Sunday, February 20, 2011

Triage - by Erik

Every surgical and emergency medicine trainee learns the “ABCs” of the “primary survey”. It is a simple way to keep focused during the evaluation of a trauma patient. “Airway, Breathing, Circulation, Disability, and Exposure.” As any surgical trainee – past or present – will testify, these fundamentals are engrained upon your psyche as you manage patient after patient in the trauma bay. As simple as it is, I still remind myself of this basic approach with each patient because it’s amazing how easy it is to become distracted by the chaos surrounding a sick patient in the emergency department.

The other day, the surgical intern called me to ask for help with two multiply-injured ladies who had been brought by good Samaritans to our Casualty. Behind the red curtains separating patients in Casualty, I found these young women in serious condition with life-threatening injuries. As I ran through the “ABCs” in my head, I knew that at least one woman needed to have a breathing tube placed immediately – nothing else should come first. The logistical issues of getting a breathing tube and the necessary equipment became secondary to the question of what I would do with this woman if I did intubate her. While we are very fortunate here to have an ICU with ventilators, there is limited space, and if I intubated her now only to find that the ventilators were taken by patients with better chances of living then I’d be stuck having to make the ultimate triage decision. Before “Airway” comes “Availability of a ventilator.”

The same weekend, I was in the operating theater with an older man with multiple medical problems who needed an emergency operation. Just before induction of anesthesia, a resident from labor and delivery came to the OR because a pregnant woman needed an emergency Cesarean section. There was one anesthetist in house and our initial efforts to contact back-up help by phone and courier were unsuccessful. Standing over my patient in the OR, the anesthetist and I looked at each other both querying what we should do. “Who has the better chance of living?” The answer was clearly the young mother, not to mention the fact that in her case two lives were at stake. We decided to leave my patient on the OR table with someone watching him while the anesthetist readied another OR and I went looking for more anesthesia help.

These situations are far from unique and certainly not as dramatic as those that many other physicians in developing countries experience on a daily basis. In developed countries, terms like “access to care” and “limited resources” are bandied about by students and politicians alike in support of their own social agendas often without a realization of what people in the 2/3-world experience every day. Sub-Saharan Africa has a dire need for healthcare where “limited resources” may mean “no resources” for millions of people.

I am grateful and honored to have the opportunity to serve the sick and needy, to show the love of Christ, and to address the massive healthcare needs more broadly as I join others to train African physicians to increase the healthcare workforce in Sub-Saharan Africa. May God continue to glorify Himself in and through His church.

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