Some wins, some losses

Some of the folks here (ex-pat docs, etc) who are old hands at global health tell me that it can be incredibly hard to get traction with some ideas. They are right. Even if you (the brilliant mind from the "developed" world) thing this is the best thing since sliced bread, it may not fit with style, tempo, ingrained comfortable habits, whatever.

The major win appears to be chart dividers. The nurses love it and even embellished my simple dividers with names, and they even started putting neat labels on books, pamphlets, and other things around the ICU. I am really happy with that.

Dividers rock!!!

Another win was a pre-op consult. One of the surgeons wanted to do a thyroidectomy on a patient that day because she had come a long way. She had a large, enlarging goiter and she wanted something done about it.

The surgeon felt that it was  perfectly ok to operate because they were out of reagents for doing thyroid function tests, and since we couldn't do the tests, there was no way we could prep her. I offered to see her:

Thankfully I had loaded UpToDate (yup, my legal copy) onto my netbook and figured out what to do that was pretty generic and independent of TFT's. The surgeon has agreed to postpone the surgery for a week to let the Lugol's solution and atenolol work, and she'll go to the ICU after the operation.

Other neat stuff I've done included the first use of pressure support ventilation in the country, teaching the nurses how to do drip calculations, figuring out how to substitute antibiotics when we run out of the most appropriate one, and we did a blood gas without measuring the pO2 (all other reagents were present, but not the oxygen one.)

The two big disappointments are that the docs are pretty resistant to formal orders; they want to write them in the progress notes.  The other disappointment has been some resistance to more aggressive use of fluids. I still have plenty of time, and hope to make some headway.

We've seen some pretty sad cases here. There are a huge number of RTA's (road traffic accidents) that result in very serious injury; we're managing a quadriplegic and a little 5 year old who was struck by a car when she ran into traffic. It is unlikely that she will survive, and the quadriplegic has very, very few options for long term care here if he manages to survive the acute phase of his injury. We are also managing a 26 year old woman with a perforated appendix, who lives so far out in the boondocks that it took her six days to get to care, and another day to be transferred to Thimphu so she could get surgery. The surgeon, who is a good guy and a careful doc, said that her belly was an absolute mess, filled with pus and stool.  We'll do our best.