The Going Global blog is an opportunity for emergency physicians to share their experiences practicing and teaching outside the United States. Submit an article about your experience to EMN at firstname.lastname@example.org. Be sure to include a brief biography and photographs of the authors. Photos taken during time spent abroad are also welcome, and should be 300 dpi and in jpg, tif, or gif format.
This blog was started by the emergency medicine residents of Palmetto Health Richland in Columbia, SC, who travel the globe on medical missions. The program is under the direction of Thomas Cook, MD, who oversees one of more than 40 academic departments of emergency medicine that sponsors Global International Emergency Medicine Fellowships.
Friday, January 09, 2015
By Christine Butts, MD
I typically write my columns about the “how” of ultrasound, but it's also important to think about the “why.” Ultrasound to me is a tool that can be shared across cultures and barriers to broaden education and to improve patient care.
So when a colleague approached me about teaching ultrasound in Kurdistan, Iraq, I was intrigued. Nervous but intrigued. I have been teaching ultrasound to residents, students, and other faculty here in the States for almost seven years, but have always harbored a desire to teach internationally.
I spent two months as a medical student working in a hospital in Zambia, and had experienced firsthand how devastating a lack of resources and knowledge can be. I was hopeful that bringing my experience with ultrasound to underdeveloped regions would empower local physicians to improve the care of their patients. Since that first anxious trip to Iraq, I have had the opportunity to teach in Kurdistan twice and also spent three weeks this summer working and teaching in an ED in Haiti. Ostensibly, I went to these regions to teach, but I also learned a great deal about ultrasound and its place within emergency medicine.
Twenty-four hours into my first trip to Kurdistan, Iraq, I was reminded of just how far from home I was. Patients surrounded our small group, holding copies of blood work, CT scans, and MRIs. Looking through the information they held in their hands, I saw that most of them had undergone appropriate workups and were on the appropriate treatments. Our evaluation of their workups seemed to reassure them because we were “American doctors.” I wrote prescriptions for medications, crutches, wheelchairs, and, in one strange circumstance, a house. It was certainly a far cry from my day-to-day job of teaching emergency medicine and ultrasound here.
I spent most of my time in Kurdistan teaching surgeons and internists because emergency medicine is not yet a separate specialty. The physicians I encountered there were adept and capable in their respective specialties, but the idea of using ultrasound at the bedside to evaluate critically ill patients and to augment the physical exam was foreign to them. They accepted its use in the FAST exam and for guiding central lines, but my suggestions to use ultrasound to evaluate the soft tissue of a patient with skin changes or the lungs of a patient with undifferentiated shortness of breath were met with quizzical responses.
Surgical residents practicing FAST skills in Duhok, Iraq
The Kurdistan emergency departments are staffed by internists at one hospital and surgeons at another. The concepts that we hold dear as emergency physicians, such as triage and rapid evaluation and treatment, were not universally evident. Seeing people wander through the ED at will and having to push my way through a group of family members surrounding the bedside of a critically ill patient was culture shock.
I was encouraged that trainees I met on my initial visit, however, shared cases in which they used bedside ultrasound when I returned a second time. Many physicians, particularly those in training, were intrigued by the idea of point-of-care ultrasound, but I realized that the concept of bedside ultrasound was as foreign as the concept of emergency medicine as its own specialty. It seemed on my return visit that some inroads had been made because the skills used to evaluate critical trauma patients had been passed from my initial trainees to a new group of residents. Some reluctance still remained, however.
Both places are very hot, but you couldn't find more different cultures than Kurdistan and Haiti. Emergency medicine is a burgeoning specialty, and the trainees were eager to learn ECHO, FAST, and pulmonary ultrasound. I felt a real satisfaction in seeing them grasp the concepts and put them to use, at times in diagnostically challenging cases such as undifferentiated pelvic masses or strangely dilated loops of bowel. I was frequently reminded of my limitations by theinability to act on the diagnoses that were made. A case of pyomyositis that was identified and aspirated with ultrasound guidance had me on top of the world until the news that the patient had died shortly after surgical debridement sent me crashing back to the ground. Despite these challenges, seeing a trainee get a look of understanding was as fulfilling as it is here in the States.
But these young doctors had learned to think like EPs, and they were able to understand how a quick cardiac exam might be beneficial in a hypotensive patient or how evaluation of the soft tissue might help to distinguish septic bursitis from a septic joint. Fittingly, this fall, the hospital will launch its first class of emergency medicine residency trainees.
Point-of-care ultrasound has great power to improve medical care in areas lacking resources. Lack of equipment, meager financial resources, and lack of proper training are barriers to its integration. But failure to incorporate the basic concepts of rapid evaluation and treatment may prevent the widespread adoption of point-of-care ultrasound in areas where emergency medicine has not yet been established as a specialty.
Dr. Butts is the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her @EMNSpeedofSound, and read her past columns at http://bit.ly/ButtsSpeedofSound.
Monday, November 03, 2014
By Remi Kessler & Natalie Catherwood
Ms. B was middle-aged and lying on a gurney without a sheet in the grossly under-resourced ED of the largest public hospital in Phnom Penh, Cambodia. She clearly had an altered level of consciousness, and she was not attached to the monitor that was behind the bed. Her open shirt exposed her to the entire ED, but her family had other concerns.
They were quick to leave as we made our way toward the bed. It became evident that she had not been seen by a doctor, despite her deteriorating condition and her family's persistent anxiety. We saw her chest rise and fall irregularly with fast, shallow breaths. Her glassy eyes failed to meet ours as we attempted to introduce ourselves.
We rapidly assessed her condition, simultaneously auscultating her chest. Her lung sounds were not normal. Upon closer listen, we heard an extra noise, similar to that of a heartbeat, just at the tail end of her expiration. Uncertain of what it was, we auscultated once more, closing our eyes to block out the surrounding mayhem. Her breathing became more labored until it dramatically slowed. That extra sound was still there, but brief gasps for air characterized her respirations as agonal. We held our breaths as we waited for her chest to rise again. We listened once more, this time unable to identify a heartbeat.
We felt for a pulse, struggling to identify its presence because of the girth of her neck. We watched as her heart came to a stop. It was disturbing to realize that we, the most inexperienced people in the room, had recognized a critical situation and needed to act. Her family watched what must have appeared to be an assault on their mother as we began resuscitation and chest compressions. No local staff had discussed the care plan with the family, who only spoke Khmer. Instead, Ms. B's family stood stunned at the pace at which she appeared to deteriorate.
A crowd of medical students and nurses quickly circled the bed, yet most were merely observing. They were apprehensive and unsure of how to help. This was unsurprising, given that Cambodian medical and nursing students' knowledge of chest compressions was based solely on textbook learning; they had never practiced on a manikin, much less a live patient. The ED's main physician was nowhere to be seen, which added to the chaos of the situation. Because there was no functioning monitor, we couldn’t get a blood pressure or cardiac rhythm for Ms. B, and not one nurse or staff had bothered to call another department for ECG stickers or a defibrillator or contact a physician with knowledge of advanced life support.
It was baffling to us that none of these items or a physician was readily available in the ED. Chest compressions were performed in a chaotic manner because many were struggling with basic techniques and required simultaneous instruction. Medical staff did not know to move when it was time switch compressions, which resulted in lots of pushing people out of the way. Two doctors who finally arrived: One was feeling for a pulse during compressions, while the other, who was in charge of medications, quickly left without a word. No one was in charge of Ms. B's care, and no one responsible for charting which drugs she had been given. It was utter madness.
As CPR continued, we began to fear the worst given the circumstances. Who would be the one to determine when to stop these extreme measures? What if this was the end for Ms. B? How would we know? After 15 minutes, we thought we felt a pulse. We auscultated. It was only after we heard the heartbeat that we realized we had been holding our breaths the whole time. No one had yet spoken to Ms. B’s family or even acknowledged their presence, and they had become increasingly confused and horrified.
It was only at this point that the main physician returned to the ED and asked why Ms. B had sought medical attention. She had had a syncopal episode and hit her head. Western medicine would have surely sent her for a CT scan. Because Ms. B's family could not afford one, however, she was instead shipped off to the general medical ward with no transfer of care. There wasn’t as much as a scribbled note, a drug order, a patient history, a diagnosis, or a care plan. As two foreign students, we were the only ones there the entire time. Now on the ward, we felt utterly helpless because there was no one around for us to share our account of her situation.
The general medicine doctor received an intubated, critical patient for which he had no information. And once more, Ms. B's family was left at the end of the bed, uninformed, their eyes silently pleading with ours. After completing his assessment, the doctor spoke briefly with the family before disappearing again. Unable to pay for Ms. B's hospital stay, the family asked requested to take their mother home. Ms. B's daughter broke down in tears because she realized that her mother's death was inevitable and quickly approaching.
This triggered our own emotional shock and sense of defeat. We struggled to suppress the feeling of finality and the frustration that resulted from our inability to alter the transpired events. The uncertainty, chaos, and unanswered questions left us with a sense of failure that we could not fully grasp. We had brought Ms. B back from the brink of death, and now she was being sent home to die. We knew we had to leave the family to be with Ms. B for whatever time she had left.
As we were leaving, our eyes met with Ms. B's daughter’s. It was clear to all of us that these were Ms. B's final moments. Many other patients in the ED required our attention. In the midst of this busy department, life carried on for everyone but Ms. B.
Without a dedicated physician assuming charge of Ms. B's care, she suffered in a medical culture that unfortunately lacks accountability and professional responsibility. Would anyone ever reflect upon her death and attempt to improve the quality of care for future patients? Will the chaos of the ED be repeated with the next patient who comes through the doors?
This type of medical culture permits recklessness and neglect, and the lack of reflective practice means that opportunity for learning and quality improvement is swiftly lost. But patient outcomes can be improved by incorporating basic measures into medical training, including promoting clear communication during hectic situations, thoroughly discussing a patient's condition following a transfer, and identifying what can be done differently in the future. Similar to many developing nations, the prevailing medical practices in Cambodia have yet to recognize the importance of accountability in medicine, prioritizing patient safety, and reducing preventable harm. This is no doubt in part because of Cambodia's brutal history under the Khmer Rouge.
The Communist-backed Khmer Rouge systematically destroyed health care institutions, all health care infrastructures, and exterminated virtually the entirety of its educated population, including nearly all of its physicians. Cambodia had approximately 270 physicians between 1975 and 1979, and only 40 remained in 1979, and 20 of those emigrated. (CMAJ 2000;163:1176.) Emergency medicine is not a recognized specialty in Cambodia, and the infrastructure in the ED is wholly inadequate. Severe trauma patients often wait days for appropriate consults, and the continuity of care is hindered by inept patient handoffs during shift changes. With an overall increasing demand for acute care services, it is of utmost necessity to address these shortfalls as developing nations grapple with simultaneous capacity strengthening and quality improvement.
Emergency medicine as a specialty offers the opportunity to care for patients during the worst and often the most traumatic moment of their lives. That comes with a tremendous responsibility. Valuing this responsibility is fundamental to the quality of care that is provided, not just in the ED, but for the health care that follows. Often this is underemphasized as emergency medicine becomes grounded in foreign health care systems that may not yet recognize the vital role that EPs play in providing the bridge to further health care and the evident benefits to society as a whole. Only when a heightened sense of professional responsibility becomes standard protocol in these developing nations can the quality of care become what patients in these countries deserve.
Ms. Catherwood, is a fourth-year medical student at Queens University Belfast School of Medicine in the United Kingdom. Ms. Kessler is a freshman at Johns Hopkins University.
Thursday, October 02, 2014
By Chris Stodard, MD, and Steve Tanner, MD
April 5: Today is the first day of camp and clinic. We started the day off with a lecture for the local health care workers, and then set our sights on taking care of patients. They were already lining up two hours before we opened our doors. The villagers have not had access to this type of health care for more than a year. The most rewarding experience we had today was with a patient who had a febrile seizure. The patient’s mother was panicking but felt much better and thanked us after we were done. Multiple patients had musculoskeletal complaints and upper respiratory symptoms. We treated all GI complaints with antibiotics. We saw patients with large groin abscesses, mouth cancer, and an old ruptured globe.
April 6: Clinic yielded many cases of gastritis and eye complaints. A dental abscess was the highlight of my day. We taught local Nepali doctors how to do dental blocks. After clinic, we had a local celebration with song and dance around a fire. We introduced s'mores to the locals.
April 7: We started the morning with a trauma lecture. Every day starts with a lecture, and today we reviewed primary surveys and quick interventions to help stabilize patients. Other lectures have focused on ENT, orthopedics, and OB. We had another half-day of clinic and then began our trek to the next village. We were stopped halfway by another village that wanted to celebrate all of the good that Himalayan Healthcare has done for them. It delayed us more than an hour and a half, however, and we were then caught in a rainstorm and everything got soaked. Luckily when we got to camp, tents were set up so that I could dry off my things as much as possible. We camped by a large river with a suspension bridge over it. We walked down to the cool waters and just enjoyed the scenery.
April 8: We began our trek to the gorge. We had a half-day hike and then set up for clinic again. We started seeing more of the same things: gastritis, gastritis, gastritis. I did have an interesting case of epididymitis and meningitis, though. We settled into camp and showered again.
April 9: This was a full day of clinic, and it was very busy. The cases were more of what we saw in other villages. We capped off the day with beer and rum punch. There was also a festival with lots of dancing again. The pace of a clinic day is much faster than at home, but the severity is less, and we are providing only basic care. Overall, the experience has been very rewarding.
April 10: Today was our last day of clinic. We then set off on our trek home. It was gorgeous passing through some local jungle.
April 11: We had a long day of trekking. We stopped for lunch in a local village. Our trek concluded with a stop near a river, and everyone took a dip regardless of clothes. It was the perfect end to a long trek.
April 12: It was a long drive back to Kathmandu. We all had whiplash from riding in the back of the 4x4 down the mountain.
Drs. Stoddard and Tanner graduated from the Palmetto Health Richland emergency medicine residency in July.
Wednesday, September 03, 2014
By Zubair Chao, MD
Dr. Thomas Cook and I escaped the dry heat of South Carolina to land in Chengdu, China, home of West China Hospital, in July 2012. He was set to teach an emergency ultrasound class, and I was on a global mission as part of my emergency medicine residency.
Some say it is the largest hospital in the world, boasting 5,000 beds, nearly 100 operating suites, and a large outpatient center, which, on any given day, has about 10,000 patients.
West China Hospital
The ED at West China Hospital recently moved to its new home in a larger, more modern facility. It sees about 160,000 patients a year, which is about twice what we see at Palmetto Health Richland. They have about a dozen attendings and more than 30 residents, in addition to rotators. The department is divided into several areas based on the severity of the case, and it has a few operating suites though they’re not currently used because they don’t have available staff. It also has a fast-track area, a low-acuity observation area, a secondary moderate-acuity rescue area, a high-acuity primary rescue area, and an emergency ICU. There is also a debridement room for procedures and a trauma area. Patients who come to the ED, primarily by private vehicle, are first seen in triage, where they are referred to the appropriate location depending on their acuity. The ED also has a cashier and a pharmacy; patients pay a-la-carte for tests, procedures, and medications.
Dr. Cook and I spent the first week in China teaching an ultrasound course, with lectures and workshops for attendees to practice their skills. This course was a great success, and I stayed another month to work in the emergency department. I spent my time rounding with the teams in the morning, and I taught residents ultrasound scanning in the afternoon. Once a week, I gave a presentation on a particular area of ED point-of-care ultrasound (bedside echo, FAST exams, etc).
My first official week was spent in the observation unit. The day started at 8 a.m. with all of the residents, attendings, and nurses crowding into a lecture hall for daily morning rounds. Each unit in the ED gave a quick report on the events that transpired over the past 24 hours, plus information on any interesting patients. The unique part about these rounds was that they were delivered in English on Wednesdays and Fridays. One of my roles was to help the health care providers improve their English proficiency.
I reported to the observation unit after morning rounds and checkout. The observation unit at West China hospital fulfills a role that we do not really have in the United States. Most patients seen in this area are those we would simply discharge to follow-up. These patients, including many who have travelled from distant cities to be seen at West China, are kept in the observation unit for a few days until serious pathology is ruled out, however, because the primary care sector is essentially nonexistent in China.
Many Chinese people, especially in rural areas, do not have access to hospitals, and a lot of them seek practitioners of traditional Chinese medicine for their ailments. Consequently, physicians in China are much more familiar with herbal medications than health care providers in the West. One week I saw numerous patients with snakebites whose first treatment of choice was an herbal paste that they slathered over the affected extremity. It yielded positive results.
The observation area has the capacity to accommodate nearly 60 patients by doubling some of the beds with two seats. Some patients are kept there for days, and even weeks, as they wait for inpatient beds to become available. It is easy to imagine that many people get fed up with this scenario and would rather go home. As in America, these patients must sign AMA forms to leave. The ED has a list of those at home waiting for an inpatient room to become available; it is 3,000 to 5,000 names long at any given time.
Two attendings were responsible for the 40 to 60 patients in the observation area, and each was responsible for a team of about seven to 10 residents. Most of these residents were interns, though each team had one or two upper levels as well. I found it particularly interesting that I could immediately distinguish interns from upper-levels by the way they interacted with each other. Interns always looked a little lost and were questioned about findings, and they didn’t always have the answer. The senior resident let them flail for bit before rescuing them, just like in America. Rounding took most of the morning, after which the team split up to accomplish their tasks for the day.
Residents working in the ED
Many of the higher acuity patients were seen in the rescue area, and it was the largest and busiest area of the emergency department. It was split into primary and secondary rescue areas, the former having about 10 beds and the latter about 30. Overflow beds were everywhere. The 10 beds in the primary rescue area were staffed mostly by two or three senior residents, who were also responsible for incoming traumas. Stabilize patients were moved to the secondary rescue area or the EICU.
Three attendings with a team of five to seven residents did rounds on patients in the secondary rescue areas. The secondary rescue areas were similar to the observation unit; teams rounded on patients. Here, three attendings with a team of about five to seven residents each rounded on patients.
Admitting physicians at Palmetto Health Richland manage admitted patients even if they are still physically in the ED. The ED staff at West China manages all patients regardless of admission status. Patients are worked up as a result with tests like rheumatoid factors, ANCA, and other tests I have not seen since my medical school days. Rounding in the secondary rescue area felt like rounding on the floor. The closest we ever come to rounding in our ED is when we run the list, which takes less than five minutes.
West China Hospital also serves as a regional referral center for the Sichuan province and much of western China because of its size, reputation, and resources. Many patients are transported there every day by ambulance from other facilities. Many more are individuals who have heard of West China’s reputation and have driven from thousands of miles away to be seen instead of going to their local hospitals. China has a shortage of physicians, and paradoxically many graduates cannot find jobs because the physician shortage is in underserved rural areas. These places have a difficult time attracting physicians, just like U.S. rural areas. The pay in these areas is also significantly less than in the cities.
The quality of physicians in rural China is not as high and medical licensing is not as standardized as it is in the United States, so someone who has not finished residency or has not passed the certification exam can still get a job in a rural area. Practitioners of traditional medicine often fill the dearth of physicians, which means most patients do not trust their local hospitals. This leads to physicians in rural hospitals having less clinical experience, further eroding the public’s trust in them. Attempts have been made to encourage people to visit their local hospitals instead of crowding into the overwhelmed regional referral centers like West China. We had many rural physicians rotating with us to gain more clinical experience and become more familiar with managing different diseases. The attendings in our department also visited satellite campuses, but people still swarm to West China, often with unrealistic expectations.
One of the most interesting patients I saw was a 15-year-old boy transferred from a regional Tibetan hospital. He had been thrown from his horse and had a massive skull fracture with an intracranial bleed. He was about a week out from the accident by the time he got to us, and he was intubated and his pupils were fixed and dilated, which did not bode well for his ultimate diagnosis. His family still seemed to hope that we were going to cure him, and all that was required was stepping up the level of care by transferring him to West China. The physicians there told me that this happens frequently, and families are disappointed when they find out nothing can be done for their loved ones.
On another afternoon, I stopped by the physician work area to ask if anyone needed a scan. One resident asked me to do an echo on bed 35. There I laid eyes on a young man strapped down in the bed. He spat and drooled onto the towel-bib laid over his chest. Straining against his restraints, he fought to lunge at me as I approached the bed. I cautiously placed the ultrasound probe on his chest as he continued to spit and snap his teeth in an effort to bite my hand. I assumed he had some kind of psychiatric disorder, so imagine my surprise when a passing resident said, “Be careful, he has rabies.” "WHAT?!" I thought, "Thanks, first resident, for leaving out that important piece of information."
Rabies is actually a rare disease in the United States, averaging only two reported cases per year, but it is common in rural China. I saw three cases during my month-long visit. This condition is usually fatal. Once doctors confirm the diagnosis, the family is informed, and they take the patient home to die. As in America, the ED at West China sees a number of suicide attempts. Many are ingestions, notably paraquat. This is never seen in the United States because it is banned, but paraquat seems to be the agent of choice for suicide in China. Ingestions above a certain threshold are inevitably fatal. We saw a few cases of paraquat poisonings each week. Treatment is usually supportive because toxic doses lead to multiorgan system failure. Experimental protocols are being tested at West China using CRRT, but it seems that even this simply prolongs the inevitable.
I had a few chances to go out with the ambulance to respond to some calls during my week in the rescue room. The chief residents took turns going out with a nurse instead of emergency responders. The ambulances are owned by the hospitals, and there does not seem to be a central command center, like the dispatch centers we have. West China’s ED has two vehicles that are converted vans with a stretcher in the back, oxygen, and an EKG machine. A nurse brings a jump bag with supplies to check vitals and blood sugar. The doctor also has a jump bag with airway equipment, among other necessities. My calls out included an elderly lady who had a syncopal episode while visiting her husband at one of our affiliated hospitals, and an elderly man experiencing post-stroke side effects. We tried to find beds for them in the rescue area.
My fourth week in China was spent in the emergency ICU. It makes sense to have a unit within the ED to manage critically ill patients while they wait for ICU bed. The West China emergency ICU has 15 beds and one private room with one-to-one nursing. The majority of patients in the ICU are intubated. EM residents, like in the United States, usually do their own intubations, with anesthesia as backup if necessary. Residents seemed very proficient from what I observed. I also saw a Blakemore tube used for the first time.
Many patients in the ICU succumb to their illnesses, so emergency physicians are often required to have end-of-life conversations with families. I generally felt families seemed more accepting of death as a part of life, and once they were faced with the inevitability of death, they chose to take their loved ones home to die. The Chinese feel it is better to die at home than in a hospital. Perhaps a part of this is that they must pay for health care services. Physicians also are reluctant to pursue heroic measures in patients that are terminally ill.
One interesting case I had was a foreigner from the Netherlands who was visiting China when she developed abdominal pain and persistent diarrhea; she came into the ED in septic shock. She had a complicated medical history of multiple abdominal surgeries for abdominal cancer and numerous other comorbidities. Fortunately, I was able to talk to the repatriation doctor of the Netherlands, who had spoken with her primary care physician and specialists to compile an extensive list of her medical history and everything else we could possibly need. Moral #1 of this story: Don’t get sick when traveling abroad. Moral #2: Make sure you have international insurance.
I bade the ED farewell during my last week in China to spend time in the operating rooms to work on intubations. I got 11 tubes on my first day, and was reminded why anesthesiologists are airway experts — they do so many! I feel fairly comfortable with most simple airways after two years of residency, but I still dread difficult airways. I felt really fortunate to have this opportunity to spend an entire week refining my airway skills. I even picked up a few tricks for better bag ventilation while learning one-on-one with the anesthesia attendings.
The Chinese anesthesiologists preferred MAC blades; nearly every uncomplicated airway I did was with a MAC 3. They explained that they only use the Miller blade for pediatric patients. They tend to go for an Airtraq first for difficult airways. This intubating device was purportedly invented by an Italian emergency physician; it provides direct visualization of the vocal cords via a mechanism similar to a periscope. Once the cords are visualized, the preloaded ET tube is simply advanced along the track and it goes right in. I used it a few times, and felt that it was bulky and not as maneuverable as the GlideScope, but I can see its appeal and definitely think that with some practice, it can be just as effective.
One day I accompanied one of our ED attendings to an affiliated hospital in the countryside. I imagined a tiny rural clinic from what all the residents were saying about this hospital, but it was a 500-bed, 10-story hospital that had an ED with ambulance bays and surgery suites. I guess everything else seems like a rural clinic when you work in the largest hospital in the world. A handful of residents worked at this affiliated hospital, and it did not seem that the ED was being used to its full capacity. Even the floor beds were somewhat empty, and the hallways seemed deserted. The hospital had opened just three months earlier, so I hope it is simply a matter of time before people start going to it. I could not shake the image of empty rural hospitals as sick people bypass them to crowd into the regional referral centers.
A 500-bed, 10-story “rural” hospital
The remainder of the week was spent intubating patients in the operating rooms. The tubes were easier than in America for the most part, which I think is in large part because of thinner body habitus of patients in China. That doesn’t mean there weren’t a few difficult patients, though. One that stands out in my mind was a 15-year-old with TB, Pott’s disease, and numerous abscesses on his back that needed to be opened up and drained. He could not be placed on his back, so he had to be intubated in the lateral decubitus position. The week ended with a night out with a few of the anesthesia attendings for hotpot and to catch a local movie (The Vanishing Bullet; I give it 4.5/5 stars).
I spent my last weekend in China going to SongXiao Qiao, a collection of stalls and stores selling “antiques” and artwork. I planned a walking tour to get to the city, which was about an hour away. On my way back, I ran into the infamous fainting vagrant.
The fainting vagrant is a young man in his 20s who found his way to Chengdu a few weeks after I did. I first heard about him during a morning report checkout when the chief resident complained about how she had to respond to five calls the previous day on this one person. Like most vagrants, he did not have any money nor did he have his government-issued ID giving him a hukou (a kind of residency permit that, among other things, gives you access to social services in your area). He would have fainting spells during which he would clutch his chest.
Concerned bystanders would call the ambulance, and he would then refuse to go to the hospital. This happened five or more times a day, and always play out the same way. As I was walking back that last weekend, I ran into a crowd surrounding this person. Wanting to see whether the situation would play out as I had heard, I hung around and, sure enough, someone in the crowd of bystanders called 120 (911), and an ambulance rolled up eight minutes later (pretty good response time). One of the chiefs came out, tried to examine the patient despite his refusal to cooperate, and they went back to the hospital empty-handed after 30 minutes of attempting to convince him to come to the hospital.
Later, one of the chiefs asked me if I wanted a tube, "Of course,” I said. “Who needs one?" "Sit tight, we're still waiting for the family to decide if they want to pay for it."
That was a conversation I had in China that I have never had in America, and it highlights one of the fundamental differences between the two countries about who bears the burden of health care. The West China ED initiates treatment including code drugs, resuscitation, and intubation for all critically ill patients before sorting out payment. This particular patient was terminally ill and near the end of life, and the real question was whether the family wanted to pay for heroic measures in what might have been a futile resuscitation attempt leading to a prolonged vent wean if he made it to the ICU.
The way in which this scenario is framed as a cost-of-futile-care issue contrasts sharply with the attitude in America, where discussion of cost (and by extension resource allocation) is almost a taboo discussion. This particular patient’s code status would have been couched in the language of what his wishes would be. If a patient came to the ED with respiratory failure and no advance directives dictating his code status in America, we would intubate him or do whatever we felt necessary, almost always without considering the costs of the procedures or tests. EMTALA essentially mandates that every patient get a workup and any life-saving treatment necessary, and it incomprehensible to many of us who grew up or trained in America to withhold therapeutic interventions or even diagnostic tests from a patient who obviously needs it.
We in America have come to view health care as a right, and the preservation of life trumps everything else. The patient’s ability to pay is not usually something that is part of the decision-making process. The Chinese way is a fee-for-service model where a patient’s family is responsible for paying prior to services being rendered, whether those services are administration of medications, blood draws for tests, or intubations. The physician writes a prescription for a medicine, test, or imaging study that needs to be done. A family member then takes this prescription to a cashier, and brings back the medicine or a receipt that allows for the medicine to be given or the test to be done. Many physicians in China have told me that the way we practice medicine in America would bankrupt hospitals in China. Hospitals in America stay afloat and remain quite profitable through a variety of methods, such as cost-shifting and government reimbursements for taking care of the indigent.
As a physician who trained in America, I feel uncomfortable withholding life-saving treatment from someone simply because they cannot pay. This would have implications on the way we practice as well. Instead, for example, of relying on the gold standard tests for diagnosis or rule outs, we would have to tailor each patient’s management based on his financial status. These alternative tests or medications may not have the same sensitivities/efficacy as more expensive alternatives, and may ultimately result in different standards of care. I feel this would go against most Americans’ ideal of egalitarianism (though many would argue that this scenario is, in fact, already an unspoken reality). There is also the concern that someone would be allowed to die simply because family was not around such as in cases of trauma where the next of kin is often not present.
All things considered, I feel a very compelling argument can be made for a fee-for-service model. The biggest benefit I think this type of model would offer is more judicious use of resources. This is obviously a bigger issue in the developing world than in developed nations, but even in America, I think most doctors would agree that we order too many unnecessary tests. Of course, this would have to go hand-in-hand with changes in the litigious environment of medical practice and tort reform. Speaking of which, is the practice of medicine in China fraught with fear of litigation? Yes and no. Throughout my rotation in China, I often witnessed attendings reminding residents to document carefully and obtain consents for everything in case there was a bad outcome.
One week, I even witnessed a local camera crew covering the poor outcome of a patient’s case. At the same time, the legislative process does not seem as developed as in America, and residents in China recount numerous cases of family members taking matters into their own hands and physically attacking doctors. A few years ago, an ENT physician at West China was stabbed after a patient was unhappy with his surgery. Another time a medical student was fatally stabbed when she was at the wrong place at the wrong time, and a disgruntled family member went on a rampage. Even while I was there, I witnessed multiple confrontations between overworked doctors and stressed-out family members.
Dr. Chao graduated from the Palmetto Health Richland emergency medicine residency in 2013, and is now a fellow in emergency ultrasound there.
Tuesday, August 05, 2014
By Jon Virkler, MD
Arrival in Haiti was a stark contrast from departure in Miami.
I had my passport scanned by an electronic sensor and rode two moving sidewalks and a train to gate D55 in Miami. I deplaned in Haiti at one of the two gates at the only international airport in the country, walked down the steps from the airplane onto the tarmac, and got onto a standing-room-only bus that took us to customs. Our bags arrived on the only baggage carousel in the airport.
The airport in Haiti.
We left the airport as a group, and fought through the throng of porters hoping for a tip of one or two American dollars, packing into the back of two Land Rovers. We drove past streets lined with shops and tap-taps — pickup trucks as taxis — and pulled into the gates of Hospital Bernard Mevs after passing by the guards armed with shotguns.
Guards at the gate of Hospital Bernard Mevs.
Hospital Bernard Mevs is one of many in Port-au-Prince, most of which are run through relief organizations or Doctors Without Borders. Bernard Mevs is supported by the University of Miami, and staffed by a mix of volunteers and Haitian staff. The Haitian staff was incredibly willing to learn and eager to have American involvement. Haitian nursing and medical students were also on hand.
The hospital itself had a triage shanty (three walls and some curtains), a two-bed ED, a four-bed ICU, a nine-bed medical-surgical unit, and a 10-bed spinal cord unit. A separate pediatric ward doubled as a PICU. The hospital also had an orthotic and prosthetic shop, outpatient clinics, three operating rooms, and an infectious disease ward with four beds.
The hospital’s triage area.
The hospital had impressive capabilities for Haiti. It had several adult ventilators, a BiPap machine for use in the ICU, and the only pediatric ventilators in the country. It sometimes had an onsite x-ray machine and a CT scanner. The CT scanner only worked occasionally because it ran on city power, which was frequently down.
All sorts of surgeons were on call: general, orthopedic, neurosurgery, and Ob/Gyn. Medical and pediatric admissions were handled mostly by the volunteer physicians. Sometimes capability or bed availability necessitated transfer to outlying hospitals. This was difficult because these either have a poor reputation or were in areas of town even Haitians are hesitant to enter.
Many of the simpler complaints were handled in the triage tent by the nurses, paramedics, and Haitian doctors staffing that area. The more serious complaints were brought to the ER for resuscitation, where most equipment was readily available.
Patients were initially screened at the gate by an armed guard and a translator. Their chief complaint was presented to the triage doctor or ER doctor, and the patient was allowed in or told to leave.
Common complaints include vomiting and diarrhea, febrile illness, and traumatic injury. Haiti has a significant amount of street-level violence, so stabbings, assaults, and head trauma are all common. The country has no traffic laws, so pedestrian injuries and motor vehicle collisions are frequent. HIV is also rampant, and the sequelae of this disease are frequent. Other serious pathologies I encountered included eclamptic seizures, respiratory failure, PCP pneumonia, stroke, and pneumothorax. There were also many machete assaults and other simple lacerations.
Often, the CT scanner did not work and the x-ray machine was unavailable, leaving only the physical exam and an old SonoSite ultrasound machine. Ultrasound was incredibly useful for everything from cardiac and pulmonary exams to biliary and musculoskeletal complaints, and I used it to diagnose pneumothorax, long bone fracture, volume overload from renal failure, liver metastasis of gastric cancer, appendicitis, and many other conditions.
Volunteers were typically not allowed outside the gates, except for a nightly trip to the United Nations, which has a restaurant. This provided a nice respite from the stress of running a hospital in a developing country, and allowed a nice return to American food as opposed to the normal fare of goat, chicken, and rice. The local beer, Prestige, is cheap and drinkable, and flows freely at the UN.
Haiti had some comforts, but for the most part the complex definitely felt like a developing country. There was wireless Internet available, so we were able to chat or Skype with family back home. The showers were abysmal: there was no hot water. The water was unsafe in Haiti, so all drinking water had to be filtered. The mosquitoes and heat were intense, even in March, and the air conditioning worked well but infrequently. A week deployment feels longer when you are in the midst of it, but you realize you want to stay when the week reaches its end. Haiti grows on you, especially its people. There is definite need, and Bernard Mevs does well to meet that need in harsh circumstances. All told, it was one of the best experiences of my life.
Dr. Virker graduated from the University of South Florida School of Medicine. He graduated from the emergency medicine residency at Palmetto Health in 2012. He lives and works in Palm Beach, FL.