What has COVID-19 taught us thus far.

On a brighter note, more than 150 countries have less than 100 cases as of April 5, 2020. That being said, there probably isn’t an unaffected country on our planet. I am from Nepal, and we have identified 9 cases with one local transmission as of April 5, 2020. One recovered, and 8 in isolation with no death reported to date.[1] It may be hard to comprehend the effect 9 cases have on a country where the probability of dying between the age of 15 and 60 years is 171 per thousand, but total expenditure on health is only 5.8% of GDP. The effect is fairly straightforward but too subtle to get the spotlight amidst this crisis. I contemplated if this is the right time to document these subtleties, but reflections are most useful for future reference only if made accurate. And a major component of accurate reflection is the “time since the event.”

I will take you to the time during my USMLE step 3 preparation and try to tie that in with my point here. One typical day during my preparation, I was doing my 2nd Uworld block and stumbled upon a deceivingly simple question. The gist of the question was: why do patients ask for euthanasia or physician-assisted suicide? I, in the hope of breezing through the question, answered physical pain. To my surprise, that was the most common wrong answer—the right answer: the anticipation of a lack of control and loss of autonomy.
If we are to understand the fear my country is going through, we need to let that information sink. The anticipation of a lack of control makes people ask for help in ending their life.

Nepal ranks 150 in terms of the overall health system in the world. I have been a doctor in one of the most academic tertiary care hospitals here, and I won’t hesitate a second to tell you that our health system will break the moment a fraction of the so-called tsunami of COVID-19 hits us. The country has been on lock-down for nearly two weeks now and plans to stay that way for some more days [Meetings is ongoing, and the final decision hasn’t been reached]. Of course, that will mean people will not have enough money to sustain. Patients of chronic illness will not have enough medicine. The country’s already crippled economy will be damaged beyond repair, and whatever first steps the country was attempting to make towards development will not only be held but legs fractured and eyes blinded. If God forbid, the pandemic hits us hard, no one in Nepal will have outrage that we did not increase the number of ventilators. That just isn’t a variable worth considering [to the general public], given our economy. We are talking about a country where when a village gets a USG machine; it is not used until inaugurated by someone at a position and the inauguration is celebrated like a festival. Everyone who understands the stake knows that we are praying to avoid a war we will invariably lose.

Having said that, I am impressed by the steps taken by the country. Lock-down was a gutsy move. Right when the director-general told people of WHO that lock-down is just a second window of opportunity for countries to prepare for what is to come, I was interested in what our preparedness looks like. Makeshift quarantine rooms are being constructed, test kits being brought in [Update: test kits were of too poor quality to use and hence were returned to China].[2] Patan Academy of Health Sciences, where I studied, has taken the initiative to make their own PPE. Some municipalities are mobilizing locals to make sanitizers, and the government is subsidizing some of the public expenditure. Of course, proportional to the country’s economy, but all this is happening when the country has 9 cases. Remember that actual physical pain was a wrong answer, and the anticipation of future suffering was the right one?

Number of ICU beds increased as preparation for COVID-19 at Patan Academy of Health Sciences, Nepal. Image by Saugat Sen Dhakal via https://www.healthaawaj.com/news/11928/
PPE being prepared at Patan Academy of Health Sciences, Nepal. Image by Saugat Sen Dhakal via https://www.healthaawaj.com/news/11928/

With people staying inside comes a myriad of difficulties. We have already seen it happen, “lucky” us! Everyone will start hoarding on essential supplies, which will increase the price because, apparently, the market still runs on supply and demand. Fear, loneliness, and abundance of time to ruminate on every minuscule of a problem on earth will start showing their effect. Depression, anxiety, and many other psychiatric morbidities will use the time as a breeding season. Household violence increases, and quality of life will take a big toll. Less affluent portions of the population will take a bigger hit in all aspects because inequalities in health are a double injustice; most affected are the people who are already suffering. The graph we hope to flatten will lend its height to the one plotting many other problems.

But we are willing to take that trade and probably everyone should. By no means am I saying that Nepal is doing a great preparation because I know it isn’t. There is much more we can do if we had the resources and global political influence.

We have seen countries with abundance kneeling before this virus. I pay my deepest sympathies to the lost lives around the world and even deeper respect to the frontline warriors. My message here, I guess: When prevention is better than cure is wrong not only because there is no cure but also because you know you will fail to provide care, you better prevent it as your life depends on it. Because it probably does.

Cite this article as: Sajan Acharya, Nepal, "What has COVID-19 taught us thus far.," in International Emergency Medicine Education Project, April 13, 2020, https://iem-student.org/2020/04/13/what-has-covid-19-taught-us-thus-far/, date accessed: July 11, 2020

References

  1. WHO. Coronavirus disease 2019 (COVID-19) Situation Report—76 [online], 06 apr 2020. [cited 2020 Apr 6]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200405-sitrep-76-covid-19.pdf?sfvrsn=6ecf0977_2.
  2. Sapkota R. Nepal to test COVID-19 test kits from China. Nepali Times [Internet]. 2020 Apr 1 [cited 2020 Apr 6]. Available from: https://www.nepalitimes.com/latest/nepal-to-test-covid-19-test-kits-from-china/ 

Headache – A Telephone Encounter

Headache - A Telephone Encounter

Learning happens in between cases in the ER. Be it a well-managed case by your colleague or a particular procedure you could have done differently. You learn something after each encounter. At times, learning happens when most unanticipated. Like when you are about to snuggle into your warm bed after a tiring day at the ER. My night was supposed to be calm, maybe punctuated by some calls by a concerned parent of minor flu ridden child, but calm nevertheless. You would not have completed rehearsing your thank you message that you are going to say the day after to the scheduler and the telephone rings. You pick it up because that is literally the only job description for tonight. Answer health queries that people might have. No wonder I was brave enough to feel cozy on the bed in the telemedicine room. It was a call from a 37-year-old female who lived in a village almost 3 hours from Patan Hospital, where I was.

At Patan Hospital, a telephone-based telemedicine service is provided 24/7 via doctors and interns working in the ED. Telephone encounter with a patient has its own challenges. For one, you don’t get to see the patient and hence won’t be able to tell the degree of discomfort. All your Sherlock Holmes like sharp power of observation that you have built through years of practice can only use one of the multiple senses. Listening becomes not only the most crucial skill but the only available tool you have.

Fear to land in the wrong place

Sometimes, you hear that one word that triggers the fast-acting, decisive and flight or fight-mode-run emergency physician in you. That forces you out of habit to think parallel while taking history. A boon and a curse in its own might, differential diagnosis starts popping up and canceling themselves. The goal is either 1) providing the patient reassurance that nothing serious is going on and she can visit a primary care in convenience or 2) urging them to visit the nearest ER because something sinister might be going on. The division seems very black and white but the near distance between the two divisions is so big that you fear to land in the wrong place without a return ticket.

Differentiating headaches

For a starting practitioner that I was, differentiating primary headaches was easier in a precisely articulated MCQ but rather difficult in a real patient scenario.

Temporally jumbled case history, intersecting symptomatology, and vital clues to the diagnosis buried underneath a mist of unrelated information constitute a patient history. To dissect through that mist and reach a sensible differential is an art that comes with practice. As I am sure I will reiterate in years to follow, I hadn’t honed the art form to the degree I have now. I present to you a telephone conversation between an intern on duty at telemedicine and a patient with a headache.

Telephone encounter

Patient

Hello! I have a bad headache.

Me

Hi, I am sorry you have a headache. Let’s talk for a bit; I will try to quickly characterize your headache and advise you on what to do next. Does that sound like a good plan?

Patient

mm hmm. I haven’t had this bad headache ever.

‘First or worst headache’ - this sounds like SAH.

Me

On a scale of 1 to 10, how bad is it?

Patient

I would say 8!

Headache severity

Me

When did it start?

Patient

Around 2 hours ago.

Me

Have you had comparable headaches or headaches on a regular basis?

Patient

Sometimes. I don’t remember.

Me

Do you remember how your headache started? Have you hurt your head?

Trying to rule out the obvious causes like trauma.

Patient

No, I came back from work. At first, I felt nauseous. Then the head gradually started throbbing. It felt like a drum was beating in my head.

At that point, I decided to open up UptoDate and look through the causes of thunderclap headache. SAH, cerebral infections, HTN crisis, Ischemic stroke, cerebral venous thrombosis – the list continued. (1)

Me

Apart from nausea, do you have any other symptoms?

Patient

I am finding it difficult to stay in bright light.

Photophobia! Could this be meningitis or migraine?

Me

Do you feel feverish?

Patient

No

Me

Any rash?

Patient

None that I see.

CNS infection checked off. I feared that I was asking too many questions. Had she presented to the ER, I would have managed her pain first, ruled out my differentials with history taking and sent her for appropriate investigations. The inability to accurately assess the degree of pain further adds to the limits of telephone medicine – you have to trust what you hear without having the opportunity to manage in real-time. History is essential to a proper recommendation, especially when that is the only tool you have – I thought to myself.

Me

Do you have any trouble seeing or walking?

Patient

No

She has been answering well, so no difficulty in speech - her neurological status seems intact.

Me

Do you have any other medical problems? Are you under any medication?

Patient

No. I just took paracetamol but it was of no use.

Me

Do you have nasal congestion or discharge?

Patient

Not now, but I had the flu a week back.

Acute sinusitis is another common cause of headache. (2) Having ruled out serious threatening causes of headache. I was relieved – this sounded like a case of the primary cause of headache, a common presentation in every ER. I needed to remember the differences between different primary headaches – a quick UpToDate search away. Maybe, telemedicine does have some pros – like searching up the internet might not have been very appropriate while talking to your patient.

Me

Where is your pain? Does the pain seem to spread to any other area?

Patient

It’s just in front of my head.

Me

Did you feel anything abnormal before the headache started?

Trying to rule out any aura

Patient

No

Me

Do you feel the urge to isolate yourself and not hear loud noises.

Patient

No. Not really.

Me

From my evaluation, you seem to be having a tension headache. It is not a serious condition and is the most common cause of people presenting with headaches. (3) But I would suggest you visit your nearby health center to ensure you get the right diagnosis nonetheless.

Learning is the summation of moments

Learning is the summation of moments we really understand something, those aha moments, ones that feel like an epiphany. I always knew photophobia and phonophobia occur in migraine and not in tension headache. I may even have read before that day that one of those can happen in tension headache as well. But never had I ever imagined that one day I would reassure a patient that she has a tension headache because she doesn’t have both. The nature of medicine is such that we really learn something after each encounter.

References

  1. Schwedt TJ. Overview of thunderclap headache. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/overview-of-thunderclap-headache
  2. Dodick D. Headache as a symptom of ominous disease. What are the warning signals?. Postgrad Med. 1997;101(5):46–50,55–6,62–4.
  3. Jensen RH. Tension-Type Headache – The Normal and Most Prevalent Headache. Headache 2018; 58:339.

Further Reading

Cite this article as: Sajan Acharya, Nepal, "Headache – A Telephone Encounter," in International Emergency Medicine Education Project, January 20, 2020, https://iem-student.org/2020/01/20/headache-a-telephone-encounter/, date accessed: July 11, 2020

Macro-lensing the Emergency Department

Macro-lensing the Emergency Department

How do you remember the emergency department (ED) that trained you? Could it be that you have learned a lot more than just medicine there? Between worrying about the delayed laboratory report and explaining the need to rule out a myocardial injury to a visitor of a patient with peptic ulcer disease, you might have picked up other attributes. Subtle traits that have nudged your personality. Remembering the ED where I did my internship sparks nostalgia and makes me want to speed up my typing. As if I need to attend to something else right after this. Hopefully, I’ll give you a glimpse of what putting on different lenses can show even when we look at the same object.

Peeling yellow paint, some old cracks in the wall, and an acute sense of urgency lingering in the air are what I remember of the department. Patan Academy of Health Sciences has an ED where confused students scratching their heads to the witty professors’ question takes you to your own golden days. A subtle grin on the wise face of a grey-haired professor eagerly waiting for the next wrong answer makes you want to reach out to your old mentor. A know it all student on the verge of blurting out the answer physically holding himself behind makes you wonder what that one classmate of yours is doing these days. It is a place where teaching, helping people, running against time and having fun while at it, blends into an experience of a lifetime. Stories of eased pain, dodged suffering and narrow escapes from grave aliments enrich the history of the department.

One fine evening in the department as an intern I found myself seated in the doctor’s station, a rare but insightful experience. I found myself pondering about the lessons I can take from this part of the hospital: not just medical knowledge but lessons I can share with people from different facets of life. Below I list the common situations or sayings used in a typical ED and try to translate it for use in day to day life.

Think horses before zebras but watch out for zebras that can fly

A patient with mild fever, chest pain, and some respiratory distress probably has some sort of URTI. But the very fact that he/she landed up in the ED makes the doctor order an ECG because of the chest pain. The doctor will, of course, be leaning towards a more common diagnosis. Ruling out a diagnosis with grave prognosis, however, will be among the top priorities. 

searching zebra

This can translate into studying common exam materials while also being aware of the zebras. Zebras show up rarely, but when they do, they tend to be stubborn. Be aware of the topics that don’t usually show up in your exam but impact the outcome when they do. We can also borrow this idea while thinking about anything in general. We tend to assume the worst, but when your date is late to dinner, it probably is just the busy traffic.

Communication is the key

A medical officer reads the patient’s history to the professor using as few words as possible, pertinent negatives and a precise format. The information and condition of the patient are conveyed very accurately. When reporting history, we aim for effective communication at its best. 

communication

I wonder how many day-to-day problems can be solved if only we communicated that efficiently outside of history taking and reporting. Using clear words, very few fillers and addressing what we don’t mean beforehand can help in getting the intended message across.

Prioritizing

The most critical patients that visit Patan Hospital head for the ED. Recognizing them and treating the ones who need immediate attention is the second nature of a good emergency physician. Likewise, being able to focus on the most critical aspects of one’s life can be an attribute worth borrowing from the department. 

prioritising

How many times do we complain that we just do not have enough time to do things that are important to us? It’s mostly about deciding what comes first.

Resource allocation

This sort of ties into the previous one. Most experienced physician attends the most critical patient. More nurses are allocated to and the best USG machine is used in the red triage area. Time, money, physical or mental effort all are resources we use to get tasks done. Sometimes success differs from failure, not in how much effort is put but where it is used. Determining which task is most resource-intensive or most productive can be a worthwhile idea to learn from the ED.

resource allocation

Did you check your tools?

Monitor connected to a gradually stabilizing patient beeps rapidly, indicating a sudden collapse. As you run towards the patient with your ACLS neurons firing at a rate more rapid than the patient’s declining pulse, do take a look if the pulse oximeter is connected correctly. Translated in the world where things go south more frequently than not, decide if it is a perceived problem or a real one. How many times have you let yourself go into flight or fight mode only to realize that the threat wasn’t even there?

Give thiamine before glucose

Hypoglycemia kills. Glucose save lives. Even then, giving thiamine before glucose is the norm in most EDs. The biochemistry behind is simple; thiamine is a cofactor used by many enzymes in glucose metabolism and depleting more thiamine can cause Wernicke Korsakoff disease. Look at it with the lens of a student who needs to start preparing for an exam. Determine your thiamine (proper sleep, good food, exercise, enough water and probably mindfulness). Only then glucose supplementation (studying) will yield results.

The loudest screamer isn’t always suffering the most

“How do you triage when there are more people than you can attend to?” asked a professor. The answer was funny but made a point firmly. “You should ask the most critical patients to come forward. Then you attend those that are left behind!”. The idea being; sickest of them all won’t even be able to advocate for themselves. Similarly, we can be tactful when overwhelmed by problems. Try to come up with ideas to segregate the screamers (problems that seem to be the biggest) from the sickest (actual problems).

triage

Know your limits and ask for help

We manage acute exacerbation of COPD in the ED. Not all patients that feel relieved are discharged from there. Some patients require medical consultation and transfer. This, in no way, means that the ER physicians are incompetent in managing the disease throughout. Rather it is the evidence of understanding the job description and trust in the system as a whole. Asking for help when need be is critical to our wellbeing. Being able to ask for help shows courage and humility above all.

knowing limits
Cite this article as: Sajan Acharya, Nepal, "Macro-lensing the Emergency Department," in International Emergency Medicine Education Project, October 28, 2019, https://iem-student.org/2019/10/28/macro-lensing-the-emergency-department/, date accessed: July 11, 2020

A Medical Student’s Encounter with Disaster

a medical student's encounter with disaster

25th April 2015

A 7.8 magnitude earthquake struck Nepal on 25th April 2015, affecting 35 of the 77 districts of Nepal and causing a death toll of over 8000 lives with 22,309 people reported as injured and an estimated 2.8 million displaced. The following article is based on the first-hand experience of a then fourth-year medical student from Patan Academy of Health Sciences, a tertiary care center in Lalitpur District, one of the worst-hit districts in Nepal.

Rescue work following 7.8 Richter scale earthquake. Image by Omar Havana via https://www.theatlantic.com/photo/2015/04/nepal-after-the-earthquake/391481/
Rescue work following 7.8 Richter scale earthquake. Image by Omar Havana via https://www.theatlantic.com/photo/2015/04/nepal-after-the-earthquake/391481/

Reflection

25th April 2015, started off as a casual Saturday morning. At the boy’s hostel, everyone was preparing for the inter-medical college football tournament which was to start off that day, until the first jolt changed plans for the whole day and many more days to come. Our first response was to rush out of the hostel and make sure our family members and friends were okay. Just as all of us were frantically, unsuccessfully so, trying to contact our families, a friend of mine came running and informed that all medical students were to go to the hospital with their aprons. We had not even considered going to the hospital until my friend arrived; maybe because none of us had faced such a situation before or because we were yet to come back to our right state of mind.

Students ready to receive disaster victims. Image by Online Khabar via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Students ready to receive disaster victims. Image by Online Khabar via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

As we reached the hospital, it was already flooded with injured patients from the disaster. Everyone started doing what they could. Some started giving analgesics to people who were agonized by the pain, some started talking and trying to calm down people who were on the verge of hyperventilation, some took gauge pieces and pressed it against the bleed on people’s head and some helped in patient transportation. There were a lot of people doing a lot of things, but neither was I in very observant state of mine nor could I recall enough now to mention the minute details. One thing I remember with absolute clarity is that me and my friends (as I found out in the after talks) forgot that we were trying to contact our families when we were called.

Medical students providing Tetanus Toxoid injection to victims. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Medical students providing Tetanus Toxoid injection to victims. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

A lady was lying on the floor, covered with mud, she wasn’t moving at all. My friend and I suspected she was seriously injured but didn’t see any obvious wound from where we were standing. We went near and tried to feel the carotid pulse. Never in my life had I even remotely imagined that one day I will confuse whether or not the carotid pulse is present. But there I was. I didn’t feel the pulse, but I was reluctant to admit that she didn’t have one; so we decided to ask one of our teachers. We did and got the obvious answer. Now we were to put the black tag on her and take her to the black area. She was the first to be taken to the black triage. Before putting her down from the stretcher, we took the pulse again. It was one of my first encounters with death declaration.

I came out of the front door and was among a lot of injured patients; nerve wrecked students and doctors trying to help people in the best possible way. It was then that most of us remembered that we hadn’t contacted out families yet; maybe sadness had taken over our survival instinct or maybe we were learning to keep our professional duties up ahead. This continued for the day and the next day was nearly the same; only a little more organized. Basically, the name of the game for the couple of days that followed was help in all that you are capable of.

Apart from being the most traumatizing experience of our life until now, this earthquake also taught us some lessons and profoundly so. I knew that survival instinct takes over everything at first when you perceive a threat to our life; however, once you are just out of the instinct and see before you, the circumstance that you are trained to deal with, you prioritize things and work in the line of your training.

Survival instinct takes over everything at first when you perceive a threat to our life...

Students raising awareness to prevent possible outbreaks. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Students raising awareness to prevent possible outbreaks. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

a need for disaster curriculum to be rigorously taught to every medical student.

One thing that I realized while trying to help the casualties that will help me every time I sit to study is: no matter how much you memorize stuff until you really understand something well, you won’t be able to use the knowledge when it is most needed. The disaster drill that we performed a few months before the disaster helped us make sense of triage, proper transportation and of what was happening. I realized the importance of training and keeping myself updated on skills that we need at times when we are less likely to think rationally. Also, I felt a need for disaster curriculum to be rigorously taught to every medical student. Medical students formed an important workforce during this disaster. Having occurred on the weekend, medical students were the most readily and adequately available resource. However, with limited knowledge and skill, medical students left to work unsupervised are prone to cause harm to themselves and patients; hence proper training and work delegation are required so that they can become a better-skilled workforce.

This was yet another example for me to ponder and reinforce upon myself that not everything will go on as planned; hence, I need to keep myself updated and work on my improvising skills. This event as devastating as it was also made me feel proud of what I am training to become and instilled in me more passion towards my profession.

Further Reading

  • World Health Organization, Regional Office for South-East Asia. Nepal earthquake 2015: an insight into risks: a vision for resilience. New Delhi, India: World Health Organization, SEARO; 2016. Available from: https://apps.who.int/iris/handle/10665/255623
  • Sheppard PS, Landry MD. Lessons from the 2015 earthquake (s) in Nepal: implication for rehabilitation. Disability and Rehabilitation. 2016 Apr 23;38(9):910-3.
  • Nepal earthquake of 2015 – link
Cite this article as: Sajan Acharya, Nepal, "A Medical Student’s Encounter with Disaster," in International Emergency Medicine Education Project, August 5, 2019, https://iem-student.org/2019/08/05/a-medical-students-encounter-with-disaster/, date accessed: July 11, 2020