Fight against superdrugs

October 11, 2021August 25, 2021 ~ Sajan Acharya, Nepal ~ Leave a comment

This is an essay I wrote for the Antibiotic Week celebrated at Patan Hospital back when I was a medical student. Here I portray myself as a happy bacterium that is thriving in a world where antibiotic stewardship is not followed.

Anti-Antibiotics week has been being celebrated in the bacteria world since the first beta-lactamases were invented. This year, an adolescent staphylococcus with a lot of wisdom is giving a speech.

VRSA, the vice president of Fight against Super Drugs Development (FSDD), has been actively advocating (mechanisms of antibiotic resistance) among less privileged groups of bacteria. “Triumph of hope over desperation,” said the vice-president of the FSDD club, pointing towards the antimicrobial week that humans celebrate. Then he invited a bacterium on the stage to shed some light on the glorified FSDD club.

“Hello! I am a bacterium. I belong to the staphylococcus group according to the classification done by another species here on earth. An anecdote; they consider themselves superior enough to fight against us. They are that foolish a species. Today, I’ll tell you about my daily activities and my life goals. Now, it’s a known fact that we fit in the grand scheme of things better than any other species. Well, maybe viruses are debatably our competitors in that regard, but that’s an issue I’ll consider later. My parents tell me that I am a very happy and brave bacterium, just like them. As you all know, we, staphylococci, are very social bacteria. We like in clusters and love keeping cats as pets. It’s funny how human beings think we’re catalase positive. But anyhow, Almighty didn’t make them as bright as us! They’re bad!

I love traveling. I stay in people’s homes, their dishes, food, and all the places you can imagine. I love dirty hands. I hide just under a dirty nail and say goodbye to my siblings as they go to all the places the unclean hand touches. And you’d be amazed if I tell you where people let us go without washing their hands. This one time, I was talking with my cousin Roy the streptococci under a thumb-nail, and the man under whose thumb-nail we were discussing our career option touched a tiny human being. They call them neonates, I guess. After a week, Cousin Roy wrote to me that his career goals are being met and that he has a thriving business of causing impetigo on that small neonate’s cheeks. He is also thinking of extending his business. Chains of impetigo maybe, like chains of hotels humans came up with so that we can harbor on leftovers and unhygienic food.

If you are starting to think that humans might be actually helping us take over the world, wait till I tell you about some more kind human beings. But first I’d want to tell you about some human beings that are rude and unhelpful. They belong to no specific place and are very hard to recognize. Most of them wear this white coat and carry some long rope around their neck. They’ve invented and are using chemicals to kill us. The funny thing is, even after we had a head start in evolution; they came up with such powerful substances. But thanks to our brave ancestors who used all their wit to figure out ways to survive. (Mechanism of resistance and things like transposons etc.) that our vice president advocated at the beginning was their gift to us.

This is where the kind among these white coats-wearing people fit in the story. It would sound unbelievably funny, but they started using those chemicals so rampant that we had enough samples to bring to our labs, test them with our brightest minds and make changes in us that would render these chemicals useless. I mean, why would you use only the power you have against your strongest enemy so carelessly? They started prescribing antibiotics to people harboring our friend viruses and fungi; they started taking fewer doses of these chemicals, which helped us take samples and conduct more studies on them. As ridiculous as it may sound, they started giving them to other animals even when they weren’t sick. There are plenty of journals written by our bacteria brothers who live in pigs about inventing different approaches to render these chemicals useless. Thanks to an ample number of samples provided by the pig farmers.

Talking about researches, some are going on the human side of the battlefield too. That’s our greatest threat. But here’s the good news; we are inventing new tricks and tweaks to get by the chemicals humans use to kill us with. They are not creating more chemicals as efficiently. Once I was on the hand of this biochemist who forgot to wash his hands after touching a petri-dish; that’s my birthplace, by the way. He was in this conference where people were discussing hurdles to the development of super drugs. I was tiny then, so I couldn’t catch all of what they were speaking, but things like insufficient funding and pharmaceuticals being more interested in modifying the same drug and making it earn more for them came up repeatedly.

I would like to end with a quote I heard at that very conference. “With great power comes great responsibilities.” So, let’s remember when we come up with great ideas to get by every weapon humans have against us, we have a responsibility to share it with our offspring. Let’s rule the world!”

Cite this article as: Sajan Acharya, Nepal, "Fight against superdrugs," in International Emergency Medicine Education Project, October 11, 2021, https://iem-student.org/2021/10/11/fight-against-superdrugs/, date accessed: June 6, 2023

Healthcare: A back up industry

June 16, 2021April 30, 2021 ~ Sajan Acharya, Nepal ~ Leave a comment

Examples of system failure are littered around the medical field and often disguised as professionalism or better yet heroism. “One resource seems infinite and free: the professionalism of caregivers”, says an opinion piece published in The New York Times. The article goes on to say that an overwhelming majority of health care professionals do the right thing for their patients, even at a high personal cost. Noteworthy is the availability heuristic that comes into play. “Of course they should work in favor of their patients, no matter what, isn’t that why they chose the medical profession!?”, you ask. They sure did. A lot of why you believe that medical professionals must go out of their way to help patients can be explained by what news you are being exposed to these days. The availability heuristic! That kept aside the gist of the article can roughly be summed up in the following excerpt

“Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just a bad strategy. It’s bad medicine. This status quo is not sustainable — not for medical professionals and not for our patients.”

I invite you to, for some minutes, drop all the preoccupation and think about it logically. I have, time and again, submitted myself to the idea that empathy and not logic is the best way to get my point across. But today, let us first think about some pertinent analogies.

As we anticipate the dreaded tsunami of COVID-19, many governmental healthcare institutes are sending out a notice for recruiting doctors and nurses for a certain time. My sister who is a nurse said, “Why do they have to make it sound like we are disposable?”. To which, I wittingly replied, “ Well they are probably looking for paid volunteers.” But the same recurring theme covers the core of our conversation. We simply were treating healthcare as a per-need industry. When the reality is, again, a contrasting opposite. Indeed, healthcare is a backup industry. You do not wish to use it when things are going smoothly. The healthcare system of any country should stand on its mighty ability to deal with crises.

Most other industries can either do with the number of people already in the industry or have to let go of people they already had, during a disaster. That is a contrasting opposite to the healthcare industry. Every time the health of the public is threatened we start to search for volunteers and temporary hires. I argue this is because the healthcare industry is ruled by businesses in the most powerful countries. To the point that the notion of just enough or even fewer doctors working in a setting is looked upon as a heroic measure. I don’t suppose you would say. “Oh! That busy bank has only one teller, and she also works as a receptionist. How heroic of her!”, do you?

There are reserves in almost every industry. Take transportation as another example: I visited Kathmandu on a night bus during my vacation as a child. My dad introduced me to two men. Both of them were drivers. I was taken by surprise when I found out the bus only had one steering wheel. “What would the other driver do!?”, the inquisitive child in me asked. My dad was semi-asleep when he answered, “They will drive for the whole night. Don’t you think they need to rest?”. I sure do Dad, I sure do!

In aviation, the first officer (FO) is the second pilot (also referred to as the co-pilot) of an aircraft. The first officer is second-in-command of the aircraft to the captain, who is the legal commander. In the event of incapacitation of the captain, the first officer will assume command of the aircraft. A second officer is usually the third in the line of command for a flight crew on a civil aircraft. Usually, a second officer is used on international or long haul flights where more than two crews are required to allow for adequate crew rest periods.

There have been some examples of what would be analogous to a natural disaster in other industries. Let us take some economic ups and downs as examples. Remember, India demonetized Rs. 500 and Rs. 1000 notes? Bankers had to work extra hours to make sure the undertaking completed in due time. They, of course, were paid an extra allowance for that. Interestingly they did not have to open up more positions for the work to be carried out. Remember the great economic recession? It “forced” business owners to let go of their employees. Not recruit more!

I vividly remember feeling proud of one of my seniors who was portrayed as an ideal healthcare worker. “He was arranging the medicine cabinet when we visited him”, one of my professors boasted. I felt not only proud but a desire to be at his place and do as he did one day. Today I understand that 1) he could be doing something way more productive and 2) what my senior was doing when my professor reached there was a clear example of a system failure.

Let me give you an example of my intern year to demonstrate the lack of consideration of the human element in designing healthcare systems. I had to take leave for some days. It was the flu. I understand that the coronavirus situation has alchemized the glory that flu deserved all along, but those were different times. I had a severe sore throat and my body ached like some virus was gnawing on my bones. I remember feeling very guilty about being ill because while I was sniffing Vicks and popping paracetamols in the hostel. My friends (fellow interns) were working their asses off. But when the system was designed, did no one think that someone might get sick? I mean, we work around infections every day. C’mon system designers, that is blindness, not just shortsightedness. The irony is: we are in an industry where we boast about our ability to empathize with human pain, suffering, and ill-health.

Human development has been punctuated by disasters of some sort, time and again. It is almost comical that we haven’t learned our lessons and that harrowing circumstances have to keep reminding us of the need for preparedness. It almost feels like I am writing a reminder the second time. After I failed to follow through my previous reminder. For me, the first time was the Nepal earthquake 2015. I am sure you have your own first time. I can only speak of the healthcare industry because that is what I have been fortunate enough to see closely. I am sure preparedness means different things in different settings. For healthcare, it means 1) taking into account the human element and 2) realizing that healthcare is a backup industry.

Recent Blog Posts By Sajan Acharya

Fight against superdrugs

Healthcare: A back up industry

Neutropenic Fever Syndrome

Mindsores

Better Decisions

What has COVID-19 taught us thus far.

Neutropenic Fever Syndrome

January 18, 2021January 1, 2021 ~ Sajan Acharya, Nepal ~ Leave a comment

The story of Carl Wunderlich, his dedication to determine average body temperature, and his not so accurate thermometer is well known among the medical fraternity. Like any other physiological parameter, the average temperature should be looked at as a range and not a number. There are certain instances when a temperature above 0.5-degree centigrade of average is too hot for an ER doctor. Let us talk about one such condition today.

Cancer patients being treated with anti-neoplastics are at risk of neutropenic fever syndrome (NFS). An overly simplistic, and hence super helpful way of looking at NFS is: anti-neoplastics damage gastrointestinal mucosa, help bugs translocate into the bloodstream, and at the same time damage our white blood cells. All this happens in the background of malignancy, already an immunocompromised status.

Eighty percent of identified infections in NFS arise from endogenous flora. Well, that backs up my oversimplification. Now I can confidently tell you this statistic; infectious sources are only found in up to 30% of the cases.

NFS is a disease of acute leukemia patients. Up to 95% of leukemia patients, 25% of non-leukemic patients with hematologic malignancies, and 10 percent of patients with solid tumors get NFS after being started on cytotoxic therapy.

Fever in neutropenic [Absolute Neutrophil Count (ANC) <500] patients is a single temperature of 101F or a temperature of 100.4° F over one hour.

How would you calculate ANC?

Total leukocyte X (% of neutrophils + % of band neutrophils)

How do you measure temperature?

Neutropenia is one of the two common instances when a rectal temperature is wrong; the other is thrombocytopenic patients. Oral temperature is adequate; make sure they don’t have oral mucositis that can falsely increase the reading in the patient’s thermometer and your head at the same time.

To make it even more complicated, guess what most patients on cancer chemotherapy are taking? Glucocorticoids! Also, remember, they are neutropenic, meaning they don’t have an adequate inflammatory response. Infections in neutropenic can present without elevated temperature, so be aware of SIRS: tachycardia, tachypnea, hypotension.

There are scoring systems to stratify NFS patients in high and low risk; CISNE and MASCC scores are examples, but none are comprehensive and hence are underused.

The management’s holy grail is antibiotics, but with such diverse and elite targets, where do you shoot? Let us try and oversimplify this: If the bugs are coming from our gut, they better be gram-negative rods (Pseudomonas aeruginosa!) That was so very true back in the day. Now, with the introduction to long-term indwelling central venous catheters, the empiric antibiotics to cover P. aeruginosa, and other gram negatives (Ciprofloxacin)– Staphylococcus epidermidis is winning the race. The gram-negatives are catching up; 60:40 is the score currently.

Fungi are not frequently the cause of the first febrile episode, but candida from the gut (of course!) and aspergillus from the lungs are culprits in long-term invasive fungal infections.

Here is another one for those who like analogies; Remember how there is a time-dependent door to needle approach in treating STEMI or acute stroke? There is one for NFS, sort of; 60 mins, some agree, some don’t! The unanimous consensus is to do it fast!

The problems like time for confirmation of neutropenia, a protocol for what to cover, and where to start antibiotics are yet to be discussed and solved. Studies have been done to demonstrate that mortality increases with every hour delay in administering antibiotics. A good rule of thumb to follow is administering antibiotics right after you draw blood for culture and before you send it.
They pose one last problem while recovering from neutropenia. Myeloid reconstitution syndrome is fever and a new inflammatory focus while neutrophil numbers go up. That is vaguely reminiscent of immune reconstitution syndrome in newly started HAART patients.

Next time you see a patient being treated for leukemia with a temperature of 100.4° F being triaged to a green zone in your ER, know that green has different shades.

Cite this article as: Sajan Acharya, Nepal, "Neutropenic Fever Syndrome," in International Emergency Medicine Education Project, January 18, 2021, https://iem-student.org/2021/01/18/neutropenic-fever-syndrome/, date accessed: June 6, 2023

Mindsores

October 12, 2020October 3, 2020 ~ Sajan Acharya, Nepal ~ Leave a comment

The patient said he did not care about his stage IV ulcers. He refused antibiotics for chronic osteomyelitis until we gave him opiates. He denied all other non-opiate alternatives. “The patient has an opiate use disorder but also has pain,” said the pain and palliative doctor. In medicine, we try our best to explain all that a patient is experiencing with one diagnosis. A patient suffering from two different diseases as a diagnosis is frowned upon. But here was a seasoned doctor, speaking with his years of precious experience reflected in his white beard and even whiter apron, telling me that the patient I have barely started to present to him, had two diagnoses.

I had taken care of this patient for some days now. In my head, I would associate all the requests he makes, everything he says, and every single complaint he has, to his addiction. “I do not have an opiate use disorder, I have a pain problem!” said the patient as soon as “addiction” was mentioned. The doctor said, “I know you don’t think you have opiate use disorder.” I thought that was clearly mentioned to calm the patient down. Later I would be surprised to know that the doctor actually meant it.

He gave me an ‘overly simplistic heuristic’ that had helped him remember what patients with substance use disorder are going through. “The first time a patient takes a substance, he feels the intended high. The effect remains for a couple times more. As the effect due to the same dose decreases with subsequent exposure, the patient increases the dose to get the intended effect. This seemingly linear relationship is a tricky one. Soon the patient will depend on the substance only to feel okay. Which, let us remind ourselves, the patient felt before starting to take any substance. Hence, many patients with substance use disorder, claiming they do not do it for the high, they do it because they cannot tolerate “normal” without it. Substance use disorder is a complex topic and one that deserves much more effort and attention than is the scope of this conversation but I hope this ignited an enthusiasm to learn more, in you” That night I read some papers on opiate use disorder.

I sometimes wonder if I am not as sensitive to suffering as my patients are. I wonder if what they taught me about signal transduction in my first year of medical school holds true for day-to-day emotions like it held true for addiction’s pathophysiology. The more we are exposed, the more we desensitize. “Being emotional is understandable but unnecessary and unhelpful”, says Sherlock Holmes in one of his many palimpsests. Maybe I was trying to objectively look at this patient of mine. So much so that it did not occur to me that the patient had stage IV ulcers. All I heard was a cry for the high, which, mistake not, was there. But there was something more, something that was hidden to my objective eyes. In focusing my attention on the patient’s mindsores, I was ignoring his very physical and painful bedsores. I dare say Sherlock was wrong. Only emotions can drive passion. People who are so passionate about the pathways and mechanisms of addiction and people who are emotional about the patients’ problems are the ones who we rely upon to solve this tangled problem of pain and addiction. I appeal to you to acknowledge that this is a complex issue. That is the sole intention of this article. And that is the first step in trying to understand and hopefully help patients with multiple sores.

Cite this article as: Sajan Acharya, Nepal, "Mindsores," in International Emergency Medicine Education Project, October 12, 2020, https://iem-student.org/2020/10/12/mindsores/, date accessed: June 6, 2023

Better Decisions

July 27, 2020July 18, 2020 ~ Sajan Acharya, Nepal ~ Leave a comment

Why is a physician working in the Achham district of Nepal worried when he finds that a patient tested positive for HIV, but a physician working in Humla district is worried but also skeptical? Why do we generally not prescribe high dose IV Vitamin C + Thiamine + Hydrocortisone when the combination has shown to provide a substantial mortality benefit in sepsis? Why do we encourage a patient, very rightly so, to get flu shots every year?

When making decisions, we think, we use our knowledge, weigh pros and cons, and make a choice. The variables, whose salient feature is that we barely think of them, are biases and heuristics. We are influenced by various medical journals we read, colleagues we work with, and even movies and advertisements we watch. Another, sometimes lethal feature of these decision influencers is that their influence is inversely proportional to the time we have to make a choice. This becomes relevant in ED, where split-second decisions are the norm.

So how do we make decisions that are backed more by studies and less by our implicit biases? How do we compare two tests that measure the same variable or two vaccines that work against the same infectious agent? There comes the role of statistics. Every physician, especially those making life-saving decisions in a fraction of seconds, should have an intuitive understanding of medical statistics. This will help us make decisions that are backed by our best understanding and understand our limitations.

Achham district of Nepal has the highest prevalence of HIV/AIDS in the country. When the disease’s prevalence is high, the chance that your patient has the disease given the positive result is high. This is the Positive Predictive Value (PPV). The same physician would want to re-run the test on asymptomatic patients if the test was negative. That is because, given the high prevalence, the Negative Predictive Value (NPV) of the test is low. One would also worry about the sensitivity and specificity of the test in question. Although these are properties intrinsic to the test and do not change with the prevalence of a disease in a population, their knowledge adds to the confidence with which we can prescribe a test to a patient.

One way of thinking about sensitivity is: among 100 diseased patients, how many will the test identify? You would want your screening test to have very high sensitivity so that you do not miss any diseased person. Specificity can be thought of as: among 100 healthy patients, how many will the test identify as negative for the disease? If a highly specific test tells you that a patient has a disease, chances are – he does. So the worried physician of Achham district probably used a very sensitive test and followed it with a highly specific test to confirm before talking to the patient about the result.

We encourage all patients to get the flu vaccine every year because of something called the Number Needed to Treat (NNT). It is the number of patients you need to treat to prevent one additional bad outcome e.g., severe flu, death, etc. Every 12 – 37 flu shots prevent one healthy adult from influenza when the vaccine is well-matched. That means the NNT of the flu vaccine is 12 to 37. [1]

The combination of high dose IV vitamin C + Thiamine + Hydrocortisone had shown to provide a substantial mortality benefit in a small retrospective study in 2016. We generally do not prescribe this in sepsis because we do not have a large RCT that supports the claim yet. The GRADE working group suggests a system for grading the quality of evidence. [2] When we say that evidence is graded 1A or 3B, we are commenting on the type, quality, and the number of studies that back the claim. Familiarizing ourselves with the grading system and hierarchy of evidence can be a good start in the world of evidence-based medicine.

References

Kolber MR, Lau D, Eurich D, Korownyk C. Effectiveness of the trivalent influenza vaccine. Can Fam Physician. 2014;60(1):50.
Petrisor B, Bhandari M. The hierarchy of evidence: Levels and grades of recommendation. Indian J Orthop. 2007;41(1):11-15. doi:10.4103/0019-5413.30519

Cite this article as: Sajan Acharya, Nepal, "Better Decisions," in International Emergency Medicine Education Project, July 27, 2020, https://iem-student.org/2020/07/27/better-decisions/, date accessed: June 6, 2023

What has COVID-19 taught us thus far.

April 13, 2020April 13, 2020 ~ Sajan Acharya, Nepal ~ Leave a comment

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?

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: June 6, 2023

References

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.
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

January 20, 2020January 18, 2020 ~ Sajan Acharya, Nepal ~ Leave a comment

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

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

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

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

Schwedt TJ. Overview of thunderclap headache. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/overview-of-thunderclap-headache
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.
Jensen RH. Tension-Type Headache – The Normal and Most Prevalent Headache. Headache 2018; 58:339.

Macro-lensing the Emergency Department

October 28, 2019October 25, 2019 ~ Sajan Acharya, Nepal ~ Leave a comment

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.

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.

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.

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.

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).

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.

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: June 6, 2023

A Medical Student’s Encounter with Disaster

August 5, 2019September 4, 2019 ~ Sajan Acharya, Nepal ~ 1 Comment

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.

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.

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.

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...

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.

Dear #medtwitter #FOAMed #EmergencyMedicine #MedEd – what do you think?

Disaster-related topics should be in the medical school curriculum.
— iem-student (@iem_student) August 3, 2019