2018 Medicine in Addis
I've been trying to write a post on "The State of Medicine in Ethiopia" since my last blog post. A small topic. Needless to say I have failed to conjure any new ideas, synthesize my own feelings, or fully encapsulate my experience thus far (a full 11 days). Add to the mix the fact that I am currently sitting on the balcony of an apartment I rented in Dar Es Salaam for the weekend. Muhimbili Hospital in Dar Es Salaam started an ED Department and residency program 1-2 years before the Addis program started. Famous for building one of the continent's best ED departments and setting the standard for emergency medical care in East Africa, not to mention frequently training visiting residents from nearby countries such as Ethiopia and Mozambique, this program is amazing and further deepens/conflicts my feelings about Addis. But that's going to be its own post.
Rather than delivering a treatise on healthcare in Addis today, I thought I'd simply share some of my recent experiences - things I liked, things I didn't, pleasant surprises.
Drug shortages - No norepinephrine, no pralidoxime, no streptokinase/TPA. There are some medications in the ER but most of the time the patient's family has to go out and buy the drugs recommended by the doctor. Doesn't seem to be the case with antibiotics and some cardiac drugs or pressors but I have no idea what the rules are. I know that for norepi and streptokinase, they are available in nearby drug stores but the family would have to go purchase, and if the family has enough money to go purchase, then they likely have enough money to take their loved one to a private hospital.
Imaging - We are able to get CT scans and x-rays done usually in the same day but typically don't get results or discuss results until the following day
Testing - Most of the basic emergency lab tests are available and can be done in the same day but again, results are obtained or discussed until the following day - Can get HIV results in 20min but troponin takes >24hrs
Knowledge - The doctors are smart. They know their textbooks and they function remarkably well under the conditions, whereas I find myself frequently paralyzed by the setting even if I know a patient needs to go to surgery (i.e. a decompensating patient with an alleged partial bowel obstruction on XR now with altered mental status and dark green output from his nasogastric tube) but I didn't know who to tell, who to call, or how to make that happen. So I reminded the resident caring for him that we really need surgery to come see this patient...today...or now...or 10 minutes ago. The biggest challenge in translating books to practice is recognizing when patients are really sick and acting ina timely fashion. There's lots of good thinking to be done but we can do it after we stabilize the patient and sometimes that sense of urgency isn't there. Some of the residents have it, some don't, and I'm not sure if it makes things get done faster here or not.
Without a functioning EMS system, the scope of Emergency Medicine is extremely limited. I have yet to see a cardiac arrest brought in from the field. I haven't seen any trauma cases yet but supposedly we do get them. But without a functioning EMS system, people end up waiting too long to seek care and by the time we get them in the ED, it's almost too late and/or it makes our job easier. The hardest cases to manage back home are the ones where I'm on the fence about someone going home or getting admitted to the hospital. They're probably sick enough to come in but really want to go home because their kids are coming in from out of town, they promise to follow up with their primary physician but I know that if they hadn't told me that then I'd definitely admit them. Those are the hard ones in the US. At Black Lion, one of the brand new residents put it best when the attending pushed her to discharge a patient. She was clearly waffling and came over to me to discuss it further. I told her that I'd heard the conversation with the attending but what did she want to do? "Well, I want to admit him but then again, I want to admit everyone here to the hospital!" she exclaimed. It was a beautiful moment, the innocence of medical school idealism coming face to face with the reality of Emergency Medicine and resource constraints. We can't admit everyone (we'll come back to this).
The Bread and Butter case is a cancer-related complication. Pneumonias, fatigue, unable to eat because of constant vomiting, fluid in the lungs, fluid around the lungs, fluid in the abdomen. It's surprisingly different from what I expected. When people hear "Medicine in Africa," they think malaria, ebola, HIV, famine, war, sexual violence against women, etc. More realistically, most Americans probably just think ebola, ebola, ebola, AIDS, ebola, AIDS...ebola and AIDS? Without a doubt, there are infectious diseases. HIV and tubercolsis are very real and kill many people. Luckily no ebola and minimal malaria in Addis but still a possibility (as I forgot last week when teaching a case to the first year residents and malaria was their top suspected diagnosis and hadn't even made my list). But our most common type of patient in the critical care room is a patient with an advanced cancer and now a life-threatening complication. Building on the point above, usually by the time they get to us, there's nothing we can do. It sucks to be right when you look at a patient and despite your best intentions, immediately predict that they won't survive the night. Cancer is a non-communicable disease, which means that it's a marker of progress because in a system without any public health programs, no one lives long enough to get diseases of development (Type 2 diabetes, cancer, heart failure, etc). But it clearly demonstrates the limits of the healthcare system in that they are able to diagnose cancers, and maybe even start treatment, but god forbid you have even the smallest complication, and you're quickly out of options. When my Dad toured the gastroenterology unit at Black Lion, one of his main takeaways from his colleague was that they really need palliative care/hospice units. I was told that the oncology floor/team has only 5 beds at Black Lion.
Resources are limited. The other night, a woman with known metastatic cancer stopped breathing while in the orange pod. When faced with 30 people waiting to be seen in the Grady Hallways, I'll often say that I'd rather have them in the hallway than the waiting room because there's no better place to have a cardiac arrest than in the ER. The patient was moved from the Orange Pod to the Red (Critical/Resuscitation) Pod. They started CPR, gave her epinephrine and put in a breathing tube. Some of the details may be off because this was all told to me the next morning 3rd hand as the day team tried to figure out the events of the nighttime. After the first year resident presented the case to the attending, she asked "why did we intubate this patient?" The new resident thought it was a trick question, kind of tilted his head and cautiously replied "well she stopped breathing so..." "yes but why did we intubate?" A blank stare from the resident. "She has known metastatic cancer, we all know she's not going to get better." She put the patient on a spontaneous breathing trial where we pause the ventilator to see if the patient will breath on her own. She didn't. Her pupils were dilated and din't react when bright light was shown in them. Although we can never be 100% sure, we were all 99.99999% sure the patient no longer had any meaningful brain function. And so the doctor asked again, "why did we intubate her?" And no one had an answer. We hate facing our own futile efforts, especially when in the moment, we hold absolute conviction that we are doing the best thing for our patients. We are saving lives people, come hell or high water, that breathing tube is going down your breathing tube so we can breath for you until either A) you wake up and breath on your own or B) an older, wiser doctor comes by and sees that you won't wake up. In the US, we rarely get confronted by the latter. Watching it happen was awkward and uncomfortable and I don't know that either the resident or the supervising doctor was right, or even if there is a right. But her point was well taken that there are limited resources. There are two breathing machines that can provide life saving therapy. But not if they are only being used for life sustaining therapy in a patient who won't get better. And yet, we also have to try. Maybe the key is becoming more comfortable facing the limits of our interventions and being willing to try (put in a breathing tube), succeed (put patient on a ventilator), and then stop (because the situation isn't going to improve). Stopping is different than failing.
This story is not a condemnation of this one attending. I've seen every attending at one point or another discharge a patient because there was nothing else we could offer them. These patients were the ones who weren't sick enough to require a critical care bed, were still able to walk with assistance, and had no emergent problem. Like the intern above, I don't want to discharge any of them, but the attendings also have a point that sometimes we can't offer anything else, at least not from the ER.
On a more uplifting note, sometimes people do get better. For example, one of our patients who attempted to commit suicide by drinking pesticide was recently moved out of the critical care bay. Without the ED, he would have died. That's a win. Some of our unstable cardiac patients were also stabilized and moved out. More wins. So the wins are there, and they aren't hard to find. I don't mean to focus on the bad or the challenging. It's just where my mind spends more of its time, trying to frame the problem(s) so that we can begin talking about improving them. But the wins are there and should never be dismissed.
Rather than delivering a treatise on healthcare in Addis today, I thought I'd simply share some of my recent experiences - things I liked, things I didn't, pleasant surprises.
Drug shortages - No norepinephrine, no pralidoxime, no streptokinase/TPA. There are some medications in the ER but most of the time the patient's family has to go out and buy the drugs recommended by the doctor. Doesn't seem to be the case with antibiotics and some cardiac drugs or pressors but I have no idea what the rules are. I know that for norepi and streptokinase, they are available in nearby drug stores but the family would have to go purchase, and if the family has enough money to go purchase, then they likely have enough money to take their loved one to a private hospital.
Imaging - We are able to get CT scans and x-rays done usually in the same day but typically don't get results or discuss results until the following day
Testing - Most of the basic emergency lab tests are available and can be done in the same day but again, results are obtained or discussed until the following day - Can get HIV results in 20min but troponin takes >24hrs
Knowledge - The doctors are smart. They know their textbooks and they function remarkably well under the conditions, whereas I find myself frequently paralyzed by the setting even if I know a patient needs to go to surgery (i.e. a decompensating patient with an alleged partial bowel obstruction on XR now with altered mental status and dark green output from his nasogastric tube) but I didn't know who to tell, who to call, or how to make that happen. So I reminded the resident caring for him that we really need surgery to come see this patient...today...or now...or 10 minutes ago. The biggest challenge in translating books to practice is recognizing when patients are really sick and acting ina timely fashion. There's lots of good thinking to be done but we can do it after we stabilize the patient and sometimes that sense of urgency isn't there. Some of the residents have it, some don't, and I'm not sure if it makes things get done faster here or not.
Without a functioning EMS system, the scope of Emergency Medicine is extremely limited. I have yet to see a cardiac arrest brought in from the field. I haven't seen any trauma cases yet but supposedly we do get them. But without a functioning EMS system, people end up waiting too long to seek care and by the time we get them in the ED, it's almost too late and/or it makes our job easier. The hardest cases to manage back home are the ones where I'm on the fence about someone going home or getting admitted to the hospital. They're probably sick enough to come in but really want to go home because their kids are coming in from out of town, they promise to follow up with their primary physician but I know that if they hadn't told me that then I'd definitely admit them. Those are the hard ones in the US. At Black Lion, one of the brand new residents put it best when the attending pushed her to discharge a patient. She was clearly waffling and came over to me to discuss it further. I told her that I'd heard the conversation with the attending but what did she want to do? "Well, I want to admit him but then again, I want to admit everyone here to the hospital!" she exclaimed. It was a beautiful moment, the innocence of medical school idealism coming face to face with the reality of Emergency Medicine and resource constraints. We can't admit everyone (we'll come back to this).
The Bread and Butter case is a cancer-related complication. Pneumonias, fatigue, unable to eat because of constant vomiting, fluid in the lungs, fluid around the lungs, fluid in the abdomen. It's surprisingly different from what I expected. When people hear "Medicine in Africa," they think malaria, ebola, HIV, famine, war, sexual violence against women, etc. More realistically, most Americans probably just think ebola, ebola, ebola, AIDS, ebola, AIDS...ebola and AIDS? Without a doubt, there are infectious diseases. HIV and tubercolsis are very real and kill many people. Luckily no ebola and minimal malaria in Addis but still a possibility (as I forgot last week when teaching a case to the first year residents and malaria was their top suspected diagnosis and hadn't even made my list). But our most common type of patient in the critical care room is a patient with an advanced cancer and now a life-threatening complication. Building on the point above, usually by the time they get to us, there's nothing we can do. It sucks to be right when you look at a patient and despite your best intentions, immediately predict that they won't survive the night. Cancer is a non-communicable disease, which means that it's a marker of progress because in a system without any public health programs, no one lives long enough to get diseases of development (Type 2 diabetes, cancer, heart failure, etc). But it clearly demonstrates the limits of the healthcare system in that they are able to diagnose cancers, and maybe even start treatment, but god forbid you have even the smallest complication, and you're quickly out of options. When my Dad toured the gastroenterology unit at Black Lion, one of his main takeaways from his colleague was that they really need palliative care/hospice units. I was told that the oncology floor/team has only 5 beds at Black Lion.
Resources are limited. The other night, a woman with known metastatic cancer stopped breathing while in the orange pod. When faced with 30 people waiting to be seen in the Grady Hallways, I'll often say that I'd rather have them in the hallway than the waiting room because there's no better place to have a cardiac arrest than in the ER. The patient was moved from the Orange Pod to the Red (Critical/Resuscitation) Pod. They started CPR, gave her epinephrine and put in a breathing tube. Some of the details may be off because this was all told to me the next morning 3rd hand as the day team tried to figure out the events of the nighttime. After the first year resident presented the case to the attending, she asked "why did we intubate this patient?" The new resident thought it was a trick question, kind of tilted his head and cautiously replied "well she stopped breathing so..." "yes but why did we intubate?" A blank stare from the resident. "She has known metastatic cancer, we all know she's not going to get better." She put the patient on a spontaneous breathing trial where we pause the ventilator to see if the patient will breath on her own. She didn't. Her pupils were dilated and din't react when bright light was shown in them. Although we can never be 100% sure, we were all 99.99999% sure the patient no longer had any meaningful brain function. And so the doctor asked again, "why did we intubate her?" And no one had an answer. We hate facing our own futile efforts, especially when in the moment, we hold absolute conviction that we are doing the best thing for our patients. We are saving lives people, come hell or high water, that breathing tube is going down your breathing tube so we can breath for you until either A) you wake up and breath on your own or B) an older, wiser doctor comes by and sees that you won't wake up. In the US, we rarely get confronted by the latter. Watching it happen was awkward and uncomfortable and I don't know that either the resident or the supervising doctor was right, or even if there is a right. But her point was well taken that there are limited resources. There are two breathing machines that can provide life saving therapy. But not if they are only being used for life sustaining therapy in a patient who won't get better. And yet, we also have to try. Maybe the key is becoming more comfortable facing the limits of our interventions and being willing to try (put in a breathing tube), succeed (put patient on a ventilator), and then stop (because the situation isn't going to improve). Stopping is different than failing.
This story is not a condemnation of this one attending. I've seen every attending at one point or another discharge a patient because there was nothing else we could offer them. These patients were the ones who weren't sick enough to require a critical care bed, were still able to walk with assistance, and had no emergent problem. Like the intern above, I don't want to discharge any of them, but the attendings also have a point that sometimes we can't offer anything else, at least not from the ER.
On a more uplifting note, sometimes people do get better. For example, one of our patients who attempted to commit suicide by drinking pesticide was recently moved out of the critical care bay. Without the ED, he would have died. That's a win. Some of our unstable cardiac patients were also stabilized and moved out. More wins. So the wins are there, and they aren't hard to find. I don't mean to focus on the bad or the challenging. It's just where my mind spends more of its time, trying to frame the problem(s) so that we can begin talking about improving them. But the wins are there and should never be dismissed.
Comments