Tired before the long journey

Most articles related to rural health bombard us with problems, the solutions to which are often out of reach. We can classify most of the issues into large and sometimes intersecting domains; logistics, workforce, finance, and education. Also, most reports on medical education boast its universality. We can build the two arguments; 1) There is an apparent lack of a well-trained workforce in the rural and 2) We should solve this problem by incentivizing urban trained physicians to work in the rural. The second part of that argument doesn’t always hold; a discussion for other times.

A solution many governments, including that of Nepal, implement in solving the apparent lack of physicians is to produce more paramedics. I have before, and I continue to argue that paramedics have a significant role in rural health. Certain aspects of rural health deserve a bit more robust education and training. One such aspect is mental health.

A 67 years female visited a rural PHC. The endless excuse of a road through the forest, down the hill, and across the river brought her to a very dedicated health assistant. She complained of fatigue. “Do you have any abdominal pain?” asked the concerned provider. “No,” replied the old lady spontaneously. Almost as if she knew where this discussion is headed. “Are you bleeding from anywhere?” “No.” “Fever? Headache? Nausea? Vomiting? Diarrhea? Anything?” The old lady kept nodding no as the list of symptoms, as long as the road that brought her to the PHC continued. A multivitamin was prescribed before calling up the next patient. That week I talked about depression with my paramedics.

Mental health is an essential yet ignored aspect of health. As universal as that is, my two years in Beltar made me acutely aware of mental-health-related ignorance that prevails among the providers in the rural.
Paramedics we produce are not equipped enough to deal with a lot of mental health issues. After being a boss, a colleague, and a friend to many hardworking and dedicated paramedics in rural Nepal, I can confidently tell that they seek to understand more. The lack certainly is on the delivery side. We need to figure out ways to train our rural providers to better manage mental health issues.

While some rural health issues are extensive and require significant effort to solve, others are easy to address yet equally important. I sometimes wonder if we should incentivize physicians who serve in the rural for a limited time to train the paramedics who stay there longer. Being in the same room as the patient who could not articulate her symptoms of depression and the paramedics who, while being very attentive, wasn’t adequately trained to identify subtle signs of depression can be a good incentive. But I strongly argue that is not a good kind of incentive.

An update to the curriculum, refresher training and provision of adequate resources to learn about mental health can help the providers of rural help many of these patients who are “tired” before their long journey to the PHC.

Cite this article as: Carmina Shrestha, Nepal, “Tired before the long journey,” in International Emergency Medicine Education Project, May 5, 2021, https://iem-student.org/2021/05/05/tired-before-the-long-journey/, date accessed: October 1, 2023

Recent Blog Posts By Carmina Shrestha

Death on the Roads

Death on the Roads

Save the date: 17th November 2019!

Why? Because road victims will be remembered that day. Starting from 2005, The World Day of Remembrance for Road Traffic Victims is held on the third Sunday of November each year to remember those who died or were injured from road crashes (1).

Road traffic injuries kill more than 1.35 million people every year and they are the number one cause of death among 15–29-year-olds. There are also over 50 million people who are injured in non-fatal crashes every year. These also cause a real economic burden. Total cost of injuries is as high as 5% of GDP in some low- and middle-income countries and cost 3% of gross domestic product (2). It is also important to note that there has been no reduction in the number of road traffic deaths in any low-income country since 2013.

The proportion of population, road traffic deaths, and registered motor vehicles by country income, 2016 (Source: Global Status Report On Road Safety 2018, WHO)

Emergency care for injury has pivotal importance in improving the post-crash response. “Effective care of the injured requires a series of time-sensitive actions, beginning with the activation of the emergency care system, and continuing with care at the scene, transport, and facility-based emergency care” as outlined in detail in World Health Organization’s (WHO) Post-Crash Response Booklet.

As we know, the majority of deaths after road traffic injuries occur in the first hours following the accident. Interventions performed during these “golden hours” are considered to have the most significant impact on mortality and morbidity. Therefore, having an advanced emergency medical response system in order to make emergency care effective is highly essential for countries.

Various health components are used to assess the development of health systems by country. Where a country is placed in these parameters also shows the level of overall development of that country. WHO states that 93% of the world’s fatalities related to road injuries occur in low-income and middle-income countries, even though these countries have approximately 60% of the world’s vehicles. This statistic shows that road traffic injuries may be considered as one of the “barometer”s to assess the development of a country’s health system. If a country has a high rate of road traffic injuries, that may clearly demonstrate the country has deficiencies of health management as well as infrastructure, education and legal deficiencies.

WHO has a rather depressing page showing numbers of deaths related to road injuries. (Source: Death on the Roads, WHO, https://extranet.who.int/roadsafety/death-on-the-roads/ )

WHO is monitoring progress on road safety through global status reports. Its’ global status report on road safety 2018 presents information on road safety from 175 countries (3).

We have studied the statistics presented in the report and made two maps (All countries and High-income countries) illustrating the road accident death rate by country (per 100,000 population). You can view these works below (click on images to view full size).

References and Further Reading

  1. Official website of The World Day of Remembrance, https://worlddayofremembrance.org
  2. WHO. Road traffic injuries – https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
  3. WHO. Global status report on road safety 2018 – https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/
Cite this article as: Ibrahim Sarbay, Turkey, "Death on the Roads," in International Emergency Medicine Education Project, November 1, 2019, https://iem-student.org/2019/11/01/death-on-the-roads/, date accessed: October 1, 2023

A Road not Taken: Patient Transport in the Rural

Patient transport in rural

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

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

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

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

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

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

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

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

Cite this article as: Carmina Shrestha, Nepal, "A Road not Taken: Patient Transport in the Rural," in International Emergency Medicine Education Project, September 6, 2019, https://iem-student.org/2019/09/06/a-road-not-taken-patient-transport-in-the-rural/, date accessed: October 1, 2023

So What About Those Ambulance Crews?

A few years ago, a staff pediatrician at my hospital asked me who ranked higher - a paramedic or an Emergency Medical Technician (EMT)? I remember thinking two things: first was the obvious "duh!", but the second was "hmm...maybe some things are not so obvious to non-Emergency Medicine (EM) physicians."

If you are already doing an EM rotation at an Emergency Department (ED), then chances are that EM is already established or is being established at that locale. Chances are, your ED is receiving ambulance traffic and of course you know the answer to the above question.

So why even talk about pre-hospital emergency medical services (EMS) at all? What does that have to do with your EM/ED rotation, or even with your future EM practice?

Image by F. Muhammad from Pixabay

Receive your information about a patient directly from the ambulance personnel.

For one thing, it’s simply prudent and efficient. What was happening at the scene? Who called? Who else is coming? What did the EMS medics do or not do? What is the patient’s primary concern, and does that match or not match the ambulance crew’s primary concern?  Much information can be lost or misconstrued if we solely rely on the nurses, even worse – on paper, to tell us the full story.

Watch the patient on the EMS gurney carefully

Often their facial mimics, gestures and the way they are looking around the ED will tell you a lot. Can they transfer to the ED bed themselves? What’s their body mechanics while doing that?  There is much to learn here in just a few seconds –  trust me.  The patient may not end up being yours, but in a little bit of time, an hour or two, look them up on the ED board and see if your own initial impression was right: sick or not sick? Serious or so-so? Admitted or discharged?  This is a critical skill to hone for any EM provider.

Anticipate EMS patient needs even before they are roomed.

While it is true that most of our ED patients are walk-ins, multiple analyses have shown in multiple locations around the world that the EMS patient population tend to be sicker. So this population is where some of those cool and awesome procedures that you want to see, learn or perform are often found.  Healthy 18-year-old man, tall, suddenly short of breath while playing basketball with his friends – there is your chest tube arriving, see?

Your main task is to learn to comprehend the entire emergency care system. EM providers in EDs do not function in isolation. We are part of the emergency care continuum and should thus be those most proficient is seeing and knowing the big picture. EMS is the beginning of that picture.

EM physicians all around the world participate in pre-hospital work via multiple avenues:  supporting public and sporting events, serving as cruise physicians, staffing ICU-ambulances and EMS support vehicles, flying on medical helicopters, writing EMS protocols, training paramedics and providing real-time phone, radio or teleconsultations. Chances are, you will too!

So while you are rotating at an ED, especially a foreign ED or one away from your home base, take a small effort to learn about the local EMS. Talk to the medics, talk to ED personnel taking EMS radio calls and look pertinent things up on the internet on your own (like local EMS protocols). Talk to the attending EM physicians in your ED –  chances are, one of them is the local EMS guru!

Some simple things you may wish to focus on to gauge any EMS system anywhere

Finally, many an interesting medical student or resident research project began out of some EMS-related consideration or observation, so keep your eyes and ears open for those research ideas!  Good luck!.

Cite this article as: Anthony Rodigin, USA, "So What About Those Ambulance Crews?," in International Emergency Medicine Education Project, May 31, 2019, https://iem-student.org/2019/05/31/so-what-about-those-ambulance-crews/, date accessed: October 1, 2023