aka American ER Doc Gone Walkabout… 014
A few weeks ago, I wrote a bit about waiting room overcrowding, and received a comment from Dr Nicolas Peschanski, a French ER Doc in a very large French academic ER. His comment reflected the failure of the French to have any more success than the English-speaking world in managing waiting room overload.
What Nico (Dr Peschanski) didn’t mention was that we worked together a few years ago in an ER/clinic that had no real waiting room times (actually, no real waiting room). So, I’d like to comment a bit on how we managed it.
A bit of background:
The clinic that we staffed was at an altitude of about 3500 meters, a 6 day walk from the nearest road on the Annapurna circuit trekking route in rural Nepal. We averaged 6 patients per day – about half local, and half trekking westerners passing though the area en route to a high point at 5200 meters (about 17,000 feet).
Here we go:
- Eliminate the time drag of electronic medical records. Easy to do if there is no electricity (actually, the town had a micro-hydro-generator system that provide about 2 hours of electricity each evening. When it worked.) Our medical records consisted of a single line in a log book. If more was required, it was handwritten on a blank paper and given to the patient to carry. Complex/chronic patients carried their medical records with them – a little roll with individual hand written sheets. Often in a variety of languages: English, French, Nepali, Hebrew. Exceedingly efficient if you happened to hit the same language as the last doctor. University of Colorado is now catching up: we have an iPhone app for patients that gets them into their medical record – if they show up at another hospital, they can pull up their labs, medication lists, allergy lists for the doctor. Unfortunately, can’t get directly into physician notes, imaging, EKG copies – but, it’s a start.
- Adequate staffing. We had 3 doctors – me, Nico, and my wife also an ER Doc – for an average of 6 patients per day. Since we were volunteers, we could afford these staffing levels.
- Eliminate insurance and billing, and required payment at the time of the visit. We charged $0.67 (roughly – the Nepali rupee to dollar exchange rate was a bit vague) per visit for locals, and $30 USD for trekkers. No billing or insurance, except in the rare large charge (one French guy spent 2 days in our Gamow – hyperbaric – bag, and his French insurance paid for 2 days of ICU care – providing about 2/3 of our annual budget).
- Eliminate excess testing. No electricity, no labs, no imaging. We had a pulse oximeter, blood pressure cuff, otoscope/ ophthalmoscope. Done. My best guess was that we could estimate a relatively simple diagnosis and be right maybe 80% of the time. Better than having no trained medical person available. Felt pretty good if you’re a “glass half full” kinda guy. On a previous trip, I worked with a doc who was a “glass half empty” guy, and he appeared to think that 80% was near zero diagnostic accuracy. He had to be evacuated after 3 days of work.
Unfortunately, this requires coming to grips with some diagnoses that can’t be made or confirmed: we saw a few people in the lowlands on my first trip who had profound anemia, and gigantic spleens on clinical exam with a course of weeks to months. No idea what it was until I returned to the States and was able to do some reading. Almost certainly visceral leishmaniasis – kala azar. If known at the time, we wouldn’t have had the treatment available, but we might have been able to send them to Khatmandu.
Other stuff, could make do with simple equipment. We had some dental bone rongeurs that we used to complete a mid foot amputation on a severely burned little girl who had stepped into a fire- so that we could get back to healthy bone and soft tissue and get a good, clean wound closure.
- I worked, on a previous Nepal trip, in a traveling clinic. That trip, we did have large waiting room crowds – not unusual to have many hundreds in the courtyard when our 8 doctors showed up in the morning. After several weeks, we were completely out of supplies and our translators had to go outside and tell the hundreds still waiting that the clinic was closed. A riot ensued. Eventually we went out the back windows, and the army showed up and fired a few automatic rifle bursts into the air. It seems that automatic weapons are an efficient way to decrease waiting room overcrowding. I hesitate to mention this – if anyone from Arizona reads this, they might try it.
Thanks for the memories, Nico.