Ebola news

The Ebola outbreak that is ravaging West Africa is a daily staple of the lay press and of scholarly medical publications. Ebola evokes fear among both the public and clinicians. It also evokes a sort of therapeutic nihilism — after all, if there is no treatment, what can be done? And without an Ebola-specific antiviral medication, of what use are infectious-disease clinicians? Without oxygen, let alone mechanical ventilators, how can acute and critical care clinicians possibly contribute?

We have traveled several times to West Africa and done primary patient care in treatment centers and hospitals in Guinea (Conakry and Guéckédou), Sierra Leone (Kenema primarily), and Liberia (Monrovia and Bong). Before each trip, as we prepared to go to the front lines of Ebola medical care, we, too, felt a certain unease about treating a highly transmissible infection for which there is no vaccine, no specific therapy, and a high mortality rate. Yet we also appreciated that most viral illnesses, and certainly most critical illnesses, have no specific therapy. And after spending much of the past 5 months treating patients with Ebola virus disease (EVD), we are convinced that it's possible to save many more patients. Our optimism is fueled by the observation that supportive care is also specific care for EVD — and in all likelihood reduces mortality. Unfortunately, many patients in West Africa continue to die for lack of the opportunity to receive such basic care.

EVD presents much as many other viral infections do, with nonspecific signs such as fever, asthenia, and body aches. After a few days, however, the predominant clinical syndrome is a severe gastrointestinal illness with vomiting and diarrhea. Volume depletion with a range of metabolic disorders ensues, and hypovolemic shock ultimately occurs.

A common assumption is that a lack of material resources constitutes the dominant barrier to clinical care. That is not the case. Intravenous catheters, fluids, and electrolyte replacement are readily available but thus far are being used much too sparingly. When patients can no longer drink, placement of an intravenous catheter and delivery of appropriate replacement solutions are required, but we have seen many critically ill patients die without adequate intravenous fluid resuscitation. On the occasions when we've been able to obtain basic biochemistry measurements, we have commonly found extreme serum sodium and potassium abnormalities. With the current focus on diagnosis of Ebola, we are routinely measuring Ebola viral loads in some of the world's most logistically challenged medical care environments using advanced polymerase-chain-reaction assays that are unavailable in most tertiary care centers. Yet we are not routinely deploying basic biochemical and hematologic diagnostic capabilities. We could do so. Simple interventions can prevent deaths attributable to hypovolemia and metabolic abnormalities. The high mortality from Ebola continues to reflect the natural history of the illness, not an inability to alter its course.

We believe we can and must do better in providing supportive care. There is a historical bias against aggressive interventions, including intravenous cannulation, for many transmissible illnesses. Percutaneous injury to health care workers does carry substantial risk, but such risks are not specific to Ebola. It is now ethically untenable and medically unjustifiable to deny life-supporting therapies to patients with human immunodeficiency virus (HIV) infection, but only a few decades ago, the fear of HIV and the perception that AIDS was uniformly fatal led to an approach similar to that currently being taken for EVD.

Another common assumption is that a lack of skilled personnel constitutes a barrier to clinical care; this assumption is in fact valid. There is an insufficient number of clinicians to meet the primary and routine care needs of the population. Yet the skills needed to care for patients with Ebola are fundamental acute care skills, not the privileged domain of tropical medicine, infectious disease, or critical care.

There has recently been immense media, public, and medical attention to specific treatments for Ebola virus infection. Although these experimental interventions represent important potential treatments, they also reflect our seemingly innate focus on developing magic bullets. It seems that focusing on reducing mortality in the existing “control group” by applying the current standard of care is less interesting, even if much more likely to be effective. Though we recognize the potential incremental value of new antiviral options, we believe that EVD requires a greater focus on available basic care. We recommend that experimental therapy be introduced on a foundation of very good supportive care; indeed, in assessing these therapies' effectiveness, it will be critical to consider the extent to which historical controls received such supportive care.

With nearly 5000 cases to date, more than half of them in the past month, there is a pressing need to gain control of this epidemic. As we mourn the loss of nearly 3000 victims thus far, there is an urgency to prevent new cases, but also to reduce the case fatality rate.

Public health interventions including characterizing the outbreak epidemiology, contact tracing, social mobilization, and public education are essential steps in stopping Ebola and will ultimately save many more lives than can be saved by individual patient care. The high mortality associated with Ebola, however, threatens the ability to perform many of these tasks. The public is reluctant to engage in contact tracing, infected persons are hesitant to present for treatment, and clinicians are frightened to provide care. Although infection prevention and outbreak control are essential components of the Ebola response, they need not be at odds with equally essential syndrome-specific therapy for people who are already infected. Excellent clinical care and improved outcomes will result in improved community compliance, will help to break transmission chains, and will lead to a greater willingness of health care workers to engage in care delivery. To quote William Osler, “The best preparation for tomorrow is to do today's work superbly well.”

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article was published on September 24, 2014, at NEJM.org.

SOURCE INFORMATION

From the Centre de Recherche Clinique, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada (F.L.); Réanimation Médicale, Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France (C.C.); Liverpool School of Tropical Medicine, Liverpool, United Kingdom (T.F.); University of Washington, Seattle (S.T.J.); University of North Carolina at Chapel Hill, Chapel Hill (W.A.F.); and University of Toronto, Toronto (R.A.F.).

Ziua medicului internist

SALVATORII CU ARIPI

Salvatorii cu aripi DUMINICA, 13 MAI 2007 PUIU OANA-MIHAELA , PULSUL MEDICINISTULUI, IASI Evaluare articol: / 7 Cel mai slabCel mai bun În septembrie 1990,cu un prim apel de urgenţă,SMURD a început o lungă poveste de succes,ce a antrenat oameni,muncă,talent,dăruire,pasiune şi profesionalism. SMURD-ul,al cărui părinte e dr. Raed Arafat a încercat introducerea în România a unui nou concept, medicina de urgenţă. La început,a fost munca de voluntariat, cu nopţi nedormite şi dăruire totală, toate echipamentele venind din donaţii, văzându-se în lumea întreagă că la SMURD se face totuşi ceva. Mulţi îşi amintesc de doctorul străin, care avea o maşină veche şi alerga la intervenţii de urgenţă, cărând uneori singur bolnavii...dr. Raed Arafat a convins şi cucerit rapid un oraş, un judeţ, fiind un model pentru o ţară întreagă! În cele din urmă, Raed Arafat şi serviciul SMURD a primit votul a 96% din suflarea judeţului, pentru că pe roţi sau pe calea aerului, ei vin cu “spitalul” la locul tragediei, uneori făcând şi minuni. Sâmbătă, 19 august, ora 23.30...la SMURD e linişte, totul pare să indice o seară fără probleme. La 112 e anunţat un accident rutier la 50 km de Tg-Mureş. La Unitatea primire urgenţe se confirmă: 2 victime în stare foarte gravă. Ambulanţa porneşte girofarele, o echipă de medici fiind deja la locul accidentului şi comunicând cu cei de la SMURD. De serviciu e dr. Vanghelie Bogdan, pe mâna căruia e lăsat SMURD-ul când nu e Raed, care conduce acum planul de salvare.Ajungând la locul accidentului,se iau măsuri pentru stabilizarea victimelor...Unitatea primire urgenţe aşteaptă sosirea ambulanţei...a doua zi, victimele erau in afara oricărui pericol...! Nu poţi decât să rămâi înmărmurit, aceşti oameni luptă cu moartea şi cu imposibilul, gama intervenţiilor incluzând toate urgenţele ce pun viaţa unei persoane sau mai multora în pericol imediat. Uimită fiind de ce se întâmplă, am îndrăznit să o întreb pe cea mai pasionată de zbor de acolo, de ce SMURD? Răspunsul a venit imediat „La SMURD se lucrează la standardul internaţional al specialistului, urmează doar să generalizăm la nivel de tară experienţa noastră”,zâmbeşte Simona Bratu. La SMURD este o importantă muncă medicală şi umanitară, de care toţi ar trebui să fim mândrii, sunt un model de serviciu medical modern. Prin voluntariat, funcţionează ca un element de pregătire continuă pentru viitorii medici. Am rămas impresionată de entuziasmul şi devotamentul pe care îl demonstrează personalul; nu numai că acoperă o cerinţă locală, dar arată şi ce se poate prin cooperarea dincolo de frontiere profesionale şi naţionale, un exemplu excelent pentru alte sectoare ale medicinii din România. Munca la SMURD? Sânge rece si adrenalină... De ce? Pentru că a fost înfiinţat din pasiune pentru medicina de urgenţă! „Visul este motorul care te poartă iar omul este cel care îi permite să se realizeze în întregime. Fie ca Raed să viseze multă vreme”, declară dr. Francois Richter din Paris. Sunt nişte oameni obişnuiţi, dar care salvează vieţi zi de zi, care iubesc zborul şi sunt absolut pasionaţi, buni colegi care comunică bine cu echipa tehnică...fac totul cu pasiune, fiind îndrăgostiţi de misiunile cu elicopterul. Sunt oameni cu o putere de muncă ieşită din comun, lucrând şi după program. „Personal, consider că trainingul de la ei face mai mult decât practica din toţi anii noştrii de facultate”,declară un fost participant al Şcolii de vară de la Tg-Mureş. Aş vrea să provoc amintiri plăcute celor care au fost şi le-a plăcut şi să le fac poftă celor care vor să meargă. Am găsit şi lăsat la SMURD nişte luptători pentru viaţă...adevărate valori umane! Celor care zilnic se luptă pentru a înlătura durerea omenească, vă mulţumesc pentru lecţia de viaţă! Pentru cea care a fost Lala

Foarte adevarat!"Being a good medical student doesn't mean you'll be a good doctor!"

Being a good medical student doesn’t mean you’ll be a good doctor AMY HO | EDUCATION | OCTOBER 6, 2013 There is a saying that you enter medical school wanting to help people but exit it wanting to help yourself. It may be a cynical view, but a realistic one. The criteria to being a good medical student are far different from being a good doctor. Medical education may be breeding a legion of self-serving, grade-grubbing, SOAP-note spewing machines rather than the empathetic, compassionate and caring physicians of admission essays yore. I was no different. My first two years of medical school, I was largely a disinterested student. I didn’t care for basic sciences, research or pathology. Like many others, my knowledge waxed and waned with the test schedule, and after Step 1, I entered my clinical years an acceptably successful medical student. Excellent medical student, terrible clinician Third year begins a reign of terror lead by the constant gauntlet of heavily-weighted rotation grades, standardized exams and the looming threat of residency applications and the Match, when, after 20 years of schooling, some pie-in-the-sky computer would tell me if I was good enough or not to be a doctor, and subsequently determine my life for the next three to seven years. Grades were a priori to make myself the most competitive residency candidate possible. I studied and worked hard. Each patient became an opportunity for me to impress on notes, rapid-fire oral presentations and predict nuanced “pimp’ questions. I learned to charm patients just enough that they’d acknowledge my care to the attending during rounds. I interrogated my patients just enough to write the excellent notes I knew I’d be evaluated on. I learned about my patients by memorizing their daily lab values to proudly recite on rounds. Patients weren’t people with problems but stepping stones to rack up points with the attending. Once rounds were over, patients became time-sucks from studying time, an exam worth 30% of every rotation grade. Real humans do not follow textbook presentations, but exams do; the warm body in front of me only detracted from my evaluation by cold scantron. By my attendings’ clinical comments, I was an excellent medical student, but I knew I was a terrible clinician, rehearsed only in the games of academia, not medicine. How I learned to stop worrying about the Match and love patient care My shift in paradigm came with a shift in career path. My worst fear as a fledgling surgeon was not matching for a residency spot. My worst fear as a fledgling emergency physician was killing a patient. Suddenly playing doctor became very real, and in the middle of my OB/GYN rotation, I started to care not about textbook presentations but real-world ones. I didn’t care for OB/GYN and volunteered to cover the peripartum critical care unit, a similar environment to emergency medicine. My first day on the unit, I saw a patient roll in as I was in the middle of practice questions on the computer. I glanced up but returned to my test preparation, justifying my delay in evaluating the patient because the resident was still in surgery. Half an hour later, the resident came to evaluate the patient and I followed — the patient was obtunded, hypotensive and sitting in a growing pool of her own blood. It would not have taken a MD to realize that this patient required immediate medical attention, and I kicked myself for not evaluating her sooner. I may have been a pretend doctor, but it finally struck me that I was a pretend doctor on very real patients. For the rest of my time in the unit, I made it a point to personally round every hour, on the hour, on every patient. I didn’t always write notes for these hourly rounds — getting credit was no longer important to me — patient care was. While they initially questioned my obsessive rounding, the residents quickly came to trust my dedication and leave me to my own in the unit, knowing I’d alert them if necessary. At my institution, hell hath no fury like an OB/GYN resident unnecessarily interrupted, so I spent my time reading on appropriate treatment courses for the different conditions I saw in the unit. After I rounded, I’d give the resident a list of orders to put in, and the nurses began to treat me as the main provider in the unit. I got to be the first person to make critical medical decisions, responding to truly acute situations and drastically changing the course of a patient’s treatment. I pulled long hours and hardly studied in the traditional sense with prep books and practice questions, but I was constantly reading on my patients. That shelf exam and clinical evaluations were my best of the year. I had learned to stop worrying about the Match and love patient care. Not “just” a student After that revelation, I fought to earn more responsibility and trust on each rotation; I learned more, gained competence and became more satisfied in my chosen career in medicine. During emergency medicine , the specialty that started it all for me, I learned more medicine in one month than I did in my entire third year. It was a pass/fail course with no motivation by grading, but I was terrified I would be the first person to evaluate a patient and not recognize a critical condition. That hemorrhaging patient from day one on the peripartum critical care unit still haunted me. People can decompensate quickly and unpredictably — at any moment, you may go from being “just” a student, to being the only medical provider in the room. At the end of that rotation, Step 2 breezed by with none of the misery I experienced with Step 1. Behind each question I’d see faces of patients with that exact presentation; behind each answer choice, I’d see the clinical consequence of making the wrong decision. Finally, I understood what it mean to be both an excellent medical student, and (at my level of training) an excellent clinician. The academics of medicine often makes us forget the “59 yo AA M, PMH CHF dx 2010 (EF 20% by TTE 8/2013) p/w SOB x 2d” is a real person, with real vulnerabilities and real fears. We are not “just” students, but trainees and members of the medical profession. Grades and exams do not define us, but are simply checks on clinical competence. Trite as it may be, remember what you wrote about in your admissions essay — why you embarked on this journey in the first place. We came to medical school not to become excellent medical students, but to become excellent doctors. Always keep that in mind. Everything else, the grades, the Match, the exams, will fall in place. Amy Ho is a medical student.

"Povara"de a fi rezident in Romania..

...Si uite-asa,m-am intors scriind..ce-i drept,dupa o lunga perioada de absenta,timp in care m-am luptat cu.....rezidentiatul si birocratiile lui..pt ca,stim cu totii,nu e usor sa fii rezident in propria-ti tara. De felul meu sunt patrioata,si tot din acest felu-mi ,am ales sa raman in tara mama.Gresit sau nu,eu inca lupt sa imi croiesc propriul drum,desi cum ma intalnesc cu cineva cunoscut,prima intrebare este,evident,daca nu am plecat inca. Nu,nu am plecat,si nici nu am de gand..cineva,trebuie sa ramana si aici ,cineva are nevoie si de noi....inca mai sper ,in demnitatea "furata" a medicului in Romania. Cand am ales interne la rezidentiat,visam deja la un film frumos,in mintea mea se derulau episoade si cazuri discutate din bine-cunoscutul serial Dr.House..cu un spital mare,ferestre largi si multa lumina,usi care se deschis silentios,saloane curate si personal binevoitor..lucrurile insa au stat cu totul altfel.. Inca de la inceput,din primul an,rezidentii erau repartizati medicilor indrumatori,unii dupa pile,altii dupa cum nimereau.. Dupa cateva luni,a venit si timpul punerii garzilor,4-5 la numar pe luna,neplatite bineinteles..nu pot sa uit o intamplare,cand de Pasti,o rezidenta de an mare,sustinuta bineinteles de seful de sectie,mi-a plasat "cadou"o garda fara sa ma anunte..(tin sa precizez,ca aceasta "punere a garzilor" era obligatorie,dar oarecum democratica intre noi,fiecare alegandu-si data)..eu ,simtindu-ma neindrepatita,am ripostat si m-am sters de pe lista,avand deja 4 garzi in luna aceea..nu a trecut mult timp si am fost chemata in "biroul suprem"pt a da exlicatii cum de am indraznit o astfel de fapta,adica,sa ma sterg de pe o lista unde am fost pusa intentionat de acea rezidenta,intr-o garda care oricum,nu era obligatorie.. In zadar mi-am strigat dreptul de a alege,pentru ca singurul raspuns,a fost o "sedinta" cu seful de sectie unde in loc sa am parte de consiliere,am avut parte de multe urlete si jigniri...acesta a fost primul meu contact cu "adevaratul" rezidentiat in Romania..am iesit din acel birou umilita pe nedreptate,fara drept de apel-pt ca nu cunosteam pe nimeni,si pt ca eram un biet rezident de anul I care isi cerea drepturile.. Din fericire nu ma las batuta usor si sunt o luptatoare..au urmat bineinteles si alte momente umilitoare pentru mine,momente in care -desi nu sunt genul-a trebuit sa plec capul..aa..si pana la urma,m-am prezentat in acea garda..la insistentele parintilor,"ca sa nu am probleme"...desi,in curricula noastra e precizata ca obligatorie,doar o singura garda.. "Din aceste garzi inveti"...ar spune multi..da,e adevarat..inveti,cand nu ti se impune nimic,cand esti privit ca un coleg,nu ca un servitor,cand din propria ta initiativa de cunoastere vrei sa vezi,sa faci mai mult..sau poate vrei sa inveti doar cand esti platit..sau noi medicii rezidenti,nuuu,nu trebuie sa ne gandim si la o rasplata financiara a muncii noastre..noi trebuie sa muncim fara bani,caci doar astfel se vor lipi ceva cunostinte medicale de noi.. ..Realitatea crunta este,ca,in anul intai,garzile astea nu fac altceva decat sa iti provoace o oboaseala extrema,se plaseaza pe umerii tai o responsabilitate neasumata de titularul garzi..iar la raportul de dimineata,pe care il prezinti tu,servitorul,medicul rezident,care nu a dormit toata noaptea,si daca se nasc discutii asupra cazurilor,esti luat tu la raspundere,servitorul,cel care trebuie sa taca si sa faca..dar asta este o alta poveste..pe care am sa o scriu in postarea urmatoare.. Pana atunci..sa aveti spor la toate..;)

Cariere in alb

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