On Managing the Saline Shortage Crisis in the US

Another good friend shared a couple of articles on the American shortage of saline and mitigating it by oral rehydration. Yes, a shortage of that bag of nothing else but water and salt.

Ingredients: Water, 9 mg/ml of salt and nothing else

But apparently it's not easy to manufacture; it has to be the right concentration (there are various formulations) and pure (of impurities and germs). Amazingly, the whole  US gets its bag of saline from only 3 manufacturers (my observation has been that all of peninsular Malaysia is supplied by Ain Medicare). Apparently Hurricane Maria jeopardized the American supply as manufacturers can't simply ramp it up; interestingly 1 reason for this is the high barrier to entry as the hospital groups' purchasing power ensure that they buy saline at the absolute lowest prices (only the companies with the lowest costs win).

“Oral rehydration therapy has been studied for nearly 60 years. It has been shown to reduce mortality from diarrheal illnesses by 93% and to reduce the case fatality rate of cholera from 30% to 1%. It is less expensive than IV-fluid therapy, and its use results in fewer admissions and shorter lengths of stay. A 2006 meta-analysis showed that oral rehydration was equivalent to the administration of IV fluid for the management of dehydration due to gastroenteritis in children. Data on use in adults have revealed similar efficacy, although in smaller studies. Oral rehydration therapy has been widely adopted in low- and middle-income countries where IV fluids are expensive and resources limited. Conversely, despite this evidence, oral rehydration has not been widely used in adults in high-income countries, probably owing to the widespread availability and ease of use of IV fluids.”

Interestingly, the saline crises has forced American ED's to stop being lazy and do the right thing and encourage oral rehydration. Despite good evidence that it's better than iv fluids (both in terms of efficacy and cost), we still stick to iv fluids for what can only be described as "laziness". There's just nothing easier for the nurses than putting that iv line in, spike that bag of saline, hang it up, and continue with ward work instead of the kind "Western way" of encouraging patients to drink that solution of electrolytes; imagine if it was a typical Asian parent instead of that nurse instead. And if the patient can tell us that the bag of saline has just finished, all the better as now you can simply chart it as 500 ml (or 1 L) in!

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On Improving Ward Rounds (and Thus the Doctor-Patient Relationship)

This article was shared by a friend who has moved on to become a doctor in greener pastures away from Malaysia:

“The sun is barely up when the curtain is pulled back, revealing a group of mostly strangers.

They are talking to each other. I understand every third word, I think.”

It’s interesting that English-speaking people don’t understand full-blown medicine-speak. 

“Patients — sleepy and confused, with un-brushed teeth and un-combed tresses — stood over by healthy figures in positions of authority wearing makeup, ironed clothes and swept-up hair.”

We have no time to wait for you. Not in the developed Western world, and definitely not in a more resource-constrained environment. In Malaysia, housemen are expected to see patients before 7 am (what time do you think they woke up and drove to work?). Rounds may start by 8 (occasionally even 7.30 am). They have no time to know whether your favorite child is planning to follow the same career.

“The moments when I stay behind and connect with the patient are small, but significant. Is there something I can get for you? How did you sleep? Is that sunlight in your face? Can you reach that glass of water? Would you like the door open or closed? How are you feeling?

Sometimes patients ask me who the person was just talking to them, not because they’re delirious, but because they just weren’t told. Sometimes they report a new symptom or ask a question. Once I even had a patient ask which specialty we were from.”

We’re all guilty of rushing things. But when you’re rounding 40 patients in the general ward (as a specialist), general talk with patients is a luxury. Unless if you plan for rounds to finish at 1 pm, give HO's and MO's an hour or two to settle ward work (while others go for lunch breaks) and finish the PM rounds by 6 earliest, followed by 1-2 hour traffic (I'm very lucky to commute by public transport most of the time, with the option to just walk at times). But yes, we can do better to be more human in an efficient manner.

“A 2005 study done at a hospital in New York City found fewer than half of patients discharged from hospital knew their diagnosis.

And fewer than one in five hospital patients could name the doctor in charge of their care, another study from the University of Chicago found.”

This is a problem, for both patient and doctor (there are times when the patient's memory is the account of his/her medical history). With time at a premium, getting patients to read their discharge notes is a head start. Ensuring that patients know their diagnosis during the major rounds is probably effective too.

“We can start with small changes like giving patients advance notice of when the team will be at their bedside, capping the number of staff present, seeking permission to begin the consultation, and providing clear introductions via the senior doctor.

During the visit the lead doctor should sit at the patient’s level, someone could take notes specifically to give to the patient, and genuine opportunities to ask questions should be created.

These seem like small steps. But for the person under the glare of scrutiny — sick, tired, bewildered — they are critical. Let’s reshape the hospital system and start each and every day with the patient at the centre of our care.”

When our doctor-population ratio is better (senior doctor numbers, not just housemen and junior medical officers), this is definitely something that we should focus on as proper bio-psycho-emotional-spiritual treatment of patients. Not when rounds already take forever with the need to teach etc. Having more people means that 1 specialist has to see only less patients.

I’m so lucky that my “ward rounds” consists of seeing critically ill patients (the majority of whom can’t talk, of which one review typically takes 30 minutes-1 hour) or patients being managed specifically for their pain and not in charge of them as a whole. When new cases are referred for preop assessment in the ward, it’s not uncommon for the review to take more than an hour without other extracurricular talk. You need more manpower to treat patients as people and not as diagnoses.

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Ideas on Studying Moving Forward

And so I passed the recent FCAI Written Exam on the 28th of February. So now I can start planning on how to approach the Final Clinical/SOE. So far I haven’t decided on when to sit for it. There will be 2 available dates: 1 in May and another in November. I’m leaning towards November as I need a mental vacation. It might also be difficult to do the exams in May as I’m in the GICU rotation that month. Just going on cruise control for a while is probably the best choice. Besides, short of winning some gambling games, I don’t see me having enough money to sit for the exam and associated travel (they only host it in Dublin).

I think that I should try to break up my notes into smaller, more quickly finished topics. One thing I noticed during the written exams was that there was a lot of low-hanging fruit which I didn’t cover with focus. Most of the topics were all ones of the “I’ve read this once upon a time” variety and were quite frankly relatively simple.  But if you’ve never read them anyway and thought of your daily work in an academic manner how would you be able to put it in writing?

With the way I do notes at the moment, I’ve been trying to cover fully the topics I’m making notes on, whether the issues are common or relatively obscure with the same level of attention. This is especially difficult when trying to continue making notes on another day, trying to recover the train of thought from the previous note making session (which can sometimes be a few days in between). By breaking them up into smaller subtopics and focus on what is the likely hot key points, I can quickly move on to another major topic, while not hindering the ability to work on another subtopic at another time without messing up the flow. The more obscure points will be covered by reading alone without writing. This is partly inspired by OpenAnesthesia’s Key to the Cart podcasts: just a few minutes talking based on a few key words. This seems to be the best way to approach the way the CAI has been in my experience: a broad base of topics, with only some topics discussed deeply and many others relatively superficially.

As for sources of topics to cover in day-to-day studying, in addition to the usual "stuff that I encounter" and "stuff on Wednesday teaching sessions", I'll go back to my usual email AnaesthesiaUK newsletter of past FRCA questions (different format but similar breadth of topics I'd assume) to look for things to cover.

Examples of question from the AnaesthesiaUK newsletter

The priority will be given to reading for all "stuff that I encounter" and "Wednesday tutorials" first. Whatever free time is left will be spent on note-making on a variety of topics, with the priority on (Addendum: questions that came out in the written exam and) sample questions from AnaesthesiaUK, while looking at the CAI website and ensuring that I have a healthy balance between the different major topics. Since it's a structured oral exam, the key will be getting the important keywords and not go too lengthy (and take away time that should be spent a wider base of topics). But notes must be made: the process of processing information into a "final form" that is readily accessible has been the key so far to efficiency and efficacy.

Not so much a revolution, but more of a fine-tune to the approach that I've used since 2013, that has given me slow but steady success.