Emergency Medicine in the Evidence-Free World

Cape Town in November. Sunshine and the fresh air of spring make the third biennial conference on Emergency Medicine in the Developing World a tempting event. I have been looking forward to meeting other Emergency Physicians who face the same kind of dilemmas as I do in Botswana. Knowing what the right thing to do does not help you much when the right equipment and medicines are not available. There are so many things I have to relearn. As far as I understand this conference is a South African initiative. Most delegates are from Africa. A few Asians are to be seen, probably because they are there to present a poster. The speakers are almost exclusively from South Africa, the UK or North America. Without exception they are well prepared and excellent speakers. Maybe it is their fluency in English, maybe it is that they are clinically active and try to make it relevant for anyone who is. Regardless of which they make most of the professors I have listened to at the EuSEM conferences seem rather dull. Emergency Medicine in Southern Africa is a lot of trauma and a lot of infectious diseases, mainly HIV/AIDS and tuberculosis. We do not have a significant amount of either in Sweden. Even though I might have sufficient theoretical knowledge, I definitely lack the necessary experience to function as any kind of specialist or expert in this setting. South African doctors unfortunately have a lot of experience of both trauma and AIDS and the ones who work in tertiary hospitals have access to fairly modern equipment and treatments. They are fully aware, however, that that is the exception rather than the rule. Somehow they manage to make their talks relevant for my practice in Sweden as well as in Botswana, which I find impressive.

Most of the speakers from overseas have no experience of working in a resource limited setting. They proudly present the evidence for how to treat hemorrhagic stroke and seem taken aback by questions about how to make that diagnosis without a CT scanner, or rather, they can present the evidence for why a scan is necessary, but not offer much guidance on how to manage the patient with sudden hemiparesis when a CT scan is not an option. Some speakers realize the problem and admit it during their talk. Others promise to teach us things that we can take back to our next shift. We are then presented a patient who is bleeding on Dabigatran, a drug which, at least as of Aug 1 2011, has only been approved in one African country, namely Namibia. The drugs that are suggested for reversal of the coagulopathy and could be of benefit (nothing really seems to work) cost hundreds of dollars and are definitely not avalaible in most hospitals. Where I work it is often hard to get even 0 negative blood. I wonder if there is even evidence to suggest that anticoagulation is beneficial for patients with AF in this setting where trauma is common and helicobacter pylori infection is highly prevalent. The mortality of acute gastrointestinal bleeding for patients admitted to the ICU in Togo was 45%, even without anticoagulation (Med Trop (Mars), 2010 Jun). If there is no evidence available you cannot practice evidenced based medicine. You can only do what seems reasonable, based on what you do know. Using evidence from a totally different population is likely to do more harm than good since it makes you think that you are actually practicing evidenced based medicine and reduces your critical thinking.

To lighten up the talks some show a few slides of their hospital and home town. During a talk on intensive care we are shown a hospital with more than 200 ICU beds, with another 100 beds on the way. We cannot believe our ears. No wonder that intubating a patient does not seem to be a big deal! After the talk a Sudanese Emergency Physician has a question: – In Khartoum, with a population of four million, we only have six ICU beds and two ventilators. How can we intubate a patient and maintain eucarbia. Should we just bag them? The fancy EtCO2 curves just faded away. -Yes, just bag them at a rate of 8-10 breaths per minute, the speaker replies. He has nothing else to offer. – For how long? For 24 or 48 hours? She is trying to use his expertise to improve her practise, but probably also to make a point. – 24 hours, 48 hours, as long as you have to. In this case it is obvious to me that the expert cannot provide better care than the medical officer in the local hospital. Everything we do requires a risk-benefit analysis and the results of those analyses in the US are just not applicable to a resource limited setting. Doing the right, evidenced-based thing here, might kill your patient. An intensivist from Angola told me how he and one nurse were responsible for fifteen patients. When there was a power cut the ventilators stopped working. Two sets of hands cannot possibly ventilate fifteen people and they had to prioritize, sometimes letting the patients with multiorgan failure die. Disturbingly familiar with equipment failure, they knew not to keep the patients too sedated, which in a first-world setting might not be good practice, but in this case saved lives, since the patients could breath for themselves. It is important to emphasize that good practice might not be so good if the patient ends up dying as a direct cause of it.

Somethings are barely mentioned during the conference. Things like how basic barrier care and good hygiene reduce nosocomial infections and save lives, just like team work and good communication do. The South African speakers like to refer to some treatments as ”sexy”. They generally refer to intensive insulin therapy or advanced airway equipment when they say that, not team training or alcogel. I cannot say that we are good role models in the rich world, either. Reducing complications by washing your hands does not give you the same status as using more advanced and expensive measures. The means are sometimes more important than the end itself. To practice medicine in a resource limited setting is of course much more difficult, but it is also in some ways easier. The patients present late with findings on their physical exams and x-rays that are easy to appreciate. In the rich world we are searching vigorously for indications of disease, feeling a need to provide evidence for absence rather than presence of disease. Many of us realize that we might have taken it a step too far, but it is very hard to stop investigating and treating diffuse chest pain or pleuritic chest pain in healthy young women who are found to have a minor pulmonary embolus.

We can use our experience and knowledge to help the development of emergency medicine in Africa, but if we do not learn from the experience and knowledge that the doctors here have, it is probably not going to benefit our own patients. Following the development here, we can learn which of the interventions we consider standard care, actually carries the highest benefit. What is the minimum acceptable care, and how big is the difference in outcomes between the two? In a tax financed health care system, as we have in Sweden, the resources are definitely not unlimited and it would be great to know what the natural course of small pulmonary emboli is. I know that we do not see a lot of young women who are brought in dead after an episode of pleuritic chest pain here in Botswana. Working together with the local doctors and universities we can improve the evidence for patients everywhere. Or, we can pretend to have all the answers and just give them a lecture on the Wells criteria…