When you're called to the ED.....

I was on a WhatsApp call with a strategic hospital partner from the States when my phone rang. "Doctor, please come to the ED." Now, in the States, this call is typically placed after a patient is stabilized and is ready for admission. Occasionally, Internists get called to the ED to help manage a critically ill patient. As a resident we typically met the ambulance and patient when a patient came in for a massive heart attack. It was our role to take the patient to the cardiac catheterization lab. Seldom do we get called for general triage and management of patients.

Our ED, at SMAH, is staffed by Medical Officer, most have a few months of training post-medical school. They are wonderful physicians in training. We have no ED physician. So when you are called to the ED you never know what you are going to walk into. Well, tonight is my third night on call at SMAH. I don't think I'll forget tonight for a very long time.

As I walked into the ED the first patient I saw had consumed an unknown quantity of organophosphate (OP) poison. The second patient, I was quickly told, had no measurable blood pressure. The third patient was a pregnant lady who also consumed a smaller quantity of organophosphate poison. While we were attempting a resuscitation of the second patient another patient rolled in following an electrocution. Now, the reader must understand that it would be unusual for an ED in the western world to see OP poisoning once in a year (or maybe even in a career), unfortunately, in Nepal, these are fairly common presentations to emergency rooms. Needless to say, with a quick prayer for wisdom, I set to work with the team to resuscitate patients as best as we could.

I really want to protect the privacy of our patients. Had these presentations not been so common I would not be posting this brief narrative. I'll share a few general reflections.

First, atropine is an amazing drug. We follow a Sri Lankan protocol for OP poisoning and have fairly good success at pulling patients through. The antidote for OP poisoning, pralidoxamine, works okay, but the backbone of treatment is Atropine. Basically, you give 5 ml of Atropine every 5-minutes until they are "fully atroponized", meaning, their pupils are dilated, they are not diaphoretic, and their heart rates are above 100. Over the next few days we titrate down the atropine. Decreasing it too quickly can result in "intermediary syndrome", a syndrome with a hallmark feature of muscle weakness. I'll be writing more about OP poisoning, but, briefly, it is tragic and horrible!

Second, our staff work really hard to safe patients. While we need to work on team-based resucitation to reduce some of the chaos our team worked really hard to help every patient that came into the ED tonight. I am thankful for the back-up availability of my co-internist to answer a few questions in the midst of a busy evening.

Third, resources are limited. One of the patients had some concerning ECG findings. Magnesium Sulfate was indicated. Unfortunately, we are out of MagSulfate. Supply chain management is really tough! Currently I am working with our pharmacy team and finance team on redesigning our drug ordering process. We are brainstorming how we can negotiate more competitive contracts for the hospital. Part of the contracting will be to ensure an adequate supply of critical access drugs -- drugs, like MagSulfate, that we should never run out of. Trying to develop reliable administrative systems is challenging and yet very neccessary to ensure we have the treatments we need. I commend our staff for working towards improving our systems to ensure we can offer the highest quality of care.

While, it's time for me to head to sleep...another day awaits.