March 5, 2011

Don't Just Stand There: DO SOMETHING


Addia Ababa, Africa
Seth has invited me to be his co-blogger; knowing Seth, I suspect an ulterior motive, but that's another post. As a lifelong contrarian, I thought I would title my first post the exact opposite of the tag line of the blog.

Anyway, I got the invite while I was in Ethiopia-- Addis Ababa to be exact working, at a Korean Hospital here (the pic is of the resus bay). They have a functioning ED, a trauma system, and an ICU. For Africa (as I understand it) it's a very good hospital, indisputably the finest in Ethiopia as shown by the number of VIPs treated here.

That said, it's still (emergency) medicine in the developing world, which means things go sloooooowly. Coming out of a fast-paced urban tertiary ED, it gave me pause to reflect on something that is central to the MD aware mindset: very, very few things in the ED or in medicine in general are so time-critical that seconds count.

What I have seen here is head injured patients with GCS 4 who don't get intubated for 45 minutes and keep breathing; comatose patients who wait an hour for a head CT; hypotensive patients who don't get fluids for 20 minutes and don't die; babies with cap refill ~8 seconds who wait 40 minutes for a fluid and bolus, and so forth. They are things that in the USA we get very excited about and start running around to get stuff done, but in reality most things can wait. As Obama would say, let me be clear: I don't think this system is ideal, but it has given me a good deal of perspective on what is an emergency and what is not.

So since I'm over here moving at the speed of Addis I decided to come up with a list of SECONDS-MATTER EMERGENCIES: things in medicine that cannot under any circumstances wait even 30 seconds. I did not include things that must happen cognitively very fast (i.e. cric) but only those that must be in-progress or done in a matter or a few seconds.
  • Defibrillation
  • Control of arterial hemorrhage
  • Decompression of tension pneumothorax
That’s about it, I think.

-MJP


from seth:
This gets at the main thrust behind the “don’t just do something- stand there” philosophy  don't spin your wheels unnecessarily. Seconds-matter emergencies are great opportunities to really help people; it just saddens me when people (routinely) focus on the wrong things — running around like the patient’s going to die in the next 10 seconds unless we push labetalol on the asymptomatic patient at 180/100; or pushing lasix on the APE patient instead of the NIV mask.

-nst