Gerties News Issue 57 | Mar. 2016

Gertrude’s News

QUALITY AND PATIENT SAFETY PROGRAM

Twenty two (22) Heads of Departments and Twenty One (21) Section Heads successfully completed a one year training in Healthcare Quality and Safety offered by the American Institute of Healthcare Improvement (IHI). The managers who graduated during the Quality and Safety Conference, held on November 29th, 2015, were trained on Quality Improvement Capability, Patient Safety, Leadership in Quality and Safety as well as Person-and-family Centred Care. They are now better placed to improve the quality and safety of care provided by the hospital. During the Quality Conference the hospital management team and resident paediatricians reviewed the previous year quality and safety performance and discussed the focus areas for quality and safety in the current financial year, 2015/16.

Previous Year Review

The hospital made good progress in the previous financial year in improving quality and safety of care. The hospital reviewed its quality statement to incorporate the key elements of safe, effective, timely, efficient, equitable and patient cantered care. The Hospital was successfully recertified for ISO 9001:2015 and ISO 22000:2005 and was admitted as a member of the Children’s Hospitals Association in the USA which will be a good forum for benchmarking and learning. The hospital maintained all the requisite legal and regulatory requirements for operation.

WELL DONE: Head of Finance and Shared Services, Mr. Samuel Moko (R), receives his certificate in Healthcare Quality and Safety from the CEO Mr. Gordon Odundo.

appy New Year and welcome to the 57th edition of our exciting, informative and inspirational Gertrude’s News, the first for 2016.

The year 2015 has really been a great year for our hospital. We have witnessed tremendous growth as a health institution and particularly key being our recent inclusion in the Children’s Hospital Association, a worldwide umbrella body for paediatric institutions in the world. Our Hospital Foundation launched its inaugural Mombasa Golf Tournament in May which realised a total of Kshs. 1.2 Million. This was followed by Kshs. 4.5 Million raised during the 25th Annual Charity Golf Tournament at Muthaiga Golf Club in September. The proceeds from this charity event help treat the needy and less privileged children in the society.

In 2016, we endeavour to continue in the same spirit. I am pleased to report to you that during this first quarter, we shall be opening a new clinic at Thika Road Mall. This is in line with our agenda; Provision of Quality Healthcare to all.

Finally, I wish to thank you for your continued support and strong partnership with us. I would like to take this opportunity to wish you a Happy and Prosperous 2016 as you continue reading the exciting magazine.

Gordon.

Previous Year Review

Customer satisfaction levels remained high at 95% with a second customer incorporated in the Patient and Family Rights Committee as a community representative to provide the customers perspective of quality and safety.

A detailed survey was also conducted to ascertain customer expectations and their perception of the hospital’s services. All the clinical indicators of care were maintained at high standards. Safety among staff was generally good with incident reporting improving to 328% over previous year. The hospital migrated to electronic medical record in the inpatient and the specialist clinics in addition to the outpatient becoming the first hospital in the region with fully integrated electronic medical record.

Quality and Safety Focus 2015/16

The team held detailed discussions on how to successfully implement nine high level quality and safety objectives for 2015/16: enhance

new staff induction; Improve Blood Transfusion Safety; Improve care outcomes at the Critical Care Unit; Improve patient and family education and communication; improve the safety of care during transition; enhance infection prevention and control; implement and effective risk management process; and achieve the Joint Commission International Accreditation.

Each Head of Department presented the quality agenda for each department. This included specific risk management actions and quality improvement initiatives to be implemented at the section level. Later, each department held detailed workshops to discuss approaches and strategies to implement their quality and safety objectives.

The Chief Executive Officer, in his comment, noted the exceptional support provided by the hospital Board of Trustees with regard to quality and safety and challenged the team to ensure all staff members are involved in the quality and safety process.

St. Monica Kibera Medical Outreach

The school’s management expressed their appreciation on behalf of all participants, and to Gertrude’s Hospital Foundation for accepting to take part in the noble course.

The outreach activities take place quarterly with the aim of providing care and treatment and routine screenings for the children of Kibera.

On 17th October 2015, a volunteer team from Gertrude’s Hospital Foundation, in liaison with Volunteer Foundation for the Children of St. Monica Nursery School and Soweto Academy participated in a one day medical outreach activity held at St. Monica Primary School, Kibera. The services offered included VCT, health education, water and sanitation hygiene demonstrations, nutrition assessment as well as treatment. A total of 127 children were seen.

Sunshine Smiles team with a section of the children and teachers in Kibera St. Monica academy

World Day Of Remembrance Of Road Crash Victims Event

Gertrude’s Children’s Hospital, as well as the National Transport and Safety Authority (NTSA), Usalama Watch Initiative and Association for Safe International Road Travel Kenya, held a commemoration event at the Children’s Traffic Park in Nairobi to remember the many millions of adults and children killed and injured on the world’s roads including Kenya, together with their families, friends and many others who are also affected.

The World Day of Remembrance of Road Crash Victims is commemorated annually and is a Day in which people reflect on the tremendous burden and cost of this daily disaster to families, communities and the countries at large and on ways to halt it.

According to the WHO Global Status Report on Road Safety 2015 report, it estimates that 12,891 people died on Kenyan roads in the year 2014. A significant proportion of the casualties are pedestrians – 47%.

Speaking at the event, Chief Guest, Mr. Mathew Munyao - the Road Safety Director at the National Transport & Safety Authority (NTSA), mentioned that his organization is working towards the enforcement of speed limits on roads.

In addition, Gertrude’s Hospital Foundation Manager Dr. Carol Waweru, said that it is time for the National Assembly to pass the Traffic (Amendment) Bill, which is currently in the second stage reading in the National Assembly.

Jill Barack Ayot

She indicated that the Bill is a necessary change needed to safeguard the children on our roads through the adoption of a speed limit of 30kph around schools and health facilities. This is because many children and traffic lollipop men have lost their lives due to senseless overspeeding near and within schools’ vicinities.

Every child’s life counts, in today’s world, one life lost is too many.

Thanks Gertrude’s for saving my son’s life, your receptionists were good 2 me your nurses too n da doc was great, your surgical room was also ok am forever grateful, thank u

Patrick Kahora Gkhans (Nakuru) Keep up the spirit of helping hand

Kate N Monari

Good evening. I would like to share my gratitude towards the staff at your Lavington clinic. They have proved to me and my family that

and kindness truly exists. I am deeply humbled by the kindness they showed me and my three year old when i was taken ill at their clinic. My child may have been scared stiff at the sight of his mum being so helpless but they were on hand to assure him that all would be well and still had the time to offer first responder’s care till help arrived. May God bless each and every one of you abundantly and i hope someday someone just as kind will get a chance to come through for you and you did me.

Gertrude’s Children’s Hospital

compassion

Gertrude’s Hospital Foundation Manager, Dr. Carol Waweru, speaks during The World Day of Remembrance for Road Traffic Victims (WDR)event at The Children’s Traffic Park, Nairobi on Saturday 14th November, 2015.

Demystifying the HIV/AIDS Stigma -the Sunshine Smile’s Clinic Perspective

By Sarah Agak.

Gertrude’s Children’s Hospital Clinical Services department together with the Institute of Child Health and Research host one hour CME (Continuous Medical Education) sessions on a weekly basis at the main hospital in Muthaiga. These CMEs are geared towards improving the practice of medicine with a bias towards promoting quality health care for children.

World AIDS day is marked on December 1st thus the decision to have our team from the Sunshine Smile Clinic make a presentation during on 3rd December was without doubt, well-timed. Sunshine Smile Clinic provides a patient and family-centred approach to care. All medical and social care provided in this model incorporates input from the patient, their family and clinic staff, as applicable. Patients and their care-givers leave the clinic feeling their needs have been catered to and they have had some say. Care is therefore tailored to suit individual needs.

The Sunshine Smile Team is part of a global family that is focused on making the world

AIDS-free. The team’s contribution towards increasing awareness, demystifying HIV/AIDS and eliminating stigma as part of the greater national effort has steadily had an impact in our society with the current HIV/AIDS prevalence rate dropping to 5.6% (2013) from 7.2% (2007).

The new global 90-90-90 initiative in respect to ending the AIDS epidemic by the year 2020, expects that 90% of all people living with HIV will know their HIV status; 90% of all people diagnosed with HIV will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have the viral suppression.

What remains a challenge both for Sunshine Smile Clinic team and other stakeholders is the stigma that is still associated with the disease over 20 years later. You and I have a role to play; we can all contribute locally and globally by demystifying HIV/AIDS and eradicating both the disease and the stigma associated with it. We need to get to zero infections globally.

Twitter Notifications

Thank you so much @GertrudesHosp I can’t forget to thank Emily Murei at your Lavington Clinic for the great services she offered to us!!!

@GertrudesHosp on Othaya Road has the best customer service and turnaround time of any hospital I’ve ever experienced.

#TwitterThumbsUp

Al Kags @alkags

The folks at @GertrudesHosp Nairobi West are incredibly efficient - fast and courteous. Well done!

Gertrude’s Children’s Hospital @GertrudesHosp

Jay Jay @JayJayMmo

Carol Musyoka @carolmusyoka

Gertrude’s Insititute Of Child Health And Research’s 10Th Graduation Ceremony

By Duke Ogoti

Friday the 20th November 2015 was a busy day. The usually calm Muthaiga Road was soon overrun with traffic. All roads led to Gertrude’s Institute of Child Health and Research’s Graduation square. The Decade History graduation celebration drew large numbers from medical fraternity, friends and relatives of both the school and the 2014-2015 graduating class.

By 1pm, the guests were seated just in time for the arrival of the Chief Guest, Dr. James Mwanzia (Senior Health systems and Public Health Specialist) and his entourage.

The ceremony kicked off with a prayer and a rendition of the National Anthem by Dr. Noah Sylvia. This was immediately followed by a dance and skit by the 2015-2016 class with a message to all who came; enhance knowledge-seeking behaviour and attitude change.

The principal, Ms. Perez Obonyo gave an opening remark. She gave a brief history of the school and highlighted its achievements spanning from East and Southern Africa all the way to Central Africa. Ms Caroline Ayilo then spoke heartily on the positive impact of specialization on her staff with tangible results evident in client satisfaction.

The CEO, Mr. Gordon Odundo, then stood up to congratulate the graduands. His key highlight was emphasis on the importance of furtherance of education which he said would have a positive impact on society at large. This message was drilled home by speaker after speaker. Mr Terry Davidson, a member of the Board, then welcomed the Chief Guest Dr. James Mwanzia who spoke passionately about the Kenyan healthcare system. He particularly emphasized the need for constant training and re-training of staff to keep up with the constant advances in medical science.

Ms. Caroline Ayilo then proceeded to award Diplomas in the faculties of;

• Paediatric Nursing-March and September 2014 classes

• Paediatric Critical Care Nursing (PCCN) -September 2014 class

• Emergency Medical Technology (EMT) -July 2014 and February 2015 classes

Mr. Daniel Gai delivered the closing remarks marking the end of the lavish ceremony.

Gertrude’s Children’s Hospital

The Chief Guest, Dr. James Mwanzia, receives a bouquet of flowers from Grace Mwikali Mutua during the Gertrude’s Institute of Child Health & Research 10th graduation.

Antibiotics Aren’t Always the Answer

When an antibiotic is not prescribed, ask your child’s doctor or pharmacist what can be used to relieve symptoms.

Taking antibiotics for viral illnesses:

• Will NOT cure your child’s illness

• Will NOT help your child feel better Will NOT keep others from catching your child’s illness

Bacteria cause illnesses like strep throat that are often treated with antibiotics.

REMEMBER:–there are potential risks when taking any prescription drug. Antibiotics should only be used in the cases where your child’s doctor determines they are needed.

Antibiotic use can:

Most cough and cold illnesses are caused by viruses. ANTIBIOTIC use can only cure bacterial illnesses–not viral illnesses. Common illnesses that antibiotics CANNOT treat include:

Colds

• Influenza (the flu)

• Runny noses

Most coughs

• Most bronchitis

• Most sore throats

• Most sinus infections

• Some ear infections

Viral illnesses, like colds, usually go away without treatment in a week or two. Even many bacterial ear infections go away by themselves.

• Kill good bacteria in your child’s body, which may lead to complications, such as diarrhea or yeast infection.

• Cause a serious allergic reaction that may require hospitalization.

• Result in an antibiotic-resistant infection. These bacteria are stronger and harder to kill. They can stay in your child’s body and cause severe illnesses that cannot be cured with antibiotics.

A cure for a resistant infection may require stronger treatment and possibly a hospital stay.

Talk with your child’s doctor about the best way to care for your child during this illness.

Gertrude’s Children’s Hospital

Some of the doctors/paediatricians who attended the Pain Management training held at Gertrude’s Institute of Child Health and Research, Muthaiga.

Nurse Betty Rutto talks to a family at Muthaiga Outpatient department. Gertrude’s staff guarantee friendly healthcare services.

Left to Right: Ms. Carol Ayilo Deputy Matron, Mr. Gordon Odundo CEO, Ms. Elizabeth Russell (Andy) Member Board of Trustees, Chief Guest Dr. James Mwanzia, Mr. Terry Davidson Member Board of Trustees and Ms. Perez Obonyo Principal Child Institute of Health and Research during the 10th Gaduation Ceremony

Dr. Esther Njoroge (2nd left) Regional Director, Africa Smile Train International, donates a laptop for use by the Smile Train Program. Receiving it are Head of Finance and Shared Services Samuel Moko (2nd right), Foundation Manager Dr. Carol Waweru (R) and Dr. Sylvia Noah (L).

This wheelchair is part of the anonymous donations received by the hospital for use by patients.

Graduands recite the Nurses’ Pledge during the 10th graduation ceremony held in Muthaiga.

Nurse Esther Kithome attends to baby Gilbert Ndui at Gertrude’s Githogoro Outreach Clinic

Former Miss World Kenya, Idah Nguma, with Baby Beatrice Otieno Gati and her father Elvis Obuyu after a successful cleft-lip operation under the Smile Train program.

Fun

Doctors

Gertrude’s Children’s Hospital

Daniel Gai and Paul Kasili demonstrate first aid procedures to children during the World Day of Remembrance of Road Crash Victims.

Participants take part in a walk to commemorate the World Day of Remembrance of Road Crash Victims on 14th November 2015.

Dr. Njeri Karianjahi speaks to youth during the biannual youth seminar held in Muthaiga.

Christmas carols sang by St. Stephen Church Choir Jogoo Road mesmerized the children during the Children’s Christmas party.

and games complemented the singing and dancing during the Children’s Christmas party.

and nurses keenly follow a session during a Blood Transfusion training held at the hospital.

Children are served cake during the Children’s Christmas party held in Muthaiga.

Jubilee Christian Church Parklands dance team entertains during the Children’s Christmas party.

Something Good For The Youths

By Daniel Gai

Gertrude’s Children’s Hospital held the Biannual Youth Seminar on 3rd and 4th December 2015, at the training school. The seminar brings on board youths of various age groups from different institutions and backgrounds. The speakers included a team of paediatricians, clinical psychologists, addiction counsellors, adolescent health specialists and relationship experts.

The participants, aged between 13 and 21 years were educated on various topics that included:

• How far when it comes to relationships?

• Is there anything cool about abusing drugs as a youth?

• How to cope with stress in our Youth?

• When NO! means NO!

The youth were given a ‘secret box’ to place all manner of questions they wished discussed during the seminar. It emerged that there was a pressing need to talk about sexuality and sexual relationships during this period in their life and was thoroughly addressed by the facilitators.

Gertrude’s Children’s Hospital believes in

Some of the youth cheer after completing a group activity of cup balancing

abstinence among this age group and their main focus is helping the youths build high selfesteem to resist the peer pressure that emanates from the physical changes they undergo during this period. Psychological changes, secondary sexual changes and the irresistible socioemotional needs make the youths vulnerable to risky behaviours. Our experts, with the parents’ support, are dedicated to helping these youth transition smoothly into adulthood.

The next seminar is scheduled for April 7th and 8th 2016. For more information kindly visit our social media platforms below.

Gertrude’s Children’s Hospital

Gertrudes Hosts Nurses Working In International Schools In Kenya

Gertrude’s Children’s Hospital hosted a team of 30 nurses representing al]tleast 15 International Schools in the country. Through their association, INSET, the nurses usually come together to share their work experiences in their unique environment. There has been a long-standing partnership between hospital, the parents, pupils and teachers of these schools so the gatherings play a key role in the nurses’ professional development.

The December meeting was an eye opener towards disasters in schools. The program was run in two sessions. The first session was chaired by Mr. Job Kithinji, a Clinical psychologist and addiction counsellor with NACADA. He focused on the growing trend of drug abuse in this young population.

The second session was Co-Chaired by Dr. Dan Obat Alaro (paediatrician & member of the Kenya Paediatric Association as well as the course director of the newly introduced Paediatrics in Disasters course) together with Mr. Conrad Wanyama, an instructor in Emergency Medicine and Pre-Hospital Care at Kenya Red Cross.

This was mainly an interactive session where they both focused on the level of disaster response preparedness in the schools with the nurses giving feedback on the situation in their respective institutions.

Head of Nursing Services, Ms Emily Nguu leads the children to cut the Christmas cake during the children’s Christmas party.

On 18th December 2015, Gertrude’s Children’s Hospital held a Christmas party for the children in hospital and their parents. The event was held at the main hospital play ground. The children were treated to lots of fun

By Daniel Gai

Dr. Alaro and Mr. Wanyama pledged technical support in streamlining disaster plans in schools in the country.

The visiting nurses expressed their sincere appreciation to the Gertrude’s Children’s Hospital’s Staff for their hospitality and continued support in healthcare provision. They made special recognition of Sr. Carol Osundwa (OPD Manager, Muthaiga) for her commitment to their professional growth and development and for accepting to host them at Gertrude’s.

The meeting was formally closed at 2pm with Head of Nursing and Inpatient Services, Ms Emily Nguu, giving the final remarks on behalf of the Hospital.

Here Comes Santa Claus

like dancing, singing and games. The event is held annually and its purpose is to put a smiling face to the children and their parents.

With tools of simple material, such as play, songs, laughter, discussions, humanity, the hospital staff supported, strengthened and em powered the children themselves, as well as their parents. Santa Claus even made a trip to all the wards to surprise kids at the hospital. He helped employees hand out various gifts and the Christmas cake to the children who spent their Christmas in their hospital.

We try to give the children the message that the hospital could be a place of play, joy and crea tivity. The pleasant environment that drives out the tension and has a redemptive impact on the souls of the children, parents and the staff.

International School Nurses pose for a photo with Head of Nursing, Ms. Emily Nguu, hosted by Gertrude’s Children’s Hospital.

Anxiety Among Patients Undergoing Diagnostic Radiological Examination

By Jedidah Sakwa

Avisit to a hospital can be a stressful experience for patients and their care givers and can induce feelings of anxiety. Anxiety can be caused by a multitude of factors including; unfamiliar surroundings and noises, the feeling of loss of control, dependence on strangers who give various mandatory instructions and the perceived or actual risk of medical procedures.

Anxiety and panic attacks affects people in different ways. In most cases recorded they are characterized by short periods of intense fear and the rapid onset of symptoms which may include shortness of breath, nausea, hyperventilation, dizziness, palpitations and visual disturbances. Subjects often feel as though they are having a heart attack, are about to die or are losing their mind.

It is an incredibly frightening and upsetting experience. Anxiety can cause hyperactivity of the autonomic nervous system resulting in an abnormally rapid heart rate or difficult and even laboured breathing, digestive and psychic disorders. These symptoms may make patients less co-operative during their radiological examinations.

Anxiety issues affect both patients and also their medical providers and have an effect on the accuracy of diagnostic results. Some of the adverse effects of anxiety include unintended increase in severity of patient

distress symptoms and a compromise of the quality of diagnostic aspects of the imaging study. This may decrease the efficiency of the imaging facility due to delayed, cancelled or prematurely terminated examinations. Anxiety has a negative impact on treatment and recovery time following a procedure.

Anxiety interferes with the medical staff workflow by increasing medication need and procedure time and may compromise diagnostic quality (e.g. due to an increase in patient motion). This in turn raises the costs of managing radiology departments due to increased waiting times, high rates of film rejections and increased likelihood of the patients dishonouring their appointments.

Training medical team on how to better communicate with the patients can make a significant difference by diffusing tension early shape their expectations in a more helpful manner. Referring doctors need to provide patients with detailed information regarding their medical condition and the way the requested examination will be used to direct the medical management of the anomaly that may be revealed. Radiologists and radiographers need to explain to the patient the requested procedure and ensure their understanding and co-operation.

The first Adolescent Health Symposium was held on 27th - 28th October 2015 at the Hilton Hotel in Nairobi. The symposium was organized by the Ministry of Health and other partners focusing on adolescent health issues and recognized the need for improved efforts in addressing adolescent health issues.

It showcased the contributions of various stakeholders towards positive health and development outcomes during adolescent years. It also provided a platform for sharing innovations and strategies that are aimed at improving adolescent health.

Adolescent mental health is a grey area that needs more evidence-based research. The Sunshine Smiles team is set to conduct an assessment of mental health Status and its correlation to treatment outcomes. The study will be led by the psychosocial team in consultation with Dr. Stanley Ndwiga and Dr. Mbuthia.

There exists an information gap in Sexual and Reproductive Health matters among adolescents, hence the need for inclusion of tailored SRH sessions for adolescents. A Technical Working Group for the clinic was formulated after the symposium with a goal to implement weekly sessions by December 2015. These sessions are envisioned to take place during the adolescent clinic days.

Fare Thee Well Long Serving Staff

Gertrude’s Children’s Hospital bid farewell to four of their longest serving staff in an emotional cocktail held in October 23rd, 2015, at the Institute of Child Health and Research in Muthaiga. The staff were vital in the tremendous growth of the hospital and were commended by every speaker who stood to commemorate them. They served in different capacities and departments and in it was evident that their services would be admired even after their departure.

In his speech, the CEO, Mr. Gordon Odundo jogged their memories on how they would struggle to move from one step to another. He praised their passionate commitment in their work and went ahead to wish them the best in the new ventures.

Gertrude’s Children’s Hospital

HAPPY ENDING: Esther Muthee (centre), her friend and Catherine Gitonga (right) during the farewell cocktail.

A section of the Sunshine Smiles Clinic team together with Dr. Njeri during the Adolescent Health Symposium held at the Hilton Hotel Nairobi.

Thika Health And Beauty Fair Event

Gertrude’s Thika Clinic took part in a two- day event on health and beauty fair event that took place at Ananas Mall in Thika Town on 31st October and 1st November 2015. The volunteer staff offered free dental and BMI screening to at least 166 people, more so creating awareness on the availability of our services in Thika.

A Gertrude’s Thika clinic staff attends to a client who visited us during the beauty fair event in Thika

Citam Trade Fair

Gertrude’s Buru Buru Clinic participated in a Trade Fair organized by Christ is The Answer Ministries (CITAM), on Sunday 20th September 2015. The team offered free dental screening, blood sugar and Blood pressure to the people who visited our stand. They also interacted with other corporate who had stands and distributed fliers.

Gertrude’s Buru Buru staff attend to parents and children during the CITAM trade fair event.

Lavington United Church Golf Event

Gertrude’s Children’s Hospital joined Lavington United Church in a Fundraising Golf Event by giving health checks to the golfers and staff at Vet Lab. The golf event took place at Kabete Vet Lab Golf Course. Among the services offered included Body Mass Index (BMI), blood pressure, cholesterol and nutritional counselling.

Gertrude’s Lavington staff attending to the golf participants.

Nannies First Aid Training

Gertrude’s Lavington clinic held a First Aid Training for Nannies at the clinic’s grounds on 26th September 2015. A total of 31 Nannies and one parent were trained. The training sort to give nannies basic knowledge in paediatric care. The nannies said that they were happy to be called for this training stating that the skills they will help them greatly in taking care of the young ones under them.

A nanny demonstrates the first aid procedure as her collegues keenly watch.

Gertrude’s Children’s Hospital

Tonsillectomy In Children

A. What is tonsillectomy?

Tonsillectomy is the surgical removal of the tonsils. The tonsils are two small almond-shaped mounds of that sit on either side of the back of the throat. They are part of your body’s are only important years of life. Tonsils there will be no external (outside) cuts or scars.

This involves blood tests and general health checks. Blood grouping will also be done so as to have blood on standby for transfusion incase excessive bleeding occurs during the surgery.

Removal of the tonsils is usually recommended in cases

swollen tonsils that make it harder to breathe or swallow. It is also recommended when one has recurrent episodes of her normal school or work life. Removal of the tonsils improves the general health and greatly reduces further

is normal to spit small amounts of blood stained saliva. hospital.

ounts of red coloured saliva is swallowing.

Bleeding from the surgical site may also occur and but this risk is extremely small for tonsillectomy.

The hospital or the doctor should be contacted in case any of the following occurs:

•

•

Or the painkillers are not controlling the pain. One should see a doctor immediately in case there is problem one may be experiencing.

•