Early Recognition is life-saving

Today’s lesson is in “early recognition”. I have probably said this over a million times in my short career thus far but I truly think that early recognition and early action are the pieces missing in resource-limited settings. In resource limited areas it is difficult to decide when that early intervention should occur. Frankly, ICU medicine as we know it in the US is a very resource intensive and costly intervention--it has to be redefined in resource-limited countries. I feel very strongly about the power of education and that is not just at the level of health care providers but community level education.  I am referring to going out in the community and talking about the signs/symptoms that should bring people into the hospital, it is far too often that we see the end result of a disease process, when it is too late to act. It is even more important that this early recognition occurs especially when a patient is IN hospital. While on rounds this morning we discussed the new admission, she is a patient who came in with nausea and vomiting, with a history of prior abdominal surgeries. A tube was placed in to her stomach to help decompress her stomach, an X-ray was pretty convincing for bowel obstruction. Over the next 12 hours she started having abdominal pain and there was a concern that her obstruction was worsening so she was taken to the operating room. There she notably had a perforated intestine and had low blood pressures during the procedure. She was taken to the Post op area and for three days continued to have low blood pressures. By the time she came to the medical ICU we were seeing blood pressures of 66/30 (as seen in the picture). I will tell you--when we see this in a medical ICU in a resource-rich country the nurses are already grabbing the pressor medication to help support the blood pressure so that vital organs can be perfused. In many resource limited settings such as this one there may be only one medication available, usually it's Dopamine which is a medication we do not reach for anymore. If the patient requires an additional medication to support his/her blood pressure the patient's family will need to go purchase this medication from the pharmacy and then return with it. Time is crucial in this setting--the longer the patient's blood pressure remains this low the more injury there is to the kidneys, to the brain, to the heart, to all of the vital organs. Unfortunately this patient's family could not afford the appropriate medications and this patient despite everything we COULD do within our capabilities, did not survive. Because of the limitations of the hospital system, of space, the availability of a ventilator--this patient was not able to receive timely interventions. 

This is the devastating reality of what medicine looks like in these parts of the world.