Trying to be a bAddis ER Doc

Tenastellegn Addis! Has it really been 6.5 years since I was last here? It must be because while so much of the city is comfortably recognizable, the daily reality of 2018 Addis is full of new surprises, challenges, and landscapes. In the summer of 2011 I had just finished my first year of medical school, was excited to show off my knowledge to my mentor, Rick Hodes, still couldn't tell the difference between a systolic or diastolic murmur (I think I finally can now?) and had only the slightest inkling of how much medicine I didn't know.

Now, 78 months, 2 degrees, 83% of a residency, a marriage, and a dog later, I'm back. I will be in Addis from January 1-28, 2018 as part of Emory's Global Health Residency Scholars Program working with and learning from the Emergency Medicine residents at Addis Ababa University and Black Lion Hospital. For those worried that I am cockier than before, don't worry, I am now acutely aware of just how much medicine I still don't know. The past week has been wild. Like meeting up with your childhood best friend who moved away in middle school, things are "same same but different." Let's jump in. 

My parents and sister had the crazy notion that it would be fun to visit me during my now 4th trip to Addis. While their timing was a bit off, it allowed them a week to tour the northern part of the country and see many of the tourist highlights (Bahir Dar, Gonder, Simien Mountains, Lalibella). After an action packed week, they returned to Addis Ababa for our rendez-vous. Together, we had an incredible personal tour of Ethiopia's most famous contemporary artist's home and studio (thank you Fikru!), relaxed poolside at the Sheraton, and enjoyed a performance of traditional Ethiopian dancing. My parents joined me for rounds in the Black Lion emergency room one morning and then sharply contrasted the hospital's overflowing, under-resourced wards against the flower-filled courtyards and spotless recovery rooms of the world-famous Hamlin Fistula Hospital. We had an action-packed five days capped by shabbat at Rick's and hopefully just whet their appetite for this amazing country. 

Starting last Monday morning, I met with one of the outgoing chief residents for a mandatory tea-egg sandwich-macchiato breakfast where he gave me an overview of the residency program. Unfortunately Temesgen and his fellow chief residents are currently locked away in the library studying for their final certifying board exams at the end of January, but it is an exciting time to be visiting with all of the residents moving into new leadership roles or in the case of the first year residents, spending their first days in the emergency department (ED). And now for my observations after week 1: 

1) It's too early for real feedback

The struggle is real. The ED is crowded and it's nearly impossible to identify patients from the 3-4 family members sitting on/beside the bed providing nursing care. Supplies are scarce (2 breathing machines but 3 patients with who need them...). Medication shortages dictate care (severe infections gets dopamine (a medicine that improves your blood pressure but isn't first line) because there's no norepinephrine (first line drug) in the hospital unless a patient has $ to buy it from an outside pharmacy). It's easy to see problems, it's hard to find solutions, and it's harder still when I'm still trying to figure out how the pieces of the system fit together.

2) Limited diagnostics leads to (educated) guesswork

Back home, we EM docs frequently (proudly) bemoan our plight of working in an information-poor, high-pressure and time-limited setting. This is true but I am certainly spoiled by the ability to get a test that tells if you're having a heart attack within an hour (or less) and a chest x-ray after putting in a breathing tube or daily on patients who are stuck in the emergency room while on ventilators. The last lab test ordered here to tell if someone was having a heart attack when all markers were point to YES took more than 24hrs to come back from the lab. That's not terribly helpful. Similarly for chest x-ray, we were holding a few patients on ventilators for 3+ days. Each had gotten a chest x-ray the first day the breathing tube was put in but none since. If they spike a fever and have new lung sounds, we assume it's an infection. If the ventilator alarm go off, you try to figure it out before the patient fights you off because they're wide-awake while breathing through a straw and there are no medications for sedation. Then you hope the family has money to go buy a few vials of sedating medication before the patient pulls out their breathing tube. 

3) I really hope metrics are being tracked

I don't think reimbursements here are linked to patient satisfaction (nor should they be) but I have a new appreciation for the importance of data collection when trying to make improvements. After asking the attendings how many patients are treated daily or annually, there are no hard numbers. How about main diagnoses or length of stay or patient demographics? ...crickets... And so perhaps visits/presenting complaints/diagnoses and other vital information is being tracked but even if it is, this information needs to be readily available if we are to democratize the quality improvement process.

4) Emergency Medicine is Emergency Medicine

Heart attacks in Ethiopia have identical EKGs to heart attacks in Atlanta. You can diagnose a septic shock patient from the doorway at Black Lion just as easily as you can at Grady (albeit, there are no automatic BP cuffs here so the "shock" part involves more guessing). Drinking pesticide in an attempt to commit suicide here looks just like the textbooks say but people in urban Atlanta don't have the same access to pesticides and too much access to heroin/guns, so the mental health crisis looks a little different. But when broken down to its core, it is reassuring to see that Emergency Medicine is pretty consistent the world over. Vital signs are vital and in the eternal words of Dr. Liebzeit, "oxygen is good and blood goes round and round." 

5) Prehospital Medicine/EMS drastically impacts the practice of Hospital Emergency Medicine

Black Lion has a cardiac cath lab. They also know how to give lytics (clot busting medication) if someone presents with an acute heart attack, even though the patient would have to buy the drugs from a nearby pharmacy on their way into the ED. The third year residents I rounded with said they had seen clot busters given once. No patients have gone from the ED to the cath lab. This is not for a lack of heart attack patients. But if you sit at home for three days before coming to the ED or if it took a week to get transferred from your regional hospital, or if you had to walk for the past 5+ days to get to the ED, then you're outside the window for acute intervention. All that's left is for the ED physician to do an EKG, order some meds, call the cardiologist and get you admitted. Without a functioning ambulance system, the number of life-saving interventions available to emergency docs shrinks exponentially. Those who survive long enough to get to the ED will probably continue surviving. Those who didn't survive we never hear about. 

Quick list of hypothetical patients seen in the ED (warning: lots of medical terminology):

- Two intentional organophosphate ingestions/suicide attempts - both intubated, one with a ventilator and one with nasal cannula tubing running from the O2 tank into the endotracheal tube. There's atropine but no pralidoxime 

- STEMI, NSTEMI, AFib with RVR on digoxin

- Septic Shock in patient with severe kyphoscoliosis who's bedbound and has at least three potential sources of infection

- Aortic thrombus that presented as abdominal pain, then had acute respiratory failure/asthma exacerbation and was intubated, then a few days later became peritonitic with abdominal distension, found to have mesenteric ischemia, and unfortunately died the next night

- Crohn's disease with known fistulae, now urosepsis, no one wanted to admit her

It's late and so I'll save my Addis musings for another day. In the meantime, excited to give my second lecture tomorrow (Mechanical Ventilation! Oh boy! What a Treat!) and so I'm off to rest my eyes. Goodnight Addis and Merry Christmas!