Bridging the training gap to avoid treatable, preventable deaths.
Septic, ashen, profusely sweaty, no blood pressure. Pulse oximeter won’t read. We have a problem. Patients like this fill Emergency Departments across the cities and towns of the United States and much of the developed world.
“IV, O2, monitor, advanced airway equipment to the bedside. Commence resuscitation, gather clinical information, start a workup and treatment simultaneously.” This is a pretty standard Emergency Medicine practice that is both accessible and achievable, something we take for granted every day in the U.S.
Unfortunately, there was nothing standard about this case and nothing standard about the situation, the treatment or the outcome. You are about to go on an adventure, an adventure that plays out each day in one way or another across the world. An adventure that reminds us basic Emergency Medicine skills are needed throughout the world and they are needed now.
Imagine for a moment that you are not in your ED. Not only are you not in your ED, you are not even in your own country. Instead, your find yourself in Kenya, now classified as a middle-income country, but you are in a low-income, low resource area. Then imagine you have been taken out of the comforts of a general hospital and transported into a palliative care hospital. You have some wonderful nurses, some basic equipment, but you are still only in a palliative care hospital. You are called to see this septic, ashen, hypotensive patient.
Near Lake Nakuru, Kenya. On the road back to Nairobi after working and visiting the palliative care hospitals in and around Eldoret. Courtesy Mel Herbert, MD.
You ask yourself, “How did this patient end up here?” In low- and middle-income countries, when a patient is sick it does not matter what comes before “hospital.” You are the hospital. Your level of training or type of training does not matter. If you are a doctor or a clinician, you are the doctor for every type of emergency.
A few months ago, I had the privilege of visiting Kenya with my family to see our “Kenyan family.” Our dear friend Juli runs Kenya’s first and only palliative care hospital and had recently opened a second one. Soon after we arrived, after the joyful tears subsided, Juli turned to my wife — an NP — and me and asked if we could come by the hospital. A previously healthy man, about 70-years-old, had shown up and was deathly ill.
He had been seen a few days prior at a clinic somewhere, was diagnosed with pneumonia, and was started on some oral antibiotics. Juli, also an NP, had not understated the situation. This poor gentleman, a visitor from the United States, was seriously ill. The team at the hospice gave some IV fluids and antibiotics, but the cause of his rapidly-deteriorating condition was unclear. After a careful history and exam that any EM-trained clinician could do, it was clear that this was not pneumonia or any exotic African illness. This was good, old-fashioned sepsis with peritonitis, likely from ruptured diverticulitis.
In the United States, you would continue the resuscitation, review the antimicrobial coverage, and broaden it to include gut organisms. You would get on the phone and arrange a stat CT, consult surgery, order a pre-op ECG and labs, and arrange a post-op ICU bed. But remember, you are in a palliative care hospital in rural Africa and you have none of that.
So, what do you do? The correct answer is simple: the best you can. After talking with Juli and a local medical officer, it was clear we had two difficult choices. One option was pain relief, supportive care, discussion with the patient that his condition was likely fatal and, ironically enough, the use of the exceptional services of this palliative care hospital.
The second option was to search for a CT scanner to confirm the diagnosis, try to locate a surgeon and a hospital to accept the patient (a foreign national), and convince them to accept a credit card to pay for all these services. You would do all this knowing that the odds of a favorable outcome were quite low. The delays would probably be significant and the services even at the local general hospital are quite rudimentary compared to even a small hospital back home.
It was time to inform the patient of his options. “Mr. Smith, you are sick. You are extremely sick, and you are probably going to die. I am very sorry to have to tell you this. We have two options, neither of them great, but here they are. Either way, you should call home, speak with your family, and make arrangements. I am so sorry.”
After thorough discussions with the patient and the local experts, it was clear that the patient’s only hope was to try to get a CT scan and a surgeon. Remarkably, we were able to make this happen and the CT showed free air. The report was hand written on a scrap of paper! Next, the surgeon took the patient to the OR. Rather than a perforated diverticulum, he found a perforated stomach ulcer, which he repaired.
There was hope for a few days. But it quickly faded. The sepsis won and Mr. Smith died in the palliative care hospital.
So, what is the point of this story, this tragedy? The answer is simple. If Mr. Smith had been seen a few days before by someone with basic Emergency Medicine training, this poor outcome could potentially have been avoided. Mr. Smith never had a cough or other history to suggest pneumonia or any other respiratory illness. His symptoms started as abdominal pain. That abdominal pain got progressively worse and it ended in a perforated ulcer with sepsis.
Mr. Smith had been seen by a clinician who was not trained in the fundamentals of Emergency Medicine and in low- and middle-income countries like Kenya, this is the norm. In fact, Emergency Medicine has only recently been recognized as a medical specialty in many African countries. As such, very few physicians have any Emergency Medicine training, and access to quality emergency care is extremely limited.[1]
Photo Credit Mel Herbert MD: Homemade sling and splint.
Emergency Medicine developed specifically because it was clear that a different type of clinician was needed: one trained in seeing undifferentiated diseases and sorting the potentially very sick from the not so sick. These superheroes of medicine are trained in the early recognition and intervention of the potentially sick patient. No specialty existed that did this previouly. We tend to think that Emergency Medicine is all about technology and procedures and making impossible diagnoses. In reality, 90% of what we do is simple: history, exam and perhaps a few targeted tests.
What matters is the training, the mindset, the focus on the knowledge base required to care for and resuscitate the undifferentiated patient. It is needed in low- and middle-income countries, just as it is needed in high-income countries. Perhaps the outcome of a correct diagnosis a few days earlier might not have changed the outcome for our patient in Kenya, but it sure would have helped.
It is estimated that 1 in 2 deaths occurring in low- and middle-income countries could be prevented if patients were provided prompt and effective emergency care.[2]
At the 72nd World Health Assembly in April 2019, the WHO Director-General said, “No one should die for the lack of access to emergency care. We have simple, affordable and proven interventions that save lives. All people around the world should have access to the timely, life-saving care they deserve.”[3]
Low-income, high-income — it doesn’t matter. The world needs Emergency Medicine. The world needs it because your training and expertise really matters. You, the Emergency Medicine clinician, have a unique set of skills that no one else has, but everyone, everywhere needs and deserves access to.
The details of the real cases in this story have been altered for HIPAA compliance.
References
- “Kenya’s emergency medical services need major work.” The Conversation. Interview with Ben Wachira. January 24, 2017. http://theconversation.com/kenyas-emergency-medical-services-need-major-work-71565
- African Federation for Emergency Medicine official website. https://afem.africa/
- Kenya Foundation website https://www.emergencymedicinekenya.org/72wha/