Working as a doctor in a high income country gives the young, unexperienced residents the illusion that medicine is for free and costs nothing. Especially in countries where everything is covered by health insurance. But that is not the reality. Beside the financial aspect, there is the rational part of medicine. Why do I need this lab? What will this ultrasound tell me? How can the investigation help us in finding the diagnosis and treating the patient in the best way?
These questions are crucial to ask oneself in a humanitarian setting. We are not able to offer Computer Tomography or Magnetic Resonance Imaging. But do I need them in our circumstances and how can we work without them? Do we need all available labs to provide quality medical care? These are the other questions we need to ask ourselves.
Our medical stocks contain what are known as the “Essential Drugs” (as defined by the World Health Organization [WHO]: “drugs that satisfy the healthcare needs of the majority of the population; they should therefore be available at all times in adequate amounts and in appropriate dosage forms, at a price the community can afford). These drugs are causing problems among our local medical staff.
I’m hearing complaints about drugs they consider to be crucial missing from the stock, and questions as to why MSF can’t provide them. For example, Betahistine, ananti-vertigo drug, or cough syrup for children with coughs. Often our GPs face demanding patients who are not satisfied with our prescriptions and demand something to stop a cough immediately. They insist on being given the names of other drugs so they can go and buy them themselves.
GPs working with us are obliged to stick to our guidelines and not prescribe outside our means. We will not be able to provide the variety and quantity that other local medical structures can, but we shouldn’t be compared to other institutions as we pursue different goals.
So with every new GP we interview, we make sure to establish their motivations for working with MSF. This helps to avoid future conflicts and disagreements with our guidelines. However, it’s only once our GPs begin working with us that they are fully able to see the limitations of humanitarian work.
But as a supervisor I am aware of the battles the GPs have to fight each time they face these obstacles. For instance, there are situations where none of the “Essential Drugs” outlined by the WHO are a good solution. For example, when a patient is diagnosed with deep vein thrombosis.
He presented with typical and acute signs of thrombosis in his right lower leg (swelling, positive Tschmarke sign [pain upon compression of the calf] and a predisposition to varicosis of both legs). The only treatment to avoid a pulmonary embolism is low-molecular heparin to dissolve the thrombus in the leg. But this is not available in our Tripoli project. In this case, to be on the safe side, before admitting the patient to secondary healthcare we referred him to for an ultrasound of the veins to clarify the exact location of the thrombus.
But the patient was refused by the hospital we referred him to, in spite of the radiologist’s statement of a severe thrombosis. In the hospital’s opinion, it was not a thrombosis.
We were back to square one. I did not want to treat him with anticoagulant and I couldn’t find any guidelines supporting it. So, do I give permission to “prescribe” low molecular heparin on a piece of paper to save his life? I intended to do so.
We called a pharmacy to find out the price but were put off by the cost, which was clearly not affordable for the patient. We were confronted by an indifferent secondary healthcare system, financial obstacles and a patient in pain with a high risk of a fulminant [sudden] event if we did not act fast.
We decided on applying a compression dressing according to Fischer (the suitable dressing for thrombosis applied in two layers going from distal to proximal) with the elastic bandage we had, which again was not ideal. We stressed to him that he needed to keep his leg elevated and that he should not move too much. Unfortunately, he is a daily worker on a vegetable market and he cannot take sick leave.
When we followed up, his wife told our social worker that he refused to go and see a doctor but he is in good health. We arranged a follow up to make sure that he is doing fine.
Retrospectively, we could have tried a combination of acetylsalicylic acid and clopidogrel, though they are not the first line of treatment for deep vein thrombosis.
The same applies to the referral to labs, specialists and imaging. In a setting where our resources are limited we are not able to play fast and loose. Our actions have to be well thought through and rationally justified.
A case I like to present during interviews with GPs is how they would asses a 25-year-old woman presenting with lower right abdominal pain. And almost everyone so far answered that they would do a lab and an ultrasound.
When I enquire why, they would answer: “to look for elevated signs of inflammation and (in the ultrasound) for signs of inflammation of the appendix”. I explain then that according to several international guidelines and to my personal experience neither a lab nor an ultrasound can confirm nor exclude appendicitis with certainty.
In MSF we follow a syndromic approach (Syndromic management, according to the WHO, is based on the identification of consistent groups of symptoms and easily recognised signs , and the provision of treatment that will deal with the majority or most serious organisms responsible for producing a syndrome), which means we are always looking for the underlying diagnosis – this should always be the goal.
Our GPs are challenged every day, not only by the special cohort of patients, their exceptional circumstances and vulnerability, but also by the high standards we apply to them to guarantee the best medical care with a minimum of resources. We therefore place great importance on supporting them, and helping them to find solutions.
We ARE Doctors Without Borders, but every day we face obstacles and limitations that we have to try to overcome, evaluating situation by situation, patient by patient, to reach the best solution for our patients!