The past two weeks have been busy yet rewarding.
ECU update:
We had a successful ECU meeting this past week with the ECU working group and the MTC clinical team. During the meeting, we discussed the ECU formulary (essential drugs list) and I gave a presentation on the MTC ECU curriculum that I have been preparing.
ECU formulary:
We reviewed the 141 medications on our initial ECU formulary, decided to remove several, marked several more for further discussion, and created a list of possible additional medications to include. The discussion centered around multiple factors, including:
medication cost
ability to regularly source the medication
minimizing medications that perform a similar function
what medications do the MTC inpatient/outpatient departments already have access to
do the resources and skills of the ECU allow for the safe administration of the medication
does current evidence support the use of the medications on the list
We now have a final working draft, which will be reviewed over the next several weeks by the ECU working group and the clinical team/pharmacy team. Our goal is to have the final ECU formulary prepared by December.
ECU training curriculum:
I have been working on the MTC ECU training curriculum, utilizing the WHO Basic Emergency Care (BEC) course as a template. The BEC is an open-access curriculum designed for frontline pre-hospital or facility-based healthcare providers who manage acute life-threatening conditions with limited resources. The course provides a systematic initial approach to managing acute, potentially life-threatening conditions even before a diagnosis is known. I first became a registered facilitator for the course during residency and have facilitated BEC courses in several countries. Currently, I am modifying the WHO BEC course to fit the unique context of the MTC ECU. That involves removing some aspects that the staff are already skilled in (i.e. IV cannulation) and adding additional modules and skills such as basic life support (BLS), advanced medication discussions, and more complex case scenarios to reflect the cases seen at MTC. We are also creating simulations, allowing the future ECU team to work together to care for simulated patients.
After discussions with the ECU working group and the MTC clinical team, we have decided to run a BEC training of the trainer (TOT) course for a select group of Burmese doctors and senior medics who will, in turn, teach the upcoming ECU BEC lectures. This way, the ECU BEC course will be run in a Burmese/English high-bred to ensure a complete understanding of the material. We will also be translating some of the course materials to Burmese.
Due to the Myanmar military coup in 2021, there has been an increase in internally displaced Burmese and Burmese refugees, including medical providers. Due to peaceful civil disobedience to the violence perpetrated by the Myanmar military during the coup, many physicians were forced to leave their homes as they were threatened with imprisonment and death. Although the first batch of TOT participants are highly educated and skilled, only one of them is formally trained in emergency medicine. Therefore, I am expanding the BEC TOT course to accommodate the various backgrounds of the participants to ensure everyone is prepared to teach the course. The TOT course will be held over two days during the week of November 6th.
Medical Cases:
As usual, the past few weeks involved many complex pathologies. Here are two cases with interesting US findings.
30s-year-old Male presents with shortness of breath for one month, no fever. Arrives in hypoxic respiratory failure, requiring supplemental oxygen. On ultrasound, he was found to have diffuse pulmonary edema and bilateral small pleural effusions (fluid on his lungs) and echocardiogram (ultrasound of the heart) showed severe mitral valve regurgitation and stenosis. In this setting, the most likely diagnosis is rheumatic heart disease, although the patient is not aware of a history of rheumatic fever. This is not something commonly seen at home as treatment of group A streptococcal pharyngitis (aka strep throat) with antibiotics prevents the development of rheumatic fever and rheumatic heart disease.
40s-year-old female who presented with right upper quadrant abdominal pain, nausea, vomiting, low-grade fever. On ultrasound, she was found to have several large gallstones in her biliary tract, causing dilated bile ducts and a distended gallbladder with sludge. Her diagnosis is on the spectrum of biliary pathology. She has choledocholithiasis with likely cholecystitis. She is at risk of developing a deadly pathology known as cholangitis. She was started on antibiotics and will be referred to a hospital with the capability to perform an ERCP to remove the stone.
Non-medical happenings:
Last weekend I rode out to the countryside on my trusty Honda Wave 125i and worked on the above projects at a rural cafe. The ride was beautiful, with lush foliage, waterfalls, rivers, and twisty roads. A few pictures are below.
I also saw a cool bug...
This weekend, I enjoyed a Friday night hot pot with several MTC staff members and their families. Tomorrow, I will be celebrating the full moon, a with friends who will be sharing their Buddhist traditions.
Until next time.
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