När Fikru Maru inte fick föra in den medicinska utrustning svenska sjukhus skänkt, eftersom han saknade kvitton och tullen överskattade värdet grovt, tänkte han ta med den hem igen. Han betalade 5% av värdet i någon form av tull. (Ja, man måste göra det fastän man tar hem grejerna, glöm logiken – det blir bara förvirrat om man tänker rationellt.) När han skulle checka in måste han betala för övervikten på bagaget. De tog inte emot kreditkort och han hade inte tillräckligt med kontanter. Han hade inte så mycket tid, utan bad en flygplatsanställd gå ut med grejerna till tullen igen, medan han gick på planet. Efter en stund blev han hämtad av polis. Det är bakgrunden till hans åtal för smuggling. Det är förstås absurt och när han talade med sin vän hälsoministern kontaktade denne tullministern och förklarade omständigheterna. Tullministern kontaktade i sun tur åklagaren som la ned ärendet. Det är i väntan på rättegång för det ”korruptionsbrottet” som Fikru suttit fängslad i 3,5 år.
Här är sammanfattningen från åtalet, som en lokalanställd på Sveriges ambassad i Addis Abeba författat:
När svenska media skriver att Fikru gripits för att han varit inblandad i en stor korruptionshärva, men att det mesta av misstankarna avskrivits är det på gränsen till förtal, enligt min åsikt.
Så skriver en thoraxkirurg när jag förklarar vilken vård Fikru får i Etiopien. Det knyter sig i bröstet när jag tänker på Fikrus varma leende, som jag har färskt på näthinnan. Han verkade inte ett dugg döende när jag såg honom för exakt ett dygn sedan.
Jag förstår att det är förvirrande. Hade jag träffat Fikru på akuten i Sverige hade jag inte varit särskilt oroad. Hans tillstånd är inte livshotande i Sverige där det finns god vård. Men han sitter fast i Etiopien, inlagd på ett sjukhus där det ibland inte finns rinnande vatten och där operationssalen bara kan klara mindre kirurgi. Hans etiopiska läkare gör allt vad de kan för honom, men det räcker inte för att rädda hans liv.
Domstolen skulle ha förkunnat dom i fredags, men de domare som tjänstgjorde fick ärendet i handen samma dag. Därför har de skjutit upp det till måndag. Eller, rättare sagt, de ska FÖRSÖKA lämna besked på måndag. På tisdag är det stor helgdag. Att något skulle hända före onsdag är osannolikt. De har också framfört det som ett alternativ att vänta tills domstolen öppnar officiellt 6 oktober, efter sommarstängningen. Ur ett medicinskt perspektiv är det inte att tänka på, men Fikrus hälsa är inte domstolens högsta prioritet.
Det finns ingen logik i det här, inga rationella beslut, inget att förstå. Allt är ett politiskt spel där ingen domare vill vara den som fattar ett beslut som senare kan få politiska konsekvenser. De måste få instruktioner från högsta instans att avsluta fallet. Från premiärministern och justitieministern (som också har titeln riksåklagare, hur absurt det än låter). Det innebär att vår regering måste kontakta deras. Och det kan inte vänta. För då dör Fikru. I Etiopien spelar det ingen roll. Där är inte ett människoliv värt någonting. Hur är det i Sverige?
Efter att ha lämnat frukost till Fikru på sjukhuset åker vi till domstolen. Vi kommer en stund efter att förhandlingarna skulle ha börjat kl 8.30, men ändå är vi först. Successivt droppar folk in. Komera, lokalanställd på Reuters som frilansar åt SVT, är den enda journalisten. De enda svenska journalister som varit här är Emanuel Sidea för Veckans affärer 2013 och Peter Alestig för Svenska Dagbladet i maj 2016. Emy berättar att Komera gjorde många reportage kring Johan Persson och Martin Schibbye när de satt fast i Etiopien. Jag undrar om det var journalister från Sverige här då också? – Jovisst, många olika team från olika bolag.
Den svenske ambassadören ansluter och vi står och pratar i solen om hur Fikru ska kunna evakueras. I nuläget ser det ut som att han skulle kunna flyga reguljärt tillsammans med en specialistläkare. Strax därefter kommer Fikrus etiopiske advokat, som går in i domstolsbyggnaden för att höra när det är dags för Fikrus fall. Han kommer tillbaka med beskedet att jourdomstolen inte kan fatta något beslut eftersom de precis fått ärendet i sin hand. En kafkainspirerad fars följer där vår lilla grupp villar runt inne i domstolen efter närmare besked. Jag försöker att inte vara i vägen, men ändå vara närvarande. Vid ett ögonblick befinner vi oss i en liten klunga mitt på golvet framför alla åhörare i rättegångssalen, där andra ärenden pågår. Hur hamnade vi där? Domaren sitter visst i ett litet rum bredvid och vi tränger oss in där. Två kvinnor jag inte känner igen står framför oss och pratar med en man bakom ett skrivbord till höger. Innan de har talat färdigt börjar Fikrus advokat att prata med mannen bakom skrivbordet till vänster. Man ska visst hålla ett respektfullt avstånd på minst två meter, så alla tränger ihop sig eftersom samtalstonen är så lågmäld att jag nog inte skulle förstått ens om det varit på engelska.
Domaren förklarar att han förstås inte kan fatta något beslut eftersom han inte haft tid att sätta sig in i ärendet. Varför har inte domarna vid förra tillfället i tisdags gjort det, undrar han. De var ju väl insatta i fallet? Det här kanske är så komplicerat att det måste vänta tills den ordinarie domstolen öppnar efter sommarstängningen? Han lovar i alla fall att försöka, med betoning på försöka, att få allting färdigt till på måndag så att det kan komma ett besked då.
De journalister från olika svenska media som har kontaktat Emy tvekar. Om Fikru inte släpps fri finns det väl inget att rapportera om? Att domstolen skjuter upp beslutet är ju ingen nyhet. Hon svarar tålmodigt på frågorna och jag beundrar hennes lugn. Själv har jag lust att skrika att om medierna hade valt att följa Fikrus fall hade det varit en riksangelägenhet och de hade varit här på plats. Då hade de själva kunnat rapportera om det absurda i den här processen i stället för att referera till uttalanden från Fikrus advokat. De hade kunnat intervjua Fikrus behandlande läkare i stället för att citera en läkare i Göteborg som bedömer tillståndet som livshotande. Och de hade kunnat publicera det intetsägande åtalet, i stället att skriva att Fikrus familj hävdar att han är oskyldig.
At the end of our Swedish emergency medicine conference in March 2015 I decided to give a short closing talk. The idea came up in the lunch break before it was about to happen. I put some photos from the conference together and gave a ten minute talk about the future of EM in Sweden, in English. It was one of my better talks ever. I was so sleep deprived and stressed out after organizing the conference, I could barely stand on my feet, yet the talk was passionate and more coherent than most sentences I had spoken during the days of the conference.
I drew the wrong conclusion from this experience: That I could deliver talks in English as well as I can in Swedish, and that improvising only gives it a better touch.
What I should’ve learned is that passion is my strength and that when the topic is close to my heart and I speak to an audience that is friendly and willing to accept my message, speaking English is no obstacle.
In October 2015 I gave a talk on EM education in Sweden at the EuSEM meeting. It was in one of the smaller rooms and the microphone was stuck to the podium. It made it more difficult to connect to the audience, but gave the security of having the presenter’s view on the computer in front of me. It was an ok talk.
What I learned: Speaking about ”How it is in my context” is the most difficult type of topic. There can be no take home message and there is no learning objective. You have to go for a storytelling approach, but it is easy to get caught up with explaining the context and the background. It also made me realize that speakers from the US and the UK never get invited to speak about how it is in their countries, but how it is in a universal perspective (and often also how it should be everywhere else).
Shortly after the EuSEM conference I gave a talk about ethical issues in Emergency medicine for the Swedish Society of medicine. I had received the invitation to speak only two weeks in advance and was quite busy preparing my other talks, but could easily put together some rather good looking slides and delivered a passionate talk that was very well received.
What I learned: People like to hear talks that confirm their beliefs, even if it doesn’t add any new information. Once again, passion is the most important ingredient in a motivational talk.
In November 2015 I had been invited to give a talk at the first meeting of the Serbian EM society. I travelled there on the day before the conference and had the opportunity to meet and get to know the wonderful people who are struggling to introduce the inhospital specialty of emergency medicine into their system. Meeting them and watching some of the talks at the conference made me change my talk quite a lot. I managed to speak about how we have worked on developing EM in Sweden with clear references to what was going on in Serbia. Since the other talks had very conventional slides, I was a bit worried mine wouldn’t go down well, but they did and my talk was a success.
What I learned: The feeling that you are talking to and encouraging your friends is very comforting. And when you feel comfortable it isn’t that difficult to make last minute changes to rearrange your talk.
Only a week later I went to Leeds, UK, to give a talk at their Leadership meeting. The topic was about Leading change in Sweden. I could have given the same talk as in Serbia and gotten away with it. And I used many of the same slides. But I wanted to convey a completely different message. I believe that we as emergency physician are part of an imperfect health care and welfare system, where all failures of other parts of the system will end up in the ED. I truly don’t support the idea that spending more money on emergency medicine is the solution to that problem. Judging from all other talks at the conference I was the only one with this opinion. And I tried to include that message in my talk. I thought I had learned from the conference in Serbia that last minute changes wouldn’t be a big problem.
The conditions for my talk were terrible. I was up too late the evening before, but still woke up early and couldn’t go back to sleep. I had come down with a cold and had a running nose and a heavy head. I wanted to upload my presentation during the coffee break, but the lectures didn’t finish on time and I started to worry that there wouldn’t be a coffee break before my talk. Just as we were about to start I was told that the last speaker wasn’t coming, so I needn’t worry about time, which made me speak more freely and add things I had taken out. The speaker before me said some things that upset me. I always feel uncomfortable when management people start to talk about their leadership and now the whole audience was full of them. So I gave my talk and it was the worst delivery of a talk I had done since grade 8 in primary school. It came as a total surprise and quite a disappointment to me that I could be that bad at public speaking.
What I learned: Don’t try to include a controversial message in your talk if that isn’t the main purpose of your talk and you have built your talk around it. Stick to the topic that people expect you to talk about and if you think that there is a risk that you can’t give a high class delivery – go for a safe delivery of good enough.
Then came the invitation to be a backup speaker at ICEM. Some speakers had cancelled and I was offered to choose between ortho or surgery. I thought I could talk about hip fractures, since we have special fast tracks for them in Sweden. ICEM was only a few weeks after our national conference which is a cognitive melt down for me. And since I had not at all studied the literature on hip fractures I had quite a lot of reading to do. Since I knew I was going to present at SMACC I took this as an opportunity to practice and decided to speak without any slides. We arrived in Cape Town a few days early and I assumed that I would have some time to go through my talk, but the wifi was so slow that I spent most of my time trying to get online. I still had a fairly good manuscript and decided to take a written version as back up. But I had the feeling that I hadn’t prepared properly. And just as I was supposed to get up, my mouth got all dry. That had never happened to me before. I didn’t feel very nervous, I don’t even think I had palpitations, it’s just that it suddenly got very difficult to speak. And there was nothing I could do about it. I managed to get through my talk. It wasn’t great, but it was ok.
What I learned: Confidence is key. The feeling of not knowing your material well enough will mess up your talk. Expect the unexpected and plan for disaster. Control the environment. What if the projector shuts down? What if the speaker before you puts everyone to tears through their amazing talk.
Wise from the experience, I thought, my conclusion was that I would have to know exactly what to say for my SMACC talk. This was the talk where you had to get everything right. I was going to prepare so well. My topic was Biomarkers and I wanted to make it about how we as clinicians deal with uncertainty and how lab values affect our decision making. I started reading books about the psychology behind decision making and I searched for literature on biomarkers. I realized there were several angles to this topic and when I found that many studies on biomarkers are authored by scientists who own the patents, my talk took another turn. After hours of research I had a content that I was very happy with and a presentation that would tell the story, but which contained many quotes and facts that had to be presented correctly and in the right order. To make sure I got everything right I wrote down the manuscript word for word, which I usually don’t do. Every time I went through it I thought about changes, but decided to not make any last minute additions, an urge that was quite difficult to resist.
So came the time to deliver my presentation. Scott Weingart went before me and during his talk it occurred to me that I had forgotten most of what I was going to say. I got started anyway, but suddenly realized that I wasn’t able to see the upcoming slide on the projector, which I always do when I use my own computer. It made me lose myself totally and I had to start over. All of a sudden there was nothing fun about presenting at SMACC, but I managed to get through my talk. Great content delivered with total lack of confidence and finesse.
What I learned: I hadn’t learned the previous lessons well enough. When delivering under high stress conditions the story that sounds great when you practice on your own is not going to come out that way. For a talk that doesn’t follow a timeline you can squeeze in important parts anywhere, but if things need to be said in a certain order, it is better to set up the slides so they give you the important cues. It doesn’t mean you have to write bullet points, but a certain picture or symbol can give your overloaded brain the signals to keep you on track. Passion will not get you out of the situation where you have forgotten what to say, neither is it an important part of a talk that is more factual than motivational.
I also learned that speaking in English is an important obstacle to me. From my previous experiences of speaking English in Sweden or Serbia, I thought it wasn’t, but looking back at my other international talks I understand it is. My speaking skills in English are what my Swedish skills were several years ago. In Swedish I can cover up the mishaps. In English they knock me off my feet. I think that means that I need different strategies for preparing talks in English and Swedish. So I thank SMACC for letting me learn that lesson. That embarrassment is temporary and failing is the best way to learn, I learned already in grade 8, as anyone who read my lesson learned based CV knows.
I keep hearing that best care in rich countries is not the best solution for developing countries, but I struggle to figure out what it means. Because I strongly believe that best care is always defined by the patient’s need and the available resources, regardless of where you are.
It was only when I met emergency physicians from Angola that I learned that patients with tetanus can be better off with very little sedation, so that they can take a few breaths themselves if a power cut makes all the ventilators shut down. Many patients would have died had they been subjected to ”best care” in a setting where ventilators have safe backups.
But best care in Sweden is also provider dependent. A patient in cardiac arrest will get intubated if there is an anesthesiologist or an anesthetist nurse around, but ventilated through an LMA if cared for by a prehospital nurse practitioner. A patient with a STEMI will go straight to the cath lab in most parts of the country, but given thrombolytics in others. It is all best care. The problem is when experts familiar with only the university hospital setting, write guidelines to be applied throughout the country.
Modern medicine is about calculating risks, benefits and costs; for the individual patient and for the health care system. The fact that we have good adherence to warfarin treatment in Sweden and readily available PCC, makes me draw the conclusion that many patients with atrial fibrillation should be on warfarin. In a setting where patient compliance is low, NOACs may be a better option. In a setting where it is very difficult to monitor INR and blood products are hard to get, most patients are probably better off with no treatment at all. This is best practice whether you are in a rich country or in a poor country. It is also the reason why knowing your setting is crucial when deciding on your treatment protocols.
It surprises me when some experts from rich countries fail to understand that their practice is not applicable to developing countries, but needs to be adapted. Without clinical experience from other settings it is however understandable. What I can’t comprehend is why providers in developing countries think that outsiders could do their job better than them. That must be a question of confidence. Maybe that is where they have the most to learn from the visiting experts.
The case of Dr Fikru Mary, the Swedish cardiologist detained in an Ethiopian prison since 2013 I’ve written about before, has taken an unexpected turn.
On Friday Fikru developed a spontaneous pneumothorax and was taken to hospital. On Saturday protests in the Qilinto hospital escalated into violence. Somehow the building caught fire and gunfire ensued. At least 23 prisoners were killed. The part of the prison where Fikru was held has been evacuated and the prisoners have been taken to other facilities outside Addis Abeba. It is very unclear whereto he will be sent when he is discharged from hospital. There is a substantial risk that it isn’t to somewhere where his relatives can make sure he gets his insulin and proper food. This is turning into an emergency.
Today I met with Fikru’s daughter, Emy Maru and the Swedish lawyer who has been working on the case ever since the arrest. He confirmed that there are no charges of bribery. Instead Fikru is accused of gaining ”inappropriate advantage” through his relations with the Director and Deputy Director of the revenues and customs authority. Basically, when Fikru was charged with the attempt to smuggle medical supplies into the country, the case was closed by the prosecutor after contacts with the Directors.
It is of course difficult for the prosecution to provide evidence that Fikru was involved in this process. That is probably why the last day in court, before the two month summer closing, the burden of proof was put on Fikru. The court decided that he needs to provide evidence of his innocence. The farce continues. I just hope Fikru’s health is good enough to survive it.
This recent article in the EMJ has been shared, but not discussed, on Twitter. Is there really no controversy here? Or are people afraid to speak their minds?
Few people argue that men should be overrepresented as speakers at medical conferences because there are more male professors. They offer it as an explanation, but I have never heard anyone say that it is important to maintain this imbalance for the sake of fairness, which I actually think would be a reasonable argument. Is that because we have a common understanding that we are on a trajectory towards equality and that this development is desired?
The conference program represents the society or organization behind it. At our national conference in Sweden I want to make sure that delegates are shown a diversity of role models in emergency care, from different parts of Sweden and abroad and with different backgrounds. Not because there are quotas to fill, but because I believe that it makes for a better conference.
In an ideal world gender is not an issue and chance alone decides the ratio of men to women at a conference. But we are not there yet. For some societies and in some cultures this will take years to accomplish. That’s just a natural reflection of the development of the medical profession. Without conscious decisions by the governing bodies this process will take longer. A strong signal on the importance of equal opportunities would be to ensure that half of keynote speakers at all conferences are female. Even where women constitute a minority of all doctors you should be able to come up with a handful of highly qualified speakers. If you can’t, that’s where the problem lies and we all need to be very worried.