Friday, January 17, 2014
Rural medicine in Idaho, Africa and elsewhere
Rural medicine, I guess, can be defined as health care that happens in places that aren’t big cities or referral centers. The vast majority of the populated earth’s crust that has any health care at all is served by rural practitioners. I have done a little bit of rural medicine in Haiti, in Mexico and now a bit more in South Sudan. I have also worked in a rural health care system in Idaho for nearly 20 years. People benefit hugely from health care delivered to them in their less densely populated home turf, despite the fact that health care in such locations lacks technology and specialist services that are often available cities or university medical centers.
In the U.S., most rural health outposts are within an hour of a major medical center, either by ambulance or helicopter, so transfer to a high tech center is usually possible when there is an indication. In developing countries people are often grateful for any medical care that can be provided and transfer to a higher level of care is much slower or impossible.
When a person in the U.S. discovers that he or she is very sick they usually call an emergency medical service team which sends at least 2 trained medical technicians within a few minutes to evaluate the patient and transport them to a hospital if that is necessary. In some areas like the Alaskan bush and truly isolated parts of the U.S. this is not true, but the vast majority of non-city dwelling Americans have access to emergency medical services. In rural South Sudan a person who is very sick will first receive any folk remedy available and if that is not effective, will begin the long journey, on foot or carried on a litter by relatives, to the nearest health care facility. Such a trip may take days.
On arrival at a rural emergency room in the U.S., patients will usually immediately see a well-trained doctor who will respond appropriately to their life threatening needs with interventions that are similar to what they would get at a hospital in a larger city. Specialists will be called if appropriate and often will be at the bedside in close to no time. Testing, including CT scanning, ultrasound, advanced lab testing and X-rays, is completed quickly and a likely diagnosis and treatment strategy is determined usually within a few hours. An IV line is usually placed and, if in doubt, the patient is put on oxygen by nasal cannula. If appropriate treatment for the patient’s condition isn’t available, transfer to a larger facility is arranged. If the patient is sick but can safely be managed in the rural hospital, admission is arranged. The patient is then taken to a moderately comfortable electrically controllable bed with clean sheets and a pillow, with a pitcher of water and toiletries on the bedside table.
In a very good rural hospital in South Sudan, like the place I worked, testing is limited to a fingerstick test of glucose and creatinine (for kidney function), vital signs such as blood pressure and oxygen saturation, if the machine is working, possibly a bedside ultrasound if the health care provider has been trained and the machine is available. Very sick patients are placed on a mattress on an ancient bed in the ward, if a bed is available, and may be given intravenous fluid or medications if their condition warrants it.
There is no oxygen, water pitcher, bedside table, sheets or pillows. The medications available are limited, and if what we have is not what the patient needs, they might get whatever is closest to what they need, or nothing at all. Transfer is sometimes possible, but usually delayed by days and sometimes longer. If the problem is one of several tropical diseases which are common, treatment is rapid and appropriate and miraculously life-saving at a tiny overall cost compared to treatment of anything in the U.S.
If the patient’s breathing stops or the heart ceases to beat, that is usually the end, without resuscitation unless the cause is clearly quickly reversible, like having choked on a peanut. Blood transfusion is possible and sometimes life-saving, since many of the worst tropical diseases are associated with severe anemia. Although blood typing can be done, a full screen for transmissible organisms and minor blood incompatibility is not possible, so potential donors must be people for whom there are very few risk factors which mostly means medical staff. The blood comes out of the donor and is immediately infused into the recipient, relieving symptoms of weakness and heart failure. There are no facilities for processing the blood so it is fresh, whole blood that is transfused, which actually has some theoretical advantages over the stored packed cells most patients receive in the U.S.
Some women with problems of labor and delivery can receive life-saving help, based on the expertise of the attending physician or health care worker and people with wounds or injuries can often be patched up or splinted or casted. Abscesses can be drained. Sores, including tropical ulcers, can be cleaned and dressed and often healed.
In the U.S., detailed and scrupulous records are usually kept, often in digital format that can be searched if you know how to do it. Records in the tiny hospital in South Sudan are very brief and often inadequate to communicate the course of events without the additional input of the caregivers who may remember what happened and what everyone was thinking. The lack of complete records of medications given was particularly frustrating for me. There were, however, twice daily vital signs most of the time, which are often not available in less excellent hospitals.
In order to make an impact on a person’s disease it is necessary to know what is happening with the person, thus vital signs such as blood pressure, temperature and pulse are important, as are changes in a patient’s symptoms and signs of disease. If we don’t know whether the treatments we order are actually being given, our ability to adjust therapy to achieve a desired result is extremely limited. The excessive and almost obsessive data gathering that we suffer from in the U.S. can overload us, but the ability to have some objective data regarding a patient’s physical state is extremely helpful. I longed for more documentation in my visits to Haiti, Mexico and Africa.
On the other hand, there was something beautifully basic and adequate in the concise paper records in South Sudan. Patients had a card, half of a standard size piece of printer paper, which documented all of their inpatient and outpatient complaints, diagnoses and treatments. They knew to keep these cards and brought them with them for each visit with a health care worker (or received a scowl if they didn’t.) The more extensive records from a hospitalization were just thrown away when the patient left the hospital, but a brief summary stayed on the card. The cards were often dirty and wrinkled, but people kept track of them, which made a huge difference in being able to find a way to cure patient’s persistent or new ills.
So … rural medicine is such a very different thing in different settings, and so incredibly important. It is fraught with huge challenges, especially in the most remote places. These can look like the hospital I saw in the South Sudan, or even smaller primary care health centers, staffed only by a single community health worker trained to treat only a few specific diseases out of the myriad that people have, with a very small formulary of remedies.
It can be so very rewarding to see patients who work hard and never ask for medical resources be cured of diseases that stop them in their tracks and threaten to ruin not only theirs, but their entire family’s livelihood. And this does happen, using very basic tools. A few packets of oral rehydration solution or a course of amoxicillin can be lifesaving. In my rural hospital in Idaho we can’t transplant a kidney or bypass the blood vessels whose blockage causes a heart attack, but we can care for nearly all of the sick people who come to us, and we do a really good job. And the community health workers in Africa also do a really good job, treating malaria in children with fevers who might otherwise die, pneumonia in infants who are desperately ill, identifying and treating malnutrition and referring the worst affected to appropriate nutrition programs.
After all of the American volunteers leave the hospital I visited in South Sudan and the rains fall, turning roads to impassible mud, South Sudanese health care workers treat patients who continue to present with life threatening illnesses. There is so much that they can’t do, but, much more importantly, so much that they can.
Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
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