Best care – everywhere in the world

september 11, 2016 Lämna en kommentar

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 farce continues – #freefikru

september 6, 2016 1 kommentar

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.

Are there too few women speaking at emergency medicine conferences? 

augusti 21, 2016 Lämna en kommentar

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.


My most important blog post ever

juli 7, 2016 2 kommentarer

Our lives in Sweden started in the same year, in 1975. We studied medicine at the same university, the Karolinska Institute in Stockholm. His career was in cardiology, mine in emergency medicine. I believe we’ve both been appreciated clinicians. When writing about him on Facebook, I immediately got a direct message saying he was the best doctor who had ever worked at that particular clinic.

My medical adventures in Africa were more about learning than making valuable contributions to patient care. Not that I didn’t want to, I just didn’t have the necessary knowledge and experience to achieve that. He, on the other hand, made a long term commitment when he co-founded the Addis Cardiac hospital, providing a service that had up till then been unavailable in Ethiopia, with procedures such as PCI and pacemaker implantations. It’s mission is not only to provide high quality care to patients, but to train local doctors, nurses and technicians as well as investing in research and increased awareness about cardiovascular disease.

Swedfund, the development finance institution of the Swedish state has invested in the Addis Cardiac hospital, and he used to collect medical equipment from Swedish hospitals to bring when he travelled there. Once he was asked in customs for much higher duties than expected since they overestimated the value of the goods and he didn’t have the receipts. He left the suitcases there and was planning to take them back to Sweden. On his way home he paid a 5% fee (yes, apparently you need to even if you are taking things back). He would then also have to pay for excess baggage, but he didn’t have enough cash and they didn’t accept credit cards. He was running late for his flight, so he asked the airport staff to take the bags back to customs and boarded the plane. But he was taken off that plane and taken into custody, charged with attempting to smuggle goods into the country. It took eleven days before he was released and could go back to his family and work in Sweden. Fikru continued to travel frequently to Ethiopia and his hospital. He was of course eager to get rid of the smuggling charges and after the Health Minister contacted the Director general of the Ethiopian Revenues and Customs Authority, who subsequently talked to the prosecutor, the case was closed.

Three years later, in 2013, when visiting Ethiopia for his important work at the clinic, they came and arrested him at his house. He was accused of having influenced the Director General of the Ethiopian Revenues and Customs Authority to have his case closed. There was no accusation of bribery, only that Fikru had ”gained inappropriate advantages of his relations” with the government officials. Ever since then he has been incarcerated at the infamous Kaliti prison, waiting for a trial that just keep being postponed. His case is part of a group trial involving around 50 defendants, a process that some experts estimate can take ten years.

An innocent doctor has spent three years incarcerated under terrible conditions for taking the risk of working in a developing country. That makes me furious. I could have been that doctor. It is who I aspire to be like. The kind of doctor who engages in building sustainable care, who tries to make a difference. What upsets me even more about this case, though, is that I probably couldn’t be that doctor. If I as a white, native Swedish doctor had been arrested under these circumstance you would have heard about it all over the western world. When Dr Fikru Maru, born in Ethiopia, but a citizen of Sweden and Sweden only, has his long awaited hearing in court, it doesn’t even make in to the Swedish evening news programs. There are no new articles in International media that I can link to, because none have been written, but two years ago Swedish radio wrote about the case in English. 

The Swedish Ministry for Foreign Affairs claims to engage in the case, but neither the Prime Minister nor the Minister for Foreign Affairs have visited him in prison when traveling to Ethiopia.

Dr Fikru Maru needs to come home to Sweden. The only way to make that happen is to bring attention to the case. Let the world know that health care providers working in developing countries have your support and this is an issue that needs to be sorted out immediately. Share this post to #freefikru.


Systemfel – eller kanske systembrist

juli 3, 2016 4 kommentarer

Patienten skrivs ut från universitetssjukhuset. Han har remitterats dit från länsdelssjukhuset eftersom han behöver en mer avancerad utredning för att utesluta att en smittsam sjukdom är orsaken till hans symtom. Det är det inte, konstaterar universitetssjukhuset och skriver ut patienten till hemmet. Med sig får han ett utskrivningsmeddelande: Om du har några frågor kan du ringa 1177. Och uppföljning får ske på vårdcentralen.

Så patienten åker hem lika sjuk som han kom in och utan planerad uppföljning. Och det som skulle utredas av en specialist på sjukhus, ska nu i stället utredas på vårdcentralen. Hur det ska gå till finns det ingen plan för. För sjukhusspecialisten verkar det inte spela så stor roll. Man är ju färdig med sitt jobb. Återstår då för patientens husläkare att försöka reda upp vad som är gjort och vad som ska göras. Och 1177 då? Vad förväntas sjuksköterskorna där kunna ge patienten för information eller råd?

Det är så här vi håller på i sjukvården. Vi skyfflar patienterna hit och dit och gärna en sväng förbi vårdcentralen där man bistert konstaterar att utredningsresurserna och specialistkompetensen ju ska finnas på sjukhuset. Vården blir dyr, ineffektiv och otillgänglig. Patienterna känner sig inte välkomna någonstans. Sjukvårdspersonalen känner sig otillräcklig.

Anledningen till att det blir så här är ett systemfel. Ju mer jag tänker på det tror jag faktiskt att problemet till och med är en total brist på system. Vi har helt enkelt inte sjukvårdssystem där de olika delarna koordineras till en helhet utifrån patients behov. Det här kan inte lösas av oss som arbetar med patienter utan måste lösas av någon i organisationen som har ett helhetsperspektiv. Vem är det?


Vårdplatsbrist är ingen ursäkt för dålig vård

Jag tillhör den lilla skara vårdpersonal som tycker att vi nog har för många vårdplatser. En stor andel av platserna på sjukhus tas upp av äldre människor som skulle må mycket bättre av ett annat boende, eller mera vård i hemmet, men väntar på beslut från kommunen. Det har alltid varit en gåta för mig hur lösningen på det problemet skulle vara fler vårdplatser på sjukhuset.

Men även om man bortser från dessa patienter, är det onödigt många som vårdas inneliggande på sjukhus. En patient jag träffade på akuten hade komplikationer efter operation på ett mindre sjukhus utan akutmottagning. När jag ringde jouren där, fick jag besked att patienten skulle följas upp dagen efter. Det var lätt för mig att se till att patienten klarade sig till dess. Att få till ett mottagningsbesök till dagen efter på ett större akutsjukhus är dock omöjligt. Beskedet man får är att patienten ska läggas in. Eller komma tillbaka till akuten. Att det inte går att få till en snar uppföljning i primär- eller specialistvård är för mig en absurd indikation för slutenvård, men ack så vanlig.

I andra fall finns indikation för slutenvård. Patienten har en okontrollerad smärtsituation, kan inte äta och dricka, eller är helt enkelt för svag och orolig för att kunna klara sig hemma under drägliga förhållanden. Den indikationen glöms ofta bort och det krävs att man står på sig som akutläkare för att patienten ska beredas plats. Ju mer subspecialiserat (av vissa kallat högspecialiserat) sjukhuset är, desto svårare är det att anpassa vården efter patienten snarare än efter sjukhusets organisation.

Vissa patienter har komplicerade sjukdomar. Eller, egentligen är de faktiskt inte så komplicerade, men berörda läkare väljer att krångla till det. När man inte vet om patienten är sjuk på grund av en infektion, abstinens eller leversvikt, nekar man vänligt men bestämt plats på sin egen avdelning, men erbjuder sig att komma som konsult dithän där patienten råkar hamna. Det skulle förstås inte vara något problem om samtliga specialister samlades och slog sina kloka huvuden ihop för att komma fram till en gemensam plan, men så går det inte till. En patient med flera sjukdomar kan på detta sätt få sämre, men mer avancerad (läs dyrare) vård, än på ett litet sjukhus.

Det är inte bara läkare som skapar den här kulturen. En bakjour från en medicinklinik ville inte att patienten som gick på deras mottagning och var under aktiv behandling skulle läggas in där, eftersom sjuksköterskorna inte kunde hantera patientens kirurgiska omvårdnad och enligt erfarenhet blev det ofta problem och slutade med att sjuksköterskorna blev utskällda av sina kolleger på kirurgavdelningen. Ett sjukhus där personal skäller ut varandra, eller ens upplever att de inte får stöd av sina kolleger, har problem med sin kultur. Den fina värdegrunden spelar ingen roll alls i sammanhanget.

I sjukvården är alla resurser ändliga. Inom den akuta sjukvården är det mer påtagligt, eftersom vården är oplanerad och flödet ojämnt. Det betyder att man måste prioritera. Rimligen innebär det att man fördelar sina resurser jämnt och rättvist. Men vi får inte förledas att tro att detta faller sig naturligt för oss som vårdgivare. Vi ser inte de patienter vi inte har framför oss. Därför är en patient som inte tas emot, en patient som någon annan borde ta hand om och därmed någon annans ansvar. Jag har många gånger förvånats av hur lätt det är att arbeta utanför de stora sjukhusen. Hur man efter nattjouren berättar om en patient man träffat för någon överläkare på en annan klinik som lovar att ta tag i problemet och följa upp patienten.

När vårdplatsbrist tillåts bli ett giltigt argument för att avvisa patienter är det ett symtom på en patientfientlig vårdkultur. Patienter som skickas hem från akuten med ett ”Du borde läggas in, men vi har inte plats” är en skam för sjukhuset. Visst kan det saknas sängar, men om patienten har ett vårdbehov som borde föranleda inneliggande vård, finns det ingen ursäkt för att inte någon från sjukhuset ringer upp patienten dagen efter för att försäkra sig om att vederbörande mår bättre. Eller att patienten har ett nummer att ringa vid frågor. Men då måste den som svarar på det numret förstås kunna se till att patienter kan komma till rätt instans. Det är oacceptabelt att en patient som varit inneliggande på en avdelning och ringer dit efter några dagar blir hänvisad till att ringa 1177.

Ett sjukhus som inte anpassar sin verksamhet och fördelar sina resurser efter patienternas behov, kommer aldrig att kunna ge god vård. Möjligheten att ge god vård är det viktigaste för att personalen ska ha en bra arbetsmiljö. När de inte får det, vill de inte arbeta där. Då blir det brist på vårdplatser. Vårdplatsbristen är inte roten till det onda. Den är ett symtom på en underliggande sjukdom.




My digital self is just me

mars 24, 2016 5 kommentarer

This week’s assignment is to write a blog post about our digital selves, from a private and a professional perspective. I’ve been involved in social media for several years. Through the four twitter accounts that I manage, I have been able to engage in the international emergency medicine community and in the more limited Swedish Twitter community. On a more personal level I interact with my friends on Facebook, both real-life friends and people I have made friends with through Twitter. And I write this blog, which started out as a way to promote emergency medicine in Sweden, but quickly developed into more personal reflections on my own development as an emergency physician.

I use social media on a daily basis, but I don’t understand the concept of having a digital identity. All my reflections online are the same as I would have in a real-life discussion. I don’t make any distinction between Tweeps and other friends or acquaintances. Some are closer than others and it is always great to meet up with people you have never met in person, but who you already consider your friends.

Having a strong social media presence has never been a goal for me. I don’t strive to increase my number of followers, but rather think that having a lot of followers would put pressure on me to write interesting things. Neither do I have any career goals for my digital presence. The Twitter accounts that I manage for our society are not meant to be reflections of my personal beliefs, but I like to keep my private accounts very personal and have omitted all references to my being a representative of others.

I wrote the above several weeks ago, but didn’t feel it was worth publishing on my blog. It seemed to plain and lacking of reflection. Then I learned that one of the high profiles of our social media community had been accused of sexually assaulting a patient. Since he is American, his name and photo, along with the name of his wife, were published in numerous online papers, something that would be unthinkable in Sweden. I don’t know if he was ever on Twitter, but he isn’t now and his amazing blog and podcast have been shut down, probably by himself. If he was on Facebook, he is not any longer. His name has been taken off the list of keynote speakers at an important conference. Most hits on Google are about the recent allegations and you have to search thoroughly to find his valuable contributions to emergency medicine. Even if I understand that erasing your digital self is a way to protect your privacy, it also takes away the opportunity for your social media friends to offer their support, like I would like to do to this person who has taught me so much.

Just like it is easy to reach world wide fame through a strong digital presence, that same platform can be used to bring you down in the most brutal way. Maybe that is one of the reasons I have been content with my rather anonymous presence. A badly worded tweet can easily cause irreparable damage if spread outside the small community used to my sense of humor. I don’t like to put myself in that position in real life, and my digital self is no different. We are one.