Ecuadorian ER part dos
Connected to the portable heart monitor is apparently the only defibrilator in the ER. Only it seems that the only problem it has is that it doesn't really work. In a code today they went to defibrilate the patient, and well it just kinda didn't fire. I don't know it was kinda weird.
Overall though it's an amazing experience there. I have been working a lot with one of the residents and he's great to work with a very intelligent. Its pretty amazing how much they can do with so little.
The other day when I arrived a patient came in overnight who was 24 and had been shot twice in the neck. One bullet exited and the other shattered a vertebrae and lodged itself in the cord between c6 and c7. It was sad obviously but also amazing to see how he was managed. He wasn't in any ICU bed because it was full and the only monitor was the mash era heart monitor. He had been on dopamine overnight because following his injury he couldn't maintain his pressures so he was on dopamine until they filled him with enough fluids to compensate for the dilation of his vasculature following the lesion. I was impressed that here you don't call up a pharmacy and order dopamine, you know the needed dose, you calculate how much to add to a bag of normal saline and then you make it up yourself.
They do have some central lines, but only single lumen lines. So they drop in a single lumen line and then rig up multiple splitter to run in multiple fluids or draw off blood as they need. The most amazing thing I saw was how they measured the central venous pressure. So in the states you just hook this gadget up to one lumen of the central line and then plug it into the computer and it gives you a readout of the CVP. Here they just connect a tube to the line, tape the tube to the IV pole so it runs up vertically and then they have a piece of cardboard with centimeters hashed off so you can read the CVP off it. It was so simply done, but obviously how it was originally done and it worked which was really cool.
This was an incredibly sad case for me though. This 24 year old guy had his cord severed between C6 and C7. Which means he'll essentially have some feeling/function in his shoulders and parts of his arms, but other than that is a quadriplegic. One normally breaths using your diaphram and the muscles between the ribs, but in this situation you lose the fuction of your rib muscles and only have your diaphragm. So he couldn't breath quite as well as someone normally would, and you can also tire out your diaphram in this situation so that you can't properly ventilate yourself.
So in the United States, If you had a patient with worsening respiratory status you would intubate them(stuck a tube down their airway) and put them on a respirator if need be to help them breath. Then over time you would try to wean off the ventilator if possible. People in the US survive with these types of injuries and I had just been assuming it wouldn't really be that different here because I hadn't really thought about it.
I realized it was different when the doctor I was working with told the girlfriend/wife of the patient, that unless he improved in the next 20 minutes they would stop supportive care and pretty much let the guy die. I stood around talking with a number of the doctors who explained that they don't really have huge ICUs to support patients like this, and that they don't have the money are resources to deal with the complications down the line. The resident who was working with me turned to me and said "in the US do you have floors like this, full of respirators to keep patients like this alive?"
I was mildly confused at first and then just simply said that yes we do.
The sad thing is that it pretty much comes down to money. In the United states, the way we practice medicine is we pretty much do everything within our power to treat people as long as there is a chance for benefit and it's what the patient wants. Here, and I imagine in the majority of the world, it's different. There is not much money, which limits medicine, and unless you are independently wealthy if you get a bad injury such as this you simply die.
It was upsetting to see, because I have never seen someone die for lack of resources. It's upsetting to see someone die because they are poor and they live in a poor country.
Overall though it's an amazing experience there. I have been working a lot with one of the residents and he's great to work with a very intelligent. Its pretty amazing how much they can do with so little.
The other day when I arrived a patient came in overnight who was 24 and had been shot twice in the neck. One bullet exited and the other shattered a vertebrae and lodged itself in the cord between c6 and c7. It was sad obviously but also amazing to see how he was managed. He wasn't in any ICU bed because it was full and the only monitor was the mash era heart monitor. He had been on dopamine overnight because following his injury he couldn't maintain his pressures so he was on dopamine until they filled him with enough fluids to compensate for the dilation of his vasculature following the lesion. I was impressed that here you don't call up a pharmacy and order dopamine, you know the needed dose, you calculate how much to add to a bag of normal saline and then you make it up yourself.
They do have some central lines, but only single lumen lines. So they drop in a single lumen line and then rig up multiple splitter to run in multiple fluids or draw off blood as they need. The most amazing thing I saw was how they measured the central venous pressure. So in the states you just hook this gadget up to one lumen of the central line and then plug it into the computer and it gives you a readout of the CVP. Here they just connect a tube to the line, tape the tube to the IV pole so it runs up vertically and then they have a piece of cardboard with centimeters hashed off so you can read the CVP off it. It was so simply done, but obviously how it was originally done and it worked which was really cool.
This was an incredibly sad case for me though. This 24 year old guy had his cord severed between C6 and C7. Which means he'll essentially have some feeling/function in his shoulders and parts of his arms, but other than that is a quadriplegic. One normally breaths using your diaphram and the muscles between the ribs, but in this situation you lose the fuction of your rib muscles and only have your diaphragm. So he couldn't breath quite as well as someone normally would, and you can also tire out your diaphram in this situation so that you can't properly ventilate yourself.
So in the United States, If you had a patient with worsening respiratory status you would intubate them(stuck a tube down their airway) and put them on a respirator if need be to help them breath. Then over time you would try to wean off the ventilator if possible. People in the US survive with these types of injuries and I had just been assuming it wouldn't really be that different here because I hadn't really thought about it.
I realized it was different when the doctor I was working with told the girlfriend/wife of the patient, that unless he improved in the next 20 minutes they would stop supportive care and pretty much let the guy die. I stood around talking with a number of the doctors who explained that they don't really have huge ICUs to support patients like this, and that they don't have the money are resources to deal with the complications down the line. The resident who was working with me turned to me and said "in the US do you have floors like this, full of respirators to keep patients like this alive?"
I was mildly confused at first and then just simply said that yes we do.
The sad thing is that it pretty much comes down to money. In the United states, the way we practice medicine is we pretty much do everything within our power to treat people as long as there is a chance for benefit and it's what the patient wants. Here, and I imagine in the majority of the world, it's different. There is not much money, which limits medicine, and unless you are independently wealthy if you get a bad injury such as this you simply die.
It was upsetting to see, because I have never seen someone die for lack of resources. It's upsetting to see someone die because they are poor and they live in a poor country.
posted by Fried Guinea Pigs at 3:49 PM
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