical staff makes Sagar Hospitals one of the most trusted healthcare providers in Bangalore. Following international management practices, the hospital caters to patients from India and overseas. Luxurious patient rooms range from presidential suites to general ward categories. Attractive health insurance plan makes it possible for people to avail complete medical benefits. Various health check-up packages for different age groups are available at the preventive health check department of Sagar Hospitals. LOCATION It is located in the South of Bangalore in the city’s largest residential locality – Jayanagar. The hospital started functioning in July 2002. 8
  • 9. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP VISION AND MISSION VISION STATEMENT To create an enduring legacy in medical care and well-being using state-of- the art technology and processes that stand for the ultimate in care. MISSION STATEMENT To offer best of the class healthcare service to primary, secondary and tertiary needs at affordable prices. 9
  • 10. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP FACILITIES 250 beds 40 specialties Private deluxe rooms Luxurious presidential suites Spacious single rooms Comfortable semi private beds Economical General ward beds (male & female) Cost effective Daycare DIAGNOSTICS & TREATMENT SERVICES 60 Intensive Care Beds 7 Operating Theatres 12 bed Day Care Unit 16 bed Neonatal Unit State-of-the-art Cathlab Drug De-addiction center Birthing Suite Yoga & Physiotherapy CT / MRI 24 hour pharmacy, laboratory, ambulance and blood bank.. OPD consultation rooms Well-equipped OPD consulting rooms to avoid long waiting time and a spacious patient waiting lounge with comfortable seating and pleasant ambiance. Laboratory 10
  • 11. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP Hi-tech laboratory with pneumatic systems to transfer samples and medicines; complete range of investigations in the areas of Haematology, Clinical Pathology, Biochemistry, Histopathology, Cytopathology, Microbiology and Immunology. Open 24 hours with a dedicated team. Radio Diagnostics The latest 128 slice cardiac CT and 1.5 Tesla MRI with Total Imaging Matrix. Casualty and Emergency A team of skilled and experienced paramedics, headed by an experienced doctor specializing in emergency and trauma care. A dedicated operating theatre is attached to the emergency unit with a spacious triage and recovery room functioning 24 hours. Preventive Health Check Various health check packages for different age group ranging from a newborn to 90 year olds. Patient Rooms Spacious and Comfortable rooms with television, internet and video conferencing facility. Spacious and comfortable Presidential Suites. Isolation wards for patients with infectious diseases. Yoga and Physiotherapy The Physiotherapy Department provides post-operative care for patients and the Department of Yoga offers a therapeutic yoga certificate course. Book Shop, Coffee Shop Dedicated admission and billing counters and a team of insurance advisors. 24 hour Blood Bank Dialysis Centre Dedicated labor rooms with birthing suites Cubicle ICUs 11
  • 12. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP Minimally Invasive Operating Theatre with L.E.D. lights Green Light Laser procedures for treating enlarged prostate Robotic Enabled OT Roof-top food court CENTRES OF EXCELLENCE • Sagar centre for cardiac care • Sagar center for diabetes and endocrinology • Sagar centre for pediatrics • Department of neuroscience • Department of nephrology and urology • Department of orthopedics 12
  • 13. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP QUALITY POLICY We will offer the most competitive cost advantage with the world's most advanced medical and technological infrastructure while practicing best in class medicine. ACCREDITATIONS Sagar Hospitals is NABH accredited and ISO 9001 certified. National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent of Quality Council of India, set up to establish and operate accreditation programs for healthcare organizations. The board is structured to cater to much desired needs of the consumers and to set benchmarks for progress of health industry. NABH accreditation for Sagar hospitals, Jayanagar was in December 2007 Globally, ISO 9001 has been established as the most fundamental quality management system. ISO 9001 emphasizes customer satisfaction and continual improvement for sustained growth of the business. ISO accreditation for Sagar hospitals, Jayanagar was in September 2004. 13
  • 14. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP CARE FOR INTERNATIONAL PATIENTS The team at Sagar Hospital's International Patient Care Center extends to a full range of personalized services to international patients and their accompanying family members. A dedicated team of professional patient care coordinators ensure that every patient's visit is comfortable, pleasant and hassle free. The International Patient Care team at Sagar Hospitals takes care of every minute details of overseas patients, offering world-class medical treatment at approximately one-third of the cost compared to the West. Interpreters are available to help you understand your medical condition and treatment procedures. Interpretation services are provided in the following languages: English, Bengali, Arabic, Urdu, Japanese, German, French and Hindi. Language assistance by qualified sign language interpreters are provided for those challenged with impaired hearing 14
  • 15. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP STUDY OF DIALYSIS DEPARTMENT 15
  • 16. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP DIALYSIS In medicine, dialysis (from Greek "dialusis", meaning dissolution, "dia", meaning through, and "lusis", meaning loosening) is primarily used to provide an artificial replacement for lost kidney function (renal replacement therapy) due to renal failure. Dialysis may be used for very sick patients who have suddenly but temporarily, lost their kidney function (acute renal failure) or for quite stable patients who have permanently lost their kidney function (stage 5 chronic kidney disease). When healthy, the kidneys maintain the body's internal equilibrium of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, sulfate) and the kidneys remove from the blood the daily metabolic load of fixed hydrogen ions. The kidneys also function as a part of the endocrine system producing erythropoietin and 1,25- dihydroxycholecalciferol (calcitriol). Dialysis is an imperfect treatment to replace kidney function because it does not correct the endocrine functions of the kidney. Dialysis treatments replace some of these functions through diffusion (waste removal) and ultrafiltration (fluid removal) PRINCIPLE OF DIALYSIS Dialysis works on the principles of the diffusion of solutes and ultrafiltration of fluid across a semi-permeable membrane. Blood flows by one side of a semi-permeable membrane, and a dialysate or fluid flows by the opposite side. Smaller solutes and fluid pass through the membrane. The blood flows in one direction and the dialysate flows in the opposite. The counter-current flow of the blood and dialysate maximizes the concentration gradient of solutes between the blood and dialysate, which helps to remove more urea and creatinine from the blood. The concentrations of solutes (for example potassium, phosphorus, and urea) are undesirably high in the blood, but low or absent in the dialysis solution and constant replacement of the dialysate ensures that the concentration of undesired solutes is kept low on this side of the membrane. The dialysis solution has levels of minerals like potassium and calcium that are similar to their natural concentration in healthy blood. For another 16
  • 17. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP solute, bicarbonate, dialysis solution level is set at a slightly higher level than in normal blood, to encourage diffusion ofbicarbonate into the blood, to act as a pH buffer to neutralise the metabolic acidosis that is often present in these patients. The levels of the components of dialysate are typically prescribed by a nephrologist according to the needs of the individual patient. TYPES OF DIALYSIS There are two primary types of dialysis, hemodialysis and peritoneal dialysis, and a third investigational type, intestinal dialysis. Hemodialysis In hemodialysis, the patient's blood is pumped through the blood compartment of a dialyzer, exposing it to a semipermeable membrane. The cleansed blood is then returned via the circuit back to the body. Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane. This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer. This pressure gradient causes water and dissolved solutes to move from blood to dialysate, and allows the removal of several litres of excess fluid during a typical 3 to 5 hour treatment. In the US, hemodialysis treatments are typically given in a dialysis center three times per week (due in the US to Medicare reimbursement rules), however, as of 2007 over 2,000 people in the US are dialyzing at home more frequently for various treatment lengths.[2] Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours. These frequent long treatments are often done at home, while sleeping but home dialysis is a flexible modality and schedules can be changed day to day, week to week. In general, studies have shown that both increased treatment length and frequency are clinically beneficial. Peritoneal dialysis In peritoneal dialysis, a sterile solution containing minerals and glucose is run through a tube into the peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal 17
  • 18. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP membrane acts as a semipermeable membrane. The dialysate is left there for a period of time to remove waste products and water, and then it is drained out through the tube and discarded. This cycle or "exchange" is normally repeated 4-5 times during the day, (sometimes more often overnight with an automated system). Ultrafiltration occurs via osmosis; the dialysis solution used contains a high concentration of glucose, and the resulting osmotic pressure causes fluid to move from the blood into the dialysate. As a result, more fluid is drained than was instilled. Peritoneal dialysis is less efficient than hemodialysis, but because it is carried out for a longer period of time the net effect in terms of removal of waste products and of salt and water are similar to hemodialysis. Peritoneal dialysis is carried out at home by the patient and it requires motivation. Although support is helpful, it is not essential. It does free patients from the routine of having to go to a dialysis clinic on a fixed schedule multiple times per week, and it can be done while travelling with a minimum of specialized equipment. Because survival and quality of life are similar with both peritoneal and hemodialysis, the selection of modality by the patient should be dictated by the life style that each therapy offers. Hemofiltration Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different principle. The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used. A pressure gradient is applied; as a result, water moves across the very permeable membrane rapidly, "dragging" along with it many dissolved substances, importantly ones with large molecular weights, which are cleared less well by hemodialysis. Salts and water lost from the blood during this process are replaced with a "substitution fluid" that is infused into theextracorporeal circuit during the treatment. Hemodiafiltration is a term used to describe several methods of combining hemodialysis and hemofiltration in one process. 18
  • 19. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP THE PHYSICAL STRUCTURE OF THE DIALYSIS DEPARTMENT It is located in the first floor. Total area is roughly about 1500 sft Present Bed Capacity - 7 bedded, with sufficient place for the beds with the equipment and place for personnel to freely move round Equipments – Total 10 machines including 3 machines used as standby which are normally used in ICU. DIALYSIS MACHINES The machine Company - Model Number and Quantity Nikkiso – DBB26 : 2 nos Worked Hours : M- 1 :- 34068 hrs. M- 2 :- 33612 hrs. Nipro – Surdial : 2 nos Worked Hours : M- 3 :- 29819 hrs. M- 4 :- 32970 hrs. B.Braun – Dialog : 2 nos Worked Hours : M- 5 :- 25602 hrs. M- 6 :- 24806 hrs. Gambro – AK 95 S : 4 nos Worked Hours : M- 7 :- 12384 hrs. M- 8 :- 10264 hrs. M- 9 :- 09722 hrs. M- 10:- 03959 hrs. 19
  • 20. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP ORGANIZATIONAL STRUCTURE HOD - Dr. Sanjeev Hiremath Consultant Nephrologist. Reports to: MD Senior Technician Mr Sundar Singh Academic profile: Grad in B.Sc. 6 Months training in Dialysis at Apollo Hospital, Chennai. Experience: 22 Years Repoorts to: HOD Technicians No. of technicians - 6 Academic Qualification required: Diploma in Dialysis Technology or Trained in Dialysis technology post graduation Experience: 3 to 10 years Reports to: Sr. Technician Nurses Total number of nurses – 8 Nursing in charge – 1 The nursing incharge reports to the Nursing Superintendent All other nurses report to the Nursing In charge Academic profile of nurses: Diploma in Nursing or B.Sc. Nursing Experience: 3 to 10 20
  • 21. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP SHIFTS General shift 9 am to 5 pm First Shift 8.00 am to 2.00 pm Second Shift 2.00 pm to 8.00 pm Night Shift 8.00 pm to 8.00 pm DISTRIBUTION OF RESOURCES Sr. Technician : General shift Technician : First (Morning) shift - 3 technicians, Second (Afternoon) shift - 2 technicians, Night shift - 1 technician. ACTIVITIES UNDERTAKEN TO SUPERVISE 1. Preparing the machines for dialysis before the patient comes. 2. Receiving and preparing the patient for dialysis, initiation and termination of dialysis. 3. Ensuring that all the parameters are set in the machine. 4. Continuous monitoring of all the relevant parameters throughout the procedure. 5. Ensuring that all the necessary materials are available at all times. 6. Taking instructions from the consultant and implementing the same. EXTERNAL CLEANING OF THE MACHINES AFTER EVERY DIALYSIS Acid / Bleach wash for the internal hydraulic tubing at end of the day. M-1, M-2, M-3, M-4 : Manual Setting – 30 minutes M-5, M-6 : Auto Program – 38 minutes M-7, M-8, M-9, M-10 : Auto Program – 48 minutes Check Biochemistry values once a week. 21
  • 22. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP REVERSE OSMOSIS (RO) PLANT This is the water purifying system for dialysis machines. Sand Filter - filters undissolved suspended particles from the feed water. Activated Carbon Filter - removes bacteria and odor by adsorption. Water Softener - Softens the feed water by nullifying the hardness of the feed water thus increasing the RO output. Micro filters 20” 10 micron filter is used which filters particles up to the size of 10 microns if the particles have escaped from sand and carbon filters. It needs to be changed once in three months. 20” 5 micron filter which filters particles up to the size of 5 microns if particles have escaped from sand and carbon filters and the 10 micron filter. It needs to be changed once in three months. RO unit - It is a 3 membrane unit and the approximate output is 650 – 700 lts per hr. Life span of the membrane is approximately 3 years. Collection Tanks - Permeate water is collected in 2 tanks of 2000 lts each. From the tank water is passed through UV lamp which kills micro-organisms if present. Back wash procedure for Sand and Carbon filters 1. Switch off the feed water pump. 2. Turn the handle in the multiport valve mounted on top of the filter vessel to back wash position from filter position. 3. Switch on the feed water pump and allow the water to flow through the filter. 4. Water moves in opposite direction and pushes all dust particles through the drain. Wait till the presence of the dust in the drain to clear. 22
  • 23. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP 5. Switch off the fed water pump. 6. Turn the handle in the multiport valve to Rinse position. 7. Switch on the feed water pump. Filter is rinsed. 8. Repeat the above till get satisfied and allow the water to other side. Time taken for this procedure mentioned above is approximately 30 to 45 minutes. Repeat frequency - Once in 3 days. Softener – regeneration 1. Take 18 Kg of common salt in the regeneration tank. 2. Add filtered water dissolve the salt and make it to 50 lts. 3. Turn the multiport valve handle to slow rinse (regeneration) position. 4. Place the injection tube in the regeneration tank. 5. Switch on the feed water pump. 6. Slowly open the injection valve and allow the salt solution to get sucked in. 7. Once over close the injection valve. Switch off the pump. 8. Turn the multiport valve handle to fast rinse position. 9. Switch on the feed water pump and rinse the softener. 10. Check the hardness of the water using hardness testing kit. 11. Once the desired level (<40 ppm) attained switch off the pump. 12. Turn the multiport valve handle to service position. Time taken for this procedure, mentioned above is approximately 2 hrs 30 minutes. Repeat frequency: Once in a week. 23
  • 24. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP PREPARING THE MACHINE FOR DIALYSIS 1. Connect the water input line to the RO water line and open it. 2. Place the drain line in the drain hole. 3. Plug in the electrical connection and switch on the machine. 4. Set the machine for rinse mode for 10 minutes. 5. After rinse set preparation mode and connect acid and bi-carbonate concentrate solution. 6. Machine goes in to self checking mode and come final conductivity.. 7. Once machine ready start the dialysis… 8. Connect the dialyser and blood tubing to the machine and prime with normal saline. Tap on the head of the dialyser and remove all the air from the blood compartment. Fill the tubing also with saline. Connect the recirculation connecter in the tip and set for recirculation. Time taken for preparation is 30 minutes. STARTING AND CLOSING OF DIALYSIS Before starting the dialysis the hands of the technicians and associated staff should be thoroughly washed with soap solution and dried with a clean towel. The following things should be kept ready before starting the dialysis procedure. 1. AV fistula needles 2nos 2. Disposable syringe 20ml 1 3. Syringe 1ml 1 4. Xylocaine injection 5. Sterile glove 1pair 6. HD set 1 7. Surgical spirit 8. Four Pieces of 3 inch plaster 9. Normal saline 24
  • 25. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP STARTING OF DIALYSIS Patient 1. Check patient weight and BP make the patient lie down on the bed. 2. Inform the consultant and take necessary instructions for the dialysis. 3. Open the HD set and place all the things mentioned above in the set. 4. Wear the hand gloves and clean the fistula hand top and bottom with spirit and put sterile towel under the hand. 5. Load Xylocaine 2% in 1ml syringe. 6. Select a convenient place for cannulation. 7. Inject local injection and insert the fistula needle in to the vein. One needle should be inserted towards the fistula (artery) and another one towards the heart (vein). Machine 1. Switch off the blood pump and disconnect the recirculation connector from arterial line. 2. Clean the tip of the arterial line with spirit swab and connect to the arterial needle. 3. Set the pump speed of 100ml per minute on the blood pump and let the blood flow through the line. 4. Once the saline in drained and the line filled with blood clamp the venous line of the tube and immediately switch off the blood pump. 5. Clean the tips of the venous line connect to the venous needle. 6. Release the clamp of the venous line and needle. 7. Connect the venous monitor line and release the clamp. 8. Switch on the blood pump. 9. Set the time and weight loss, confirm and press UF/ Dialyze mode. 10. The dialysis starts. 11. Load 5000 IU of injection heparin in 20ml syringe make it to 10ml and fix in the syringe pump in machine and set the flow rate. 12. Enter the time of starting, blood flow, venous pressure, TMP in the dialysis chart. 13. Check BP of the patient every half an hour and enter in the dialysis chart. 25
  • 26. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP CLOSING OF DIALYSIS Material needed: Gloves 1 pair, sterile gauze 1pack Machine 1. Wear the gloves, switch off the blood pump and clamp the artery line and the artery fistula needle. 2. Disconnect the artery line from the fistula needle. 3. Connect recirculation connector to the blood line and connect saline to it. 4. Switch on the blood pump and let 100 – 150 ml of saline to clean the blood line and the dialyser off blood. 5. Once the saline in returned to the patient body switch off the blood pump and clamp the venous line thus to prevent any air entering the blood stream. Patient 1. Remove plaster from the artery needle. 2. Tightly fold gauze piece, pull half of the needle out pour little Neosporin Powder, put the folded gauze piece there and remove the needle hold till bleeding stops and secure with tourniquet. 3. Repeat the same procedure to the venous line also. 4. Check patient BP and Post dialysis weight and record it into the patient file. 26
  • 27. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP FIGURE – ARTERIO-VENOUS FISTULA 27
  • 28. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP FIGURE – REPRESENTATION OF THE FLOW OF DIALYSATE AND BLOOD 28
  • 29. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP FIGURE: VENOUS BLOOD AIR TRAP 29
  • 30. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP MEDICAL EMERGENCY DURING DIALYSIS Hypotension A decrease in blood pressure is the most frequent complication reported during hemodialysis. When fluid is removed during hemodialysis, the osmotic pressure is increased and this prompts refilling from the interstitial space. The interstitial space is then refilled by fluid from the intracellular space. Excessive ultra filtration with inadequate vascular refilling plays a major role in dialysis induced hypotension. The immediate treatment to hypotension is to discontinue dialysis and place the patient in a trendelenburg position. This will increase cardiac filling and may increase the blood pressure promptly. Cramps In the majority of hemodialysis patients, cramps occur toward the end of the dialysis procedure after a significant volume of fluid has been removed by ultra filtration. The immediate treatment for cramps is directed at restoring intravascular volume through the use of small boluses of isotonic saline. Prevention of cramps has been attempted with the prophylactic use of quinine sulfate at least 2 hours prior to dialysis. Cardiopulmonary Resuscitation on Dialysis Check for breathing - Look, Listen and Feel. Check for Carotid Pulse. Open Airway Open the patient's airway by head-tilt, chin-lift. Blind finger sweep (open the mouth and remove any major obstructions.) Give patient O2 connected ambu mask keeping head-tilt, chin-lift. 30
  • 31. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP Commence CPR 1. Place two fingers above sternum then Place the heel of one hand 2-3 inches above the xyphoid process (tip of the sternum). 2. Place your other hand on top of the first and interlace your fingers. 3. Lock your elbows and move your body directly above the patient. This allows you to use the weight of your body, instead of your muscles, to perform compressions. You'll tire less easily. 4. Start the compression by counting 5. 1 and 2 and 3 and 4 and 5 6. 1 and 2 and 3 and 4 and 10 7. 1 and 2 and 3 and 4 and 15 8. After one set of compression give two breaths. Between each breath count as : 9. One A thousand 10. Two A thousand 11. then give breath using an ambu bag. 12. In any resistance felt assess airway for breathing by Look, Listen and Feel. 13. If no breath continue CPR Note Compress the chest wall about 1.5-2 inches down (1/3 to 1/2 the total chest depth). One of the biggest problems with CPR is ineffective compressions. Keep this in mind and don't be afraid to actually compress the chest wall-you're trying to pump the heart by squeezing the rib cage. Push hard and fast. Perform 15 compressions to every 2 breaths. After every cycle of this (2 minutes), stop CPR and check for a pulse. If no pulse, continue CPR until help arrives, periodically check for a pulse. If a pulse or resistance is felt, reassess airway and circulation. Then tilt patient to recovery position and connect O2 mask. Continue to check the pulse once a minute to ensure that you don't lose it. 31
  • 32. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP ROLE OF FIRST PERSON 1. Mr. Mr. are you okay, no response, no pulse. 2. Ask for help - HELP 3. Stop pump, lower the head end of the patient. 4. Disconnect blood lines, and give Ns. 5. Check for breath by Look, Listen and Feel. 6. Check for carotid pulse 7. No breath, commence CPR 8. Place two fingers above sternum. Place the heel of other hand and then Place your other hand on top of the first and interlace your fingers. Start giving compressions by counting. 1 and 2 and 3 and 4 and 5 1 and 2 and 3 and 4 and 10 1 and 2 and 3 and 4 and 15. After one set of compression wait for two breaths. If no resistance is felt continue CPR. When changing to another person for compression then count as; 1 and 2 and 3 and 4 and 5 1 and 2 and 3 and 4 and 10 Switch and 2 and 3 and 4 and 15. If resistance is felt stop CPR. 32
  • 33. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP ROLE OF SECOND PERSON Arrive to the patient along with the Ambu bag and O2 cylinder. Connect ambu to the oxygen Head-tilt, chin-lift Do Blind finger sweep Keep suction ON during compression Connect ambu with O2 to the patient. After 15 compressions, give two breath using ambu After one breath count ONE A thousand TWO A thousand Then give second breath If no resistance is felt Look, Listen and Feel for breath. No breath continue CPR If patient becomes concious or any resistance is felt. Check for breath by Look, Listen and Feel. Then turn patient to recovery position i.e., to the left side of the patient and connect Oxygen. ROLE OF THIRD PERSON Call the Doctor. Bring the Emergency trolley to the spot. Load the necessary Inj. As and when required. Then document the medical data. 33
  • 34. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP STUDY OF PHARMACY DEPARTMENT 34
  • 35. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP INTRODUCTION TO PHARMACY DEPARTMENT Pharmacy (from the Greek φάρµακον 'pharmakon' = drug) is the health profession that links the health sciences with the chemical sciences, and it is charged with ensuring the safe and effective use of medication. The scope of pharmacy practice includes more traditional roles such as compounding and dispensing medications, and it also includes more modern services related to patient care, including clinical services, reviewing medications for safety and efficacy, and providing drug information. Pharmacists, therefore, are the experts on drug therapy and are the primary health professionals who optimize medication use to provide patients with positive health outcomes. The term is also applied to an establishment used for such purposes. The first pharmacy in Europe (still working) was opened in 1241 in Trier, Germany.[citation needed] The word pharmacy is derived from its root word pharma which was a term used since the 1400–1600's. In addition to pharma responsibilities, the pharma offered general medical advice and a range of services that are now performed solely by other specialist practitioners, such as surgery and midwifery. The pharma (as it was referred to) often operated through a retail shop which, in addition to ingredients for medicines, sold tobacco and patent medicines. The pharmas also used many other herbs not listed. In its investigation of herbal and chemical ingredients, the work of the pharma may be regarded as a precursor of the modern sciences of chemistry and pharmacology, prior to the formulation of the scientific method. The pharmacy is one of the most extensively used therapeutic facilities of the hospital; it is one of the few areas of hospital where large amounts of money are spent of purchases on a recurring basis. It is also one of the highest revenue generating centers. A fairly high percentage of the total expenditure of the hospital goes for pharmacy services. It caters to out patients, inpatients, other areas like OT, Clinical laboratory. 35
  • 36. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP NEED FOR THE DEPARTMENT Make available all the drugs and pharmaceuticals needed for patient care according to the hospital formulary: the right drug in the right formulary and dosage. An efficient dept should determine in advance and stock adequate quantities of drugs, at the same time avoiding idle inventory. Disseminate information regarding drugs among the users, functioning as Drug information centre. Prepare certain medicines (usually intravenous fluids, mixtures and ointment) depending on the policy of the hospital. Observe high studies of professional skill in dispensing medicines according to the prescriptions. FUNCTIONS The features of the hospital pharmacy are as follows Procuring pharmaceutical items (a) Requisition (b) Purchase (c) Receiving (d) Checking (e) Storing. Dispensing items (a) Preparing (b) Packaging (c) Labeling (d) Dispensing. 36
  • 37. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP Distribution of items to different departments as per their requirements Quality control of drugs received by the hospital (a) Check on arrival (b) Periodic check (c) Random check (d) Dispensing. • Maintaining information regarding quality, cost and sources of supply of all drugs, chemical, and other items for information of medical, nursing, and other staff. • Ensuring adherence to the laws, acts, rules, and statutory, regulations applicable to pharmacies and dispensing. • Establishing and maintaining adequate accounting procedures for pharmacy charges, supplies, concessions and free services. • Furnishing reports of the activities, periodically and a comprehensive report annually. • Serve as a member of the drug and therapeutics committee be actively involved in its function and activities, and implement its decisions. • Carry out research and participate in the evaluation of new drugs. • Participate in performing therapeutic assessment of drugs and in the preparation of a hospital formulary so that equally effective but less of expensive drugs may be put on the formulary A formulary is a list of drugs approved by the medical staff and the pharmacy committee for hospital use and kept in the inventory. • Keep a note of essential list of drugs prepared by WHO. • Have up to date information of drugs and have been banned in India or other countries. • Investigate problems of complaints related the drug therapy i.e (a) evaluation of potency and active ingredient (b) Detection of harmful agent resulting due to adulteration, improper preservation or expiry of drugs. 37
  • 38. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP PHYSICAL STRUCTURE The Pharmacy department at Sagar Hospitals is having three internal departments. They are the Central Pharmacy, In-patient Pharmacy and Out-Patient Pharmacy. The Central Pharmacy supplies the necessary drugs to the In-Patient and the Out-Patient Pharmacies. The out patient pharmacy is located in the ground flood in an area which is adjacent to the outpatient department. It is roughly about 500 sft in area. The drugs are stored in racks along the walls and there are refrigerators to store medicine that need to be maintained at cold temperatures. There is easy accessibility for people/ patients as it is along the main common walkway and easy to locate. The inpatient pharmacy is located in the 4th Floor very close to the lifts. It is roughly about 400 sft in area and has two sections partitioned by a wall. The drugs are stored in racks along the walls and there are refrigerators to store medicine that need to be maintained at cold temperatures. The Central Pharmacy is located in an area where there is minimal public movement. Entry to the pharmacy store is restricted to authorized personnel. The Central Pharmacy is located in the 5th Floor of the building. It is sufficiently large and roughly about 1500 sft in area. The drugs are stored in racks along the walls and there are refrigerators to store medicine that need to be maintained at cold temperatures. The Central Pharmacy is located in an area where there is minimal public movement. Entry to the pharmacy store is restricted to authorized personnel only. 38
  • 39. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP THE ORGANIZATIONAL STRUCTURE OF THE DEPARTMENT Chairman/ Vice Chairman/ CEO Vice President Manager Pharmacy Central Pharmacy In Patient Pharmacy Out Patient Pharmacy Sr.Pharmacist Sr.Pharmacist Sr.Pharmacist Graduate Pharmacist/ Graduate Pharmacist/ Graduate Pharmacist/ Pharmacist Pharmacist Pharmacist Trainee Graduate Pharmacist Trainee Graduate Pharmacist Trainee Graduate Pharmacist Trainee Pharmacist Trainee Pharmacist Trainee Pharmacist Delivery Boys Delivery Boys Delivery Boys THE HUMAN RESOURCE MANAGEMENT HOD – Mr. Pradeep Job Designation: Manager Pharmacist Central Pharmacy – It is a team of a mix of Pharmacists, Assistant Pharmacist and Pharmacy trainees, five to six in all. Of these there are three pharmacists, additionally there are two helpers. In Patient Pharmacy – It has a total team size of seven resources. The resources are a mix of Pharmacists, Assistant Pharmacist and Pharmacy trainees. Additionally they have 6 resources for helping them. They help in transportation of drugs from central stores to the inpatient pharmacy and from there to the wards. 39
  • 40. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP Out Patient Pharmacy – It also has a team size of seven resources, a good mix of Pharmacists, Assistant Pharmacist and Pharmacy trainees. They have two cashiers and two helper boys. ACADEMIC QUALIFICATIONS AND DESIGNATIONS • D Pharma with Experience - Pharmacist, • D Pharma Fresher – till first 3 months – Trainee Pharmacists. • B Pharma with Experience – Graduate Pharmacists, • B Pharma Fresher – till first 3 months – Trainee Graduate Pharmacists. JOB RESPONSIBILITIES Manager Pharmacy 1. Seeking quotations, comparing and deciding on which drug to be purchased from which distributor. 2. Placing orders for drugs required. 3. Solving issues relating to customer problems. 4. Stock checking along with pharmacists. 5. Preparing duty roster. 6. Handling sales in case of more number of patients. 7. Reporting to the accounts department and higher management. Pharmacist/ graduate pharmacist 1. Issuing of medicines or drugs to the customers. 2. Making Purchase entry-Goods received note 3. Pharmacist working in the night shift will have to take care of billing, receiving cash and return of medicines also. 4. Makes a note of drugs which are over or are less in number. 40
  • 41. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP Cashier 1. Collects cash from the customers for the sales. 2. Hands over the cash to the accounts department after tallying the day’s collection at the end of the shift. 3. Keeps the bills of the sales during the shift at the end of the shift in the storage carton. Computer operator • Generate bills for the sales transactions in the pharmacy. REGULATORY COMPLIANCE Atleast one Pharmacist should be registered with Karnataka state Pharmacy council. The licenses have to be displayed at a prominent position. The Drug License, Narcotics License, AERB License etc have been secured. FORMULARY There is a Pharmacy Advisory Committee comprising of the director, medical director, the manager of pharmacy etc., This committee has prepared a list of approved drugs that can be prescribed by their hospital doctors. This list of hospital approved drugs is circulated among all the departments. This list is reviewed on a regular basis at a frequency of atleast 3 months. Mr Pradeep is also the secretary of this board. STORAGE There are plastic trays in the cabinets. In cabinets no 1, 2, 3, 5 tablets, capsules, are stored in the trays and below the trays syrups, tonic bottles are kept. 41
  • 42. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP All the medicines, tablets and capsules are arranged in the alphabetical order from row 1, 2, 5, 6. In the cabinet 3 ointment, lotions, drops, ampoules, are stored. In cabinet no 4 IV fluids, respiratory solutions crepe Bandages, injections are stored. In each tray in the cabinets there are 3 compartments where 3 company’s drugs are stored. Each tray is labeled with the drugs in it. At the beginning of the cabinet no 1 there is a separate storage area for only syringes. Just below the dispensing counter the fast moving ampoules, syringes, IV fluids, IV set and lozenges like strepsils and few tables like digene are placed in trays. This provides for easy and fast access to frequently asked medicines. There are closed cabinets below each shelf. The drugs are not replaced or placed in the cabinets until the medicine is over or almost over in the tray. Only when it is very less in number new drugs are placed in the tray. Until then the drugs are stocked in the closed cabinet below. This ensures the first in first out principle of drug delivery that is it ensures the drugs which were bought earlier are sold before the new stock being sold. There is also a closed attic area for providing more storage area for drugs. There is a separate store area for specific OT requirements. Here the items required for OT like, gloves, masks, orthopedic surgical requirements are stored. This area is called as surgical stores. There are two cupboards where costly items for surgical need are stored like tracheotomy tubes mesh etc is kept. In the same area there is a separate rack where expired drugs are kept until the particular distributor takes it back. This separate rack ensures that it does not get mixed with other drugs. SALES The pharmacy caters to Outpatient, Inpatients, patients undergoing surgery and walk-in patients also. 42
  • 43. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP OUTPATIENT PRESCRIPTIONS Doctors give the prescriptions to the patient which he/she brings it to the pharmacy. The pharmacist receives the prescription. He/she then places all the medicines and items required one by one at the space below the dispensing counter. She then gives the prescription to the computer operator for entering the particulars taken, amount taken and issue a bill for the same (annexure 2). In the mean while the pharmacist packs the medicines well and puts it in a hand cover. After the bill is generated the computer operator hands it over to the pharmacist. Once the pharmacist receives the bill she gives it along with the packed medicines to the cashier. As the pass box through the cashiers counter is not too big, large amount of medicines cannot be given to the customer through the box. At such times the pharmacist gives only the bill to the cashier. After payment is done by the customer the pharmacist hands over the medicines. The cashier receives the cash from the customer puts a seal saying cash received and gives a copy to the customer and keeps the copy with himself. In case of payment being done by card, the customer has to inform earlier so that the mode of payment is entered in the bill. In case of card payment the customer will swipe the card and the customer copy of the bill generated is given to him and another copy signed by the customer will be kept by the cashier. INPATIENT PRESCRIPTIONS The doctor prescribes the medicines required. The prescription is brought by the patient’s attenders to the pharmacy. The drugs are dispensed in the same way as for outpatients and it’s the same principle cash and carry. If the patient is insured then the prescription for the patient is brought to the pharmacy by the nurse in-charge of that ward. There is a provision in the software where once the hospital number of the patient insured is entered, the address and the details of the patient are displayed. The total sales of drugs for the patient are fed in and the bill is given to the nurse to hand it to the patient or the patient’s attender. 43
  • 44. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP As the computers are network connected the accounts department can access the billing details of the patient and include them in their final bill. In case a drug prescribed by a doctor, is not present in the pharmacy the pharmacist gives a substitute only after the confirmation over phone or writes and sends it back with the patient to the doctor who prescribed that medicine. Only after receiving a confirmation by the doctor alternative or substitute drug is dispensed by the pharmacists. There is a strict no to credit sales being followed at Sagar Pharmacy. If in case a patient is critical and the patients attender does not have money a maximum of 2 hours of credit time is given and only emergency life saving drugs are issued. If in case there is no attender with the patient then, only on the request from the doctor to issue an important emergency or life saving drug, the drugs are issued. Only the chief pharmacist or the in-charge pharmacist of that shift has the authority to take decisions in such cases. SALES RETURNS The pharmacy takes back unused medicines everything from IV fluids, syringes, ampoules and medicines if full strip dispensed is returned. There is a separate counter for purchase return. There is one person for this purpose at the counter. The return of medicines is taken only between 10.00 am to 6.00 pm from Monday to Saturday only. But it is flexible enough i.e. medicines are taken back even after 6.00 pm and on Sundays in case of the patient is getting discharged or any death case or so. The medicines returned are checked for proper packaging, number and so on. Then the bill number, medicines returned, date is entered. The total amount for the drugs returned is displayed on the computer. A bill is generated and handed to the customer. Cash is returned to the patient immediately at the cash counter. The stock returned is placed in the rack adjacent to the counter. The medicines are placed back into their respective places in the racks later in the day by the pharmacists. EXPIRY DRUGS RETURN Drugs before 1 month of expiry date are noted and the distributor is informed to take back the 44
  • 45. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP drugs. The expired drugs are entered in the system and purchase is returned to the distributor. Expired drugs are stored in a separate rack until the supplier takes it back. For the return taken, the supplier gives either a credit note which will be reduced from the next bill or items worth the same amount will be immediately given. STOCK CHECKING Stock checking is done every half yearly. That is once in 6 months. The management decides upon a date for the stock checking and informs the chief pharmacist. The stock checking is done by all the pharmacy staff except 2 of them who will handle the sales during that period. Stock checking is completed within 24 hrs. A list of all the drugs in the pharmacy is taken from the software. A print out is taken the particular drug is checked and entry is made against the drug name the quantity present. The list at the end of the stock check is submitted to the management. As and when sales of medicines occur during the stock checking so much of the quantity is deducted from the list. BREAKAGE Breakage if occurs in the pharmacy, the broken number of pieces are informed to the supplier for replacement. 45
  • 46. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP STUDY OF BIOMEDICAL ENGINEERING DEPARTMENT 46
  • 47. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP BIOMEDICAL ENGINEERING DEPARTMENT Modern patient care revolves around not just the skill of the doctor, but technology as well. When the equipment is running correctly, it allows the docs to do their job to the best of their ability. With the most accurate diagnostic equipment at the docs' disposal, the patients have a better chance at survival and recovery. When things are running smoothly around the facility and nothing is broken, the biomedical maintenance flight technicians use the time to perform routine preventative maintenance on all the equipment. They also provide the medics with training on how to properly use new equipment to prevent user error. Biomedical equipment models and makes also changes almost every day, It's not realistic to think you can learn everything about every piece of equipment. The technical school helps prepare the engineers by giving the foundation and framework -- the basics. The junior engineers fill in the gaps as they sort of teach themselves by using the literature and skills picked up along the way from co-workers." Plumbers work on pipes, carpenters work with wood, but we can work on everything in the hospital. We're not limited to one field, when you work on medical equipment, you have to know how to fix everything, and we do because there's no telling what you're going to see. HOD - Mr Raju Academic profile: BE in Electronics and Communication. Post Graduate in Medical Electronics Experience: 10 years. Reports to: Asst. MD Dr.Lohit. 47
  • 48. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP TECHNICIANS No. of technicians – 1 assistant Academic: BE in Medical Electronics. Experience: No prior experience. Reports to: HOD WORKING HOURS General Shift 9.00 am to 5.00 pm In addition to it - on call support 24/7. PHYSICAL STRUCTURE It is located at the second floor. The area allotted is (7` x 10`) = 70 SFT. TECHNOLOGY The department is provided with a helpline and a computer which is part of the hospital network. Within the 70 SFT area provided to the department, there is a small office space, a work station and 2 big sized shelfs, one for documents and the other for tools and equipments. PROCUREMENT The department participates in the decision making process of the procurement of Biomedical Equipment (Hospital Assets) in the hospital. It receives copies of purchase orders placed for procurement of biomedical assets. On arrival of the ordered equipment, the opening of the pack is done in presence of a biomedical engineer who inspects the equipment for physical fitness and technical compatibility. Then if the consignment meets the hospital requirements, the items are approved and in-warded. Then the goods receipt number - GRN is prepared and forwarded by the stores to the Accounts department. The installation and operating of the equipment should be demonstrated to the biomedical 48
  • 49. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP engineer as well. Also the biomedical engineer needs to be demonstrated and trained to handle some basic breakdowns. Most important thing is that the engineers should be trained on what should not be done during the course of maintenance. What activities would lead to the lapse of warranty etc., PREVENTIVE MAINTENANCE The biomedical engineer has to perform daily routine visit to all departments to take stock of the condition of the biomedical equipments. The visits are registered in a routine visit register. This register contain all the details of any new breakdowns, breakdowns pending repair, equipment wear and tear etc., BREAKDOWN MAINTENANCE When there is a breakdown call from any department, the Engineers visit the site and attend to it. There are many aspects to be taken care before opening an equipment for service/maintenance. The things to be checked before starting the maintenance procedure are as follows: 1. Check whether the power chords and plugs of the equipment are not damaged. 2. The power supply sockets are not damaged 3. The equipment warranty should be checked. If it is still under warranty, the equipment should not be opened and the service ticket has to be raised with the technical support of the vendor. 4. If the equipment is on a major breakdown, and the equipment is high value equipment and has been insured, then appropriate procedures to make the claim should be followed. 5. If equipment broken down can be repaired by the department engineers, only then it has to be opened. 6. If the equipment cannot be maintained by the departmental engineers, the respective vendors should be informed and followed up to ensure the equipments are restored with minimal breakdown time. 7. High Value equipment which are out of warranty period should be periodically checked for the validity of AMC and insurance so that 49
  • 50. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP STUDY OF AMBULANCE SERVICES DEPARTMENT 50
  • 51. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP AMBULANCE SERVICES DEPARTMENT An ambulance is a vehicle for transporting sick or injured people, to, from or between places of treatment for an illness or injury. The term ambulance is used to describe a vehicle used to bring medical care to patients outside of the hospital or to transport the patient to hospital for follow-up care and further testing. The word is most commonly associated with the land- based, emergency motor vehicles that administer emergency care to those with acute illnesses or injuries, hereafter known as emergency ambulances. These are usually fitted with flashing warning lights and sirens to facilitate their movement through traffic. It is these emergency ambulances that are most likely to display the Star of Life, which represents the six stages of prehospital medical care. Other vehicles used as ambulances include trucks, vans, station wagons, buses, helicopters, fixed-wing aircraft, boats, and even hospital ships. The term ambulance comes from the Latin word ambulare, meaning to walk or move about which is a reference to early medical care where patients were moved by lifting or wheeling. The word originally meant a moving hospital which follows an army in its movements. During the American Civil War vehicles for conveying the wounded off the field of battle were called ambulance wagons.[5] Field hospitals were still called ambulances during the Franco-Prussian War[6] of 1870 and in the Serbo-Turkish war of 1876[7] even though the wagons were first referred to as ambulances about 1854 during the Crimean War. There are other types of ambulance, with the most common being the patient transport ambulance. These vehicles are not usually (although there are exceptions) equipped with life- support equipment, and are usually crewed by staff with fewer qualifications than the crew of emergency ambulances. Their purpose is simply to transport patients to, from or between places of treatment. In most countries, these are not equipped with flashing lights or sirens. In some jurisdictions there is a modified form of the ambulance used, that only carries one member of ambulance crew to the scene to provide care, but is not used to transport the patient. In these cases a patient who requires transportation to hospital will require a patient- carrying ambulance to attend in addition to the fast responder. 51
  • 52. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP HOD: Mr Imdad Ali Experience: total 13 years in transport related industry and coordination Reports to: Dr Rajeev Matthew – HOD Emergency Department HOW THE SERVICE REQUEST PROCESSED When there is an incoming request call for an ambulance service, it is redirected to the CMO. The CMO on a call determines the need and accordingly writes a requisition slip for ALS or BLS and the required medical equipment and medicines to be carried along. The nurse based on the instructions of the CMO takes along with her the required equipment and medication. The CMO accompanies in the ambulance only is the patient condition requires that level of attention or if the patient needs to be stabilized before getting into the ambulance. Generally the entire process is completed in 5 minutes and the ambulance is moved to the location to bring in the patient. In the mean time, the necessary gadgets required for treatment are kept ready and the treatment starts immediately after the patient has reached the hospital ER. In case of patient dies mid way, normally all attenders of the patients insist on reaching the hospital if the doctor is not accompanying. However it is not mandated by Law to take to the hospital. There is a separate vehicle to transport dead body. It is carried free of cost to home. This service is provided only for non MLC cases. Metador 307 is used for this purpose WHEN IS A SERVICE REQUEST DECLINED If ambulances are not available (which has not happened till date) The ambulance is not provided for cases of DAMA – discharge against medical advice 52
  • 53. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP PRESENT DEMAND FOR THE AMBULANCE SERVICE Daily average number calls for BLS service– 7 to 8 calls Daily average number calls for ALS service - 3 to 4 calls Daily routine calls for Discharge and others - 4 to 5 calls Dead body carrying ambulance (non-MLC cases only) -- 2 to 4 cases per month THE VEHICLES AND THEIR TYPES No. of vehicles – 5 • ALS – Advanced life support ventilator – 2 nos. • Imported Chevrolet Ambulance (LH Drive) - ALS – 1 no. • BLS – Basic life support ventilator – 2 nos. • OPD patients and discharge - versa ambulance – 1 no. • Dead body Transportation van – 1 no. Features • ALS ambulance has all the features, equipment and properties of an ICU and can be considered as a mini ICU • BLS ambulance has Oxygen, Monitor, First aid and other medicines, facility for drips etc., • In both ambulances there is a shelf with all essential ER drugs, Drips, and other medical consumables. • In ALS there is a defibrillator mounted permanently but in BLS there is provision to mount portable defibrillator and other monitors. • The vehicles are basic Tempo Traveler - ambulance model taken and the body reconstructed by a professional Ambulance Body Building company. • Veeresh Auto Builders, Bommasandra Industrial Area, Bangalore-560099 are the people who do most of the ambulance body building in Bangalore and there is one or two others in Bangalore. 53
  • 54. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP Registration • Vehicle classified as ambulance is registered with RTO under the ambulance3 category with seating capacity 1+1 Permit • No permit required for ambulances to travel anywhere in India. So effectively it is having all India permit though no fees is required to be paid. Taxes • Sales tax at the time of purchase is not exempt and normal vehicle tax rates apply. • Road tax is exempted, but it is not 100% • Service offered by ambulance is not taxable MAINTENANCE OF THE VEHICLES • Engine Oil is changed after every 10,000 kms • All Vehicles are washed daily • The important parameters like the air pressure, battery charge, tyre wear, etc., are checked on a daily basis. • The inventory of the medical supplies recorded and consumption is recorded regularly. • Reorder the medical supplies if the stock has gone down below the reorder levels or have expired. • The ALS vehicles are to be charged daily and then the readings checked and recorded. • Regular inspection by the biomedical engineers for the proper functioning of the internal biomedical gadgets. • Annual calibration of the defibrillator and other biomedical equipments. • Other aspects like diesel levels, and physical damages etc., 54
  • 55. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP THE HUMAN RESOOURCE Number of drivers – 12 Academic qualifications: minimum 1st PUC, Experience: 4 yrs and over Reports to:HOD On all ambulance trips, 1 nurse from ER and 1 helper boy are accompanied. Doctor from ER accompanies if the need arises. AMBULANCE DRIVERS Ambulance department drivers are trained at St Johns and issued a certificate of training. (St. Johns Ambulance Association certification) At the St.John’s Certification course, the drivers are trained about about the basic rules and regulations of ambulance transport, they are imparted knowledge in doing basic first aid, CPR etc., SOME IMPORTANT GUIDELINES • The Ambulance has to be moved slowly while moving pregnant women. • Cardiac patients should be moved to the hospital as quickly as possible. • Siren Rules – The ambulance can use Siren while going to pick up patients and returning back to hospital. At Sagar Hospital, siren is fitted only on ALS and BLS vehicles. • The Versa Ambulance here only has beacon light and no siren is fitted and is used to transport discharged patients. 55
  • 56. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP • Driver can call 100 and request clearance in the route that they take to reach the patient as well as return to the hospital. • Trip sheet signed by the ER doctor should be carried by the ambulance driver at all times when the ambulance is engaged and moving. DRIVERS SHIFTS First Shift 8.00 am to 2.00 pm - 2 drivers+1 Second Shift 2.00 pm to 8.00 pm – 2 Night Shift 8.00 pm to 8.00 pm - 2 56
  • 57. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP RECOMMENDATIONS Dialysis department – Primarily the operations in the department is going fine. There are some machines which have worked over 40,000 hrs. These machines should reconditioned or condemned and replaced by new ones and is possible the software updated to latest versions. Pharmacy department – Space constraints were visible in the department. Presently the procurement of stents, implants is being handled by the materials department. It is more suitable if this can be handled by the Pharma department itself. Biomedical Engineering department – the space allocated for this department is very less and going forward more and more biomedical equipment are expected to come into the hospital with the changing technology. So it is recommended that a ESD safe workstation in a clean room area be allocated to the biomedical engineering department. Atleast 250 to 300 SFT of area is required under the present work load with adequate space for storage of equipment and paperwork. Ambulance Department – Presently there has been not a single reported case of breakdown while transporting patients including a puncture. Thus the maintenance of the vehicles is adequate. 57
  • 58. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP INDEX care, 6, 8, 10, 11, 13, 37, 38, 43, 50, 52, 54, 55 carotid, 34 A Carotid, 32 carton, 44 Academic, 20, 21, 51, 59 cash, 43, 44, 46, 48 active, 40 Casualty, 10 acts, 18, 39 categories, 7 acute, 15, 55 caters, 7, 38, 46 adulteration, 40 Cathlab, 9 affordable, 6, 8 Central, 40, 41, 42 age, 7, 10 challenged, 14 ambiance, 9 Checking, 39 ambu, 33, 35 check-up, 7 ambulance, 9, 54, 55, 56, 57, 58, 59, 60 chemical, 37, 39 ambulances, 55, 56, 57, 58 chloride, 16 amounts, 38 Clinical, 10, 38 ampoules, 45, 47 clinics, 6 Arabic, 14 cold, 40, 41 area, 19, 40, 41, 45, 51, 52, 61 comfortable, 9, 10, 13 artery, 26, 27 Comfortable, 9, 10 assistance, 14 commence, 34 comprehensive, 6, 39 B computer, 46, 48, 52 concentrate, 24 B Pharma, 43 concentration, 16, 18 B.Braun, 19 conductivity, 25 bacteria, 22 connection, 24 Bangalore, 1, 2, 5, 6, 7, 58 consultation, 9 beds, 6, 8, 9, 19 coordinators, 13 benefits, 7, 17 cost, 12, 13, 39, 56 Bengali, 14 counters, 11 bicarbonate, 16 counting, 33, 34 bi-carbonate, 24 CPR, 33, 34, 35, 59 billing, 11, 43, 47 cramps, 32 bills, 44 crew, 55 Biochemistry, 10, 22 Cubicle, 11 Biomedical, 2, 3, 49, 50, 52, 60 customer, 13, 43, 46, 48 blood, 9, 16, 17, 18, 25, 26, 27, 32, 34 Cytopathology, 10 Blood Bank, 11 brand, 5 D breakdown, 52, 53, 61 breakdowns, 52 D Pharma, 43 breathing, 32, 33 Day Care, 9 De-addiction, 9 C diabetes, 11 diagnostic, 50 calcium, 16 diagnostics, 6 carbon, 22, 23 Diagnostics, 10 card, 46 dialysate, 16, 17, 18 cardiac, 6, 10, 11, 32 Dialysis, 2, 3, 11, 15, 16, 20, 32, 60 Cardiopulmonary, 32 dialyzer, 17, 18 58
  • 59. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP diffusion, 16 disconnect, 26 H Disconnect, 27, 34 Haematology, 10 diseases, 10 hardness, 22, 24 dispensing, 37, 38, 39, 45, 46 healthcare, 5, 6, 8, 12 Dispensing, 39 hearing, 14 Disposable, 25 Hemodialysis, 17 disposal, 50 Hemofiltration, 18 dissolution, 15 Hindi, 14 doctors, 6, 44 Histopathology, 10 Drug, 9, 38, 44 hospital, 6, 7, 38, 39, 40, 44, 47, 51, 52, 55, 56, 60, 61 drugs, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 57 Hospitals, 1, 2, 6, 12, 13, 40 hour, 9, 11, 17, 27 E hydrogen, 16 electrical, 24 Emergency, 10, 36, 56 I endocrinology, 11 Imaging, 10 Engine, 58 Immunology, 10 Engineering, 2, 3, 5, 49, 60 impaired, 14 enlarged, 11 improper, 40 equilibrium, 15 In Patient, 42 equipment, 18, 19, 50, 51, 52, 53, 55, 56, 57, 61 India, 2, 7, 12, 40, 58 equipments, 7, 52, 53, 59 infectious, 10 equipped, 6, 9, 55 initiation, 21 erythropoietin, 16 injection, 24, 25, 26 Europe, 37 insurance, 7, 11, 53 Experience, 20, 21, 43, 51, 56, 59 Intensive, 9 experienced, 10 international, 7, 13 expired, 45, 48, 58 interpreters, 14 Interpreters, 13 F intestinal dialysis, 17 intravascular, 32 facility, 6, 10, 50, 57 inventory, 38, 40, 58 filters, 22, 23 investigations, 10 fistula, 25, 26, 27 ions, 16 fluid, 16, 17, 18, 32 ISO, 12, 13 fluids, 38, 45, 47 formulary, 38, 40 foundation, 51 J framework, 51 Japanese, 14 French, 14 Jayanagar, 1, 2, 7, 12, 13 function, 15, 39 Johns, 59 functioning, 7, 10, 38, 59 G K kidneys, 15 Gambro, 20 gauze, 27 general, 7, 17, 37 L German, 14 glove, 25 Labeling, 39 gradient, 16, 17, 18 labor, 11 Graduate, 43, 51 laboratory, 9, 10, 38 Greek, 15 language, 14 Laser, 11 laws, 39 leadership, 5, 6 locations, 6 59
  • 60. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP lozenges, 45 peritoneal, 17 lusis, 15 peritoneal dialysis, 17 Luxurious, 7, 9 personalized, 6, 13 pharmacology, 37 Pharmacy, 2, 3, 5, 37, 40, 41, 42, 43, 44, 60 M philanthropic, 6 phosphorus, 16 machine, 19, 22, 24, 25, 26 Physiotherapy, 5, 9, 11 Machine, 25, 26, 27 plaster, 25, 27 machines, 19, 21, 22, 60 pneumatic, 10 magnesium, 16 potassium, 16 management, 7, 13, 43, 48 Powder, 27 materials, 22, 60 Preparing, 21, 39, 43 Matrix, 10 preservation, 40 medical, 6, 8, 12, 13, 36, 37, 39, 40, 44, 51, 54, 55, 56, 57, 58 presidential, 7, 9 medicine, 12, 15, 40, 41, 45, 47 pressure, 17, 18, 26, 32, 58 medicines, 10, 37, 38, 43, 44, 45, 46, 47, 48, 49, 56, 57 prophylactic, 32 membrane, 16, 17, 18, 23 prostate, 11 metabolic, 16 pulse, 33, 34 Microbiology, 10 Pulse, 32 microns, 22, 23 purchase, 47, 48, 52, 58 minerals, 15, 16, 17 Purchase, 39, 43 money, 38, 47 multiport, 23, 24 multi-specialty, 6 Q qualified, 5, 6, 14 N quality, 13, 18, 39 quinine, 32 NABH, 12 Neonatal, 9 Neosporin, 27 R Nephrologist, 20 nephrology, 11 Radio, 10 neuroscience, 11 Receiving, 21, 39 neutralise, 16 recirculation, 25, 26, 27 Nikkiso, 19 recurring, 38 Nipro, 19 regeneration, 23, 24 nurse, 47, 56, 59 renal, 15 nursing, 7, 21, 39 renal failure, 15 Nursing, 5, 20, 21 replacement, 15, 16, 49 Requisition, 38 respiratory, 45 O restoring, 32 Resuscitation, 32 Operating, 9, 11 revenue, 38 orthopedics, 11 RO unit, 23 osmosis, 18 Robotic, 11 overseas, 7, 13 rooms, 7, 9, 10, 11 oxygen, 35 rules, 17, 39, 59 P S Packaging, 39 Sagar, 1, 2, 3, 5, 6, 11, 12, 13, 40, 60 paramedics, 10 saline, 25, 26, 27, 32 parameters, 22, 58 Sand Filter, 22 Pathology, 10 Science, 5 patients, 7, 10, 11, 13, 15, 16, 18, 32, 37, 38, 40, 43, 46, 47, 50, semipermeable, 17, 18 55, 56, 57, 60, 61 services, 5, 13, 37, 38, 39 payment, 46 sirens, 55 pediatrics, 11 skilled, 7, 10 60
  • 61. PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP sodium, 16 treatment, 6, 13, 16, 17, 18, 32, 54, 55, 56 software, 47, 48, 60 triage, 10 solutes, 16, 17 tube, 17, 24, 26 solution, 16, 17, 24, 25 Spacious, 9, 10 specialist, 37 U specializing, 10 stabilized, 56 ultrafiltration, 16 statutory, 39 Ultrafiltration, 17, 18 Sterile, 25 undissolved, 22 storage, 44, 45, 61 Unit, 9 Storing, 39 Urdu, 14 stream, 27 urology, 11 strepsils, 45 suites, 7, 9, 11 V sulfate, 16, 32 Superintendent, 21 ventilator, 57 surgery, 37, 46 video conferencing, 10 surgical, 6, 45 volume, 32 Surgical, 25 suspended, 22 swab, 26 W syringe, 25, 26 Syringe, 25 waiting, 9 syringes, 45, 47 ward, 7, 9, 47 washed, 25, 58 waste, 16, 18 T water, 15, 17, 18, 22, 23, 24 tank, 23, 24 technicians, 20, 21, 25, 50, 51 X technology, 6, 8, 20, 50, 61 temperatures, 40, 41 xyphoid, 33 Theatres, 9 therapeutic, 11, 38, 40 therapeutics, 39 Y therapy, 15, 18, 37, 40 Yoga, 9, 11 tobacco, 37 trauma, 10 61

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