REPORT OF INTERNSHIP ACTIVITIES at Max Super Speciality Hospital

REPORT OF INTERNSHIP ACTIVITIES
at
Max Super Speciality Hospital, Dehradun
PRESENTED TO
Prof. VIDHYA S (SENSE)
Submitted by: Internship started on – June 1, 2016
Muskan Rathi (14BMD0011) Internship ended on – June 28, 2016
Date of submission – October 23, 2016
TABLE OF CONTENTS
ACKNOWLEDGEMENT……………………………………………..……..3
SCANNED COPY OF CERTIFICATE……..……………………………..…..4
INTRODUCTION……………………………………………………5
1.1 OF THE INSTITUTION………………………………………5
1.2 OF DIFFERENT DEPARTMENTS…………………………………7
1.3 OF BIOMEDICAL DEPARTMENT……………………………….9
TRAINING……………………………………………….……….…..11
2.1 REPORT ON TRAINING…………………….…………..…….11
2.2 LIST OF EQUIPMENTS…………………………………………………….11
2.3 DETAILS OF EQUIPMENT……………………………………………….12
CONCLUSION……………………………….…………………….…24
REFERENCES…………………………………………..…………….25
ACKNOWLEDGEMENT
I can’tpossibly thankeveryone whohas contributed to the completion of the internship. Every person who came across me during the internship period has played an important part.

I would like to thank Dr. S.Gunasekaran for writing letter of recommendation and guiding all through the pre internship phase. I would pay my special thanks to my internal guide Prof. Vidhya S who provided her continuous support throughout the internship phase and to the school office SENSE.

Mr. Piyush Chhabra Assistant Manager in Human Resources department of Max Super Speciality Hospital, Dehradun, HOD (Biomedical Department) Mr.Anil , Senior Biomedical Engineer Mr. Mayank Kumar and all other members of the biomedical staff. They have been with me from the very first day of internship, provided me the opportunity of working in the renowned hospital, and provided me all the resources.

Also, I am very much thankful to the whole staff of Max healthcare Dehradun.

SCANNED COPY OF CERTIFICATE

1. INTRODUCTION
1.1 INTRODUCTION OF THE INSTITUTION
1.1.1 History
Max India Limited was founded in 1985. The Institute is a wholly owned subsidiary company of Max India Limited. Max India Limited is a Public Limited company listed on the Bombay Stock Exchange and National Stock Exchange of India with more than 37,000 shareholders.

The first Max healthcare centre was opened as Max Multi Speciality Centre in Panchsheel Park, New Delhi with OPD facilities and day care surgeries in 2000. Dedicated to mother and child care, Max Hospital, Noida was opened in 2002 with services including non-invasive cardiology, orthopedics, ENT, ophthalmology, nephrology etc. Max Heart and Vascular Institute was established in 2004 with advanced cardiac life support and air evacuation service in Saket.
Max Hospital in Patparganj was founded in 2005. In the same year, Max Eye and Dental Care centre was opened at Panchsheel Park, New Delhi. Max Super Specialty Hospital in Saket was founded in 2006 and Max Hospital, Gurgaon was opened in 2007.

In July 2014 the company formed a joint venture with LIFE Healthcare Group, the second largest private hospital operator in South Africa, with the two groups each holding a 46.4% equity stake in the new venture to be known as Max India
1.1.2 General Information
With over 2600 beds and 13 top hospitals in Delhi-NCR, Punjab and Uttarakhand, 2300 world-class doctors, Max Healthcare is one of the leading chain of hospitals in India. With over 500 ICU beds, the most advanced technology and state-of-the-art infrastructure, Max Healthcare is one of the best hospitals in India.
Headquarters: New DelhiCEO: Mr.Rajit MehtaChief information officer: Mr.Sumit PuriFounder: Mr. Analjit SinghManaging director: Rajit MehtaWebsite – www.maxhealthcare.in1.1.3 Branches
Max Super Speciality Hospital, SaketMax Multi Speciality Hospital, Greater NoidaMax Institute of Cancer Care, Lajpat Nagar
Max Super Speciality Hospital, Patparganj
Max Hospital, PitampuraMax Multi Speciality Hospital, NoidaMax Multi Speciality Centre, Panchsheel ParkMax Hospital, GurgaonMax Super Speciality Hospital, Shalimar Bagh, DelhiMax Super Speciality Hospital, Vaishali, Ghaziabad
Max Super Speciality Hospital, Mohali, Punjab
Max Super Speciality Hospital, Bathinda, Punjab
Max Super Specialty Hospital, Dehradun, Uttarakhand
1.1.4 Contact Details
Mr. Piyush Chhabra Assistant Manager – Human Resources
Max Super Speciality Hospital, Dehradun
Malsi, Mussoorie Diversion Road,
Dehradun – 248001
+91-9582623973
0135-6673879
www.maxhealthcare.in1.2 INTRODUCTION TO VARIOUS DEPARTMENTS
1.2.1 ICUs – Intensive Care Units
Following are the different types of ICUs that are functional in MAX hospital-
NICU – Neonatal ICU
CTVSICU – Cardiac Thoracic Ventricular System ICU
NSICU – Neuro Surgery ICU
MICU – Medical ICU
Post Operative ICU
The ICUs provide constant, close monitoring and support from specialist equipments and medications in order to ensure normal bodily functions. They are staffed by highly trained doctors and nurses who specialise in caring for critically ill patients.

All the ICUs are well equipped with the advanced instruments. Like NICU has Perfusor compact / Syringe Pump of Smiths medical, Cardiac monitor of Goldway, Radiant warmer. CTVS ICU has monitor of Edvard life sciences – vigilance II, Cardiac monitor of Philips, Ventilators of MAQUET. MICU has nebulisation machine, clear cuff pressure infusor, mattress pump.

1.2.2 RADIOLOGY
Radiology is a medical speciality that uses imaging to diagnose and treat diseases seen within the body. Variety of imaging techniques that are available in the hospital are-
MRI- Magnetic Resonance Imaging
X-ray
CT – Computed Tomography
Fluoroscopy
Endoscopy
Cath lab and nuclear medicine department (Gamma Camera) also uses radiations to detect the diseases.

1.2.3 NEPHROLOGY AND UROLOGY
The hospital has a separate dialysis unit where 10 dialysis can be carried out simultaneously. The dialysis unit is equipped with dialysis machine of Fresenius Medical care and dialyzers that can be reused. For kidney transplantation, there is a team of highly qualified doctors. MAX department of kidney transplant strives to provide the patients with expert treatment and care by merging two dialytic therapies to provide better kidney care. The department takes care of prostatitis, hematuria, over reactive bladder, kidney stones etc.

1.2.4 CARDIOLOGY
The cardiology department carries out in – depth investigation of the patient condition taking into account patient’s complete medical history, therefore have a tailored treatment and cost effective plan for each. There are advance ECG machines to record the electrical activity of heart, Treadmill test, and Holter test is also available 24 hours. The department takes care of arrhythmia, heart attack, cholesterol, diabetes, heart failure, hypertension and all the ailments related to the heart.

1.2.5 NEUROSCIENCES
Equipped with high-tech neurophysiology laboratory and a team of amazingly insightful and skilled surgeons, doctors and support staff, the institute gives through diagnosis, research, and treatment in all major disciplines of neurosciences/neurosurgery. The department takes are of brain tumor, stroke, epilepsy, multiple sclerosis, Parkinson disease and all other disorders related to neurons.

1.2.6 OTHERS
The other specialities include weight loss surgery, laparoscopic surgery, cancer care surgery and treatment, orthopaedics, aesthetic and reconstructive surgery, bone marrow transplant. Dental care, dermatology, ENT, eye care, gastroenterology, general surgery, IVF, gynaecology, physiotherapy, paediatric, laboratory, blood bank.

1.3 INTRODUCTION TO THE BIOMEDICAL DEPARTMENT
1.3.1TYPES OF EQUIPMENT
Diagnostic equipment includes medical imaging machines, used to aid in diagnosis. Examples are an ultrasound and MRI machines, PET and CT scanners, and x-ray machines.
Treatment equipment includes infusion pumps, medical lasers and LASIK surgical machines.
Life support equipment is used to maintain a patient’s bodily function. This includes medical ventilators, anaesthetic machines, heart-lung machines, ECMO, and dialysis machines.
Medical monitors allow medical staff to measure a patient’s medical state. Monitors may measure patient vital signs and other parameters including ECG, EEG, and blood pressure.
Medical laboratory equipment automates or helps analyse blood, urine, genes, and dissolved gases in the blood.

1.3.2 MAINTAINANCE OF THE RECORD OF EQUIPMENTS AND BREAKDOWN
TRACKER
The record of all the medical equipments in the hospital is kept in separate files for each. That includes history sheet which has information about name of equipment, asset code, name of company/supplier, location, frequency of calibration, model, date of installation, serial no., warranty expiry date. The file also includes maintainance record that has information about the date of complaint, date when the issue is resolved, breakdown time, fault, action taken.

Analysis of the equipment is done on the regular basis and a chit is placed on the equipment displaying the last analysis date and the upcoming analysis date. If a equipment gets damaged than the engineer first checks whether the equipment is under warranty, if it is than the biomedical staff calls the engineer from the company and the enginner comes and repairs the instrument. If the device is not in the warranty period than only the biomedical enginner appointed by the hospital take over the instument.

For any breakdown the biomedical enginner need to prepare a breakdown racker in Excel. This breakdown tracker sheet includes- complain no., date on which complain is registered, name of the department that registered complain, name of the equipment, company of the equipment, attended by, asset code, type of complain, complain details, log time, attended time, closure time, corrective action details, part name (if any), cost involvve, whether internal assistance or external assistance is needed, resolution time, down time, service time, resolving date and remarks.

1.3.3 TYPES AND APPROACHES TO MAINTENANCE OF MEDICAL EQUIPMENT
There are two types of maintenance:
Corrective Maintenance (or Repair) – This is done to take corrective action in the event of a breakdown of the equipment. The equipment is returned repaired and calibrated.
Planned (or Scheduled) Preventive Maintenance – This work is done in a planned way before repair is required and the scheduled time for the work circulated well in advance. It involves cleaning, regular function / safety tests and makes sure that any problems are picked up while they are still small.
The choice of approach for Preventive and Corrective Maintenance depends on the complexity of equipment
Maintenance by in-house trained technicians – The majority of the problems are relatively simple and can be corrected by a trained technician. Simple repairs and inspections are less costly when done this way. Workshop requirements for in-house medical equipment maintenance are described in references in chapter 11. Vendors should provide training to in-house technicians at the time of installation and commissioning.
Maintenance by manufacturer or third party – For specialized and advanced equipment, the vendor should provide maintenance services through a combination of on-call services and a maintenance contract negotiated at the time of the purchase. It will rarely be economical to provide this level of service in-house.
1.3.4 PRECAUTIONS THAT NEED TO BE TAKEN WHILE REPAIRING A EQUIPMENT
Unplug the appliance under repair: You must unplug the appliance under repair before you disassemble any electronic device. Turning off the source of ac line voltage is not enough.

Work dry: It is dangerous to work with wet hands or clothing. Ensure that you do not work in wet or moist environment. Remember that life has no duplicate.

Replace the entire power supply unit with similar type: It is absolutely safer for you if the power supply unit can be totally replaced as in the case of computer system. Go ahead and replace it with a new power supply unit of similar power rating.

Always wear insulator in your hands: It is a good idea to wear rubber gloves while carrying out repairs on electronic devices. Rubber glove is an insulator that will prevent shock.

Do not work with any metallic jewellery: Under no reason should you work on electronic device with your metallic jewelleries on your hand. Jewelleries are metallic in nature and hence good conductor of electricity.
2. TRAINING
2.1 REPORT ON TRAINING
The internship training was done for a period of 28 days from July 1, 2016 to July 28, 2016 in MAX healthcare hospital Dehradun, under the guidance of HOD of biomedical department Mr. Anil. The working hours were from 9:30 AM to 5:30 PM.

Starting from the working of the Gas manifold plant they showed and explained me the functioning of almost all the equipments available there.

2.2 LIST OF EQUIPMENTS STUDIED
Syringe pump – Smiths Medical Graseby TM 2000
Monitors – Philips Intellivue (MP20)
Ventilator – Maquet Getinge group
Haemodialysis machine – Fresinus Medical Care 4008s
Anaesthesia machine – Drager Fabius Plus
MRI patient monitor – Invivo
Platelet agitator – Helmer
Ultrasound machine – Philips HD7
Radiant Warmer
Defibrilator – Philips
ECG machine – Philips Page writer20
Study of Gas Manifold Plant
Nebulisation machine- Nuneb Pro piston type
Bipap A40 – Philips Respironics
Mattress pump – Arjohuntleigh Alpha Trancell Deluxe
Autoclave and sterilizers
2.3 DETAILS OF EQUIPMENTS
2.3.1 ANAESTHESIA MACHINE
Table 2.1 Troubleshooting Anaesthesia Machines
FAULT POSSIBLE CAUSE SOLUTION
Equipment is not running No power at mains socket
Electrical cable fault Check power switch is on. Replace fuse with correct voltage and current rating if blown. Check mains power is present at socket using equipment known to be working. Contact electrician for rewiring if power not present
Refer to electrician for repair
No gas output No O2 pressure in cylinder / gas supply.
Check pressure gauges for gas pressure (about 4 bar or 4 kg/cm2) Restore gas supply or replace gas cylinders.
Replace O2 cylinder and/or N2O cylinder in case of low pressure
O2 failure alarm not working
Alarm battery is low.
Alarm device is not working Call biomedical technician to fix the problem
Machine has leaks Poor seal (commonly occurring around tubing connections, flow valves and O2 / N2O yokes)
Cylinders not seated in yokes properly Clean leaking seal or gasket, replace if broken. If leaks remain, call technician for repair.
Refit cylinders in yokes and retest. If leaks remain, call technician for repair.
Flowmeter fault Over tightening of the needle valve or sticking of the float / ball Refer to biomedical technician
Electrical shocks Wiring fault Refer to electrician immediately

Fig.1 Anaesthesia machine
Table 2.2 User maintenance checklist for Anaesthesia Machines – Daily
Cleaning Remove any dust / dirt with dry cloth
Remove water and waste matter from inside
Audio-Visual checks If any leak is audible, check with soapy solution
Check all seals, connectors, adapters and parts are tight
Check all moving parts move freely, all holes are unblocked
Function checks Report any faults to technician immediately
After use, depressurize system and replace all caps / covers
2.3.2 GAS MANIFOLD PLANT
Liquid medical oxygen
Company – Inox air product limited
MAWP 15kg/cm^2
License should be taken plus SRV tests need to be done on the regular basis. Two meters are mounted on the tank one is for measuring the amount of oxygen in mmwp or in litre and other is for measuring the oxygen pressure in kg/cm^2. In this the pressure displayed was 10kg/cm^2.

The tank is manufactured by Inox india limited vadodra in technical colabration with NIPPON SASO corporation Japan .

The following information is displayed on the tank.

Equipment name – LIN/LOX cold convertor
Model no. – V-0515
Capacity – 5040l
Total weight empty – 1350kg
Job no. – 936011
Year of manufacturing – 1994
Design manufacturing code – ASME SEC VIII DIV 11992
Operating fluid – oxygen
Maximum working Pressure – 15.0 kg/cm^2
Design pressure – 16.5 kg/cm^2
Operating temperature – (-) 196?C
Air test pressure – 16.5 kgcm^2
To pass the gas to the required area from the plant a pressure of 4 kg/cm^2 is required.

Liquid medical oxygen tank is the first and the economical option for supplying medical oxygen in the hospital to the patient. In case there is some problem in the tank and is not able to supply oxygen tank. An oxygen control panel is used in this system, the control panel measures the right bank pressure, left bank pressure and line pressure in kg/cm^2. All 3 meters shows use no oil indication. In case this system also fails oxygen cylinders are used directly called emergency oxygen. This is used for patients requiring supplemental oxygen via mask.

ii. Nitrous oxide – 2 sources
Left and right nitrous oxide( N?0) bank. A nitrous oxide control panel is there having 3 meters measuring pressure of nitrous oxide and measures pressure gauge in kg/cm^2. In case the system fails cylinders of nitrous oxide are used, labelled as nitrous oxide emergency. Cylinders of bharat oxygen traders are used in the hospital.

This gas is supplied to surgical suites for its anaesthetic functions during pre operative procedure.

iii.carbondioxide supply – 2 sources
Left bank, right bank and CO? emergency cylinders are used. CO? control panel is there which has 3 meters for measuring the pressure of CO? in kg/cm^2. ‘Use no oil’ indication is there in two meters. A pressure of 4 kg/cm^2 is required for supplying the CO? to the required area in the hospital from the gas plant.

This gas is used for insufflation during surgery, and also used in laser surgery, also used for certain respiratory disorders. Insufflation is the act of blowing something such as a gas, powder, or vapour into body cavity. Used as a route of administration for various drugs.

iv. vacuum pump and air compressor
two vacuum pumps and two air compressors are used in the gas plant, only one works other is used in case the first one fails. Medical vacuum supports suction equipment and evacuation procedure supplied by vacuum pump system exhausting to the atmosphere.
v. air tank and vacuum tank
An air tank and a vacuum tank is there both have meters for measuring the air and vacuum pressure.

Air tank is used for the temporary storage of compressed air, allows the system to perform more efficiently, because of the immense pressure they contain.

vi. air dryer
An air dryer is used of trident company (dryspell).

vii. air filters
Air filters are also used of trident company (clean sweep).Model is G 100P, element type is G100P, maximum pressure is 16 bar and maximum temperature is 80?C.there is a filter in this and a meter is there which shows the condition of the filter whether it is clean (green), or we need to change it (yellow) or it is dirty (red).

fig.3 Air dryer fig.4 air filters
viii. AGSS pump – Anaesthetic Gas Scavenging System
It is used to remove anaesthetic gases directly from the patient connection of anaesthetic machine by means of air mixer, AGS outlet pipeline and AGS exhauster to provide clean and an environment free from anaesthetic gases.

Anaesthetic gases- nitrous oxide, xenon
ix.PRV Station – Pressure Reducing Valve Station
A PRV station is there for supplying medical air which is supplied in most of the part of the hospital wherever required. The required pressure is 4 bar. Medical air is compressed air supplied by a special air compressor through a air dryer and distributed to patient care areas .Some patients have extremely delicate respiratory system which rely on pure and accurate concentration of medical air ex. neonates, patients with adult respiratory depression syndrome.

This air is manufactured as required using compressor. It is used in driving ventilators and incubators where it provides uncontaminated ad controlled air flow helping to reduce high concentration of oxygen exposure, as a carrier gas for anaesthetic agents. Many patients are sensitive to oxygen toxicity, for such patients medical air is supplied to reduce oxygen exposure.

It also supplies surgical air. The required pressure is 7 bar. This air is supplied to operation theatres only, used in driving pneumatic tools in OT.

x. total of 7 pipes are passed on to the hospital building.
Pipe colour coding
i) oxygen supply
ii) nitrous oxide supply

iii) medical air supply

iv) surgical air supply

v) Vacuum

vi) Carbondioxide supply
vii) This one is connected to the AGSS
pump

Light yellow

fig.5 pipeline in gas manifold plant fig.6 Medical oxygen tank
2.3.3 ECG MACHINE
Table 2.3Troubleshooting ECG Machines
FAULT POSSIBLE CAUSE SOLUTION
ECG traces have artifacts or base line drift Improper grounding Try with battery power only. If the recording improves then problem is with grounding. Check the grounding
Power the machine from another outlet with proper electrical ground
ECG traces have artefacts in one or more traces, but not in all traces Improper electrode connection with patient or problem with the ECG cable Check the patient cable continuity with continuity tester. Replace cable if found faulty
Check the electrodes expiration date
Check patient skin preparation
Check limb electrodes and chest electrodes for damage, replace if necessary
Paper feed not advancing Incorrect paper loading Use instructions to reload paper
Printing not clear or not uniform Printing head problem Adjust the printing head temperature or position
Clean the printing head with head cleaner. If no improvement, replace the printing head.
Check the paper roller and replace if not smooth
The machine shuts down after a few minutes while on battery power. Problem with battery or charging circuit Recharge the unit overnight
If there is no improvement then replace the battery
If still no improvement, refer to technician
Fig.7 ECG machine

User Maintenance Checklist ECG Machines – Daily
Cleaning – Clean off dust with dry cloth and replace dust cover
Visual check – Check that battery charge indicator, power indicator and patient cable connector indicators are working
Function checks – Check the calibration of machine before use using 1mV pulse
Check the baseline of the ECG recording is steady
Check the printing is clear
2.3.4 DEFIBRILATOR
AED OPERATION
If rhythm monitoring active
If needed press pause and begin CPR
Press shock
If no shock advised check patient
If shock advised
If patient is
Unresponsive
Not breathing
Pulse less
Connect pads patient cable
Apply pads
Insert data card (optional)
Turn energy select to AED on

Press analyse

If shock series is set to greater than one

Manual operation preparation
Insert data card (optional)
Turn energy select knob to MANUAL ON
Using paddles
Apply conductive matter
Apply paddles to patient’s chest, using anterior apex placement
Using pads
Apply pads as directd by packaging instructions
Connect the pads to the pads patient cable
1
DEFIBRILLATION
SELECT ENERGY
Move the energy select knob to the desired level
2

CHARGE
Press charge or yellow charge button on apex paddle
3
SHOCK
Press shock. If using external paddles, or switched internal paddles, simultaneously press shock buttons on pad. To disarm press disarm

fig.8 pads used in defibrillator
PACING
Select manual on
Apply pads and electrodes
Press pacer
-adjust rate
– press start

fig. 9 Defibrillator
– adjust output if needed
ECG MONITORING
Apply monitoring electrodes
Select lead (optional)
Press lead select to choose desired lead
Set HR alarm optional
Press HR alarm to set alarm limits
To disable alarm press HR alarm
2.3.5 ULTRASOUND MACHINE
Table 2.4 Troubleshooting – Ultrasound Machine
FAULT POSSIBLE CAUSE SOLUTION
Equipment is not running No power from mains socket
Electrical cable fault Check power switch is on. Replace fuse with correct voltage and current if blown. Check mains power is present at socket using equipment known to be working. Contact electrician for rewiring if power not present.
Try cable on another piece of equipment. Contact electrician for repair if required
Fuse keeps blowing Power supply or cable fault Refer to electrician
Probe head damaged or noisy Possible internal fault Exchange probe Send for testing and repair
Image quality poor Gel insufficient
Controls set incorrectly
Mains voltage is too low
Probe / display problem Use more ultrasound gel
Check controls for correct positioning and operation (refer to user manual)
Use voltage stabiliser
Refer to biomedical technician
Display / computer error Software fault Turn machine off and restart. If problem persists, refer to biomedical technician
Electrical shocks Wiring fault Refer to electrician
User Maintenance Checklist Ultrasound machines – Daily
Cleaning – Wipe dust off exterior and cover equipment after checks
Remove any tape, paper or foreign body from equipment
Wipe probe with alcohol-free tissue or cloth
Visual checks – Check all fittings and accessories are mounted correctly, check cables are not twisted and probe is safely stored
Function checks – If in use that day, run a brief function check before clinic

Fig. 10 ultrasound machine
CONCLUSION
Through this internship I got the real time idea about how my branch of engineering is applicable in practical world. I understood for what a biomedical engineer is appointed in a hospital and the importance of a biomedical engineer in the hospital. A biomedical engineer reduces the down time of the equipment and saves money and time of the hospital. In case of emergency if the critical instruments like ventilator and defibrillator breaks down than only the biomedical engineer comes to rescue and helps in saving the patient’s life.

The role of a biomedical engineer is very critical in a hospital. He/ she Install, adjust, maintain, repair, or provide technical support for biomedical equipment. Evaluate the safety and efficiency and effectiveness of biomedical equipment and also prevents damage.

REFERENCES
http://www.maxhealthcare.in/our-specialitieshttps://en.wikipedia.org/wiki/Max_Healthcarehttps://www.google.co.in/?gfe_rd=cr&ei=HaELWLaWMYHy8Afu0Y_ICg&gws_rd=ssl#q=max+healthcare