Snakebite: Two years and 200 cases later

snakebite

We practice as independent doctors right after MBBS in Nepal. One of my professors used to say, “One day, you will sleep as a medical student and wake up as a doctor.” What that meant for me was, after I graduate from medical school, I’d pack my bags and head towards a rural village to “save lives.” Like any other life transitions, this one felt unchartered, unknown, and scary. I felt severely underprepared. As time passed by, I started appreciating my internship year. We have a year of internship after MBBS at the teaching hospital where we work as a junior doctor. At Beltar—my workplace, I’d remember how the patient with enteric fever was managed back home, brush up on the details with a quick read in UptoDate, and play doctor.

"One day, you will sleep as a medical student and wake up as a doctor." What that meant for me was, after I graduate from medical school, I'd pack my bags and head towards a rural village to "save lives." Like any other life transitions, this one felt unchartered, unknown, and scary. I felt severely underprepared.

The general structure of how I practiced medicine was; model what my professors used to do, read up on what is new/has changed, and treat patients. One day, some people carried a young child with droopy eyes, flappy tongue, and drowning in his saliva to the PHC. “He was bit by this snake!” The man with tearful eyes was holding on to a dead brown snake. Do you see a problem there? My go-to structure for practicing medicine crumbled. Underprepared would be an understatement. We were lucky that a team of trained armies helped set up the snake bite center in the PHC.

As some months passed by, I started feeling somewhat competent in managing snakebite cases. Any lesson you learn in medicine is a work in progress, but here are some I can recall:

The oversimplified version of snakebite treatment is–give antivenom and wait. In my experience, what we do while waiting, matters a lot. The neurotoxin that makes the patient paralyzed does not shut his brain down. He can listen and see, and we can use that to our advantage. Tell him what you are doing. Let him know what to expect. Talk to him. Open his eyes and make him see his loved ones are nearby. Make him believe that people are working hard to help him.

Amid scrutinized protocols, results of giant multi-center RCTs, and excellent well-formatted articles, it is easy to forget that what we do is taking care of a patient—the most basic of human skills. “LATERAL RECUMBENT!” I found myself shouting out of instinct. The patient was drowning in his saliva. My team tried hard to protect the patient’s airway as per protocol by extending his neck. But the patient was having a hard time breathing due to secretions. Sure we could not use the suction; unreliable electricity supply, broken suction machine, lack of funding, and whatnot, but we could still care. Use your mirror neurons; what would you want people to do if you were where the patient is?

Timely referral can be the difference between life and death. Understand the limitations of where you are working. Do you have a properly functioning suction? How reliable is your electricity? Do you have a ventilator? How far would you have to send the patient to get one? Manage your internal alarm accordingly. For us, the only respiratory support was a bag valve mask, and the transport to the nearest facility with a ventilator was at least 2 hours. Knowing that helps you be acceptably anxious and make informed decisions.

There is no substitution for empathetic yet informative communication with the patient and their loved ones. Clarify your assessment, plan, and signs that will prompt you to refer the patient. Talk to the anxious patient parties in a supportive tone but tell them that antivenom has ADRs, probably more than most drugs you use. When working in rural, especially in high-risk cases like snakebite, keeping the patient and their caretakers informed should be a priority.

Talk about ways to prevent snake bites. These beautiful creatures aren’t violent. Be interested in how the patient was bitten. After a while, you will start recognizing a pattern that you can use to educate the target population. Also, not everyone comes with the snake to the hospital. Have a poster of different types of snakes available. Identifying if the snake was venomous is one of the initial steps, after all. Print the local and national statistics about antivenom use and results and paste them in the waiting area. It will help patient parties calibrate their expectations accordingly.

A visual poster of common snakes found in Nepal placed at the entrance of Snakebite Treatment Center.

Summer and rainy seasons are when the unfortunate encounters between humans and snakes happen. It is easy to forget the snakebite management protocol, equipment necessary, what workarounds were used to help us, and what drugs we have in stock. A small refresher session can go a long way in boosting your team’s confidence in treating snakebites.

Snakebite Management Protocol posted in treatment center.
Logistics arranged for snakebite management.
Cite this article as: Carmina Shrestha, Nepal, "Snakebite: Two years and 200 cases later," in International Emergency Medicine Education Project, February 1, 2021, https://iem-student.org/2021/02/01/snakebite/, date accessed: April 21, 2021

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Hypoglycemia – A Rural Perspective

hypoglycemia - a rural perspective

Waiting for patients is among some of the weird perks of working in a rural ER. “Too little isn’t fun as well”, said an enthusiastic new paramedic at Beltar PHC. Later that night, I’d find a funny connection between what he said and what followed.

A 56Y/M patient is brought to the ER on a particularly silent evening. Following the usual ER premise; I reach the department from upstairs. The patient was unconscious when I arrived. A paramedic was trying to open a peripheral line, and a nurse was taking a pulse oximeter reading while keeping the patient at 2L via nasal cannula. The bystanders who brought him had no clue of what had happened or if the patient had any comorbidity. As I grabbed the glucometer from the drawer, I could not help but remember how in med school exams all the hypoglycemic patients were medics who injected themselves with insulin. As I poked the patient with a lancet and measured his blood glucose, I realized the paramedic had already given up trying to get IV access. “I couldn’t get in”, he said. The glucometer beeped exactly then as if to confirm “this is trouble” – 37! “That is hypoglycemia”, I exclaimed!

Although there is no universally accepted definition of hypoglycemia (low blood glucose), a level below 60 rings the bell. As I tried to establish the line, I requested my nurse to prepare a thick paste of glucose powder. Of all the medicine I was taught, one thing I’ve found the most useful is the “available” medicine. Sure, start with a bolus of the glucose-containing solution: D50 or D10, if you cannot get IV access go for IM glucagon and so forth. But when you’re working in a setting where you second guess yourself for wasting a lancet while checking a patient’s blood glucose, IM glucagon becomes nothing more than a very good test question.

I could not get the line started either. Minutes after we applied the glucose paste on the buccal mucosa, the patient woke up. The sigh of relief was audible in the small ER of our PHC. Eventually, we were able to feed the patient per oral. The patient turned out to be diabetic who thought, “insulin is a medicine, hence should not be ignored, but the food is optional.”

Clinical hypoglycemia is sometimes defined as blood glucose low enough to cause symptoms. For most people, this occurs at 50-60 mg/dL. Clinically significant hypoglycemia is confirmed by the presence of the ‘Whipple triad’. Yap, that’s the same Allen Whipple, the American surgeon who also coined the Whipple procedure! The presence of symptoms consistent with hypoglycemia, a low serum glucose level, and resolution of the symptoms and signs of hypoglycemia with the administration of glucose is what confirms hypoglycemia.

Because diabetics are most prone to get hypoglycemic, in a diabetic patient, hypoglycemia is defined as a self-monitored blood glucose level ≤ 70mg/dL. Everyone else must have a documented experience of Whipple’s triad for the diagnosis. There is also something called relative hypoglycemia, it occurs when a patient with diabetes reports hypoglycemic symptoms, but the blood glucose remains above 70 mg/dL. This still requires treatment. Remember, we treat patients, not numbers.

The causes of hypoglycemia can be diverse, but the horses include missed meals or overnight fasting but still using hypoglycemic agents (sulphonylureas, insulin) in a person with diabetes. Be vigilant about recent exercise enthusiasts, alcohol ingestion, weight loss, and renal failure (which can reduce insulin clearance).

Signs and symptoms of hypoglycemia in non-diabetic patients are generally fairly obvious. Sympathetic autonomic nervous system activation symptoms like nervousness, anxiety, tremulousness, sweating, palpitations, shaking, dizziness, hunger, and symptoms due to decreased availability of glucose to the brain; confusion, weakness, drowsiness, speech difficulty, incoordination, odd behavior are seen below the commonly quoted glycemic values of 50-60. In severe cases, hypoglycemia may result in seizures, coma, or death.

A logical treatment flowchart should start with a glucose-containing solution: D50 or D10. In regards to D50, be aware that the bolus may cause rebound hypoglycemia, may overshoot glycemic targets and is hypertonic hence should be given slowly over 2-5 minutes. There has been extensive debate over D50 vs D10, here is what I try to keep in mind; If using D50, give 1 amp at a time over 2-5 mins. If D10, a 100ml bolus over 2 mins. Check the patients’ glucose levels often.

Remember both of those approaches require you to have IV access. Intramuscular glucagon (5mg) may be given to raise serum glucose levels. Keep in mind two things: the efficacy of glucagon is dependent upon hepatic glycogen stores. Patients with prolonged hypoglycemia may have a minimal response and repeating glucagon does not make much sense.

If the blood glucose goes back to > 60mg/dL in a non-diabetic patient, and >70mg/dL in a diabetic patient and/or there is an improvement in symptoms, patients who can eat should do so otherwise IV dextrose drip (D5W at 75-100 mL/hr) is the way to go.

Cite this article as: Carmina Shrestha, Nepal, "Hypoglycemia – A Rural Perspective," in International Emergency Medicine Education Project, November 9, 2020, https://iem-student.org/2020/11/09/hypoglycemia-a-rural-perspective/, date accessed: April 21, 2021

Read Other Posts from Dr. Shrestha

The Rural Paradox

rural paradox

While trying to refrain from a complainer’s mindset, we often ignore discussing problems and hence seeking solutions.

The problem of having less time has existed from the day time and consciousness intersected. There are 24 hours in a day despite most of us wishing for more. I have been many things for many of those 24 hours: a student, an intern, a daughter, a friend, and a doctor. Most of the time, I’d be playing some combination of those roles. While an avid supporter of the make-time mentality, I have struggled with what one might call “Rural doctors paradox”. Simply put, the paradox is: there are supposedly fewer cases, and less severe cases in the rural, so few doctors are posted there which dramatically decreases doctor to patient ratio and has its multi-facet consequences.

What do you imagine when I say a rural doctor? How many patients a day does she look after? When does she wake up? How does her day go by? What does she reflect on while lying on the bed at the end of the day?

Not falling victim to the narrative fallacy, I would like to break this complex story into digestible chunks. Today I present you with challenges I as a rural doctor running a 24-hour emergency and a PHC can recall.

Beans again!

At the surface, it would seem like my mom’s lifetime of an attempt at hard-wiring my brain with negotiation skills failed when I agreed to buy potatoes at the offered price. The reason wasn’t my inattentiveness during those joyous negotiation classes I received, rather a phone call I used to dread the moment I stepped out of the PHC premise. “An unconscious middle-aged male is brought to the ER…”, said my health assistant. I was out buying vegetables for the week. I had to rush to the ER; 15 minutes of a run, tempo, hitchhiking, or teleportation.

Do hell with potatoes; I’ll make beans for dinner today, again!

Good but far.

“The view is serene, climate adequately cold and it is just 35 minutes away from here”. The picnic spot pitched by an office staff really stood out. Everyone was excited before we proceeded to choose, by lottery, the unfortunate souls who’d be in duty on the day. I was lucky enough to not have to stay, but that meant we would have to comply with the 30 minutes rule. Being 30 minutes far from the PHC would provoke anxiety of not reaching the PHC on time if need be. The consensus was it was not worth the risk.

Not me! The USG doctor!

“Why would the doctor make us wait for so long?”, said a patient to no one in particular. She has been waiting for her obstetric USG for an hour or so. After taking a quick shower to get rid of the stench and bacteria I accumulated from doing an autopsy on the days-old body, I rushed down to the USG room. “I hope no serious case arrives at the ER today!”, I find myself thinking. That day, while going to my bed, I reflected that the patient wasn’t mad at me for being late. Not the whole of me anyways. The me that was in the autopsy, she is fine. The patient was angry at the USG doctor. It just so happens to be me too.

Just another rainy day

Brinjals, Potatoes, Rice, and some medication: that is a typical to-get list of a villager who walks for quite some time to get to the marketplace on Thursdays. “My child often gets feverish! It was a market-day so I could not bring him with me”, says the 116th patient on a typical Thursday.

There are days when we literally wait for patients while enjoying the bright sun and delicious peanuts too. Busy-ness has a predictable spectrum in Beltar.

Like any other predictable spectrum, there are curve-balls once in a while. Those are the days that I remember the most when I look back.

Cite this article as: Carmina Shrestha, Nepal, "The Rural Paradox," in International Emergency Medicine Education Project, September 2, 2020, https://iem-student.org/2020/09/02/the-rural-paradox/, date accessed: April 21, 2021

COVID-19 Pandemic: Rural Preparations

Hoping for the best while preparing for the worst has been the theme of all medical institutes around the world, especially in counties that are yet to be hit by the dreaded tsunami of overwhelming COVID-19 cases. We have 191 positive cases 153 of which are in the hospital being treated and 33 have recovered. Fortunately, there have been no mortalities till date. [1] The current statistic may not look dreadful given the large numbers that we are exposed to daily these days. Before the cases reached 100, most Nepalese wondered, sometimes boastfully, why the cases are not spreading like wildfire. People went on record, crediting our culture of greeting with Namaste instead of a handshake, eating with hand instead of a spoon – which necessitates handwashing at least 4 times a day, the hygiene hypothesis, the fact that our country has only one international airport, and the universal coverage of BCG vaccination in Nepal. There are too many biases and heuristics at play here, but somewhere inside, I want to believe that at least some of them are true.

The Sukraraj Infectious and Tropical Disease Hospital (STIDH) in Teku, Kathmandu has been designated by the Government of Nepal (GoN) as the primary hospital along with Patan Hospital and the Armed Police Forces Hospital in the Kathmandu Valley. The Ministry of Health and Population (MoHP) has requested the 25 hubs and satellite hospital networks across the country – designated for managing mass casualty events – to be ready with infection prevention and control measures, and critical care beds where available. The Government is allocating spaces for quarantine purposes throughout the country and some sites have already been populated by migrants who recently returned from India. [2]

We have seen healthcare systems that are multi-fold advanced than that of our crumble when faced head-on with this illness. After working in the healthcare system of my country for 2 years, I am convinced that it will take a miracle for us to deal with this pandemic.

I have seen what preparations we are striving towards and what portion of it has been achieved. We are struggling to reach our preparation goals. That is not nearly as frustrating as the fact that many countries whose baseline was our goal have failed terribly. Today keeping the theme of workarounds rather than complaints about things outside of our circle of influence, I am presenting to you some preparatory works being done at Beltar PHC, a peripheral center located in one of the most affected districts, Udayapur, of Nepal. [1]

Credit, where credit is due: We have done 17878 RT-PCR, and 58546 RDT to find 191 positive cases till May 12, 2020. [1] We came up with a protocol and are also gradually updating it to meet the contemporary need. Funny word that contemporary is, especially now that no information gets to age before a new one replaces it. Speaking of temporary, a very recurring theme these days, there are temporary shelters made at every ward level in Beltar. People returning from abroad are kept in isolation for 14 days there. We run a temporary fever clinic at the PHC and refer suspected cases to higher centers for the COVID-19 test. We don’t have rapid diagnostic kits at the PHC yet. Our PHC with 26 staff has received 13 disposable PPEs that we have had the privilege of reusing. There is an Interim reporting form for suspected cases of COVID-19 (based on WHO Minimum Data Set Report Form) which can be downloaded and filled from the MOHP website. [3]

Available PPE at PHC level. Photo credit: Mr. Govinda Khadka
Fever clinic at Beltar PHC. Photo credit: Mr. Govinda Khadka
Quarantine setup at a ward in Chaudandigadi Municipality. Photo credit: Mr. Govinda Khadka

Lockdown was announced in Nepal on March 24, 2020. Excerpt from WHO Director-General’s opening remarks at the media briefing [4] on COVID-19, 25 March 2020 says this: “Asking people to stay at home and shutting down population movement is buying time and reducing the pressure on health systems. But on their own, these measures will not extinguish epidemics. The point of these actions is to enable the more precise and targeted measures that are needed to stop transmission and save lives. We call on all countries who have introduced so-called “lockdown” measures to use this time to attack the virus. You have created a second window of opportunity. The question is, how will you use it? There are six key actions that we recommend:

  1. Expand, train and deploy your health care and public health workforce;
  2. Implement a system to find every suspected case at the community level;
  3. Ramp up the production, capacity, and availability of testing;
  4. Identify, adapt and equip facilities you will use to treat and isolate patients;
  5. Develop a clear plan and process to quarantine contacts;
  6. Refocus the whole of government on suppressing and controlling COVID-19.”

In Nepal, there has been documentation of protocol for various aspects of the pandemic; PPE for each level of care has been decided, need to scale up the testing recognized, and even the support for Solidarity trials discussed. The protocol designed to tackle COVID-19 recognizes that different strategies for the rural and urban areas are necessary. The response to outbreaks in remote and rural areas where containment may be easier though assistance more difficult vs. outbreak in urban locations where containment is likely more difficult, but treatment and assistance likely to be easier.

The mist of immediate threat followed by the rubble of destruction it causes keeps us blind to the problems lurking in the background. As big and dangerous, if not bigger. Especially when you know nothing even vaguely similar to CARES-Act is being prepared for dampening the direct and indirect economic impact of the epidemic. Add to the fact that the American government’s CARES-Act already faces various criticism—that gives birth to anxiety for even the most seasoned economists. That is looking at just one domain of the post epidemic future. Healthcare might be crippled, social structure tossed over, politics somersaulted and people stripped off their faith. That may give rise to a jigsaw too complicated to attempt. It is high time we start thinking about solving some of those puzzles now.

References

1. Corona Info. Ministry of Health and Population. Accessed May 12, 2020. https://covid19.mohp.gov.np/#/
2. COVID-19 Nepal preparedness and response plan (NPRP) draft. April 9. Accessed May 10, 2020. https://www.who.int/docs/default-source/nepal-documents/novel-coronavirus/covid-19-nepal-preparedness-and-response-plan-(nprp)-draft-april-9.pdf?sfvrsn=808a970a_2
3. Reporting form for COVID. Accessed May 12, 2020. http://edcd.gov.np/resources/download/reporting-form-for-covid
4. Situation reports on COVID-19 outbreak, 25 March 2020. WHO | Regional Office for Africa. Accessed May 12, 2020. https://www.afro.who.int/publications/situation-reports-covid-19-outbreak-25-march-2020

Cite this article as: Carmina Shrestha, Nepal, "COVID-19 Pandemic: Rural Preparations," in International Emergency Medicine Education Project, May 25, 2020, https://iem-student.org/2020/05/25/covid-19-pandemic-rural-preparations/, date accessed: April 21, 2021

A case of decreasing resistance in ER

a case decreasing resistance in er

I keep games on the 4th home screen of my cell phone. The third screen is blank. A minuscule of energy required to swipe my thumb has prevented me one too many times from mindlessly launching an RPG. Only to realize 2 hours later I had other plans for those 2 hours. An American comedian, the late Mitch Hedberg famously joked once,

Mitch Hedberg (1968-2005)
Mitch Hedberg (1968-2005)

I have always believed that the subtle truths kneaded so artfully in seemingly light, small-talk-worthy jokes are what makes a comedian a genius. How many times have you thought that you need to pick up that particular grocery or fill up that one conference form only to instead get consumed by what was easily available?

Our mind is built so that it follows the path of least resistance no matter how insignificant the resistance is. Although smudged all over the canvas of self-help, non-fiction genre, medicine somehow isn’t used frequently to exemplify the path of least resistance.

Today, I present to you a case that inspired us at Beltar, to remove one such small resistance from our workflow. The implications as you will see were no less than life-saving.

Rural Health System : Oversimplified

Before I present to you the case, a small preamble: Health care in rural Nepal is still run mostly by paramedics. No matter what spectrum you fall in terms of appreciating their work, the fact remains that they are the major workforce we have at the rural. It suffices to say that they are the portal of entry to the health system of our country for many. All emergency cases, once screened and declared complicated, the medical officer (usually a MBBS doctor) at the PHC sees the patient. Majority of cases are seen only by paramedics – considering 3 to 5 paramedics, usually and barely one medical officer in most PHCs.

A mobile game I wouldn't play

Now that the characters are in place, let’s dive right into the no less than a fairy tale land of the rural health system. Lamenting about the obvious lack of resources has been so old school that I don’t even make a typo while typing about it these days. We had one ECG machine at Beltar. The old ECG machine with its squeaky sound and myriad varieties of artifacts stood with all its mighty bulk inside a locked door of a room. The key protected from no one in particular by the office assistant who would open the door, drag the machine out, bring it to the bedside. The paramedic who decided to do the ECG would then untangle the wire glazed with what little of gel we had applied to the previous patient. He would then connect the limb leads and the pre-cordial leads with the trusty suction knobs which hopefully has some gel left from the previous use and then comes the biggest connection to be made: connecting the machine to the power grid. “Don’t you keep your machine charged!?”, you ask. We do. But the Li-ion battery probably has undergone autophagy, or whatever fancy name the process is given. That is a lot of steps and by extension, a lot of resistance. If this were a mobile game, I don’t think I would be addicted to it.

A Race Against Time

A patient with diabetes who had visited our ER a couple of times before was being monitored for chest pain at around 7 AM on a Saturday morning. I was washing my clothes on the first floor unaware that my Saturday is not going to be about laundry and daily chores. When I was called to check the patient, she was already deteriorating at a rate far greater than our PHC could ever catch up. We tried to borrow the speed of an ambulance and refer the patient to a higher center. An ST elevation in any two contiguous lead is an MI. Our paramedics knew that. To everybody’s surprise, ECG was not done! Given the fact that we did not have cardiac enzymes available at the PHC and Aspirin was all we could have prescribed before discharge anyway: we gave the patient 2 Aspirin tablets to chew and referred her as fast as we could. My paramedic colleagues have demonstrated utmost clinical competence and professionalism too many times to doubt any of that. The work environment was still error-prone and the circumstance demanded a change. Could we have changed the outcome given the same resources and clinical scenario? Maybe we need to decrease the resistance I thought. Changing how we store ECG (shown in the picture below), making it more accessible not only increased the frequency with which it was being used but also served as a reminder. A physical question hanging down the IV stand asking anyone who is attending a case, “Do you need to use me?”

ECG machine in plain sight with IV stand holding the limb and pre-cordial leads for accessibility

Workarounds: Because Solutions are Late to the Party.

If you have been following my writings, you’d have noticed this as another small tweak, a workaround, a nudge to the existing system so to speak that isn’t the substitute for the actual sustainable solution. Robust training that helps hard-working paramedics conceptualize and understand the protocols related to the use of basic yet life-saving diagnostics like ECG can be a start. We tried printing and pasting some protocols on the walls; another workaround we hope would help make patient care better until it actually sustainably improves. Another workaround that a friend suggested was: everyone who aches above the waist, gets an ECG. Such simplification works well to decrease the resistance in learning complex protocols. I am sure there are plenty of workarounds used worldwide, a necessity, after all, is the mother of invention. I leave you with a thought: What effect do you think will a systematic sharing of such workarounds among the rural healthcare workers will produce?

Guides to ECG electrode placement and protocols
Cite this article as: Carmina Shrestha, Nepal, "A case of decreasing resistance in ER," in International Emergency Medicine Education Project, February 21, 2020, https://iem-student.org/2020/02/21/a-case-of-decreasing-resistance-in-er/, date accessed: April 21, 2021

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Rubik’s Cubing an Emergency Room

rubik's cubing

Lush green land and open spaces, fresh air that reminds us of how artificial our all-natural room fresheners smell, and quiet nights decorated with twinklings of a starry sky and the musical buzz of crickets. That is how most would imagine a village. Few of these imaginations remain borrowable if anyone were to engage in the same exercise in regards to an ER in the village. For starters, nights aren’t as quite, color and smell changes depending on what patient you are treating that day and the space of the room shrinks in proportion to the distance you traveled to reach that village.

Former Emergency Setup at Beltar PHC
Former Emergency Setup at Beltar PHC

Two years ago, when I was posted at Beltar Primary Health Care Center (PHC), little did I know that a sparsely populated village’s abundance of space rarely follows through to the emergency room. The obvious lack of infrastructure is, of course, the major problem. In the health system of Nepal, emergency services are designed to be provided at the hospital level. However, keeping the need for emergency services in mind, health workers in the rural areas are left to run makeshift ERs. At our PHC, what was supposed to be the waiting lobby for patients was used for an ER. The lack of a four-walled room meant that the only sense of privacy was provided by the patient’s fumbling awareness owing to intense pain and the physician’s focus completely overwhelmed by trying to be resourceful amidst obvious lack of resources. Hordes of curious onlookers crowding to see what was going on is a common scene in our ER that one would start ignoring after a month or two.

After banging our heads on problems that require far more resources and policies than that within our reach, we are left to take a sensible path – focusing on one small thing at a time and changing it for the better. Today I present to you an incident that inspired us to make an effort into making one such change happen.

A 28-year-old male

Like any on-duty doctor, I found myself rushing to the ER after a call. A 28-year-old male was brought after a sudden loss of consciousness while playing football. We quickly realized that CPR was in order and jumped right at it. Quite literally so, as the arrangement of beds in the ER was such that you could only deliver quality compressions if you are on the patient’s bed.

Elephant in the room

When I asked our paramedic to start bag and mask ventilation, he looked at me in confusion – the bed was placed against the wall and he would have to jump across the patient to provide one. Our nurse had to squeeze her way through the crowd of onlookers to find the needed medication. In the end, all of us were disappointed. Exhausted physically and mentally yet pondering on things we could have done differently, like any other resuscitation team would, after an unsuccessful CPR. After ruminating on the quality of CPR, availability of better equipment, training and all other aspects of a good resuscitation, we finally addressed the elephant in the room.

Bigger space or ...

The most obvious solution of shifting our ER to a bigger space was simply not an option. What we could do was make small changes that could make things a bit better. The nature of problem-solving has to be such that the biggest constraints remain (because we rarely can do anything about them). What is it that a bigger space adds? Big space adds orderliness. As I was pondering on this question, I had an idea that felt like an epiphany. I remembered one of my toys as a kid – a Rubik’s cube. We do not expand our Rubik’s cube to make it orderly. We rearrange it – you get to manipulate the pieces but not the whole cube. Thus, we started the mission of Rubik’s cubing our ER.

Rubik's cube

Rubik's Cubing

We had four beds in our ER. We wanted a separate resuscitation bed with enough surrounding space. We moved all three beds to one side of the room; installed two privacy screens instead of both a door and a wall (sorry onlookers!). We repaired and re-stocked the crash cart, placed each medicine in separate compartments in the drawers and labelled them properly.

Makeshift door using privacy screen
Makeshift door using privacy screen
Resuscitation area at Beltar PHC
Resuscitation area at Beltar PHC
Crash cart
Crash cart
Labelled medications
Labelled medications

A few weeks later, we performed CPR in another patient. The patient was rushed to our resuscitation bed, the privacy screens were drawn and the crash cart pulled near the bed. After we resuscitated the patient, we started the age-old culture of replaying the scene in our head and trying to figure out what else could be done. We obviously came up with a lot, this time too. But in terms of using the available resources, everyone was satisfied that they did the best they could make out of the situation.

Resuscitation will never be easy, but that is the precise reason we need to make it as orderly as possible. People who develop protocols and policies are doing their part. We, at Beltar, tried to do ours.

Cite this article as: Carmina Shrestha, Nepal, "Rubik’s Cubing an Emergency Room," in International Emergency Medicine Education Project, November 29, 2019, https://iem-student.org/2019/11/29/rubiks-cubing-an-emergency-room/, date accessed: April 21, 2021

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A Road not Taken: Patient Transport in the Rural

Patient transport in rural

Robert Frost’s left out road is much like the one, patients at Beltar PHC opt not to take. The reasons differ in some meaningful way. A child referred for evaluation and further management of sepsis after primary management is taken back home. The result is a misfortune, we usually blame to 49.2 kilometers of the road not taken the distance between Beltar PHC and a tertiary care hospital at Dharan. A severely anemic patient who clearly requires evaluations far more advanced than Beltar could offer was referred to a tertiary care. A day later, news of her demise at home ignited a discussion that has been going on since the establishment of the PHC itself. My intentions today are to discuss the possible reasons transport in rural areas is such an over looming problem. Some reasons are generic, while others are more specific to Beltar.

I vividly remember a case I suspected of stroke and decided to refer to a higher center. There are myriad of decisions and hurdles to work around in order to make the referral smooth. I remember being worried about my patients back in internship about not getting the 30 minutes earlier slots for CT scan. That compared to sending my patients to a different city for the scan seems like a funny worry. Even when you convince a patient that a referral is necessary, which is in itself a rigorous and overwhelming process for both the health practitioner and the patient party, there arises many hurdles to the process. Convincing a patient that half of his monthly income is worth the ambulance ride to a city with CT scan facility that will cost him his other half of the salary can never be an easy process. That combined with the possibility that the CT will come out to be normal is paradoxically a nightmare. Hurdles start to emerge from the least expected places. Spinal board to transfer patient to the ambulance, a simple start to make sure the patient does not move when the ambulance speeds on a bumpy road, oxygen cylinder for the travel, all are privileges that patients at Beltar PHC scarcely have.

Condition of Roads in Beltar
Condition of Roads in Beltar
Vehicles submerged during rainy season
Vehicles submerged during rainy season

Rivers surround Beltar; that means during the rainy season, transportation is very limited. So much so that, “We are referring your patient to a higher center” is a euphemism for, “We are sorry, that is all we can do here.” A gravid mother with thick meconium liquor was once referred in coordination with the municipality with the use of an excavator to cross the river. A proper functioning bridge across the river can solve this problem. The story of Beltar is many things; what it is not is a story without solutions. A common theme rather is a logical solution not implemented. Some reasons behind it are painfully obvious; others are yet to be explored.

Ambulance at Beltar PHC
Ambulance at Beltar PHC
Interior of ambulance at Beltar PHC
Interior of ambulance at Beltar PHC

Beltar PHC offers one ambulance at the subsidized fee of Rs. 4500 (US$ 39) for patient transport. It also has a fund of Rs. 50000 (US$ 432) for patients who can’t afford the fee for an ambulance. One ambulance is surely not enough for a PHC looking after 150 patients a day. What we could come up with is contacting the private vehicle owners of the area and using them in place of an ambulance. Although not as equipped, an oxygen cylinder tied to the back seat and the seat folded enough so that the patient can lie down converts any vehicle into a functioning ambulance. They charge more fare for the transport, which is another hurdle patients at Beltar face.

Patient being transported in private vehicles
Patient being transported in private vehicles

Many who visit the PHC view it as an alternative to more expensive and time-consuming tertiary care centers. That belief roots in the lack of knowledge about the hierarchy of medical care provided. This ties into the problem with rural transport because these patients view referral as a horizontal transfer rather than an upgrade of care.

Cite this article as: Carmina Shrestha, Nepal, "A Road not Taken: Patient Transport in the Rural," in International Emergency Medicine Education Project, September 6, 2019, https://iem-student.org/2019/09/06/a-road-not-taken-patient-transport-in-the-rural/, date accessed: April 21, 2021

Laceration Repair: A Rural Encounter

The word “emergency” carries some connotation with it. A lack of time to act, a situation that demands speed, a sense of acuity. Medicine on the other hand is related to healing, soothing and improving, a slow and gentle process. I sometimes wonder if the name of the specialty (Emergency Medicine) is an oxymoron.

Etymology aside, this specialty of medicine has meant at least two different things to me at two different settings. I have worked as an intern at Patan Hospital, a tertiary care center and as an in-charge of emergency services of Beltar Primary Healthcare Center (PHC), a government establishment in rural Nepal. I intend to describe my perspective and illustrate what different experiences of emergency medicine in different settings has to offer. I hope in doing so, I’ll be able to illustrate some of my workarounds that make the difference less overwhelming.

I have been posted at Beltar PHC, Nepal for the past 18 months. The center has been running primary emergency services. Initial stabilization and proper referral are two major ways Beltar PHC helps to save lives. The nearest city where cases are referred to are Dharan (50.5 km away) and Biratnagar (92 km away). Emergency personnel includes one doctor on call, one paramedic, two sisters for delivery and one office assistant. Laboratory and X-ray services are not available apart from office hours. Emergency investigations available include ECG, UPT and Obstetric USG. The government freely supplies medical equipment and a limited number of medicines.

Entrance to Emergency Services at Beltar PHC
Former Emergency Setup at Beltar PHC
Former Emergency Setup at Beltar PHC

A 27-year-old male

A 27-year-old male with a cut injury on his right forearm was brought to the PHC. It was a quiet day at the Emergency Department (ED) and most of the cases were OPD cases that did not make it on time.

One-way ED helps people here, albeit not an ideal way, is to act as a rescue for patients who travel long distances to get to the OPD if they do not make it on time.

The patient had a clean wound, about 5 cm long with smooth edges. We washed the wound using tap water; a practice equally efficacious to using saline but way more affordable for a rural setup. To suture the wound, we made our equipment ready. A long suture thread was cut from a nylon thread roll sterilized in betadine, some gauze pieces prepared by our office assistant that had been autoclaved and stored in an old dressing drum were taken out.

Suture materials at Beltar PHC
Dressing Drums at Beltar PHC

The thread was inserted into a needle, probably too big (turns out what needle size to use and when was a dilemma of privilege). Sometimes, we use needles that come with 2 ml syringes instead; they are sharper for skin penetration than the big suture needles our government freely supplies. The wound was sutured and the patient discharged.

That night I reflected on how things would have been subtly but significantly different at Patan Hospital. A sterilized suture set, autoclaved, packed and ready to use along with a ready to use surgical suture would be available. The procedure would have taken place in a more private space and not where visitors had the opportunity to peak in through our foldable privacy screen. Maybe the patient would have had to wait longer to get attention but the difference would not have been much, considering the time it takes to prepare every instrument here.

Each minor aspect of this difference deserves to be heard, talked about and their solution sought for. I plan to write about each of these as a series of article that follows. Proper resource allocation is a time and economy intensive goal; nevertheless the ultimate one. Maybe small workarounds are what we need during the period of transition, especially for places like Beltar.

Laceration repair is a common procedure in every emergency department. Setting differs and with it the availability of resources. Nevertheless, the core principles that govern patient care and the science behind it remains the same. While we wait for more convenient and sophisticated solutions, which all patients deserve, here are some points to remember regarding laceration repair that can help provide an acceptable standard of care even in resource-limited settings.

  • While working in rural, one should be well aware of its limitations. Some lacerations that require surgical consultation and need to be referred include (1):
    • Deep wounds of the hand or foot
    • Full-thickness lacerations of the eyelid, lip, or ear
    • Lacerations involving nerves, arteries, bones, or joints
    • Penetrating wounds of unknown depth
    • Severe crush injuries
    • Severely contaminated wounds requiring drainage
  • Non-contaminated wounds can be successfully closed up to 18 hours post-injury while clean head wounds can be repaired up to 24 hours after injury (2).

  • Drinkable tap water can be used for wound irrigation instead of sterile saline. At least 50 to 100 ml of irrigation solution per 1 cm of wound length is needed at a pressure of 5 to 8 psi for optimal dilution of wound’s bacterial load. The wound can be put under running water or can be irrigated using a 19-gauge needle with a 35 ml syringe (3).

  • Local hair should be clipped, not shaved, to prevent wound contamination(4).

  • Strict sterile techniques are unnecessary to be followed during laceration repairs. The instruments touching wound (sutures, needles, etc.) should be sterile, but everything else only needs to be clean(1). Clean non-sterile examination gloves can be used instead of sterile gloves during wound repair(5).
  • Local anesthesia with lidocaine 1% or bupivacaine 0.25% is appropriate for small wounds while large wounds occurring on limbs may require a regional block (1). Epinephrine should not be used in anatomic areas with end arterioles, such as fingers, toes, nose, penis, and earlobes.
  • Maximum doses of local anesthetic are as follow (6):
    • Lidocaine (without epinephrine): 3 – 5 mg/kg
    • Lidocaine (with epinephrine): 7 mg/kg
    • Bupivacaine (without epinephrine): 1 – 2 mg/kg
    • Bupivacaine (with epinephrine): 3 mg/kg
  • The suture used for skin repair include non-absorbable sutures (nylon and polypropylene) while absorbable sutures (polyglactin, polyglycolic) is used to close deep lacerations. For skin closure, silk sutures are no longer used because of skin abscess formation, their poor tensile strength and high tissue reactivity. In general, a 3–0 or 4–0 suture is appropriate on the trunk, 4–0 or 5–0 on the extremities and scalp, and 5–0 or 6–0 on the face (6).
    • Sterilization of sutures can be done by complete immersion in povidone-iodine 10% solution for 10 minutes followed by rinsing in sterile saline/water. Sutures that can be sterilized or re-sterilized include monofilament sutures (Prolene or Nylon) and coated sutures (Vicryl, Ethibond) (7).

Timing of Suture Removal (6)

Wound Location Time of Removal (Days)
Face
3 - 5
Scalp
7 - 10
Arms
7 - 10
Trunk
10 - 14
Legs
10 - 14
Hands or Feet
10 - 14
Palms or Soles
14 - 21

Tetanus Prophylaxis (8)

Wound Previous Vaccine Tetanus Vaccine
Clean Wound
Previous vaccine ≥3 doses - The last dose within 10 years
No Need
Previous vaccine ≥3 doses - The last dose more than 10 years
Yes
Previous vaccine ≥3 doses - NOT RECEIVED
Yes
Contaminated Wound
Previous vaccine ≥3 doses - The last dose within 5 years
No
Previous vaccine ≥3 doses - The last dose more than 5 years
Yes
Previous vaccine ≥3 doses - NOT RECEIVED
Yes + TIG

Factors that may increase chances of wound infection (9)

  • wound contamination,
  • laceration > 5 cm,
  • laceration located on the lower extremities,
  • diabetes mellitus

Antibiotics

  • Prophylactic systemic antibiotics are not necessary for healthy patients with clean, non-infected, non-bite wounds(10). 
  • Prophylactic antibiotic use is recommended for (11): 
    • human bite wounds 
    • deep puncture wounds
    • wounds involving the palms and fingers
  • Topical antibiotic ointments decrease the infection rate in minor contaminated wounds. 

References and Further Reading

  1. Forsch RT. Essentials of Skin Laceration Repair. Am Fam Physician. 2008 Oct 15;78(8):945-95
  2. Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a third world emergency department. Ann Emerg Med. 1988;17(5):496–500.
  3. Wheeler CB, Rodeheaver GT, Thacker JG, Edgerton MT, Edilich RF. Side-effects of high pressure irrigation. Surg Gynecol Obstet. 1976;143(5):775–778./ Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998;5(11):1076–1080.
  4. Howell JM, Morgan JA. Scalp laceration repair without prior hair removal. Am J Emerg Med. 1988;6(1):7–10.
  5. Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med. 2004;43(3):362–370.
  6. Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. Am Fam Physician. 2017 May 15;95(10):628-636.
  7. Cox I. Guidelines for Re-Sterilising Sutures. Community Eye Health. 2004;17(50): 30.
  8. Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-17):1–37.
  9. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J. 2014;31(2):96–100.
  10. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995;13(4):396–400.
  11. Worster B, Zawora MQ, Hsieh C. Common Questions About Wound Care. Am Fam Physician. 2015 Jan 15;91(2):86-92.
Cite this article as: Carmina Shrestha, Nepal, "Laceration Repair: A Rural Encounter," in International Emergency Medicine Education Project, June 21, 2019, https://iem-student.org/2019/06/21/laceration-repair-a-rural-encounter/, date accessed: April 21, 2021