How we won the war on acute pancreatitis in limited resource environments
Our Challenge in the management of acute pancreatitis came in the days when I started to see patients in Kalyani hospital in Chennai. It revealed several dimensions that define the surgical practice in a metropolis like Chennai. I was faced with patients who had destroyed their lives with alcohol and brought on themselves a disease which can potentially kill them, and most of them were broke and were under the care of surgeons who cared less about these "medical patients". I used to feel helpless when I used to see these patients being managed as I could not do anything to them unless referred by the treating surgeon.
When they became sick, the patient was transferred to the GI surgical service, which was just being launched at that time. This posed enormous challenges - the most important being financial. There was no choice for me. I got the inspiration to do more from a book called " Where there is no doctor" by David Werner. While I had grown beyond the book, I took it upon me to develop a protocol which would be simple enough for a non doctor to treat a complex disease like acute pancreatitis.
The only dedicated group was the nurses in the surgical wards. I made a simple check list which they have to follow till I arrive at the hospital. The list included essentials of diagnosis, devoid of any physical examination (impossible for nurses to examine patients and also to interpret the findings) and a simple lab investigation to confirm the diagnosis. The check list evolved over 10 versions and changed to make things more comfortable for the nurses.
Never did I imagine that these nurses would make this so successful that we lost no patient despite the extremely low cost of care. The whole cost of acute pancreatitis management with this check list was as low as 15,000 rupees, which was quite affordable to most of these patients. Well, success always should be replicated.
To successfully manage acute pancreatitis, it is essential to diagnose as early as possible after the hospital admission. How could a patient or a family member help in this? The only help which would make a difference to the patient is to reach a hospital as early as possible. The presence of upper abdominal pain along with back pain should put pancreatitis high on the list of suspicions. The pain is usually relieved by bending forward. The attending doctor would order estimation of the pancreatic enzymes in your blood - an enzyme called Amylase. A level more than 3 times the upper limit of the normal would support the diagnosis of acute pancreatitis. The doctor would also exclude other diseases which would mimic acute pancreatitis.
The immediate treatment is not a "referral to a Specialist". I have learnt that the simplest definition of a specialist is that with the passage of time, the system should need less of the specialist. The duty of the specialist is to facilitate, not to replace. The key is to relieve pain and give intravenous fluids to keep up the intravascular volume. It was difficult to establish this confidence initially, as no patient was prepared to start treatment until seen by the specialist. But the battle was won by the constant loving care of the nurses who were involved in the project.
The next resistance came for the tubes which we put into the patient to manage the fluid balance in the body. The simplest way of knowing whether we have successfully put the right amount of fluid into the body, is bu monitoring how much of urine we produce. The simplest measure, which we call as the hourly urine output proved to be an obstacle as patients objected to a tube inserted into their private parts. We made them understand why we were doing this and our reassurance that the tubes will be removed as soon as the purpose was served fetched us the necessary co operation of our patients.
After having established the right steps, the next work is to determine whether the patient has a severe or mild disease and identify the factors that contribute to the increased risk. The key risk factors are obesity, old age, organ failures at admission and the changes in the Chest X ray at admission. The Chest X ray is commonly missed as the primary reason for performing a chest X ray is to exclude a perforation and for preoperative reasons. We had to ensure that this is done. we also used the Glasgow severity index investigation to predict severe disease.
When we came to the etiology, a large portion was made simple, as most of the patients had alcoholic pancreatitis. But diligent search revealed surprising numbers of gall stones, hyperlipidemia, pancreas divisum and even an ascaris worm. By 6 hours, we had the patient on the road to recovery.
We were challenged by the inability of the patient to afford the tinned powders that would have provided them feeds. We were forced to use home made foods as substitutes and we were successful in introducing oral diet after 24 hours of resuscitation. That broke the last rim of resistance. Once we were able to feed them by mouth, patients improved in leaps and bounds.
Sometimes, when I see the confidence in my team when it comes to the management of acute pancreatitis, I wonder whether I will be able to replicate the same in other diseases as well. Oh, time only can answer that.
When they became sick, the patient was transferred to the GI surgical service, which was just being launched at that time. This posed enormous challenges - the most important being financial. There was no choice for me. I got the inspiration to do more from a book called " Where there is no doctor" by David Werner. While I had grown beyond the book, I took it upon me to develop a protocol which would be simple enough for a non doctor to treat a complex disease like acute pancreatitis.
The only dedicated group was the nurses in the surgical wards. I made a simple check list which they have to follow till I arrive at the hospital. The list included essentials of diagnosis, devoid of any physical examination (impossible for nurses to examine patients and also to interpret the findings) and a simple lab investigation to confirm the diagnosis. The check list evolved over 10 versions and changed to make things more comfortable for the nurses.
Never did I imagine that these nurses would make this so successful that we lost no patient despite the extremely low cost of care. The whole cost of acute pancreatitis management with this check list was as low as 15,000 rupees, which was quite affordable to most of these patients. Well, success always should be replicated.
To successfully manage acute pancreatitis, it is essential to diagnose as early as possible after the hospital admission. How could a patient or a family member help in this? The only help which would make a difference to the patient is to reach a hospital as early as possible. The presence of upper abdominal pain along with back pain should put pancreatitis high on the list of suspicions. The pain is usually relieved by bending forward. The attending doctor would order estimation of the pancreatic enzymes in your blood - an enzyme called Amylase. A level more than 3 times the upper limit of the normal would support the diagnosis of acute pancreatitis. The doctor would also exclude other diseases which would mimic acute pancreatitis.
The immediate treatment is not a "referral to a Specialist". I have learnt that the simplest definition of a specialist is that with the passage of time, the system should need less of the specialist. The duty of the specialist is to facilitate, not to replace. The key is to relieve pain and give intravenous fluids to keep up the intravascular volume. It was difficult to establish this confidence initially, as no patient was prepared to start treatment until seen by the specialist. But the battle was won by the constant loving care of the nurses who were involved in the project.
The next resistance came for the tubes which we put into the patient to manage the fluid balance in the body. The simplest way of knowing whether we have successfully put the right amount of fluid into the body, is bu monitoring how much of urine we produce. The simplest measure, which we call as the hourly urine output proved to be an obstacle as patients objected to a tube inserted into their private parts. We made them understand why we were doing this and our reassurance that the tubes will be removed as soon as the purpose was served fetched us the necessary co operation of our patients.
After having established the right steps, the next work is to determine whether the patient has a severe or mild disease and identify the factors that contribute to the increased risk. The key risk factors are obesity, old age, organ failures at admission and the changes in the Chest X ray at admission. The Chest X ray is commonly missed as the primary reason for performing a chest X ray is to exclude a perforation and for preoperative reasons. We had to ensure that this is done. we also used the Glasgow severity index investigation to predict severe disease.
When we came to the etiology, a large portion was made simple, as most of the patients had alcoholic pancreatitis. But diligent search revealed surprising numbers of gall stones, hyperlipidemia, pancreas divisum and even an ascaris worm. By 6 hours, we had the patient on the road to recovery.
We were challenged by the inability of the patient to afford the tinned powders that would have provided them feeds. We were forced to use home made foods as substitutes and we were successful in introducing oral diet after 24 hours of resuscitation. That broke the last rim of resistance. Once we were able to feed them by mouth, patients improved in leaps and bounds.
Sometimes, when I see the confidence in my team when it comes to the management of acute pancreatitis, I wonder whether I will be able to replicate the same in other diseases as well. Oh, time only can answer that.
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