Easy as ABC

I recently had a profound learning experience that I would like to share with you. It filled me with a lot of guilt and saddened me no end. On the other hand, it taught me a lot about myself.

I was driving somewhere one day. On the way, I saw a crowd of people gathered around a smashed-up car, the typical picture of an accident in our city. Being an emergency physician, I pulled my car over to the side and ran over to help. There was a woman on the tarmac, apparently unconscious in a pool of what looked like blood. I yelled at the police and the crowd to give me space. No one really heard me so I wormed my way over to her. To my relief, she was awake but a bit groggy. My medical training kicked in. ‘Airway (and neck), breathing , circulation’, the ABCs of resuscitating a sick person. I stabilized her neck with my hands to protect that part of her spine. This is vital because the cervical spine connects the brain to the rest of the body and controls virtually everything from breathing to movement. A tear in this delicate and exposed area of the human body and one can become paralyzed for life at best and dead at worst. I then looked at her chest and was relieved to see both sides of her chest rising regularly and equally. That meant her breathing was alright. Next, I needed to check her pulse. That would mean removing my hand from her neck, something I wanted to avoid. Luckily, the fact that she was awake and breathing significantly reduced the chances of her heart not beating so I put that off. I then yelled for a recount of events leading to the accident. Multiple people began to simultaneously recount their versions of the event. I cannot go into the exact details (due to privacy reasons) but suffice it to say that she had met with an accident after some disturbing events in her life. I then made a glaring error. I removed my hands from her neck to check her pulse (which I felt immediately quite strongly).

Nothing dramatic happened. Her neck did not snap, she did not become paralyzed and she continued breathing as before when everyone propped her up. That is besides the point. As a trained emergency physician, I HAVE to follow the ABCs mentioned above. I cannot just leave her neck based on a garbled history. I saw a smashed-up car (which indicates a high velocity accident) and a groggy woman. Ordinarily in a hospital setting, that is more than enough for me to secure her neck. Over here on the road I needed to follow my training. Perhaps, me being out of my comfort zone made me forget. Perhaps the fact that everyone else had moved her around without any obvious medical consequences lulled me into a false sense of security regarding the state of her neck. However, that is no excuse. As an emergency physician, it is my job to keep calm under pressure. If something had happened, it would be my fault alone. It costs nothing to stabilize her neck. Yet, the possible consequences of letting her neck go are devastating.

To decide if a neck can be let go, one can choose one of two famous algorithms- the NEXUS criteria and the Canadian C-spine rule. The former is simpler to follow and more relaxed about the neck as compared to the latter. The Canadian C-spine rule is marginally better but it is not unreasonable to depend on the NEXUS criteria alone. The NEXUS criteria allows you to relax about the neck if all of the following 5 criteria are met:

1)      The person is awake, alert and oriented to time, place and person,

2)      There is no evidence of intoxication,

3)      There is no focal neurologic deficit (i.e. no paralysis, loss of sensation anywhere among other things),

4)      No pain when pressing midline at the back of the neck, and

5)      No distracting injuries (simply put, a bleeding wound with say, the bone sticking out in the leg is bound to distract the victim from any pain in the neck)

With her, I could only reliably say that she met condition 1. I couldn’t confirm that she wasn’t intoxicated, given the bizarre circumstances of her accident and the fact that although she was oriented to time, place and person, she still wasn’t replying to all my questions consistently (likely due to the pain, but again, it costs nothing to keep her neck stable). She told me she couldn’t move her leg due to the pain. I also couldn’t do a proper examination to reassure myself regarding conditions 3, 4 and 5. Therefore, even by the relatively lenient NEXUS criteria, I should not have moved my hands from her neck till I could evaluate her properly or get a CT scan of her neck. Hence, the guilt.

Why the sadness though? As an ER physician, my daily bread and butter is this city’s dark underbelly. Consequences of its poverty, illiteracy, violence and mental strife are just another day in the ER. Therefore, quite naturally, I have developed a high level of immunity (and cynicism) to what most people would quail at. Whether that is good or bad is beside the point. It is necessary for me to remain detached so that I can function effectively as a doctor. Yet, seeing the very same thing I see everyday in the ER in a non-ER setting jolted my humanity awake and reminded me that the ‘guy on bed number so-and-so’ is not just another guinea pig that the conveyor belt-like triage has sent my way. Here was a woman with a horrible backstory (from what I gathered. Again, cannot go into details). Whatever the complete truth was, the end result was a devastated, injured woman with a mountain of problems. An uphill battle if ever I saw one.

What saddened me was how the police dealt with the case. I will not comment on the legal, administrative and police side of things (as it is not my place to do so), but I can give my two cents on how they handled the medical side of things. It is imperative that the police have some basic first aid training, enough so that they do no harm. Moving an accident victim about without any know-how of protecting the neck is criminal. They need to have SOPs in place that deal with this. They won’t always have a doctor at hand to help them out. While they all meant well and were most obliging to me, their lack of first aid knowledge proved a hindrance. Too much time was spent deciding whether they should keep the door of the car open to let her have some fresh air and constantly asking me if they could give her some water, despite my clear instructions regarding this. They also refused to send her to the hospital immediately. The reason they gave me was that she was wearing gold and if they took her immediately and the gold went missing along the way, they would be in hot water. Additionally, there were other logistical barriers that I cannot comment on. I later asked them that if she had looked like she was going to die any second, would they have reacted the same way? They vehemently insisted that they would have sent her to the hospital immediately. That is what bothers me. These medical decisions should not be in their hands. I understand that our emergency services leave a lot to be desired but in such circumstances, one would think the best option would be to get victims at the earliest to where they can be helped.

What did I learn about myself? I am not as authoritative as I should be. I have emergency training from arguably the best hospital in the country. I know exactly how to proceed in such situations. I must have confidence in myself and my abilities. There is a lot of research that backs everything that I do in such situations. I should learn to trust it, especially in such situations where I am the only advocate for my patient.

Lessons from a Symposium

Today, I attended a workshop at my university (just so we're on the same page, I'm in medical school in Karachi, Pakistan) entitled “Pediatric Emergency Care in Developing World: Setting Priorities” and boy, was I inspired alhamdulillah. I ditched my day off from classes and went to uni to attend and it was totally worth it. I hope to infect you with the can-do spirit and excitement for the future I'm feeling right now through this article. It was organized by the Aman Foundation and Childlife Foundation (the former is an Ambulance service among other things and the latter a child health organization) in collaboration with certain doctors at the Aga Khan University (my institution), including the head of the Emergency Department, Dr. Junaid Razzak (also involved with Aman) and Paediatrician Dr. Naseeruddin Mahmood (also involved with Childlife) among others. Dr. S.V. Mahadevan from Stanford University was also present and was undoubtedly the star of the show (NOT because he's from Stanford. But with faculty like him, one can see why Stanford is among the premier institutions of higher learning in the US).

A little background on why I attended. I love Emergency Medicine and hope to specialize in it one day. Mainly because I don't have to do boring clinics, counsel patients about their lifestyles (most of my patients would present with more urgent problems such as with convulsions or strokes, so talking about their inappropriately large consumption of Jack Daniels isn't the best idea at the time). I don't like Paediatrics so I was there mainly for the Emergency part.

Also, I attend these conferences to remind my self of the 'bigger picture', i.e. the lofty goals I set for myself at the start of medical school; the ideals I had. I would serve people, improve the health status of our population, do research etc. But in the myriad of textbooks and all-nighters in university, one tends to forget these ideals. So these conferences help keep my morale up and remind me as to why I am in pursuing the noblest profession (I said noblest, not oldest OKAY?). Though it really feels weird when you're all pumped up after these symposiums, only to come home to study some obscure disease of the eye, something you'll probably never see, especially if you don't plan to go into eye. But I suppose our academia knows best, right?

Dr. Mahadevan talked about how his travels across the globe have taught him some interesting things. In Nepal, till 2009 there were no ambulances. Being a Sherpa nation, patients in need of urgent care were carted to hospitals on the Sherpa's backs. In Cambodia, the Khmer Rouge systematically killed all the intellectuals (doctors included) a few decades ago so the country went from a nation with a fairly well-developed medical system to one in the dark ages within a few months. The Cambodians had to start from scratch. Indeed the situation was so deplorable, doctors didn't even know how to use a stethoscope to hear the chest. Stanford helped train these doctors to recognize medical emergencies via video aids etc. But his crowning achievement (and possibly failure) is probably India. He helped train paramedics to international levels here via innovations like computer games (you are presented with a patient and given options, You choose a wrong option and your patient's health plummets. Do the opposite and it goes up). He trained these paramedics to be able to become instructors themselves. Sadly, after training, many of these paramedics left the country for greener pastures like Dubai defeating the purpose of the training (to boost India's Emergency Medical Services). But that didn't make him lose hope. The lesson he learnt was that he should place such teaching tools in place (e.g. video aids etc) that many people can use with minimum facilitation so as to mass-produce high quality paramedics.

Another thing I noticed about his program was that it catered to local needs, sensitivities etc. Instead of copy pasting diagrams from textbooks. They made new pictures where any humans were ethnically Indian and wrote textbooks that weren't wordy and hence easy for the paramedics' levels. This impressed me and got me thinking about how differently the West does things differently from us. We copy the West. They create. We think its sufficient to build a 4-walled clinic, staff it with a doctor and nurse and the country is saved. On the other hand, the West is professional; they research the area's needs and create programs tailor-made to suit these needs. Then they monitor the program they've set in place and change what's not working. The major problem is that we lack specialists. We don't have pediatric emergency medicine specialists among a million other things. The ones we have have crossed the Atlantic. In reference to my earlier example, we think a 4 walled structure can be a clinic. Slightly larger and it's a hospital. However, an architect specializing in hospitals would know the nuances of such a structure and would build it appropriately and efficiently.

Dr. Mahadevan then talked about how even his training at Stanford couldn't prepare him for somethings that he faced in India. In the States, a woman is usually in Hospital well before she is at the brink of giving birth. In India, they call the ambulance when the baby is tunneling it's way out of the uterus. So in the US, paramedics virtually never have to deliver babies. In India, 1/3rd of ambulance calls are births. In addition to this, snakebites and organophosphate poisoning is something he never comes across. Again, these are commonplace in India. This got me worrying. My life plan is to graduate from AKU, inshaAllah go abroad to specialize (since the training abroad is superior to ours) and come back to serve my people. Go ahead cynics, mock me. See if I save your sorry rear ends when you present to my ER with suicidal depression. Anyhoo, since I saw that my training abroad would not completely prepare me for the nature of medical emergencies I'd face in my country, I am beginning to debate whether going abroad is the best thing for my country. I talked to a Doctor who went abroad and came back and is now running a system of clinics in Karachi. He said that the main reason I should go abroad is to observe the systems in place in the west and to bring them back here. Any differences in your medical training will be made up when you come back inshaAllah. He cited his own example of how tuberculosis is an unknown entity in the west. So he didn't know how to treat it when he moved back. Over here, the disease is so common sadly, every general practitioner knows how to treat it. But he learnt when he came here and now he faces no problems. His experience in the States has helped him set up his chain of clinics. Another option for me is do my residency here and fellowship abroad. I suppose I should discuss this matter some more with doctors who have gone abroad and come back. And do istikhara of course.