Friday, September 2, 2011

More beans, less rice

Eating more beans and less rice lowered the risk of metabolic syndrome (thickened waistline, low good cholesterol, high blood pressure, and some other factors that are often precursors to diabetes and cardiovascular disease) in this study of 1,879 Costa Rican people, published recently in the American Journal of Clinical Nutrition.

Recommending less white rice in favor of a protein probably makes good nutritional sense, but many people will be unable to afford the substitution. White rice is cheap and filling, and in some places, whatever's eaten with it is viewed more or less as a condiment.

Why do people eat polished rice when unpolished rice (containing the husk, bran, and germ) is nutritionally superior? I believe the answer is that it's easier to store polished rice, as rice germ contains fats that spoil easily. The price people pay is worse nutrition--not only a higher risk of metabolic syndrome, but also thiamine deficiency.

Friday, July 1, 2011

Easing hyperglycemia with H2O

French researchers reported some interesting preliminary results of a study of people with diabetes. Those who drank more water had a lesser risk of developing high blood sugar than those who didn't drink as much water. It's not clear if there's a cause-and-effect relationship yet (it may be that a third, unknown factor leads to both a lower blood sugar and a tendency to drink more water), and these results haven't yet been reviewed by other scientists. But it would be awfully convenient if diabetics in a low-resource setting could take better care of themselves by doing something as simple as drinking more water.

(Of course, that's assuming they have access to clean drinking water--not a safe assumption in many parts of the world.)

Wednesday, March 16, 2011

WHO's List of Essential Medicines

The World Health Organization publishes a frequently-updated list of essential medicines, organized by type of drug and whether it's a "core" drug to treat high-priority conditions, or a complementary drug for settings with more resources and specialists. It flags drugs for which any equivalent drug in the same class is just as good, as well as those that are only for children or other subgroups. It's worth browsing if you're looking to put together an essential toolkit for a low-resource setting.

I get a little misty looking at this list. Every one of these drugs is a technological achievement, the result of years of work and centuries of scientific investigation into chemistry and physiology. We've gradually learned how the human machine works, and now we have this--a toolkit, a concise record of human smarts directed toward relief of disease and suffering. Creationists, the evolutionists you abhor use the same methods that the inventors of your blood-pressure pills did. And Luddites, take note: technology can serve the good. This list is proof.

Saturday, March 5, 2011

Quitting smoking can be a warning sign of lung cancer

A fascinating study in the March Journal of Thoracic Oncology lends weight to something many of us physicians have long suspected: people who quit smoking after many years may be doing so in response to an early lung cancer, often long before they have symptoms. Here in our low-resource clinic, we already worry more about lung cancer in symptomatic patients who have a history of having randomly quit smoking in the last few years. That little point of history doesn't replace diagnostics, but it does raise our suspicions. This study suggests we have good reason.

Pain relief and opiates--or the lack thereof

Opiates like morphine or fentanyl are in short supply here in rural Indonesia. Our clinic treats patients who suffer from acute or chronic pain with a mixture of ibuprofen, acetaminophen (paracetamol), and occasionally codeine. Friends who have worked in Uganda and other developing countries tell me the situation is similar there. The lack of opiates condemns many end-stage cancer patients to a nightmare existence.

The International Narcotics Control Board, a United Nations drug organization, recently issued a report decrying the lack of availability of narcotic pain medications in many parts of the world, and argued correctly that such drugs should be considered indispensable in medical practice. Inadequate policies and regulatory constraints are among the reasons why many countries have made pain relief a low priority. One of my American colleagues once opined that that's because some cultures believe in the sanctity of suffering. I don't know enough about Islam to know if that's the case here, but Mother Theresa seems to have believed that, at least when it came to other people's.

But  the relief of suffering is at the heart of medicine. If prevention and cure fail, or when there's a delay before a treatment takes effect, there is palliation. At the very least, a health care worker ought to make a patient comfortable. I've never been as glad to have morphine in my toolbox as I was when I took care of a little kid in my ER in the US who had been severely burned and needed to be transferred to a burn center. He was fully conscious, suffering pain few of us can imagine, but we pulled him out of the depths of hell with large and repeated doses of morphine. His agony subsided even as he remained awake, and watching his transformation from tortured to calm made me feel a near-religious sense of gratitude to have been able to do that for him. I think about him from time to time and hope he enjoyed his helicopter ride, at least a little.

Thursday, February 24, 2011

Who needs doctors, anyway?! Lessons from rural India.

I'll let these two important New York Times articles by Tina Rosenberg about community health workers speak for themselves: "Villages Without Doctors" and a follow-up article incorporating important comments on the factors that make or break such programs.

Curative medicine, the kind physicians are trained in, has a tendency to reach the few and the rich rather than the many and the poor. And it treats so many conditions that could have been prevented. What a poor use of resources. The world needs more simple public health initiatives and basic health care, and the vulnerable poor have a perfect right to implement them. Prevention! Prevention! Prevention! Education! Education! Education!

That health care belongs to "the people" is also the core belief of the wonderful Hesperian Foundation, of Where There Is No Doctor fame--a topic for another day.

Monday, February 21, 2011

International Family Medicine: list of core competencies

A list of the things a family practice physician needs to know will vary from country to country, but as discussed in a study published in the Middle East Journal of Family Medicine last spring, there is a core set of competencies that FPs in every country should have. The researchers surveyed FP docs around the world to see how many of these core skills are being systematically taught in their countries. Australia topped the list, teaching all 44, and Indonesia brought up the rear with only 17. The most-taught subject was "Accident and Emergency," while the least-taught was "Women's Health." (Though I was relieved to see that that was treated as a separate topic from "Obstetrics and Gynecology," that statistic is still unfortunate.)

This study is helpful for putting family practice curricular issues into a global perspective, and I recommend that anyone involved in teaching family practitioners in the developing world read it. At the very least, it provides an important checklist of the topics to emphasize in your curriculum.

Thursday, February 17, 2011

"High-touch" medicine leads to lower costs--and yet it's low-resource in its way

One of the things I admire about low-resource medicine is that, by definition, it doesn't cost much. By contrast, ER visits and hospitalizations in the high-resource American system can be tremendously expensive. And it's sobering to consider how those visits could so often have been prevented, how many of those resources are spent wastefully. We've all heard about how many trauma patients might not have been hurt if only some simple measures had been in place: helmets, handing over the car keys, wearing a seat belt. What's less obvious is that ER visits for chronic diseases could also be reduced--not with even snazzier drugs and higher-tech diagnostics, but with little things, the kinds of things that the US system isn't designed to pay for. Things like careful follow-up for outpatients, coordination of prescriptions among all a patient's doctors, and robust social supports.

One Dr. Jeff Brenner is trying to do just that in Camden, New Jersey. “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise,” Brenner told Atul Gawande in the latter's recent New Yorker article about "high-touch" medical care. Damn right.

Gawande's article examines strategies by Brenner and some like-minded colleagues to cut costs by preventing repeat ER visits and hospitalizations in the people most vulnerable to them. In any given group of patients, it often turns out that a small number of people account for a huge chunk of medical costs; these reformers scrutinize databases and figure out who those patients are. Is it the residents of a particular building, who seem to suffer a lot of injurious falls? Is it someone suffering from several overwhelming chronic diseases and not enough social support? Is it a woman who faithfully fills her ineffective ER migraine prescriptions, yet never seems to find an outpatient neurologist who will tweak them till they work?

The reformers target those patients for meticulous outpatient care--"high-touch" care that relies heavily on building trust between patients and caregivers and on locating medical care in its social context. Their methods are revolutionary and low-tech. For starters, these caregivers are organized, and they talk to each other. Doctors and nurses and social workers and lay health "coaches" hold daily team meetings about their patients, making changes to prescriptions, discussing whom to track down via relatives after a no-show or who needs a same-day follow-up for that test result. Then, they pick up the slack for patients who don't adequately care for themselves. They send nurse practitioners to do blood sugar checks and health coaches to deliver moral support. They see to it that prescriptions get filled and that patients get help taking their meds. They work with social services to get vulnerable people into better housing. They even forestall 911 calls by physically taking the patient's cell phone and entering the clinic's 24-hour number into them, since some patients don't have the number handy and don't know how to program their own phones. The result: Tailored medical regimens that actually get followed, not just prescribed and forgotten. And patients grow to believe the clinic workers really do have their interests in mind, and that trust inspires many of them to do what they can to improve their own health--they quit smoking, they lose weight, they join AA.

All the attention at these clinics reminds me of Directly Observed Treatment Short-Course (DOTS) for tuberculosis, in which health workers actually watch TB patients swallow their medications several days a week throughout the long slog of treatment, routinely traveling to patients' homes when necessary. That simple strategy turns out to be both powerful and cost-effective--much more so than simply prescribing TB meds to an unsupervised patient, a method which for various reasons often leads to treatment failures and drug-resistant TB. Prescriptions are not enough. DOTS works so well that researchers have proposed using this strategy for other difficult diseases like hypertension and type I diabetes.

Similarly, when the numbers are crunched, the high-touch clinics Gawande investigated are worth it: They prevent hospitalizations and save money. (Hospitals stand to lose patients, of course: the country of Denmark, Gawande reports, has closed half its hospitals using similar strategies to prevent hospitalization.)

In short, high-touch clinics don't just examine and prescribe. They act as if they care about sick people, and they do whatever it takes to get the best available care into patients' hands. How interesting: That's often all we can do in a low-resource clinic here on the other side of the world. Our DOTS workers ride their bicycles to patients' houses, sit down with them, and help them take their pills; their efforts are the reason we cure most of our TB patients. It's high time the American health system realizes what low-resource practitioners already know: sometimes, it's the little things.

Tuesday, February 8, 2011

Online practice scenarios for trauma

Worried by their dithering the last time we had an accident victim, I just took our docs through a bit of trauma training. We don't have the materials to conduct a formal ATLS course, nor does our rural Indonesian clinic have the tools to conduct full trauma care, but we can certainly review basics. So we went over the primary and secondary surveys, as well as important concepts like resuscitation and teamwork. This is their chance to learn and practice, since they tell me that all the spots in Jakarta ATLS courses are booked till 2012.

Fun with moulage will take place in a few days (my long-suffering fellow volunteer, Dr. Bobby, will play the role of victim, with lipstick or perhaps chewed-up betel nut to denote his injuries). In the meantime, the docs asked for reading material. I wish I could find a legally downloadable ATLS manual online, but no dice. Still, there are excellent basic reviews by eMedicine and UpToDate (subscription only for the latter, alas), and this collection of interactive trauma cases online. They're free of charge, courtesy, a website dedicated to global trauma care that is well worth exploring. The cases are written in idiomatic (and very funny) English, so they might not be ideal for non-native speakers, but they do review important basics in a painless way and might make good moulage scenarios for people teaching trauma care in a low-resource environment. I plan to create teaching cases based on some of them. It should be lots of fun, though for poor Dr. Bobby's sake I don't think we'll be strictly following the "Fingers and tubes in every orifice" rule.

Monday, February 7, 2011

Neonatal incubator made of car parts

Stuff breaks.

Replace, send for repairs, or try to fix it yourself? In the developing world, choice 3 is often the only option. Unfortunately, even if you’re game to try fixing a broken machine, the parts are often all but unobtainable. And even if the parts are obtainable, modern technology has made many machines opaque.

So here's a brilliant idea: medical machinery that can be repaired anyplace where there are car parts and mechanics. The NeoNurture was invented by Design That Matters, an American NGO that creates products and services to help the poor in developing countries. This nifty incubator is made of auto components and should be transparent to anyone who understands cars. That means it can be used in remote areas (since presumably there are cars just about everywhere these days), and when it breaks or needs to be altered, it doesn't become a useless piece of junk. God knows we're glad to have our ultrasound machine and X-ray out here in our rural Indonesian clinic, but we haven't any special parts or expertise to fix them once they fail. What do we do with them then? Burn them? To borrow a quote from the New York Times, which blogged about the incubator last November:

“Every rural clinic in the developing world has a shack full of broken donated medical equipment,” said Timothy Prestero, chief executive of the Cambridge, Mass., design consultancy. 

You get it, DTM! Thank you. Can't wait to see these in production.

Check out the other ideas this firm is developing: a phototherapy device, a microfilm projector, and an IV flow controller. Their past projects sound great, too. I'd like to know more about which ones have been most successful and which ones remained at the prototype stage.

Sunday, February 6, 2011

A few cc's of public health are worth a liter of fluids

Another child with seizures, this time without a happy ending. This little girl was 40 days old, and had been sick for several days. Her parents first noticed something was wrong when she stopped breastfeeding. Soon she began to vomit.

The family visited a traditional healer. After that they took her to the local government clinic, which advised them to go to the city hospital (hours away). They decided not to go. The baby then suffered five continuous hours of seizures, after which she remained unresponsive. The following day, when she hadn't gotten any better, they brought her to our clinic, a few minutes' motorbike ride from their home.

We examined the baby. Her breathing came in slow gasps. She made no response to painful stimuli. Her pupils were dilated and didn't react to light, and when we stroked her corneas with a wisp of cotton, there was no blink reflex. Her soft spot bulged upward, indicating dangerously high pressure in the brain, and her belly was much too firm. She died a few minutes later.

We visited the family the next morning, a couple of hours after they had buried their daughter. Her mother asked us several times how this could have happened when the child had been so healthy before. Our doctors explained to her that the child may have caught a bad germ that was "very strong." (There were other possibilities, but we couldn't be sure of any diagnosis given how short a time we had with her.)

The mother berated herself for not having come to us sooner. We told her it wasn't her fault.

And it wasn't, I don't think. It's hard to know exactly whose fault it is that this woman happens to have grown up on a remote, malarial island with only occasional visits from a midwife; that she received no schooling past age 11 and her fisherman husband little more; that they just moved here a few months ago; that they didn't know how to judge the severity of this illness. Could this death have been prevented if the baby had received treatment earlier? Yes, possibly.

What can I say? When it's too late, medicine isn't enough. Strong public-health programs and education must underlie any efforts to deliver medical care.

Saturday, January 22, 2011

Refugee Medicine

The medical care of refugees, which often (though not always) takes place in a low-resource setting,
has its own fellowship at Massachusetts General Hospital. Named for Dr. Thomas Durant, who won the Humanitarian Award from the United Nations in 1995, the Durant Fellowship in Refugee Medicine promises its fellows a "full and rewarding hands-on experience in the field," caring for victims of "war, disease, drought, poverty, or politics."

Please note the honesty in the brochure's wording. People who help disaster victims do it in part because it feels so rewarding to do so. But that fact should not detract from hard questions about whether what they are doing is right in the great scheme of things, and I don't see evidence in the Durant Fellowship's online materials that it teaches participants to ask those questions. (To be fair, I haven't interviewed Durant Fellowship leaders to learn more about its aims, so consider the following words to apply to humanitarian efforts in general rather than to that particular program.)

I am lucky enough to know firsthand that it feels great to help disaster victims. Last year I went off to Haiti a few months after the earthquake to work in a field hospital, and there I was surrounded by fellow volunteers who were intoxicated by the goodness of what we were all doing. It was a tremendously good experience, and we bonded over it like kids at summer camp.

Yet there were definite downsides to what we were doing. I recall diagnosing a woman with diabetes and giving her a supply of antihyperglycemic medication, only to realize that when it ran out she might not be able to access any more. Nor did I have anyone to refer her to for long-term care. There were homeless children at the hospital who bonded week after week with new volunteers, only to dissolve in tears when it inevitably came time for the volunteers to go home.* And we were doing absolutely nothing to overcome the poverty, bad leadership, and environmental devastation that made Haitians so vulnerable to disaster in the first place. Perhaps that isn't our job--but the thought should humble us a little.

I recently read Linda Polman's book The Crisis Caravan, one of a number of books that brings a critical eye to bear on the humanitarian enterprise and argues that under some circumstances humanitarian aid can actually do more harm than good. Dambisa Moyo, a World Bank economist and native of Zambia, also criticizes the effects of foreign aid on Africa. There are a number of other books in the same genre that I look forward to reading. I don't know enough about most humanitarian aid organizations to know what kind of response they have made to these criticisms, if any. But I do know that people feel a certain romance to racing off to help the poor victims, a sense (reinforced by others around them) that they are really good people for coming all this way to help--and that that emotion can be misleading or even dangerous if it remains unexamined.

Anyone who wants an international disaster-aid experience should skeptically evaluate their proposed actions, and refrain from assuming that because they are headed off to help the sick and injured, they are heroes and immune from criticism. Too often, we doctors believe we're unambiguous warriors for good--what parent doesn't approve when their kid wants to go to medical school? who doesn't look with awe upon the intrepid Doctors Without Borders?--but I'm not as sure about that as I once was. For instance, if, as Polman argues, humanitarians are sometimes played off against one another by strongmen, then their presence in a war zone might perpetuate a tyranny rather than ameliorating its effects. Are doctors** thus turned into tools in the hands of leaders who use amputation as a war strategy? Does the organization they propose to work with have thoughtful leaders who are prepared to recognize and react to such a situation? There are other hard questions. Does their organization mishandle funds, elbow out more effective groups, or duplicate the work of other organizations? Does it engage in self-evaluation to see if its work is effective? Does it make mistakes like failing to provide for follow-up care after plastic surgery? Do the doctors help to train locals (capacity-building) so that expertise remains in place once they leave? And how, if at all, will their efforts prevent future disasters?

I would never argue that people with the power to help the dispossessed should refrain from doing so. Indeed, justice for everyone is one of humanity's highest goals, and it gives me hope for our species that we feel good when we pursue justice for others. But we must question our methods. We need to weigh the evidence about whether what we're doing will achieve the goal of well-being for all, and not reflexively accord too much weight to the rush we all get when we help.

* One, I'm happy to report, was adopted by a volunteer, and now lives happily with his new family in Ohio.
** I use the word "doctors" as shorthand for all professionals, including physical therapists, nurses, social workers, logisticians, architects, and anyone else who chooses to work or volunteer on behalf of disaster victims.

Tuesday, January 11, 2011

The road to hell and the privilege of volunteering

An odd little encounter in our rural Indonesian nonprofit clinic yesterday made me think more about the consequences of volunteering.

In the waiting room, Fitri, one of our bilingual staff members, came up to me looking puzzled. Standing beside her was a young man with Asian features and a friendly, eager expression. He was strapped beneath a huge backpack with a rain cover. While curious patients looked on, he began to speak to me in poor English. I made out that he had met me and heard about our organization. He had decided to come here and offer his services as a volunteer, too.

I was as puzzled as Fitri was. I certainly didn't remember meeting him and we weren't expecting any new volunteers. I asked him if he could explain himself to Fitri in Bahasa (that is, bahasa Indonesia, the national language) rather than in English. "Bahasa?" he said, not seeming to know what I was talking about--which was astonishing, considering we were deep in the heart of Indonesia where Bahasa is the lingua franca. "Chinese?" I suggested, thinking of a doctor we have who knows that language. Finally it emerged that he was Korean. Alas, none of us could speak that to him.

He'd confused me with another volunteer. She and her husband, who soon emerged from an examining room and helped us to clear things up, had indeed met this man two days ago as they waited in the harbor for the boat to our town. Perhaps noticing their Caucasian faces among all the Asian ones, he had walked up to them and asked them where they were going. They explained that they were volunteers with this NGO, whereupon the young man announced that he would come along and volunteer, too.

"Well, you have to learn more about the organization first," John said, taken aback. He told the young man the NGO's name and its web address, and the man wrote them down before abruptly walking off. It had been that short an interaction. Forty-eight hours later, here he was. He had taken a long boat ride to this remote town far off the tourist track, then stumped around town with his backpack asking where the clinic was. Now that he'd arrived, he was ready to roll up his sleeves and get to work. "I do anything, doesn't matter," he averred.

It seemed this young man had just finished earning a mathematics degree in Korea and was now on a sort of yearlong walkabout before joining the navy. In Korea, he explained, you could just offer your services as a volunteer and they would take you on the spot. At least, he had done so once at a tutoring organization there, where he had taught math to children.

It fell to John to gently tell the young man that we couldn't use his services at this time. It's not completely unreasonable to assume that a willingness to work without pay will open the door of any struggling NGO (and aren't they all struggling?). But that's not how it works. As with most organizations that do anything more complicated than, say, clearing invasive brush in public parks, volunteers here go through an application process. They have to agree to certain conditions, sign liability waivers, perform specific duties for which they have the skills, and learn some of the language and customs first so they can responsibly represent the organization. Many applicants are turned away, and just because this young man had come thousands of miles to our door did not put him at the head of that line. As if he were a jar of unlabeled medication, no one knew quite what to do with him--he spoke neither bahasa Indonesia nor, really, enough English to talk to bilingual Indonesians. And as if he were a drug none of us had ever prescribed, we didn't know whether he was prepared to respect local customs or if he'd make a terrible cultural mistake, hurting the organization.

He was crestfallen, but seemed to understand as John explained these things to him and suggested that he inquire at the national park office. He added some kindly advice about researching volunteer opportunities in the future. (I might add that a quick study of the local language--starting with what it's called--never goes amiss!)

In the nicest possible way, this young man's mistake reminded me of the concept in disaster medicine of the "second disaster"--the wave of well-meaning but uncoordinated volunteers and supplies that materialize at the scene of earthquakes, tornadoes, and so on. Though that seems like a good thing, in fact the transaction costs of organizing that energy and stuff are high, and too much unorganized help literally creates a second disaster. On 9/11, so many volunteer fire trucks rushed to Lower Manhattan that they blocked the paths of the fire trucks whose job it actually was to get to the scene. At a Haitian field hospital where I worked last spring, there were six-foot stacks of boxes of donated clothes, all of it lovingly sent by various American groups, none of which any of the medical staff had time to sort out and distribute, and many of which (I confirmed this by poking through them) were worn out, grubby, or otherwise inappropriate. And drug companies are notorious for dumping inappropriate supplies on disaster scenes, where workers then have to make heads and tails of them, starting with figuring out what they are and when they expire. Fiascoes have taken place on many occasions, including the 1988 Armenian earthquake, the 2005 tsunami in Aceh, and Bosnia and Herzegovina in the mid-1990s, when, according to this grim WHO recitation of such failures, 17,000 tons of useless drugs had to be disposed of at a cost of $34 million. Patients have been harmed by drugs whose use was unclear. Even assuming the drug companies meant well (not necessarily a safe assumption!), this is harmful by any measure.

The point is that, the giving instinct notwithstanding, to give can sometimes be a privilege, not a right. You have to give responsibly. And those of us already volunteering are not exempt from self-examination. We can't take it for granted that our good intentions achieve good results--a topic for another day.

As for the young man, we told him about a couple of places to stay the night and suggested a swim at the beach later that evening. He asked us to call him a taxi, but we had to explain that there are none in this town, so he started off on foot. We watched him as he trudged with his backpack down the hot and sunny road. I hope he finds the right place to give of himself.

Sunday, January 9, 2011

Follow-up: Child with status epilepticus, posturing--and recovery

I posted yesterday about a 3-year-old girl whom we saw several weeks ago whose parents brought her to the clinic after 6 continuous hours of status epilepticus. Soon after our physicians stopped the seizure, she began posturing, a sign of damage deep inside the brain. While we treated her for malaria, viral encephalitis, and bacterial meningoencephalitis (we didn't know which of these it might have been, but we dared not do a spinal tap to check--that can be dangerous if one suspects increased pressure in the brain), she remained at our clinic for three days, comatose, unresponsive except for posturing in response to pain. Then our physicians advised her parents to take her to another hospital that has higher capabilities than our clinic. But we doubted she would recover.

We were wrong. And it's not for the first time--I must learn to be more measured in my doom-and-gloom predictions about sick kids in our clinic. Half a day after I posted yesterday's sad entry, her mother walked in, child in arms, very much awake. She was so cute and lively that I didn't recognize her, but the other doctors and I were shocked when we realized who it was.

Apparently the parents chose not to go to the other hospital and took her home instead. That evening she began to regain consciousness. And now, several weeks later, having received only three days' worth of treatment, she is here with us, wiggling in her mother's arms, kicking at us playfully, and filling the waiting room with her chatter. She doesn't appear to be deaf. According to her mother, she's back to normal. If there is residual damage, it isn't obvious.

I don't know what to say. I thought she was done for. But it's nice to be reminded--especially as an ER doc who often sees people at their sickest--that even the sickest of the sick can recover.

By the way: I asked the patient's mother why they came to the clinic 6 hours after the seizures started, and, for the record, I was incorrect to speculate in yesterday's blog that they delayed because they didn't know they were dealing with an emergency. They knew it, all right. They spent those crucial hours raising the money and securing the transportation to get to our clinic--which is two hours from their home. We sent them home with a dose of rectal diazepam in case it should happen again--in such a remote area, the benefits of self-treatment of such a dangerous condition seemed to us to greatly outweigh the risk.

Tough life out here.

3-year-old girl with seizures

Some weeks ago in our rural Indonesian clinic, we saw a small girl of about three in the late afternoon. Her concerned parents brought her in because she was having a seizure during a fever. It was a quiet little seizure, and perhaps it didn't much worry them at first. She didn't jerk or turn blue or flail dramatically. She just lay limp and insensible, left hand twitching and eyes gazing to the left.

How long has she been having this seizure? we asked them.

Since morning, came the answer. Oh, no.

A seizure that lasts longer than a few minutes--the definition varies from 5 to 30 minutes in some texts--is called status epilepticus, and it's a different ballgame from the more benign self-limited fever-related seizures that little kids sometimes get. Seizing for longer than a few minutes can cause brain damage.

Our physicians stopped the seizure quickly with rectal diazepam. But she didn't recover. Instead she lay comatose, barely responding to painful stimuli like a firm rubbing of her sternum. Basic tests found no obvious explanations of her seizure other than the fever, and no obvious cause of the fever. Treatment for the most likely bugs was begun, but within minutes of her seizure stopping, she began posturing--a sign of grave brain damage. Having reached the limit of the clinic's capacities, the physicians decided to transfer her to a nearby hospital. Her prognosis for resuming a normal childhood is grim.

Though it's a completely different situation, this tragedy reminded me of Anne Fadiman's superb book The Spirit Catches You And You Fall Down. It's about of a clash of cultures--Laotian Hmong and Western medical--and how a failure of communication between a pair of well-meaning immigrant parents and a group of equally well-meaning doctors led to a little girl's suffering a devastating and seemingly preventable seizure. It's brilliantly researched and presented. I read this book before beginning medical school and it's one of the few books in my adult life that I've reread many times, because it fascinates me that cultural differences can lead to so absolute a failure to communicate.

In our case, the failure is not one of person-to-person communication; it's hard to pinpoint and blame is hard to affix. The tragedy here is in part from her parents not bringing her in sooner because they didn't realize how dangerous an extended seizure can be. Or so I speculate, across a language barrier--there may also be factors like lack of access to transportation, concerns about expense, not realizing there was a clinic they could go to, and so on. But if I'm right and it was a simple lack of alarm on their part, then this episode underscores how much medicine a layperson in a developed nation can learn simply by having access to the media. TV dramas, radio programs, newspaper articles, storybooks, all of these over a lifetime teach people the seemingly obvious fact that things like seizures or sudden paralysis or terrible chest pain need to go to the hospital right away. We aren't born knowing these things, and in areas where this knowledge isn't floating around, maybe people don't know it. Maybe her parents didn't know it. And what looked to them like a quiet little seizure turned out to be seismic.

Saturday, January 8, 2011

Review: Fabulous little EKG machine

Greetings, faithful readers, from the aftermath of a long Internet outage. I want to review a nifty portable EKG machine that our clinic recently received from a generous donor.

Sold on eBay by a Chinese company called Medeshop for $239.00 plus $29.00 shipping (American dollars), this electrocardiogram machine fits in one's palm and weighs 800 grams. It arrived promptly (to a US address, after which it was hand-carried to Indonesia) and came with detailed instructions in somewhat fractured but quite understandable English. And I couldn't be more pleased with it.

For one thing, it's a snap to use. We borrowed one of our male nurses and had it on him within minutes, using its handy suction-cup and clamp attachments. After five or ten minutes' spent studying the instructions, we'd mastered all the buttons and options, each of which was close to intuitive.

For another thing, it's all but self-contained. For one thing, the suction cups and clamps mean no disposable stickers--not only are those stickers expensive and hard to obtain in remote areas, but they also generate trash. And here in rural Indonesia as everywhere in the world, trash is a big problem. The only thing this machine does need is paper for printouts--unless you decide to hook it up to your PC and view the EKGs digitally. Our clinic is Mac-based and we're not able to choose this option, but one could conceivably go completely paperless and trashless with this EKG. In a low-resource environment, all things being equal, equipment that doesn't require disposable parts and that behaves in a near self-sufficient matter should be given greater weight in purchase decisions than equipment that relies on parts that must be continually bought and replenished. Even if one has a steady supply of parts, they can go missing or be hard to store or keep track of in a small clinic.

Finally, one can operate without power--its battery lasts at least half an hour after being fully charged. That is absolutely key in an environment where the power often goes out. And you can opt for backlighting.

This machine allows the user to toggle through each lead on a standard 12-lead EKG; one can then opt to print it out. The printout isn't like a full-sized machine that prints a series of heartbeats from the simultaneous point of view of each of the leads--on this little machine, each lead is measured for three seconds sequentially. So you have to bear in mind that you're not comparing individual heartbeats across leads.

It offers various paper speeds and filters, too. I'm delighted with this thing and hope our clinic will eventually be able to obtain a few more. But if we never do, it's so light and portable that we can carry it from bedside to bedside and use it as we would any other portable equipment.

Verdict: great product.