10-15-2010 0800 EST 19 Buzzards Bay Ave Woods Hole MA. Well, if it quacks like home and it smells like home and it feels like home then...then it is! Back into the windy quackings of a `noreaster, but a kind of friendly version of one..a lot of water and wind during the night, and now mostly wind. Fuji the little dog was happy to see me, and it was quite a kick to drink the water out of the tap. Probably the water in Addis was fine, but since "everyone"said not to drink it, I didn't .But then, I didn't do malaria prophylaxis either; never actually saw ,heard or felt a mosquito, and we didn't go low
The 6 hours in Business Class alta luxe of the Lufthansa Frankfurt airport, which does not actually have any wurst of any kind, but does have a very upscale 8 option button coffee and cocoa dispenser, was not that bad.I got a of work done comparing the two proposed medical education curricula that I have been tasked with comparing,and also sorted some of of the pictures taken. (Usually I just do the electronic equivalent of sliding them into a box on top of all the others from previous rolls). And the trip on across the North Atlantic was relatively short and sweet...business class, it makes me a little sorry I am not in business.As it happens,the bus to Woods Hole was expected 15 minutes after I got through customs. I made kind of a point of not knowing exactly when...I'm trying to figure out ways to decrease travel anxiety, and not knowing things like that turns out, for me, to be essential. Then Ray, my Woods Hole neighbor, got on the bus at South Station, coming back from a day of self directed research at the Harvard Library, so I learned more about his underwater archeology as I started falling asleep towards the end of what was actually a 24 hr travel time.
So waiting on the computer was a note from Suzanne that makes it clear I didn't write anything about my visit to the ER at St Pauls Hospital, which should have gone into the Day 14 dispatch.
This was in no way a scientific study, but having hung around Emergency Rooms and Departments (since they have grown into almost small hospitals of their own in the USA) in various parts of the world, I wanted to see what was happening at St Pauls, one of the better developed and staffed hospitals in the Ethiopian public health system. This is the hospital whose general medical curriculum I am reviewing also. (It was initiated by Haile Selassie, and has a large tryptich painting in the front entry way,showing Ras himself in various poses of lifegiving and bountitude). As we all know, if you want to talk ER docs, come in the morning. If you want to see what they do, come at night. So it was already dark when we arrived, and there was already a crowd. The ER is an add on..single story, about 800 square feet including the roofed but open waiting area to the left, and the triage area inside t he door to the right. Further inside, there's a kind of multipurpose moving around area, with the nursing station to the right, and a room labeled Nurses Duty Room, which looked like an office cum sleep room, and was closed. The multipurpose room stretches across the whole 30 feet of the building, and leading back from are a hallway with small rooms to the left, and a 12 bed double sided open ward with curtains, to the right. Guerneys to the left, sit-able patients to the right. Behind the desk, which if the entrance is to the North, is on the West side running E-W, with the open ward, running NS across the multipurpose room right in front of it.
Yes, it might be easier to send a picture, but we're getting to why I didn't save any pictures.
The joint was jumping, although no acute street trauma arrived while I was there. (Ambulances are associated with hospitals, and not a big presence...very few sirens in Addis..my guess is that most of the drivers are still professionals, speeds aren't that great yet, so the amount of closed head injuries per capita is still low...but just a guess. In Hanoi, as they added motorized trishaws, things got very bad...and when we were there 15 years ago, they still didn't have a working CT, so I helped with the first and only burr hole placement I've ever done, based on clinical exam as to where to drill the hole). There were two or three interns..meaning docs enrolled in the medical education program who have been certified as physicians (each medical school does its own, there is no national standard) and a resident, plus an older man in a white coat and hospital nametag whom I didn't meet who acted like an attending, but definitely was not making the disposition decisions. There were several young women in green scrubs who were acting like nurses (lots of moving around, hands on both charts and patients, putting charts in front of doctors), but not speaking Amharic mean't that I wasnt overhearing any conversations to be sure. What the nurses were not doing was procedures...the person I saw missing three IV insertions was certainly doing all procedures, and perhaps was a more advanced nurse rather than a rotating advanced medical student. Name tags were not much in evidence.
They use a 'surgical side'/ 'medical side' system...very common everywhere and easy to use. Charts go up into two holders on the nursing station desk as medical or surgical.They move from in to out depending on progress of the diagnosis and treatment, and may be filed in a bank of chart holders along one wall, for example as t hey wait for paper results. Lab work is slow, taking minutes to as long as an hour. This lab wasn't doing lactates, for example. A basic complete blood count might take 30 minutes. Plus,probably due to the not very complete safety net of medical expense coverage, at least in one case the family had to go across the way and apparently purchase, or sign for, the gloves, iv tubing, fluid and medication to treat their loved one. They brought it back. by hand.But the actual catheter, the ones that they missed with three times, came froma drawer behind the nursing station.
What was the matter with people? A obviously very ill manwith a major pneumonia, prob HIV plus tB. A man with an oxygen cannula taped up one nostril breathing at a rate of 30/min and with 8 meds on his home med list. Two men with painful abdomens and high white counts. A woman in her third trimester, first baby,who didn't feel good. An older woman whose right foot didn't smell good and with a fever. In other words, some of the same things as are the matter with us in any hospital here.
But don't get injured in Ethiopia,not yet. And, come to think of it, if you have to get sick emergently, get sick in Oakland.. The system I saw is a lot like the state of ER's in the USA in the 60's...before EMTALA ( 1986) the transportation based law that provided the impetus for much of the emergency system we see today. Emergency medicine everywhere has always been driven by neglect...since post-war periods in the US, our non support of routine neighborhood care has ensured ER visits for non emergent situations..while EMTALA ensures penalties for not providing care for medical problems (...the 'AL' part of 'EMTALA' refers to 'Active Labor',and one of the major triggers for that happened on my watch, so to speak, when our health plan operator could not find a specific woman on the list of people certified for care, and a private hospital decided to transfer a woman in active labor, whose baby died. Vale,Sharon). There will be changes...the note from Suzanne says they are involved in a project to assist with emergency medicine in Ethiopia..but the changes aren't there yet. In most Ethiopian hospitals, the ER is just that, a room where you come with an emergency.
As I was hanging out, muttering into my Flip camcorder, using the sound as a voice recorder and not paying attention to the picture part, a man about my age who had been in a group with one of the patients (Crowd control is as difficult as it would be at Highland in Oakland if there was no door on the ER there) came over and demanded 'who are you?' I had my name tag on,but not a white coat. He spoke not too much english,but was clearly concerned about my presence. Crowds in every country gather rapidly in situations like that. Luckily, before a major incident occurred, another family member with good english started translating,and it turns out he was only concerned that I might be taking pictures. And thats why, for good ethical reasons, I dont have any pictures to share.
Level of care? Hmm...certainly way better than Delhi 15 years ago, or Jamaica 20 years ago. Probably in terms of infrastructure about like Garberville CA in the 60's...definitely not up to Jackson Memorial or Mission Emergency in the late 60's. But the diagnoses I heard were right on, and a training plan that included nursing training and job descriptions comparable to ER nursing in the US will fit right in. A few used CT scanners would help. ..St Pauls has only really had an ER for a few years, and just started their residence training program. And I am hoping that as a country they will look for something like CALS, the Combined Advanced Life support system of teaching and certfication that was worked out by some family docs in Minnesota...instead of the overly possessive non integrated combination of ATLS, ACLS, and PALS that I had to struggle with in my life as an ER doc.
So the 'noreaster is still prowling around, its time to join Sala for breakfast (what a joy!)and then go check the boat for water level before settling down to my comparison work...on the other side of the world.
But somehow,I don't think the next dispatch from Addis is that far off!
salama
alan
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