My second week at MTC involved ECU planning, various interesting medical cases, and a new component to my fitness regimen. The end of the week was then celebrated with some MTC staff and family on a rooftop patio.
ECU Planning:
After a productive three-hour meeting with the core ECU planning group this week, we have outlined the next steps of the ECU project. Excitedly, renovations of the building that will house the ECU will commence in the coming weeks. Our next task is to finalize a draft of the essential medications required for the ECU (also known as a formulary) and share it with the MTC pharmacy acquisition team to ensure availability and troubleshoot any difficult-to-source medications. MIMS is an online service that can determine if a medication is available in various countries, especially in Asia. Their country-specific drug list informs you of the multiple brands of each available medication and the distributors that offer it in your country of interest. The ECU formulary is closely linked to the clinical guidelines/protocols being created. You can only finalize a formulary once you have completed your guidelines, as these determine the medications your institution recommends to treat various medical conditions. At the same time, you can only create guidelines if you know what medications are available. We will be working on the formulary and guidelines in tandem. Thankfully, MTC has a 2016 edition of emergency guidelines, which will be used as the basis of the new updated guidelines. Additionally, many medications planned for the formulary are already in use at MTC, and we know they are available.
Our core ECU training curriculum will be based on the WHO-ICRC Basic Emergency Care (BEC) course, with some modifications to fit the unique clinical context of MTC. We will be holding a modified training of the trainer (TOT) course in mid-November for a small group of skilled Burmese physicians currently assisting MTC who are integral to the ECU development. Afterward, we will begin teaching the modified BEC course for the future ECU medics and nursing staff. The TOT course will be conducted in English, given the excellent proficiency of the participants. The BEC course will also be taught primarily in English. The MTC medical staff complete their medical documentation in English and have solid language proficiency. Still, the staff has some variation in English language skills depending on their background. One of the critical components of training the cohort of Burmese physicians in the TOT course is so that we may conduct the modified BEC course in an English/Burmese hybrid. This will reinforce a complete understanding of the more complex aspects of emergency care and ensure that the participants may engage in detailed discussion and questions in their native language.
Case Reports:
During this past week, we had several cases of Dengue, a mosquito-borne infection, with patients showing a positive tourniquet test (Hess test). As Dengue antibody blood testing is unavailable in many places that encounter this infection, the tourniquet test is part of the WHO case definition of Dengue and aids in diagnosing this infection in the correct clinical presentation. The test is a marker of capillary fragility; see the image below for details on how to perform and interpret the tourniquet test.
We also saw a patient with severe anemia and resulting jaundice from Malaria requiring a blood transfusion. Unfortunately, due to climate change, vector-borne infections, such as Dengue and Malaria, are becoming more common globally. Emergency medicine doctors will increasingly need the knowledge to diagnose and treat these infections no matter where they practice. An article in the Lancet [Colón-González, F et al. 2021] demonstrates the significantly increased risk of mosquito-borne infections worldwide due to climate change. In fact, this summer, there have been multiple endemic cases of Malaria in the United States, the first such cases since 2003.
If you are interested in learning about Malaria from a fascinating historical perspective on how the mosquito and Malaria formed the modern world, read (or listen) to the book The Mosquito: A Human History of Our Deadliest Predator by Dr. Timothy C. Winegard.
One more case to present. A school-aged female presented with left thigh pain, swelling, and difficulty ambulating. She reported falling down several stairs about a month ago, but they could go to school and continue activities as normal. About ten days ago, she reported progressive left mid-thigh pain, which significantly worsened over the past two days, now limiting ambulation. No personal or family history of bleeding disorders and no other significant symptoms, including no skin wounds or rashes. Point-of-care (POC) ultrasound showed a deep anterior-lateral left thigh fluid collection without evident femur cortex disruption to suggest a fracture.
Left lateral thigh MSK ultrasound: image obtained with Butterfly iQ+ ultrasound probe.
The most likely differential for this US finding includes hematoma (due to trauma) vs abscess, with the additional possibility of a hematoma that secondarily became infected. The remote trauma and minimal symptoms immediately after made a femur fracture less likely. However, to properly work up this patient, an x-ray was obtained, which confirmed no fracture. Given this, she underwent a needle aspiration that proved to be therapeutic and diagnostic, draining purulent fluid from the abscess to send for culture. Given the depth of this abscess, an ultrasound-guided aspiration was successfully performed. Performing the procedure via US guidance minimizes unsuccessful attempts as you can view your needle in real-time on a screen and direct it precisely to the abscess. Furthermore, you can ensure you remove all the infected fluid. Combined with the drainage, she was started on antibiotics and had significant improvement in pain and swelling the following day. I continue to be grateful to have the opportunity to collaborate with and work alongside the incredible staff at MTC.
On a non-medical side note, I started training at a Muay Thai gym to stay in shape and meet new people I may not otherwise have met. After two training sessions, I can confidently say it is an incredible workout.
The week ended with a Friday night dinner with multiple MTC staff members and their families on the rooftop of my neighboring building. There was excellent traditional Burmese food, even better company, and lots of laughter. We also enjoyed a beautiful sunset.
Until next time...
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