Blissful Life

Category: emergency department

  • Public Health Was Always Broken, You Are Just Noticing It Now

    There is this nytimes article about how one pregnant lady who was also breathless couldn’t find appropriate care despite going to multiple hospitals. I find it nothing surprising. Our country’s public health system has never been able to provide appropriate care to people with medical emergencies (or for that matter, any health issue). Maybe now people are noticing because it comes on news.
    There is a limit to how many emergencies can be handled at a time by a small medical team. Even in tertiary care government hospitals, this “team” is a very small one. It usually includes a couple of young doctors – either doing their internship or their residency. And a couple of nurses. And a couple of janitors. It is the same whether you are talking about the ICU or the emergency room of any department. There are no mechanisms for requesting extra hands when there is a spike in cases at any moment. Crises are handled by expediting care (many a times at the expense of quality and/or completeness).
    Imagine this. You are attending to a very difficult accident victim with multiple dangerous bleeds and possible head injury and suspicious breathing. As you are assessing their breathing, another patient comes in with severe pain abdomen. The other doctor stops assisting you and goes to assess the patient with pain abdomen. And then comes in another patient who has a open fracture on both bones of one lower limb. Who on earth is going to take care of this new patient? Well, let’s say the other doctor gives a pain killer to the patient with pain abdomen and let them settle down thus relieving themselves to attend to this new patient. At that moment comes in yet another patient with a head injury. What happens now?
    It becomes worse in the ICU. You could be in the middle of a procedure and there could be a new patient coming in with lots of things to be taken care of. And another patient could crash as this is happening. There are so many things that can go wrong at the same time. But there aren’t ever enough trained hands.
    It is in such situations that doctors refuse to take patients. They know that they can’t give justice to anyone if they take in more patients, especially critically ill. This is where “referral to higher center” happens. Anything can happen, actually – misdiagnosis, unnecessary investigations, miscommunication, death, so on.
    What is the way out?
    Of course, there are a lot of things that maybe potential solutions. But I do have one idea which seems sane.
    Proper “professional” education in colleges
    Nurses can perform any intervention done in an ICU if they are trained and empowered to do it.
    Medical students should be made capable of handling cases on their own.
    In an academic institution there is no dearth of learners. If learners are properly trained and given “professional” education, they can share a lot of workload. Similarly, our country needs to stop putting the doctor at the center of everything and start allowing other professionals like nurses to do more things.
    Above all, there needs to be a culture of quality and improvement. This has to be built from within colleges. When such highly trained teams focused on quality come together, they can do debriefing, build protocols, and create Standard Operating Procedures for managing cases. They will figure out the weaknesses of the system and ask for infrastructure upgrade and many other things necessary to be done to improve the overall system.
    Unfortunately, we are stuck in “long case, short case” mode in medical education. And this is not going to help the country.

  • “Risks” vs Risks

    Decision making is almost always complicated by uncertainties. The more information that can provide context, the more stakeholders that are part of the decision, the better the chances of reaching a good decision.

    In the past few weeks, world leaders have had to make very difficult decisions. Lock down entire country? Put money into healthcare? Risk economic disasters to prevent health disaster?

    I guess the biggest problem they would have faced in making these decisions is uncertainty. Because medicine is a field of uncertainties. The first thing a doctor learns when helping patients is that they can never be sure of anything other than the fact that they have to act. Diseases, cells, organisms, molecules, environment, human behaviour – there are a lot of moving parts in medicine. Parts that you can’t control. Parts that you can’t even predict.

    A doctor is a performance artist who uses an imperfect science to help alleviate suffering. In Osler’s words, “Medicine is a science of uncertainty and an art of probability”. I’ve been fascinated by the range of dilemmas a thinking doctor faces in routine practice. When choosing who gets a ventilator they get to act God. When choosing what information to convey to the spouse of a person newly diagnosed with HIV, they get to play the Supreme Court. And not to forget the countless times they get to act human when seeing raw humanness play out in various scenarios – first breastfeeding of a newborn baby, last bye-byes before surgery (oh, thinking of it, I’ve never seen a family wave bye-bye in India. Maybe I’m watching too much of medical TV series), pain that persists even with the strongest painkillers, so on.

    We were talking about uncertainties. Yes. That’s what makes life really difficult in the field of medicine.

    Let’s take one specific question. The use of masks by public during COVID-19 pandemic. Should they wear it? Should they not?

    Let me break it down.

    What do we know about how the virus is transmitted? Just enough. We think it is through respiratory droplets and contact.

    What does that mean? A respiratory droplet is any drop that comes out of a person’s nose or mouth. It could come out while coughing, sneezing, even while laughing, or shouting. Contact is, well, contact. Touch. Touch anywhere where those respiratory droplets could have been. Surfaces, hands, wherever.

    Okay. So we know how the virus comes out of a person. But how does it enter someone else? No points for guessing that the respiratory tract is a major route for entry of respiratory viruses into someone. That includes mouth and nose. But turns out respiratory viruses can enter body through eyes too. (Warned you about uncertainties, didn’t I?) Luckily for humans, the largest organ of our body – the skin – is also a very protective sheath that makes our hands, legs, and so on less likely to be ports of entry for the virus. (Like I tell the people who come to me scared of HIV because they touched someone infected with HIV, even if a bag of blood full of HIV falls on your bare hands, unless there is a cut on your skin, there is no need to be scared. Of course, they then ask about the possibilities of microscopic cuts. But that’s another story and this snippet of that story is included to make a point that there are “risks” and there are risks.)

    Now, what do we know about masks? The medical masks that we are talking about? They can definitely protect someone’s nose and mouth from other people’s respiratory droplets. But that’s all they can do. They cannot protect their hands. They cannot protect their eyes. And the mask itself gets contaminated while protecting the mouth and nose of the wearer (Important point. The external surface of the mask is where all those respiratory droplets, if any, should get caught).

    What do we know about people? We know that people touch their face a lot. You just touched your face while reading this article. Your nose is itching as you’re reading this sentence.

    When a human goes out during the pandemic to buy grocery, they have to deal with many things. Around them, there could be a large number of people who have never seen SARS-CoV-2 in their life. They could also be walking among asymptomatic carriers who are shedding their virus in respiratory droplets. They could be touching surfaces which a carrier coughed into 10 minutes before. They could be inhaling respiratory droplets from carriers. Respiratory droplets could land on their eyes. Droplets could land on their hands and they could then touch their eyes/nose inadvertently. Droplets could land on their masks and they could then touch their masks inadvertently. Their mask itself could be a makeshift one with towel that they hold in front of nose and mouth (where the external most surface is their own, pretty, hand). And that hand could then inadvertently touch their eyes/nose.

    Do you see the risks and the risks that masks mask (pun intended)?

    Yes, theoretically masks decrease the risk of transmission by a tiny bit. But practically, probably, they don’t.

    On the other hand, there are some real risks of people wearing masks to grocery shops.

    The first thing that happens is we all run out of masks. Including the health care workers and people who care for COVID-19 infected at home. (Of course this has already happened in many cities). These people are now at definite risk for contracting infections because they deal with definitely sick people and for very long durations which increases their exposure. Many of the health care workers do not become sick, but some of them do. When they become sick the entire system is demoralized. And we don’t want that to happen when we are about to face a pandemic that nobody is sure how to deal with.

    That is why WHO and CDC and others insist that masks should be used rationally.

    Does that mean, if we had unlimited supply of masks, it would be okay for public to wear it when going out to fetch grocery?

    If you are a person who wears a helmet while walking on the road, yes.

    Of course, how could I miss this, yesterday when I went to the grocer’s, I was wearing a helmet with the glass visor closed all the time.

    — Akshay S Dinesh (@asdofindia) March 28, 2020

    Okay. Update: I haven’t considered at all the chance that you’re an asymptomatic carrier who is spreading the disease to others. In which case, suddenly there is a non-trivial effect where masks prevent the respiratory droplets from getting out of you in the first place. Uncertainties here are the proportion of asymptomatic carriers and their infectivity.

    I really don’t know.
    Update on May 30: There is piling evidence that masks are useful for source control. And now that the pandemic is well distributed inside all countries, the calculations of risk also has to change. Right now, the governments would have had enough chance to ramp up PPE production and meet healthcare needs. Right now you are at a higher risk of being an asymptomatic carrier than you were at the beginning of the pandemic when overall prevalence was low. So, yes, wear a mask. It may not protect yourself, but it will protect others.

  • Lessons One Should Learn From Shehla Sherin’s Death

    If you do not avoid news like me, you would have heard about the tragic death of a 10 year old in Wayanad a couple of days ago. You can search the name and find the story on your own, but a few facts are established already.

    1. Shehla Sherin had her foot go into a hole on the floor of her classroom and was afraid a snake bit her in that incident
    2. There was delay in taking her to the hospital
    3. Anti-Snake venom was not administered at the local hospital, and the child was referred to a tertiary care center at least an hour away.
    4. Child died on the way.

    I won’t unnecessarily go into speculations on what other things happened on that fateful day, but having managed emergency department in a rural hospital for over an year, I will use this sad death to illustrate two very important lessons for every doctor.

    Lesson 1: Never take any complaint lightly, even if the circumstances lead you to think otherwise

    There are two ways patients can come in. There are people who exaggerate, and people who downplay. Take all symptoms seriously.

    There are no insignificant complaints. There are no insignificant findings. Whatever the patient tells you has to be taken seriously. Even if the patient asks you to not take it seriously. At the height of experience and confidence you might be able to predict that something isn’t as serious as it sounds, but be really really careful before making that decision.

    I had once a patient come to the casualty with a swollen foot. The patient had intellectual and speech disabilities and therefore there was no proper history. The bystander (who apparently takes care of the patient) told that “someone must have hit him”. My colleague suspected a snake-bite because of the way the swelling looked, but nevertheless ordered a whole blood clotting time test and a foot x-ray to rule out a fracture. My shift was about to start and while I was taking charge from my colleague I inspected the foot of this patient closely (in the x-ray room). I could see two small points of bleeding close to each other – fang marks!

    We immediately told the bystander that this is not “someone must have hit him”, it is a snake bite, and that the patient will die unless something is done immediately. This bystander did not look like they liked the patient very much because they asked me “please do whatever you can here itself, don’t refer us to higher center”. We knew that the best we could do was given anti-snake venom (which we immediately started doing) but the patient might require blood products which weren’t available and required referral. So, we took a stand and sent the patient as soon as the ASV went in.

    There was this other patient who came at noon on a different day with severe chest pain, as if he was going to die the next moment. He was a smoker and alcoholic with a very good chance of having a heart attack. He wouldn’t even lay still for us to get a proper ECG, and whatever leads we could obtain looked like there were ST elevations all over. The MI protocol kicked in, we gave all the painkillers, anti-coagulants, and sent the patient to the nearest cardiology center. News later was that he was just having severe gastritis due to alcoholism. But, we did what we should have done.

    We’ve had a patient with vague headache/chest pain admitted for observation die on us under strict observation. I’ve had a patient with diarrhea go into dehydration and shock. I’ve had a lady who could perceive fetal movements but have no fetal heart activity on ultrasound. We’ve had a person with cellulitis of lower limb go into septic shock and die while we were on rounds. We’ve had a bystander who missed anti-epileptic medication die after getting seizures and aspirating. I’ve examined a kid with high fever who had febrile seizure on the way out. We’ve had a kid admitted for being dull after vaccination die in front of us, despite our best efforts. We’ve had a child in waiting area who wasn’t breathing well arrest by the time they were identified by a patient care worker to be requiring urgent attention. I’ve had a patient with vague thigh pain turn out to be deep vein thrombosis and die next day.

    Always have the worst outcomes in mind when making decisions. Be mindful about patients who you haven’t even seen yet. Communicate a lot. Err on the side of cautiousness.

    Never be afraid to wake seniors up from sleep. When in doubt, ask for help. If you are not sure about something, check it again. If something happens while you could have done something which you didn’t, you’ll regret that your entire life. And that is a pain.

    Lesson 2: It is a privilege to have access to the miracles of modern medicine. When you have the power to use things, please also have the courage to.

    There is always going to be a risk. It is risk that makes the work of a doctor exciting. If you’ve chosen to be a doctor, there is no way you can avoid risk. Even if you become a dermatologist, you can land up in soup. As a doctor, the only way to avoid risk is by quitting professional life and meditating inside a cave.

    Risks shouldn’t hold you back from attempting something that’s required for your patient. I got this lesson the first time when I was still an intern, and was in KR Hospital’s Medical ICU. I was trying to insert a catheter into someone’s jugular but I was going too superficial. My senior then told me “Always remember, what you’re doing is for the benefit of the patient. You’re only going to harm them by not doing it confidently. The patient will die if they don’t get this line. So you may as well put it in boldly.”

    There is a definite role for experience and knowledge in being able to build the confidence to do things. But neither of that will come unless you want to do those things for your patient. If you are shy of cutting, you can never be a surgeon. If you are scared of side effects, all the pharmacology you know is absolutely of no use.

    Too many doctors think that by not committing something they’re keeping themselves safe. But their fake sense of safety comes at the cost of the patient’s suffering. Laws of medical negligence apply to acts of omission as well as they apply to acts of commission. With all your training you may as well do something and fail, than be a mean coward. That’s what your license is for.

    Use anesthesia (ketamine + midazolam, if you will) when draining breast abscess. Give powerful analgesics when people are in pain (don’t give diclofenac for MI/fracture. Give something like pentazocine). Use second line and third line drugs when the first line fails. Give aminophylline or magnesium sulphate for COPD/Asthma. Steroids and immuno-suppressants are in various guidelines for a reason – use them when indicated. Even newborns may need anti-epileptics. Benzathine Penicillin is the best available cure for Syphilis. “Higher antibiotics” are not reserved for higher centers. Use vasopressors (and for heart’s sake not fluids) in hypotension where failure needs to be considered. Use nitroglycerine to control high blood pressure. Use heparin. Use atropine. Use adrenaline. Use BiPAP. Resuscitate. Use oxygen. Use fluids. Give vaccines. Conduct deliveries. Splint fractures. Suture large wounds. Intubate and bag till the ventilator in referral center. Use all the things you’ve learnt to deliver care. That’s why you’re a doctor.

    And if you feel you’re under-prepared for any of those things even after MBBS, work with sincere people in rural hospitals (like VMH or THI or BHS). Learn the skills. Learn the craft. Understand pain and suffering. Care for other humans. Become a good doctor. Then do whatever you want to.

    Epilogue

    I had a rule when I was working in ED – “Nobody dies when I’m on duty”. The only exception was patients admitted for palliative care. Imagine if every doctor in our country made rules like that for themselves.