Evidence Based Medicine Coming to Haydom

Evidence based medicine is the cornerstone of how we are now taught medicine and it's coming back to Haydom.Yes, I was a little misleading with the title, but I'll explain why in a second.

At Haydom Lutheran Hospital (HLH), where possible interventions are based on guidelines, however due to the lack of resources and staff education levels and availability of doctors, evidence-based medicine is not always practiced. And I think the key to practicing evidence-based medicine is continuing education.

This is where a new exciting initiative comes in. As of tomorrow we are running education sessions every Thursday (typically lead by the expats) for all the local interns and doctors, as well as the foreign volunteers. This a great chance for information exchange to occur between people, who have come from all over the world. It also opens up the information (that we often take for granted) to the local doctors.

Systolic Heart Failure
So for the first session we are taking a look at Systolic Heart Failure.

The paper we are using as pre-reading is;
Systolic Heart Failure by Dr John McMurray in the NEJM (2010)

We are also using ProfessorEBM's module on Heart Failure to guide the discussion.

WHERE YOU COME IN
Considering my involvement with FOAM back home, I thought it would be interesting to see if we could get an asynchronous discussion happening every week on twitter as well. Bringing the collective wisdom of even more people to this hospital in remote Tanzania.

So for now I've come up with the hashtag #HaydomJC (e.g. Haydom Journal Club). If anyone comes up with a better one let me know.

Below I've provided an overview of some of the key points of the article and additional information concerning systolic heart failure for those who don't have time to read the article.

AETIOLOGY

• Coronary Artery Disease (cause of 2/3)

PATHOGENESIS

1. ↑Afterload – due to ↑pulmonary / systemic resistance + ↑volume
2. ↑Contractility - due to SNS stimulation
3. NaCl & H2O retention – due to SNS and RAAS
4. LV remodelling – hypertrophy, dilation, fibrosis

INVESTIGATIONS

• Blood tests – FBC, LFT, urea, electrolytes, cardiac markers, thyroid
• ECG & CXR: Largely insensitive, but can provide useful findings
• Echo: allows confirmation of diagnosis and information about the heart
• Cardiac MRI: useful in difficult cases

TREATMENT
Lifestyle

• Exercise
• improved functional capacity and quality of life in patients
• Salt Restriction
• often recommended
• little evidence

 

Pharmacological

• Diuretics
• For relief of symptoms
• Loop diuretics should be given to patients with fluid overload
• ACEi
• Enalapril, Captopril, Perindopril, Lisinopril
• reduce ventricular size, increase the ejection fraction modestly, and reduce symptoms.
• Angiotensin-Receptor Blockers (ARBs)
• Irbesartan, Losartan, Candesartan
• similar effectiveness to ACEi, but more expensive
• Beta-Blockers
• Non-selective: Propanolol
• β1-selective: Atenolol, Metoprolol
• Aldosterone Antagonists
• The addition of an aldosterone antagonist should be considered for any patient who remains in NYHA class III or IV despite treatment with a diuretic, an ACE inhibitor (or ARB), and a beta-blocker.
• Hydralazine and Isosorbide Dinitrate
• Studies indicate that those of African descent respond more effectively to hydralazine–isosorbide dinitrate than Caucasian patients.
• Pneumococcal and influenza vaccinations are recommended.

Surgical

• Implantable Cardioverter–Defibrillator
• reduces the risk of sudden death in patents with left ventricular systolic dysfunction
• indicated for secondary prevention
• Coronary revascularisation
• Valve replacement / repair
• Cardiac Transplantation

Image Reference: Heart by Guga85

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An African Sting

There is a thin line that separates laughter and pain, comedy and tragedy, humor and hurt.
Erma Bombeck 

I know some of you may be wondering if I actually do any medicine at Haydom Lutheran Hospital (HLH), but don't worry I do. Up in till now I've largely steered away from telling cases from the hospital, and I'm not about to start. Instead I have a little story to tell from yesterday, with some added education.

If we start right back at the beginning, yesterday felt like the first actual normal day for me in Africa. I started the normal routine of practicing medicine at HLH, with the minor change that I had moved from General Surgery to ICU. But alas, you can not have any normal days in Africa.

In the afternoon, a group of us consisting of myself, Amin (Medical Student from the Netherlands), Tea and Anna-sofia (two Danish Medical Students), thought it would be nice to go for a walk around the sunny hillside of Haydom. Having run the route several times by myself, it was nice to finish off the day with a relaxing walk with a few of the others. On the way through the town we met some local kids, who as always seem to have great fun checking out the Mzungu. There was even a little girl who ran up to each of us, just to touch us like we where some sort of good luck charm. Two of the kids followed us on our walk past the airport, until even they sped off on their bikes.

It was then that something strange happen. The kids quickly semi-crashed/jumped off their bikes and started doing what looked like to us weird dances and running all over the road. Having just talked to them a little, we thought this was odd, but couldn't help laughing, thinking that they must be doing some funny local dance thing.

So at this point just imagine a few happy Mzungu going for a walk and seeing some kids do a funny dance. We were in ignorant bliss. We were ill prepared for what was about to happen, and in retrospect we should of gotten right out of there.

But we didn't turn back. No, for we thought everything was fine until we started to hear this buzzing sound. Our ears pricked, we turned to look at each other, and a sudden realization of what we had stepped in to and what the kids had been doing only a minute before.

 An African Bee Swarm

 

African Bee via Wikipedia

Now for those who know little about African Bees, let just say they are very similar to European Bees, just add an extra dose of aggression and about 50 more of them. They are quick to perceive a potential threat, send out more bees to any one threat, and follow victims for a much greater distance. For victims is what we were about to become. Just like the kids we had seen earlier, we ran all over the road, sprinting like most of us had never done before, just to try and shake these bees. Being persistent little Bees (not to mention venomous) a collection of them followed us a distance well over 500 metres. And whether we liked it or not, the outcome was fixed the moment we didn't decide to turn back when we saw the kids acting strangely.

Fortunately, for us we suffered only a total of 6 stings being the four of us. Somehow I don't think the kids were so lucky, and I can only hope they didn't get swarmed to death.

Bee Stings 
So to make the most out of this experience, I thought I should at least impart some medical knowledge about bee stings. For anyone who seen my Medicine in Small Doses series over at IVLine.info, I'm going to use a similar format here.

The most important thing to remember with bee stings, is that you can have different reactions each time (from mild swelling to anaphylaxis), and more stings (i.e. more venom) can lead to worse symptoms.

Clinical Features: 

• Nausea, vomiting or diarrhea 
• Headache 
• Vertigo 
• Feeling faint or fainting 
• Convulsions 
• Fever 

Management: 
In general, management can be reasonable conservative for the vast majority of bee stings.
The following is reccommended;

• Remove the stinger 
• Wash the area with soap and cool water 
• Apply hydrocortisone cream or calamine to the site
• Take an oral antihistamine
• Elevate the extremity if swelling is increasing.

 Lessons Learnt

1. No such thing as a normal day in Africa, each day is full of surprises. Arguable there is no such thing as a normal day back home, we just forget to appreciate the little things that happen around us.
2. Bee stings hurt.
3. There can sometimes be a thin line between laughter and pain, and it's important to remember that each of us draws the line at different places.

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Basic Clinical Skills

Click on the Tutorials below to view further information concerning the topic.

Clinical Examination

Performing a Cardiovascular Clinical Exam
Cardiovascular exams are used in conjunction with the appropriate history taking to ascertain the likelihood of a cardiovascular disease (e.g. congestive heart failure, arrhythmias, infective endocarditis and so on).

Performing a Respiratory Clinical Exam
Respiratory exams are used in conjunction with the appropriate history taking to ascertain the likelihood of a respiratory disease (e.g. upper respiratory tract infection, asthma, pneumothorax, pulmonary embolism and so on).



How to perform a Gastrointestinal Clinical Exam
Gastrointestinal or Abdominal examination is used in combination with suitable history taking to determine the likely disease process (e.g. hepatitis, gastroenteritis, appendicitis and so on).




An Introduction to the Musculoskeletal Clinical Exam
Musculoskeletal Clinical Exams are used in conjunction with the appropriate history taking to ascertain the likelihood of a disorder within the bone or muscles structures. The two main categories into which these disorders can be split into are Disease and Trauma.

Clinical Examination of the Spine
The Spine (Vertebral Column) serves a number of purposes (protection, muscle and ligament attachment, haematopoiesis and so on) and consequently has a range of associated pathologies. Musculoskeletal examination of the spine focuses on determining diseases and disorders that specifically effect that system in relation to the spine.


How to perform a Neurological Clinical Exam
Another important tool in a clinician's toolset. Neurological Clinical Exams are used in a variety of settings from the GP Clinic to in the Intensive Care Unit. This will take you through some basic anatomy, examination of the upper & lower limbs, and examination of the cranial nerves.


How to perform a Clinical Eye Exam
The eye allows us to observe the world around us, but it can also provide clinician's a window into a person's health. Often neglected and left to those dreaming of working as an Ophthalmologist, students and junior doctors alike miss out on a valuable source of information. Here the basics of the Clinical Eye Examination are introduced including reference to Dr John L Colvin and Dr Joseph A Reich's 35 Golden Rules of Eye Care.


History Taking

A Guide to taking a Psychiatric History
There are some areas like Psychiatry, where taking a good and thorough history can be more of a challenge for a medical student. The purpose of taking a Psychiatric History can split into three main things; diagnostic, to gain a biopsychosocial understanding of the patient’s problem, and therapeutic/psycho-educational.This guide sets out a basic structure by which these goals can be achieved.


Presentation Skills

Clinical Skills
A Quick Guide to ECG
ECG is a valuable tool in a clinician’s diagnostic toolset, however for some it’s just not easy to pick up. Most individuals skilled in ECG have achieved proficiency through practice and exposure, as interpreting ECG in the long term is a matter of pattern recognition. This post hopes to bring things back to basics.

A Quick Guide to Chest X-Ray Interpretation
Chest X-Rays (CXR) are routine investigation in clinical practice and consequently it is important for medical students and clinician’s alike to know how to interpret them. With time and practice, interpreting CXRs will become easier, but first you have to find an approach that works for you. This Guide provides you with basics and a number of approaches to help you get started.

The essentials of Basic Life Support
Basic Life Support forms a foundation level of care for treating patients with life-threatening illnesses or injuries, until the appropriate medical care can be provided. This post will run you through DRSABCD and more.

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