Ch 4. Clinical Skills (Other Than Tropical Medicine)
There is a dire need for emergency care in low- and middle-income countries. According to one study, over 80% of deaths due to non-communicable diseases (NCDs) occur in low-income and middle-income countries; consisting mostly of cardiovascular disease, cancer, and respiratory disease1. Furthermore, 90% of the global deaths from injuries occur in low-income and middle-income countries. This same study of 30 hospitals in Western Kenya it revealed that:
- Less than half had access to an anesthetist.
- Less than half had adequate resources to care for cardiac patients – i.e., functional ECG, sublingual nitroglycerine, or a defibrillator.
- Only a third of referral hospitals had an organized approach to trauma.
- Only a third of hospitals could care for diabetic emergencies.
- No facilities had clinical sepsis guidelines1.
These statistics demonstrate the large gap between the changing patient pathology in resource-limited settings and the ability to combat these pathologies. Lack of materials, resources, and skilled providers produces many challenges to providing adequate emergent care in these settings. In this chapter, we discuss these broad challenges in the context of specific challenges faced directly in the ED. We will then discuss how to combat these challenges by discussing “things to know” and “things to do”, and provide resources to help you with this.
Advanced procedures are commonly used in high-income countries to provide care to critically ill patients. However, this is often not possible in low-resource settings due to lack of equipment, resources, and specialists.
ED Equipment/Resources: Lack of physical resources is often a problem in low-income countries and resource-poor settings. For instance, intubation is challenging or unfeasible as many ED’s lack advanced airway equipment or have suboptimal equipment. The lack of appropriately sized ET tubes, end tidal CO2 detectors, adjunctive airway equipment, and ventilators could require a higher threshold for intubation than in resource-rich countries, if not precluding it completely.
Inpatient Resources/Specialists: Additional dilemmas to providing emergency care include disposition of the critical patient. Once a critical patient has been successfully resuscitated, there is often a paucity or absence of inpatient ICU beds and intensivists needed to continue the patient’s care. This raises the question: “at what point the patient is safe to leave the ED, if ever?”
Delays in Care
Clinicians working in low-resource settings need to work expeditiously to avoid delays in care. Wachira et al found that over half (58%) of the patients presenting to the ED in Kenya were investigated in the department but only 29% of patients seen received any intervention in the ED4. Paradoxically, most of the immediate therapy is provided only to patients with minor conditions who are subsequently discharged. Sicker patients most often have to await transfer to wards or specialist units to start receiving treatment. Given the stated lack of ICU beds, ED interventions and care need to become more comprehensive and definitive.
Lack of Triage/Re-evaluation
Expeditious and appropriate triage of patients is essential to identify and prioritize the sick, and subsequent regular reassessments of the patient are essential. Baker et al assessed ten hospitals in four regions of Tanzania and found that only 40% of the hospitals had formal systems for adult triage, and less than one-third of them had physician re-evaluation of critically ill patients more than once daily2.
The skills discussed in this chapter are meant to help you combat the challenges listed above. Keep these principles in mind as you read about the competencies in this chapter.
In resource-limited settings, it is not unusual for the ED clinician to have to assemble and lay out equipment, which is often done by ancillary staff in resource-rich settings. Carts and trays may need to be personally replenished. Knowing how to find and operate all the equipment and supplies yourself is important everywhere, but in the low-resource setting, it is indispensable.
Working in a resource-limited setting you may have to wear many hats, including that of department manager, pharmacist, technician, and counselor. It is not uncommon for medicines and supplies to run out. This is often due to inadequate restocking rather than the equipment not being available. You may need to take on the role of monitoring supplies and ordering ahead, taking into account turnaround time for procurement.
You may need to take a leadership role to ensure that your department or clinic operates at a high level of safety and efficacy; and leadership that stresses teamwork and communication reduces avoidable errors and speeds up processes. You may be needed to secure standards of hygiene and infection control to limit the spread of nosocomial infections. You may need to improve medical documentation, making it possible to measure quality, ensure follow-up, and help identify problem areas. Be ready to step into that role, knowing that it can make a large difference.
Remember, not all medical and social practices that are effective in your home setting are culturally appropriate in other countries and regions. It is essential to address patient and provider needs in the appropriate local context. Diplomacy with the local staff is required to work well together, as they might not be used to your way of doing things and might not share a similar approach to patients. Discussing expectations with patients and staff and having conversations about differences could improve the care of patients immensely. More about this in Chapter 7.
Things to Do/Skills to Learn
Given the above challenges and keeping in mind the above principles, the following are some things that you can do to prepare for an international clinical elective or to begin a career working in resource-limited settings.
Gain Prior Knowledge
First, know your surroundings. What resources are available at your clinical site? In resource-limited settings you must be prepared to make clinical diagnoses without laboratory results and imaging. You may be asked to perform clinical procedures that may have typically been performed by specialists in your home institution. It is hard to prepare for it all, however knowing the specific clinical, economic, and social environment of the location before you depart is indispensable.
Learn Effective Triage
Organizing the ED in a way that allows for good monitoring and an overview of all patients makes it possible to intervene before a patient deteriorates. The ability to triage patients into different risk categories is especially important, and learning basic triage concepts will help you adapt them to whatever clinical environment that you work in. Baker et al suggest that early warning scores (EWS) based on simple physiological parameters, such as pulse rate and respiratory rate, can identify patients with higher risk of death. These can be addressed prior to establishing a diagnosis by a clinician, and could be effective in reducing mortality in the acutely ill in the low-resource setting.3
Improve Clinical Exam Skills
Advanced History and Physical: The importance of a good history and physical exam cannot be stressed enough. The clinical skills attained while practicing medicine in resource-limited settings is commonly listed as one of the most beneficial experiences gained while doing an international elective. International clinical rotations foster an improvement of physical examination and procedural skills due in part to less availability and lower quality of laboratory services, lack of accessible consultants, and absence of diagnostic imaging. In addition, relying on sparse consults can delay treatment decisions and thus delay care for your patient. Everyone takes a clinical skills course during medical school: remember what you learn, and improve on these skills during your domestic clinical rotations. Unfortunately, many of these skills decline through residency as time with patients is limited and diagnostic resources are plentiful. Keep them up!
Close Re-evaluation: Given the delays in care and lack of appropriate triage, close re-evaluation of patients while in the ED is paramount. Neglected patients in overwhelmed emergency departments can suffer unrecognized clinical deterioration with devastating consequences.
Clinical Exam Resources
Medical Apps: One of the most beneficial resources you can have with you at all times is a good medical app to act as your immediate consultant when you have questions about an exam finding, or need a refresher on performing a procedure. Just make sure your phone app works without Wi-Fi. Specific applications are addressed later in this book.
Clinical Atlas: A good clinical atlas relevant to the local setting would also be useful (such as an atlas on African dermatology if working in Africa) as well as a locally relevant textbook. Check out these resources below:
Brush up on these
You may be called upon to perform procedures that you normally don’t have to perform because of the availability of nurses, ancillary staff, and specialists. You should be able to perform these:
- Intravenous and Intraosseous access
- Lumbar puncture
- Burn management and wound care
- Fracture/Dislocation reduction
- Medical management of MI with fibrinolytics (where a cath lab is not available)
Some procedures are not routinely practiced by emergency physicians in high-resource settings with the availability of specialists, consultants, and advanced equipment, but may be necessary skills in low-resource setting. Take a look at the list and heed the information in the box below the list.
- Regional Anesthesia (see below)
- Emergency Obstetrics
- Delivery of breech presentations/complicated pregnancy
- Management of post-partum hemorrhage
- Uterine evacuations
- Neonatal Critical Care
- Emergency intracranial evacuation (i.e. burr holes)
Use Caution: Any performance of these procedures must be considered with a cautious assessment of the risk versus the benefit. You may know how to intubate someone, however what happens if there is no ventilator or ICU? What good is an ED thoracotomy if there is no trauma surgeon on-call? In addition, never perform a procedure that you are not qualified to perform without appropriate supervision - this cannot be overstated enough.
According to the same Kenyan study cited earlier, less than a quarter of the patients who presented with fractures received any analgesia or sedation, even for the reduction of the fractures.4 Low-resource anesthetic techniques and regional blocks for management of fractures, dislocations, and wound care can be critical skills in the low-resource setting.
Advantages of regional anesthesia over general are:
- Regional anesthesia techniques are generally less expensive compared to general anesthesia and use equipment that is often more readily available in low-resource settings.
- The patient remains conscious or mildly sedated.
- Airway and respiration are not as often affected.
- The incidence of postoperative thromboembolism is reduced.
Disadvantages of regional anesthesia include:
- Special skills and training are required to do a nerve block successfully.
- Analgesia may not always be effective, so conversion to general anesthesia might be necessary.
- Immediate complications can occur, such as toxicity or hypotension, and adequate equipment and appropriate medications need to be available to treat them.
- The patient may not agree or be amenable to a regional block.
Common nerve blocks:
- Ring block: Indications are fractures and lacerations.
- Intravenous regional anesthesia (Bier’s block): Bier’s block may be a very effective block for upper and lower limb manipulation, such as manipulation during reduction of dislocation, managing simple fractures and suturing of lacerations.
- Intercostal nerve block: A typical indication would be postoperative pain relief after cholecystectomy or thoracotomy, as well as pain relief from fractured ribs.
- Hematoma Block: Anesthesia injected directly into the hematoma caused by acute fractures can be used to alleviate pain during reduction of fractures. Note – these don’t work in subacute fractures, as the hematoma has likely dissipated.
- Wrist block: Wrist blocks may be used if a plexus block is incomplete, as a diagnostic block, or for pain therapy.
- Ankle block: Indications are for all kinds of foot surgery, including amputations.
- Spinal Anesthesia: Rarely used in resource-rich nations because of easy access to general anesthesia and epidural nerve blocks performed by anesthesiologists.
- Hip Block: A variety of techniques are used for anesthesia after a hip fracture.
Bedside ultrasound can also be an integral part of the physical examination and aid diagnosis when advanced imaging isn’t available. It is portable, inexpensive, dynamic, and available in real time. The following are some common uses for bedside ultrasound that can be useful in the resource-limited setting. Brush up on these before going.
- Trauma: The E-FAST (extended focused assessment with sonography in trauma) exam can be used when a CT scan isn’t available to determine the appropriate intervention.
- Hypotension: The RUSH (rapid ultrasound in shock/hypotension) exam can also be performed to evaluate undifferentiated shock. The evaluation of the IVC alone can assess hydration status.
- Skin: Can be used to help the diagnosis of abscesses, cellulitis, and locate IV sites.
- Lungs: Can be used to examine the lungs for consolidation, pneumothorax, hemothorax, and pleural effusion.
- Heart: Cardiac echo can be used to look for pericardial effusion, CHF, pulmonary embolism, and valvular anomalies such as rheumatic heart disease.
- Abdomen: Can be used to assess for ascites, hepatomegaly, splenomegaly, gallbladder disease, and can help in the diagnosis of extrapulmonary tuberculosis and HIV.
- Pelvis: Very useful in assessing diseases of the pelvis as well as complications of pregnancy. Many women are unaware of the dates of their pregnancy. The ultrasound can also uncover anomalies of pregnancy as well as placental location. In a study by Shah et al from Rwanda, researchers found that 43% of the women who received an US had a change in their obstetric management, mostly to surgical intervention.5
- Nerve Blocks: US allows you to visualize the nerve to be blocked to ensure that the anesthetic goes where you want it to.
Humanitarian Response Courses
There are courses available that may help you obtain the necessary training to meet your goals and help support your interests. For those interested in disaster response or in care for refugee populations, the Health Emergencies in Large Populations (H.E.L.P.) course is beneficial. It is offered by the International Committee of the Red Cross at several locations throughout the world. The goal of the H.E.L.P. course is to provide practitioners (physicians and non-physicians) with the needed skills to respond to the public health needs of individuals in refugee, disaster and conflict situations. This is accomplished through in-class didactic activities and practical group sessions.
Many academic institutions also offer certificate or short courses related to various aspects of humanitarian assistance. Some of these courses are integrated into other graduate level degree programs. One course that is geared toward refugee care and disaster response is the Humanitarian Response Intensive Course (HRIC) offered through the Harvard Humanitarian Initiative. This two-week course provides practical training for public health workers (physicians and non-physicians) who desire to respond to complex humanitarian disasters, like the Haiti earthquake in 2010. The course concludes with a two-day simulation offering students the opportunity to practice the skills learned during classroom instruction.
Physicians for Human Rights hosts training sessions for physicians on how to conduct forensic evaluations of immigrants seeking political asylum including to document evidence of psychological or physical torture.
These are certainly not the only courses that are available out there. You will find more information on the H.E.L.P. and HRIC courses as well as other courses that we have found helpful on the table below.
- Burke TF, Hines R, Ahn R, et al. Emergency and urgent care capacity in a resource-limited setting: an assessment of health facilities in western Kenya. BMJ Open 2014; 4:e006132.
- Baker T, Lugazia E, Eriksen J, Mwafongo V, Irestedt L, Konrad D.; Emergency and critical care services in Tanzania: a survey of ten hospitals. BMC Health Serv Res. 2013 Apr 16;13:140.
- Baker, T. (2009), Critical care in low-income countries. Tropical Medicine & International Health, 14: 143–148.
- Wachira BW, Wallis LA, Geduld H. An analysis of the clinical practice of emergency medicine in public emergency departments in Kenya. Emerg Med J. 2012Jun;29(6):473-6.
- Shah SP, Epino H, Bukhman G, Umulisa I, Dushimiyimana JMV, Reichman A and Noble VE. Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008. BMC International Health and Human Rights 2009, 9:4.