Mozambique Emergency Medicine Is On The Rise

Mozambique Emergency Medicine Is On The Rise

Africa is a magical continent. It is filled with unique cultural energy. I promise you will never regret diving into this experience. Whether in a park celebrating a wedding, or simply celebrating life at a night club. Africans are master of this, the magic spreads through the air, and you can feel it.

Image by Idílio Chirindja from Pixabay

I had an incredible opportunity to experience Mozambique. In the middle of many English speaking countries, an island speaking Portuguese language.

The country is in the southeast of Africa. The capital is Maputo, which was invaded by Portugal in 1505 that established dominion until 1975 when Mozambique gained its independence. But after that, the country lived years of intense civil war until 1992. Since then Mozambique has lived in a period of relative political stability.

The official language of Mozambique is Portuguese but is spoken mainly as a second language about half of the population. Among the most common native languages are Macua, Tsonga and Seine. The population of about 29 million people is predominantly made up of Bantu peoples.

My story meeting Mozambique

Every time you have doubts about the work is done on the Internet, which many may think irrelevant, I want to say to you that I owe my medical career as an Emergency Physician to #FOAMed. Emergency Medicine was recognized as a specialty in Brazil only in 2015, after many years of struggle. So, we didn’t have much information about this specialty which is still unknown to many students who are currently choosing the specialty, as it was with me. But the fact that someone writes something down and makes it accessible on the internet can really change lives. What led me to understand who I was and what I wanted to do in medicine was this text by Joe Lex. I found my people. My tribe. I understood who I was and fell in love with Emergency Medicine.

After knowing so many amazing FOAMed blogs (emdoc, emcrit, rebelem, etc.), I was so inspired and wanted to do for emergency medicine in my country. I want to create a FOAMed content so that people like me could discover our specialty earlier. And it has to be in Portuguese.

English is important, but nothing so comforting than reading content in your own language. You can think and retain the new knowledge faster, and you can translate the knowledge better to the patient. Understanding is clearer, more accessible, and also brings a sense of belonging and appreciation.

So when I met Abigail Hankin-Wei, we were committed to producing emergency medicine content in Portuguese for the sake of our emergency medicine training programs. Abigail is an inspiring person, who is an emergency physician from the US working in Mozambique full-time to help build the country’s first emergency medicine training program. The residency program is the first one in the country established in 2016, with six young and passionate residents. So I went there to make our bond stronger.

The thing I love most in our specialty is the tribe feeling — the way we immediately recognize the passion in each other. So when you talk about medicine, you know, you understand, you feel belonging to a place, you know that you aren’t the only one crazy doctor that likes to take care of very sick patients. In my routine daily life, it is difficult to encounter this kind of bound.

So, coming to Mozambique and meeting these residents (Brito Gulela, Dino M. Lopes, Euridxe Barbosa, Maria Augusta Taimo, Hermenegildo de Jesus da Silva Macauze and Ezio Massinga) and two more physicians from US (Patrick Connel and Rodolfo Loureiro) were the same exactly how I felt. I was among friends, equals, and I felt like I was at home.

The Story

In Mozambique, we worked at the Mavalane Hospital. I assumed that it is a secondary level hospital, but with a real lack of support. The patients were respiratory failure, abdominal pain, fever, malaria, tuberculosis, lots of complications of HIV, acute stroke, high hypertensive emergencies, etc. They could only provide oxygen (with limitation), and some basic medications.

In the first week, the x-ray machine was broken, but the show must go on, and they did the best they could, treated the most likely disease in their environment with little room for a thorough investigation. They placed the sickest patients in a separate room, the only room in the department where they could get oxygen therapy, which came in two large cylinders. They transferred the most severe patients (which had to be very sick) with potential for recovery to the Central Hospital. As Patrick used to say, the work of the Emergency Physician is to separate the sheep from the goats, so they have to learn as best as they can.

One brilliant thing was the use of POCUS, which is a great value in this context, and I was able to learn a lot from them as I still developing my skills. In need of a CT imaging, the patient has to be referred to the Central Hospital (level one, but still with many limitations). It has to be really thought through because there are limited spots daily. Some conditions could be done, some conditions not. It should change treatment and outcome in a patient with possible good prognosis.

Sometimes the days were really harder, especially when you achieved a certain level of treatment, and you did not have more options to use. They couldn’t do fancy things like NIMV or intubation, or continuous infusion of drugs. They do what they could with their best, and we wait and hope.

The human body is amazing, they are particularly strong here, and one thing I brought with me from this experience is that some patients really get better despite our limitations.

Of course, it would be a lot better to help all patients get better faster and safer. But really, our job is not the most important part. The body is the king. We need to recognize this as quickly as possible in our careers and understand how much we should hasten an improvement and how much we should just wait from the body, without feeling resentful of ourselves when the body achieve its’ limitations, because, in fact, we (as doctors) don’t have that much power as sometimes we think we have.

The environment is harsh. The team has to be practical. Patients give themselves to care, and the team does what they need to do with what they have. Sometimes it was hard to see that cold reality. But again, I could testify how education and love can save the world! In one week, I could see the work of the residents changing everything, turning everything better, lighter, humanized with meaning. They educate the team; they treat the patients with passion and respect; the team wants to be like them: education is the power.

You have to celebrate each small victory

From time to time you should remember and appreciate people for the little good things they do, even if seems small in a big context. So, they don’t forget the small victories, that is what gave us fuel to keep going.

When I was about to leave, we set and talk about their expectations. I could not be more inspired by their clear awareness. They know the hard work that is ahead. But they have dreams about a more organized emergency health care system. They have a passion (inherent in the emergency physician). They have a good heart, strong determinations, vision, and they are smart.

They truly have the magic!

Patrick

They know there’s still a lot of uncertainty, will the specialty be recognized someday? Will be a place to work? Will the residency grow? Will they have a spot in the most important hospital? They don’t know yet. But they are studying, traveling, receiving people of around the world with humbleness, willing to learn, to improve, to be able to do the most exciting things for their patient and their country. 

I would like to remind that planting an unprecedented program in such an arid place is work for many people. And this team needs recognition, so my special thanks to Dr. Kevin Lunney, who creates PLeDGE Health ONG, that is helping support the residency program.

Special thanks to Sarah Mondlane to her work at PLeDGE Health, and for being the sweetest, kindest hostess in the world. Her love for this cause is pure inspiration.
And thank Dra Otilia Neves, member of the Ministry of Health, and coordinator of the program, who kindness accepted us in Mozambique.

I hope that the work of this team resonates forever in Mozambique.

Cite this article as: Jule Santos, "Mozambique Emergency Medicine Is On The Rise," in International Emergency Medicine Education Project, September 16, 2019, https://iem-student.org/2019/09/16/mozambique-experience/, date accessed: December 12, 2019

Acute Ischemic Stroke Management in the ED – Part 1

Acute Ischemic Stroke Management

Your shift has just started, and you received a 56-year-old female patient, brought by her family due to a sudden loss of movement. The patient seems awake; you approach her, introduce yourself, and ask for her name. She does not understand. You ask her to look at you and to raise her arms, then you see: the left side of her body was paralyzed. In your head, a stroke sign lights up: you need to decide whether to activate the stroke protocol immediately or not, after all:

Time Is Brain

Important Hints

  • Know the protocols and references of your hospital and your region for acute stroke management. Your Emergency Department should be prepared to suspect of stroke in any patient presenting with acute neurological deficits and have a pre-established protocol for prioritizing care.

  • The prehospital service (EMS) should provide notification to the receiving hospital that a suspected stroke patient in the therapeutic window is en route and direct the patient to the closest hospital with thrombolytic support.

  • By AHA/ASA recommendations, door-to-needle time <60 minutes should be sought in more than 50% of patients treated with alteplase (tPA) (1)

Neurons are very sensitive to changes in brain flow and die within minutes in the absence of perfusion: thus the urgency in attempting rapid reperfusion. (2)

Do not delay the patient evaluation because the emergency department is overcrowded! Move the patient to a monitored bed as soon as possible.

While the patient is being monitored, continue your focused neurological examination quickly and accurately. Asking for the patient to lift and hold the arms, then the legs, tests sensitivity and strength. Then you should ask her to try to smile, assess the eye movement, pupils, search for nystagmus, and ask her to try to expose the tongue, assessing movement and understanding. You ask her simple questions: full name, date, where she is, point to a cell phone, a mug and a watch and ask if she recognizes them. At the same time, you evaluate strength, orientation and deficits.

VITAL SIGNS
Blood Pressure: 180/110 mmHg
Pulse: 125 bpm
SatO2%: 98
Respiratory Rate: 18 bpm

Do not forget to measure capillary GLUCOSE (135mg/dl). Important to rule out other causes of neurological symptoms that can mimic a stroke.

Hypoglycemia

Hypoglycemia is the first condition we evaluate for when the patient presents with acute neurological deficit, decreased level of consciousness, weakness, syncope, convulsion, etc. Hypoglycemia is defined by a blood glucose level less than 45 mg/dl. Symptoms improve rapidly as soon as corrected in most cases. However, it may take time for a complete improvement, and does not always rule out a stroke. (3)

Seizure

Seizure and post-ictal condition are also conditions that can mimic a stroke. Todd’s Paralysis is a focal weakness localized to one side of the body, which occurs around 13% of seizures. These deficits usually last up to 20 minutes but may last 48 hours. Unfortunately, seizures may present in the setting of acute stroke or patients with a stroke history due to neuronal damage. (3)

Stroke Mimics

Stroke mimics are common, accounting for 5% to 31% of patients with acute focal neurological deficit. (3) Diagnosis is not always simple, and abnormal eye movements, increased diastolic blood pressure greater than 90mmHg, and history of atrial fibrillation or angina are most commonly found in stroke. In the presence of decreased level of consciousness, cognitive dysfunction and normal eye movements are more common in stroke mimics.

Stroke Mimics

Condition

Misdiagnosed as stroke (%)

Brain tumor
7-15
Labyrinthitis
5-6
Metabolic disorder
3-13
Migraine
11-47
Psychiatric disorder
1-40
Seizures
11-40
Sepsis
14-17
Syncope
5-22
Transient global amnesia
3-10
Other
11-37

From Konrad CN, Crocco T, Biola J, Larrabee H. Is it stroke, or something else? The Journal of Family Practice. 2010 Jan; 59 (1): 26-31.

The time is ticking, and you must make critical decisions.

  • Is it a stroke? Or a disease with an acute neurological symptom that mimics a stroke?

  • I need a brain imaging study in less than 20 minutes. (2) Will I need to protect the patient's airway before, or should I go straight to the imaging exam?

  • What brain imaging study do I have and what should I do first? CT or MRI?

  • Is there an indication for IV alteplase? Should I do it in my unit, or should I referral the patient to another center?

  • Are there indications for mechanical thrombectomy? Should I do CT angiography at the same time?

Management of acute stroke will depend on:

  • The support you have.
  • Time of onset of the stroke, that is, duration of symptoms.
  • The severity of symptoms:
    • Physical examination: NIHSS, etc.
    • Signs of a large vessel stroke
    • Area of irreversible ischemia “core” versus penumbra area, salvageable area
  • The desire of the patient/family after being informed of the risks/benefits.

Clinical History

The clinical history must be acquired quickly and directly. Essential points: time of symptoms, associated symptoms, comorbidities, and medications of continuous use.

It is important to note that the time of the symptom is counted from the last time the patient was seen without symptoms and not when someone noticed the deficit. (1) If the patient woke up with the deficit, time counts from when he/she was seen without symptoms (e.g., the day before bedtime).

Laboratory, Imaging, Management

Unnecessary tests should not delay brain imaging. It should be performed within 20 minutes of the patient’s arrival at the hospital!

If you do not have a CT scanner in your hospital, the patient should be referred for a center that has one, preferably with a stroke unit. In this situation, physical examination and accurate data of the clinical history must be passed to the place of reference. A physician should accompany the patient.

Treatment of blood pressure only if BP> 220 x 110mmHg, preferably with easy-to-control intravenous medication (labetalol, nicardipine, sodium nitroprusside, etc.). Avoid oral medications due to bronchospasm risk and unpredictable effect. Not having intravenous options, I would consider tolerating hypertension until the diagnosis is confirmed.

Venous access with the collection of samples such as complete blood count, electrolytes, renal function, TAP, APTT, troponin, and more as needed, according to patient comorbidities and medications.

Do not delay the brain image waiting for the collection of laboratory tests. Do not delay imaging or therapy with tPA expecting laboratory test results, unless it is essential.

Venous access before the examination is essential if there is a decision to perform CT angiography of cervical and intracranial vessels in the possibility of mechanical thrombectomy. However, performing CTA should not delay the performance of chemical thrombolysis if indicated. That is, the radiology sector should be prepared to perform immediately after CT if indicated.

Which imaging test is the best? and Why?

MRI

Weighted MRI diffusion shows a greater positivity than CT in the first 24 hours for ischemic stroke, especially in the vertebrobasilar territory. However, its role in ED is still limited because of its uncertain accuracy for the diagnosis of acute hemorrhage, low immediate availability, patient contraindications (not cooperating, claustrophobia, metal implants, pacemaker, etc.) and cost-effectiveness.

CT

CT without contrast, is relatively accessible in most reference centers. It discards other causes of neurological deficit such as ICH, abscess, brain tumor, etc. It may not diagnose acute stroke. But together with a compatible clinical story, it is the only necessary brain image for performing IV alteplase. (2)

Every patient with acute neurological deficit, independent of time, must perform a brain imaging, mainly to rule out other causes, such as ICH, which completely changes the treatment.

All patients with acute neurological deficits, mainly without a diagnosis, must be accompanied by a physician assistant during transfer to imaging, due to the risk of abrupt change/worsening of the clinical status.

It is important to have communication between the ED areas, to warn the radiology department in advance that the patient is on the way, and that the exam should be prioritized. (2)

You accompany the patient during the CT scan. And this is her exam:

Do the best you can, ask for help when in doubt, study and care with love.

To Be Continued.

References and Further Reading

  1. Tintinalli, Judith E.,, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Eighth edition. New York: McGraw-Hill Education, 2016.
  2. William J. Powers et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. AHA/ASA Guideline. 2018 Mar;49(3):e46-e110. doi: 10.1161/STR.0000000000000158. Epub 2018 Jan 24.
  3. Brit Long, MD, Stroke Mimics: Pearls and Pitfalls, http://www.emdocs.net/stroke-mimics-pearls-and-pitfalls/ em 07/05/2019
Cite this article as: Jule Santos, "Acute Ischemic Stroke Management in the ED – Part 1," in International Emergency Medicine Education Project, August 9, 2019, https://iem-student.org/2019/08/09/acute-ischemic-stroke-management-in-the-ed-part-1/, date accessed: December 12, 2019