I recently conducted some training on shock. It was repetition from a course that was held here last year & has already been reinforced with various workshops since then but as I am in my dying throes of volunteerism I am conducting an emergency medicine training curriculum for the still uncompleted ER.
In my lesson plan were four cases of the different classifications of shock - all real life patients I've seen here, in an attempt to prevent the "but this is Cambodia..." chestnut. I didn't get past the first patient - a 23 year old with an ectopic pregnancy - why this was the case will become clear below.
I presented the case step by step, asking questions about assessment & management. The main learning points that I wanted to highlight were as follow;
1) Insert 2 large IV cannula in the ACF of a bleeding patient
This was largely debated & rejected despite me explaining the physics of a wider, shorter tube in a larger vein being better than a small IV in someone's little finger. Also I citing ATLS/PTC - the latter of which there has been a course at BTB. Eventually ON piped up he had seen this practice in Thailand & Singapore. My point was begrudgingly then accepted.
2) Give fluid boluses in shock
I was told that giving lots of IV fluid causes pulmonary oedema. I tried to explain that in this young, previously well woman the reason she later went into pulmonary oedema was not due to excess IV fluids but because she had been inadequately fluid resuscitated and had hence gone into renal failure. My one surgical ally afterwards took me to one side to explain that the doctors in the room did not have the basic science knowledge to understand even my simple explanation. This was self evident - see below.
3) Reassess after an intervention
At this point of the training - when I explained that after giving one bolus we should reassess the patients clinical condition - I got shouted out. I was told that this patient should go immediately to theatre as it was obvious she had an ectopic pregnancy - reassessment was pointless & unnecessary. When I tried to explain that we were now only 10 - 15 minutes into the patients admission and we had only just started giving the first fluid bolus, I was called a liar, told I didn't know what I was talking about & I was trying to cover up my mistakes & stupidity.
J was shocked at this point that I didn't just walk out. I am nothing but a trier - or perhaps just very obstinate.
I had to tell them all to "shut up & listen to me" - they were all shouting & pointing aggressively & poor L wasn't being given a chance to translate my response to their initial questions & then their subsequent abuse. Afterwards my one surgical ally bought me lunch & said I should consider losing my temper with them more often. He was thrilled after 2 years I had finally stood up for myself instead of trying to be culturally sensitive - he has been wanting to tell them all to shut up & just listen for the last 10 years. The saving face culture only seems to count if its their face they are saving - clearly disrespecting me is allowed under this misogynistic culture.
I calmly explained that if you have a bottle with a hole in it how do you know that it is still leaking unless you first fill it to see if the water stays in or not, i.e. unless you replace volume & see if vital signs improve or not how do you know you have an unstable patient? Patients can tamponade & stop bleeding so although initially shocked after adequate fluid resuscitation will improve & may not need emergent surgery, if at all.
They weren't getting it. See above re; lacking basic knowledge. So I tried another tack. How much blood does a person have to lose?
Silence.
I asked again - how much blood does this 45kg woman have to lose?
Silence.
Feeling very vindictive after my verbal assault I suggested that as surgeons who cut patients open & make them bleed every day it was probably their responsibility to find out how much blood was in a human body.
Silence.
I told them - they all wrote it down in silence.
4) Give bleeding patients blood if they are unstable or their Hb is below 7
5) Take unstable patients to theatre to stop bleeding
Points 4 & 5 were never made as it was 11 30 am by now & they all went to lunch.
I can cope with being shouted at, insulted, ignored & disrespected.
But what I really can't cope with is another 23 year old dying due medical mismanaged. I am very weary now. I can feel the last bit of hope & resolve haemorrhaging away. One could say that I am in need of some serious resuscitation - but will the Cambodians notice, let alone see the need to reassess me?!
In my lesson plan were four cases of the different classifications of shock - all real life patients I've seen here, in an attempt to prevent the "but this is Cambodia..." chestnut. I didn't get past the first patient - a 23 year old with an ectopic pregnancy - why this was the case will become clear below.
I presented the case step by step, asking questions about assessment & management. The main learning points that I wanted to highlight were as follow;
1) Insert 2 large IV cannula in the ACF of a bleeding patient
This was largely debated & rejected despite me explaining the physics of a wider, shorter tube in a larger vein being better than a small IV in someone's little finger. Also I citing ATLS/PTC - the latter of which there has been a course at BTB. Eventually ON piped up he had seen this practice in Thailand & Singapore. My point was begrudgingly then accepted.
2) Give fluid boluses in shock
I was told that giving lots of IV fluid causes pulmonary oedema. I tried to explain that in this young, previously well woman the reason she later went into pulmonary oedema was not due to excess IV fluids but because she had been inadequately fluid resuscitated and had hence gone into renal failure. My one surgical ally afterwards took me to one side to explain that the doctors in the room did not have the basic science knowledge to understand even my simple explanation. This was self evident - see below.
3) Reassess after an intervention
At this point of the training - when I explained that after giving one bolus we should reassess the patients clinical condition - I got shouted out. I was told that this patient should go immediately to theatre as it was obvious she had an ectopic pregnancy - reassessment was pointless & unnecessary. When I tried to explain that we were now only 10 - 15 minutes into the patients admission and we had only just started giving the first fluid bolus, I was called a liar, told I didn't know what I was talking about & I was trying to cover up my mistakes & stupidity.
J was shocked at this point that I didn't just walk out. I am nothing but a trier - or perhaps just very obstinate.
I had to tell them all to "shut up & listen to me" - they were all shouting & pointing aggressively & poor L wasn't being given a chance to translate my response to their initial questions & then their subsequent abuse. Afterwards my one surgical ally bought me lunch & said I should consider losing my temper with them more often. He was thrilled after 2 years I had finally stood up for myself instead of trying to be culturally sensitive - he has been wanting to tell them all to shut up & just listen for the last 10 years. The saving face culture only seems to count if its their face they are saving - clearly disrespecting me is allowed under this misogynistic culture.
I calmly explained that if you have a bottle with a hole in it how do you know that it is still leaking unless you first fill it to see if the water stays in or not, i.e. unless you replace volume & see if vital signs improve or not how do you know you have an unstable patient? Patients can tamponade & stop bleeding so although initially shocked after adequate fluid resuscitation will improve & may not need emergent surgery, if at all.
They weren't getting it. See above re; lacking basic knowledge. So I tried another tack. How much blood does a person have to lose?
Silence.
I asked again - how much blood does this 45kg woman have to lose?
Silence.
Feeling very vindictive after my verbal assault I suggested that as surgeons who cut patients open & make them bleed every day it was probably their responsibility to find out how much blood was in a human body.
Silence.
I told them - they all wrote it down in silence.
4) Give bleeding patients blood if they are unstable or their Hb is below 7
5) Take unstable patients to theatre to stop bleeding
Points 4 & 5 were never made as it was 11 30 am by now & they all went to lunch.
I can cope with being shouted at, insulted, ignored & disrespected.
But what I really can't cope with is another 23 year old dying due medical mismanaged. I am very weary now. I can feel the last bit of hope & resolve haemorrhaging away. One could say that I am in need of some serious resuscitation - but will the Cambodians notice, let alone see the need to reassess me?!
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