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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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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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