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Emergency Medicine in the Evidence-Free World

november 21, 2011 Lämna en kommentar

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…

Låt dörren till akuten alltid vara öppen

oktober 29, 2011 2 kommentarer

En niomånader gammal bebis kommer in död till akuten. Han har varit på vårdcentralen flera gånger, men skickats hem. I morse slutade han andas. Och nu är han död.

Jag låter någon av de andra läkarna på akuten konstatera dödsfallet. De är vana, men det är inte jag. Barn dör hela tiden här, men de gör de inte i Sverige. Där brukar de faktiskt sällan ens bli så sjuka eller skadade att de riskerar att dö. Vi bygger säkra lekplatser, använder bilbarnstolar och utbildar föräldrar om risker i vardagen. Skulle barnen bli sjuka kan föräldrarna lätt ringa sjukvårdsrådgivningen eller få hjälp i primärvården. Är de riktigt oroliga kommer de till akuten. Oftast är det inte så allvarligt och personalen på akuten irriteras ibland över hur lättvindigt föräldrar beger sig till akuten. Många tycker att akuten ska vara till för svårt sjuka och att alla som inte är det överutnyttjar resurserna. Jag höll inte riktigt med dem förut. Efter en tid på akuten här i Botswana håller jag inte med dem alls.

Det är inte för att vi har så bra akutsjukvård som barn inte dör i Sverige, utan för att våra välnärda och vaccinerade barn växer upp i en skyddad miljö. Barn med astma eller diabetes har tillgång till bra behandling och föräldrar som är insatta i sjukdomen. Om det akuta omhändertagandet är bristfälligt kommer det inte att ge något större utslag i statistiken.

Men i Sverige är vi inte nöjda med att få barn dör. Vi tycker att det är en katastrof om något barn som kommit levande till akuten dör, vare sig det är där på sjukhuset eller efter att de har skickats hem. Det får bara inte hända. Och vi har förmånen att leva i ett land som har råd att se till att det inte händer. Om patienterna inte kommer till akuten förrän de är allvarligt sjuka försämras våra möjligheter att behandla dem avsevärt. Vår uppgift är att sortera ut de som är eller riskerar att bli riktiga dåliga .Vi har råd att att utreda hundra barn, för att förhindra att ett av dem dör eller blir allvarligt sjukt.

Ändå händer det att allvarliga diagnoser som hjärnhinneinflammation eller blindtarmsinflammation missas och barn kommer till skada.
Läkarna som arbetar på akuten är ofta i början av sin karriär och eftersom riktigt allvarliga tillstånd är så ovanliga har de väldigt lite erfarenhet av dessa. Att erfarenheten är ringa ska vi förstås vara glada för, men är det rimligt att man har så lite utbildning och träning i att hantera dessa tillstånd? När resten av sjukvården bygger på att vi har högspecialiserade läkare som är experter på de mest ovanliga tillstånd, kan vi då inte också begära att de specialistläkare som arbetar på akuten är experter på hela spektrat av akuta tillstånd? Att deras specialistutbildning är djupare än bredare än bara den erfarenhet som kommer av att arbeta med de mest vanliga tillstånden?

Det vanliga är det vanliga, brukar man få höra av äldre kolleger. Men det synsättet fungerar inte om vi ska ha en hög patientsäkerhet på akuten. Där måste vi i stället tänka att det farliga är det farliga. Med en gedigen specialistutbildning i akutsjukvård innebär det inte att vi måste utreda mera. De flesta patienter är som sagt inte allvarligt sjuka och en klinisk bedömning räcker ofta för att utesluta farliga tillstånd. Men hur kan man göra det om man inte känner till vilka dessa är och vilka symtom de ger?

Kategorier:Botswana, Svenska

First impressions

augusti 20, 2011 Lämna en kommentar

After having spent two and a half days in the A&E (accidents and emergencies) I am ready to summarize my first impressions. It is all so new to me that I try to just take it all in without judgement or criticism. I realize that might sound impossible to anyone who knows me, but even I am humbled by the very special circumstances here.

The first time I went into the A&E I was surprised by how calm it was. A few people were sitting in the waiting room, a man was lying on a mattress on the floor. Although the walls would definitely benefit from being repainted, it all appeared clean and spacious. Inside there was a separate resuscitation room and a small corridor where patients who had been seen and treated would wait for test results, leaving room for new patients. The rest was just one large room with ten cubicles, or bays as they are called here, seperated by closed drapes so I couldn’t see any patients.

I was a bit envious of the drapes since the ones we had at Sodersjukhuset were taken down and replaced by mobile screens on wheels that you have to drag around in order to keep your patient from being exposed to everyone walking by. There aren’t enough screens so unless you need to undress the patient completely you mostly don’t bother. There is of course a reason for this nuisance. The drapes were not deemed hygienic. Hygiene has a very high priority in Sweden. We have a low prevalence of multiresistant bacteria and intend to keep it that way. The doctors have had to give up their white coats since only short sleeves are allowed. Scrubs are provided and washed by the hospital and have to be changed daily. Hands must be disinfected before and after every patient encounter and if we need to touch the patient or the stretcher we should wear a plastic apron to protect our cloths. I am not sure how evidence based this is, the short-sleeves were questioned in a recent study, but to prevent harm to our patients is definitely my top priority. I still miss the drapes, though.

In the A&E all doctors were wearing private clothing. Some even had jackets on! I was introduced to everyone, but since almost no one carried a name tag their names bounced off my brain before hitting the memory center. There were several nurses, most of them in uniforms. I didn’t really grasp what their responsibilities were. All needle work was done by doctors, unlike in Sweden where most doctors don’t pierce any veins after leaving medical school. My impression was that the nurses more or less performed the orders given by doctors using oneway communication, but since I couldn’t even figure out who was a doctor I might be wrong.

At the end of the room there were a few desks and chairs. There was a whiteboard on the wall showing all patients, stating their chief complaints and what priority they had been given at triage. I was amazed that there weren’t more patients. It was actually possible to get an overview of all patients in the A&E! The waiting times were also much shorter than I am used to. I don’t know why we have so many people hanging around in the ED back home. We are about to expand to accommodate them, but I have a feeling they just shouldn’t be there at all.

Something I wasn’t expecting in the A&E was the lack of basic necessities. I had read about how they would run out of iv fluids and certain medicines, but I don’t think I believed it a the time. On my first day we ran out of test tubes and wouldn’t have been able to send blood blood samples if we hadn’t found an additional pack stacked away. How can there be expensive monitors in every bay, but no proper dressing to secure the iv lines? Why aren’t things that break being mended? The CT scanner has been broken for months and patients have had to be sent to other hospitals to be examined. It doesn’t seem to be a lack of money, but rather a lack of responsibility and coordination. I will try my best to understand this conundrum.

So, I don’t know what to think about the A&E. Maybe that it has great potential? Getting the basic things right is essential. That applies everywhere. I do know that my learning curve here will be steep and I am definitely looking forward to the ascent.

Kategorier:Botswana, English

Same, same, but different

augusti 17, 2011 1 kommentar

So, I find myself in a cold house, with a snoring guard dog at my feet, surrounded by a kind of intense darkness that we only see in the winter in Sweden. Of course it is winter here in Botswana, which just adds to my already confused mind.

I arrived yesterday. Ngaire, an Australian emergency physician, picked me up at the airport. Today she and Amit, an American emergency physician, took me out to lunch to introduce me to my work at the Princess Marina Hospital accident and emergency, A&E, department. I thought I had come here for a four-month clinical rotation in emergency medicine. The think I have come here as a specialist to help them train and supervise EM residents and medical students. The present tense signifies that I didn’t manage to convince them otherwise.

Botswana has a small population of only two million people. Thanks to the unfortunately so rare combination of democracy and natural resources, mainly diamonds, it is the richest country in Africa. Earlier they have had to rely on foreign doctors or send their students abroad for undergraduate and specialist training, but three years ago the University of Botswana, UB, started a medical school and residency programs in six specialties, among them emergency medicine. Amit, Ngaire and the head of the A&E, Andrew, who is also an American emergency physician, are here to train these residents. That is different from Sweden where every hospital can train specialists, even if there aren’t any specialists there to supervise them, which is the case for many smaller hospitals that are now starting to train emergency physicians.

Amit and Ngaire explain to me how things work here. The A&E is currently staffed with medical officers, i.e doctors who lack specialist training but may have several years of experience. Some of them have even done clinical rotations in other departments, but that hasn’t been well organized. They have just hung out there for a couple of months and it has been up to their own motivation how much they have actually learned.

But doesn’t that qualify as specialist training? Because that is exactly how we train specialists in Sweden. I did a six month rotation in cardiology. Nobody told me what I was supposed to learn during this time. I wasn’t assessed in any way after completing the rotation. As long as I did all the paperwork everybody seemed pleased with my work.