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.

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 Trauma.org, 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.

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.

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.