Modifying Evidence Based Medicine to Fit into the Resource-Limited Setting

In the ICU there is an entity called Acute Respiratory Distress Syndrome (ARDS) which has been the source of years of research and consternation. It is a process that occurs usually following an infection or trauma causing significantly low oxygen levels which often do not improve with just intubation and mechanical ventilation but require special settings on the ventilator to limit injury to the lung as we allow time to pass giving the lung a chance to heal. That's the short story of ARDS. Over time many different mods of mechanical ventilation have been tried, many medical therapies and one particularly interesting therapy called Proning. This is the act of turning the patient from laying on their back to on their stomach. This allows areas of the lung that are not receiving oxygen to receive oxygen. ARDS is defined by criteria that require obtaining an arterial blood gas and the act of proning the patient requires multiple staff and the ability to closely monitor the patient thereafter. This background is important as a new patient was admitted in the last day with a recent diagnosis of pneumonia and now has developed ARDS. A few challenges-we do not have a working machine to check a blood value called an arterial blood gas that would give us the level of oxygen in her blood stream. The oxygen saturation which displays on the monitor should correlate to some extent but this is not nearly as accurate. Furthermore, as evidenced from the last two cases the steady flow of oxygen is a problem. When a patient is proned they should be left this way for 16 hours and then turned on their back for 8 hours and this is continued for variable duration. This whole process, making particular changes on the ventilator and turning the patient on to their abdomen requires the patient to be DEEPLY sedated so that their respiratory muscles do absolutely no work and the machine does the most of it. Here comes another challenge--the availability of medications to be given so frequently. (in the US these medications are given on a continuous basis) OK so. where do we go from here then?

Being in a resource limited setting we had to come to a few large conclusions--we have to use the oxygen saturation (which is measured by an infrared probe placed on the finger which then projects a number on the monitor and this is supposed to correlate with the level of oxygen in the blood stream stated simply, but again is not nearly as accurate as the blood value),  we may be limited with staffing so this act of proning must be done with full staff available. We need to find out how frequently she requires a dose of pain/sedation medication so we can schedule this accordingly. It took some time and some coordination but, for one of the first times in this ICU a patient with ARDS was placed in the prone position with almost immediate improvement. Will the patient do well in the long run? That is yet to be determined. But the lesson here is two fold-one, many of the papers published in our field that provide guidelines and recommendations for management are not applicable everywhere, almost always their implementation is limited in resource poor settings and we must remember to modify our approach in such settings. HOWEVER--given the right effort and coordination those modifications may provide a way to bring evidenced based medicine to the resource limited setting and maybe, just maybe provide one small step in improving outcomes.

 (All pictures taken w/ permission, no identifying features are shown) The first image highlights just how many people were necessary to turn the patient. This requires making sure all of the IV lines are in place, that the breathing tube is held in place and the the urinary catheter is in place while the patient is turned. The second image shows the patient successfully proned.