aka Postcards from the Edge 010
I am a born optimist, which is why I have taken on the struggle to establish emergency medicine as a specialty in Sweden. Since EM is a supraspecialty I had to take the long way through an internal medicine residency, but now I am at least seeing the end of my EM training. I am also mildly adventurous. Not in the crazy, head-first, emergency physician way, but in a safe, Swedish way. Somehow I managed to convince my program director that a rotation abroad would make a great contribution to my education, so me and my family moved to Botswana in southern Africa for four months.
I came to Botswana for an ED rotation, hoping to do some good and learn something from it. Four months later I am ready to leave and I look back at my experience with a sense of relief. At least I didn’t kill anybody. I think.
Primum non nocere. First, do no harm. A principle that, hopefully, is more sacred to us doctors than the traditional medicine men here, whose remedies worsen the metabolic acidosis of babies with diarrhea and cause hematuria and acute renal failure in adults. Of course we know better than those quacks. We are highly educated medical doctors who practice evidenced-based medicine. Right?
Only I have learned evidenced-based in a kind of EM rule-in/rule out or good/bad way. Intubation for traumatic brain injury with GCS less than 8 is good. Intubation without proper skills and equipment is bad. But what do you do when that is all you have to work with? What is the threshold for intubation if your only airway adjunct is an ET tube size 7,5 or 9 and there is no endtidal CO2? And you are out of oral airways, except the infant sized? And there is only one ventilator, which does not work with assist-control settings, so you have to sedate the patient. And getting blood gases is a hassle since you have to rely on the benevolence of the ICU staff to analyze them? And you are lucky to even get the help of inexperienced A&E nurses?
I have no idea if intubating these patients saves more brain than it kills. And four months of experience in this setting has not made it any clearer to me. It has just made me care less. Because even if I try me very best to minimize the risks and optimize the care for a patient, I will later find them alone in the resuscitate room, with no one there to hear the alarms, while waiting for paperwork to be filled out, transport to arrive or just other doctors to make up their minds. That is when I start to blame the system. And when the system is at fault, you sort of resign from responsibility. Irresponsible doctors are lousy caregivers, so I struggle to feel responsible for every single one of my patients. I never thought it would be so hard and I doubt that I could do it for much longer.
I must admit that I had a somewhat naive perception of doctors in resource limited settings before coming to Botswana. I had heard stories about great clinicians who made accurate diagnoses based on clinical findings, auscultating and percussing the patients all over. But the only ones I see assessing chest expansion and vocal fremitus are the medical students. The medical officers have all trained abroad in hospitals with better resources, where you just order a chest x-ray. They are well trained with the same theoretical education as myself. When it comes to experience they are in some ways way ahead of me. After a year of internship they are supposed to work independently and with the patient clientele here, they quickly learn procedures and gain experience of treating very sick patients. They learn and seem to accept that they have to work with what they have got. And since x-rays are readily avalable, they are ordered in the same just-in-case fashion as back home. It is as if whatever resources are available are not limited. Another example of this is the iv fluids. During my stay we were sometimes out of normal saline and sometimes out of Ringers lactate and a few times we were out of both. You can be an expert on fluid resuscitation, but if their are no other fluids available than Dextrose when you are treating a severely dehydrated, septic child you are just as helpless as everybody else. It is an awful experience.
But when the next load of fluids arrives everything is back to normal. Almost anyone who hits the door gets an infusion. If it is there, it will be used until it runs out. In fact the iv fluids are used to clean wounds, since it is the only sterile solution available. If fluids were truly a limited resource and you knew that you only got a certain supply per month, it would not be hard to rationalize their use. The problem is not that fluids and other basic supplies are unaffordable, but that the stocks are not replenished on a regular basis and that running out of fluids, gloves or other necessities is somehow acceptable and seen as something uncontrollable. The most limited resource is structure.
CT scans, on the other hand, are indeed limited. The CT scanner in the hospital cannot do contrast enhanced exams, which means that abdominal and thoracic scans have to be ordered from outside. It is still financed by the government but the costs are much higher and the use is restricted, which means that those scans are hardly ever ordered from the emergency department. We mainly use the CT for brain scans. By some order, the cervical spine cannot be included in such a scan, even if there is a clear clinical indication and the result might actually influence the outcome. At the same time, surgery can demand a CT brain for a patient slightly confused patient with GCS 15 who needs admission for observation after a road traffic accident and refuse to admit without it. We see 85 year olds with hemiparesis, who are transferred from other hospitals for CT scans, only to confirm their strokes. This practice seems reasonable in the rich world, but if resources are limited, is this really where you want to spend your money?
To prioritize is ethically challenging and I don’t think that I, as a visiting doctor and a foreigner in this cultural context, is the right person to tell the local doctors how to use their resources, just because I have been trained to know what is possible in my own setting. And by bringing our way of practicing here, we are indeed prioritizing emergency care over other aspects of health care. If we are guided by patient-oriented outcomes, such as mortality and morbidity, we are probably doing good. But if we use surrogate markers, such as adherence to what is regarded as evidenced-based principles in the rich world, we are diverting resources away from other areas, without knowing with reasonable certainty that we are saving lives. If we successfully resuscitate a patient in cardiac arrest, that patient will need one of the very scarce ICU beds. The return of spontaneous circulation might seem like a victory, but considering how few people actually leave the hospital neurologically intact even with high quality intensive care, we have to ask ourselves if we don’t have more to gain from preventing cardiac arrest than treating it once it has occurred.
The unique dimension of Emergency medicine is time. Sometimes seconds matter and sometimes even days don’t count. Our job is to see the difference. But it is also to plan ahead and lead a team. When you are working in a well organized ED, you don’t realize how much work is done by others than yourself. You just expect carts and trays to be complete and the medicine cabinet to contain the same things today that you used yesterday. You certainly don’t expect the bag-valve mask to be assembled in a way that can give your younger patients bilateral pneumothoraces. Knowing how to work all the equipment yourself is important everywhere, but here it is indispensable.
In some ways emergency medicine here is similar to what I learned as a medical student in the mid-nineties. A myocardial infarction is chest pain with ECG-changes and STEMIs are treated with streptokinase, unless there is a contraindication. A few patients can be admitted or referred to cardiology, but that is more an exception than a rule. What happens with all the MIs that are missed this way? I have no idea. I do know, however, that the step to the current practice, where every tiny increase in troponins is an NSTEMI, is huge. Should the development here follow the same path or is it acceptable to keep missing those MIs, because other areas are more important to improve on first? What about pulmonary embolism? If we did get a CT scanner that could scan for PE, who should we scan? And what would we do with the results? There is not great evidence for anticoagulation to begin with. Who do you start on warfarin if INR monitoring is only done at the main hospital, if you cannot get even plasma to reverse the effect and to get packed red cells for a transfusion can take four hours. If more patients bleed to death, than are saved from dying of PE, we are no better than the traditional medicine men, harming people with toxic remedies.
I am convinced that a well functioning emergency department saves lives. But I think that development has to focus on getting the basics right and minimizing the adverse effects of our interventions. To secure impeccable hygiene and barrier care limits the spread of nosocomial infections at a low cost. To organize the ED in a way that allows good monitoring and an overview of all patients makes it possible to intervene before the patient deteriorates. Excellent on the floor management that stresses team work and communication reduces the unnecessary errors and speeds up processes. Documentation that makes it possible to measure quality and follow-up can help us identify problem areas. It also tells us how our patient population compares to study populations and if the evidence that is available is at all applicable in our setting. Because to use even excellent evidence from a completely different setting is not to practice evidenced-based medicine. If there is no evidence you just have to rely on your clinical judgement and common sense. And keep doing your absolute best for every single patient. In a dysfunctional organization that feels like banging your head against the wall, again and again.
But what else can you do?
— Katrin Hruska
from the edge