I have seen a few cases over last few days – yes and those days have included Christmas day and New Year’s Day, I have a 6 day week roster for the next 10 months. I have accepted this and will have to find ways to manage my stress levels and fit the much needed and important time to enable me to eat well, exercise, and have protected time out for tranquility and recreation. These are some of the things I take every opportunity I get to advise my patients about the importance of and I certainly would not be doing myself justice if I don’t take a little bit of my own advise.
In this blog I just want to blabble on a bit some issues relating to the health system in Port Moresby, from an insider’s point of view. I shall give a hypothetical case examples which highlights some limitations in our current referral system but at the same time highlight some of the things that we can do to improve this system, through which we can all work with a greater feeling of being in control, of knowing that we are doing our best, yet being kind to ourselves by sharing the our energies through this system.
If you are working at the primary health care level i.e. either as a private GP, or as a doctor at a hospital outpatient or at the district level working as a general M.O, you already know that our capacity to provide high standard tertiary level healthcare to our citizens is limited. It goes without saying to any healthcare worker in PNG, we all know the situation, but let me give an example for those readers who may not be as well versed with our situation in PNG. I am going to use the example of someone who presents with sudden onset central chest pain and I will rely on my own experience and knowledge about the current situation in Port Moresby. I appreciate that all of what I will be saying in the next few lines will not be so accurate and welcome corrections to any of my own misconceptions and assumptions.
Firstly when someone presents with sudden onset chest pains, as with any other presentation we take an appropriate focused history, examination and investigations (ECG, Blood tests, etc.) and try to reach a diagnosis as quickly as possible in order to give the right treatment promptly.
The diagnosis of a Heart attack is based on 2 out of 3 criteria:
- 1. History of prolonged ischaemic pain
- 2. Typical ECG appearance
- 3. Rise and fall of cardiac enzymes
With sudden onset chest pains, perhaps the most important questions we want answered ASAP is:
- Is this person having a heart attack?
- If Yes, what is the best thing for a primary health practitioner to do in Port Moresby.
History needs to be quick and FOCUSED, followed by examination and investigations. If from the outset, one think that the likelihood of a heart attack is high, simultaneous treatment is given while organising confirmatory investigations –
- Check ABCs and resuscitate as appropriate.
- Give an anginine tab sublingually – if the patients is in-fact having angina this can lead to immediate relief which can be of diagnostic significance.
- Give high flow 100% O2.
- Give a stat dose of Morphine 2.5 to 5mg IV with metoclopromide –> this not only helps with the pain but helps to calm the patient and relieve their anxiety which can excercebate his/her condition.
- Soluble aspirin 300mg stat.
- Cardiac enzymes
- Echocardiography – can be useful especially if the others are negative.
- And any other investigation one thinks is appropriate depending on the possible differential diagnosis – FBE/LFT/CXR Lipase etc.
OK, so all the above have been done and the patient is diagnosed as having a heart attack (an ST elevation myocardial infarct) outside of hospital somewhere in Port Moresby. The “best” thing to do now will depend on a few things and remember that this post is about systems and trying gain an understanding of our current referral system and to find ways of improving this system.
(At this stage I’d like to say that it would be great to gain the views from those people working at PMGH, the first choice of referral for the vast majority of patients having a heart attack in Port Moresby. It is PMGH that must set the benchmark for tertiary clinical care and research in Papua New Guinea).
Again for the layman, what is happening to this patient? The arteries supplying his heart muscle is blocked and therefore not being supplied with oxygen and nutrients and if this blockage is not reversed, the heart muscle being deprived will die, and if the amount of heart muscle is extensive enough to render the heart ineffective as a pump to sustain life, obviously the patient will die. SO, time is of the essence “TIME IS MUSCLE” every second counts, the blockage must be reopened (and cardiac muscle re-perfused) ASAP.
Ideally the patient should be referred to a hospital with an on-call cardiac unit with facilities to enable the appropriate decisions to be made depending on the patient’s condition. This would include:
- Confirming the ECG diagnosis
- Taking blood for repeat cardiac enzymes and UECs
- The doctors would then decide whether to proceed to coronary angiography, which will allow them to directly visualize the location and extent of blockage and then make further decisions to either re-perfuse using percutaneous coronary intervention with or without a stent or by coronary bypass grafting (CABG) which requires a cardiac surgeon.
Obviously, in Port Moresby, we do not have these facilities nor do we have anyone as far as I know who is a trained interventional cardiologist or a cardiac surgeon trained and able to do a CABG. We can however, re-perfuse using special drugs (thrombolytics) which act by dissolving the blood clot and is recommended that they should be given within 12 hours of the commence of the chest pains. With this simplified and brief outline of the clinical management options for this patient we can appreciate that the only available option we can offer him is thrombolysis.
In terms of our current referral system and the question what is the best thing to do for him? And as an urban primary health practitioner what factors will help me answer this question and act accordingly?
- What exactly will happen to him when and if I refer him to PMGH immediately?
- Is there anything that I can do that will enable the PMGH staff to help him better?
- And my BIG question CAN I GIVE HIM THROMBOLYTIC THERAPY at the primary care level, in the view of referral thereafter for further management?
- If yes:
- What are the local protocols and criteria that are already in place Port Moresby (PMGH) for initiating thrombolytic therapy.
- Ultimately, would this increase the patients chance of survival (all things considered)
- If no, why not and under what conditions would become appropriate.
- If yes:
As a primary healthcare practitioner I would be very interested in answering these question through a dialogue with my colleagues at PMGH ED and Medical Units. If we can come up with a system and protocols for the management of such patient, I can feel more confident acting at the primary healthcare level and initiating treatment before referral. Ultimately, it is about giving such patients the best chance of survival and if can do that, we can at the end of the day say we did it, we have created a system that is homegrown and works and is one on which we and our patients can have more confidence in.
The Queensland Health STEMI Management Plan for ST-Elevation Myocardial Infarction For Non-Interventional Cardiac Facilities can serve as a useful starting point for the development of our own, locally relevant protocol/plan