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Thoughts on intensive care in the developing world.
Samuel Evans, MD RES'
Illustration by Blair Thornley
When the first intensive care unit was described in Denmark in 1953, a new field of medicine was born. Patients with respiratory failure or shock could be treated in an area of the hospital where far more could be done than on the general wards. Interventions like mechanical ventilation, invasive hemodynamic monitoring, and aggressive use of blood products, as well as the presence of specially trained nurses, gave patients a chance to survive otherwise fatal illness.
Since then, critical care medicine has grown into a vast, evidence-based practice. In industrialized nations all patients are considered for transfer to the ICU if they become unstable. Patients have come to expect nothing less than the highest level of care, and physicians know that an ICU bed can almost always be made available should their patient decompensate. This is not the case in the developing world.
As the myths and realities of modern medicine take hold in the developing world, a host of new challenges becomes evident: one must consider not only the diagnosis and treatment of a critically ill patient, but how to allocate costly, individual-based care in a population where primary care and basic immunizations may still be in short supply. Another challenge involves expectations: the dissemination of so many simple, life-saving medical interventions (antibiotics, antiretrovirals, etc.), has led to a common belief that even the most intractable illness can be treated with the magic that is modern medicine.
I recently did a four-week rotation at Moi Teaching and Referral Hospital (MTRH). Located in the city of Eldoret, in western Kenya, the ICU there has six beds equipped with mechanical ventilators. Most of the patients are surgical or trauma patients, and as such anesthesiologists generally staff the ICU. There is a portable x-ray machine, chemistry, hematology, and microbiology labs, as well as blood gas analysis. Reagents to perform these diagnostic tests, however, are sometimes in short supply. Supplies of disposable blood products and invasive monitoring devices are limited but, unlike in many developing world ICUs, there is reliable electricity and clean running water.
But perhaps most surprising is the fact that general medical patients on the inpatient wards are not routinely considered for admission to the ICU if they clinically deteriorate, while patients with severe intracranial pathology, such as CVA or head trauma, occupy the scarce ICU beds. All of these limiting factors suggest the need for a reliable and accurate way to triage critically ill patients— taking into account, for example, level of consciousness (measured by Glasgow Coma Scale), and degree of respiratory failure. At this point, however, none exists.
As developing world ICUs like the one at MTRH evolve, close collaboration with western academic hospitals may help to develop reasonable ICU admission criteria. One approach to this question is to develop regionally specific models of hospital mortality, similar to the Acute Physiology and Chronic Health Evaluation (APACHE) score in wide use in developed nations. Still, no matter how accurately we can predict mortality in critically ill patients, there remains a substantial gulf between local cultural beliefs about disease and its management, and medical reality according to the physician. In the end, part of the challenge will be to effectively communicate not just the potential of intensive care medicine, but its limitations as well.
Alpert Medical School