Despite the SSS - another tragedy

[CLSmith]

This is clearly an example of poor training. ...

Let me take a wild guess: You are not from Africa?

[Ian Simpson]

[CLSmith Wrote][Let me take a wild guess: You are not from Africa?]

Correct, my work has been in India, Pakistan, China and Africa where training has been carried out very effectively. Unless there is an implication that I am not getting that somehow training cannot be carried out effectively in Africa, I am not sure how your point is relevant.

[zululand]

@ Ian – I am sure with your work in India and Pakistan you have encountered similar issues as we see here in SA/ Swaziland.
I still believe as you say through training as support we will achieve far greater success in areas like Swailand and the more
rural areas in SA. Dropping 400 vials of antivenom off in Swaziland, making the effort of setting up a great symposium
and self funding to a large extent his efforts in Swaziland Dr Bush should be praised for his efforts!

After all that effort it would be great reach out to more people on the ground in the medical field i.e. the doctors and nurses that
deal with the cases that come in. As far as I understand there is reasonably good medical infrastructure in Swaziland just not a
proper protocol on snake bite treatment.

I still believe for not a huge amount of money a training program can be set up where local or international volunteers can go to
the affected areas and present training courses where the focus could be on intubation skills and basic life support based on the
Blaylock protocols. Small country, relatively simple logistics. With the fund raising efforts already in place it should be very easy
to round up some qualified volunteers and the show is on the road?

As set out in me response on the “another day” thread it shouldn’t be that difficult.
viewtopic.php?f=19&t=21117

Maybe I’m missing something?

[Ian Simpson]

@Zululand
You are spot on, I have been involved/carried out many training programmes at both national and State/Provincial level and I agree that training is the answer. The problem is that a huge amount of money has now been spent for no positive result. This victim could probably have been saved with a resus bag and two size 5 endotracheal tubes used to improvse nasopharyngeal tubes at a total cost for the tubes of around $2. Intubation training wont happen and is unlikely. The key issue is doctor confidence.

My point is that unless you have experience in conducting training in developing countries it will not be effective and this is the major weakness of developed world experts. The SSS falls within that problem. We have seen a great many junior doctors treating krait bites (the most feared snake amongst South Asian doctors) very effectively following adequate training. Swaziland is a small country and you are right it should be very easy to fix. I agree that Roger's approach is the way to go, we worked together on an African ASV paper.

The anti venom that was donated has major problems i.e. does not cover all the necessary local species and is difficult to use as clinical symptoms are not definitive..patient with ptosis, do you give the Bioclon ASV??? what if its N. annulifera or D. angusticeps? If it is ASV will be wasted.

Unless training is carried out effectively, then the assumption in Government and Health officials is that is has been 'done'. The momentum is lost.

The key objective is that treatment is improved for victims and all the headlines and donations wont fix that. There is a large dose of practical solutions required.

[Bushviper]

I guess not being there did not help you for this argument. Intubation training was given by experts right after lunch but guess what .... half the crowd had gone home so they did not benefit. Even lay people were practicing on the dolls that were provided. Even I now know how to intubate a patient and got it right a few times in succession.

D angusticeps do not occur in Swaziland so that is kinda irrelevant. Nobody can say what its effectiveness is on N annulifera bites because ours have a venom different to the East African specimens. There were also 100 vials of SAVP antivenom donated if there is any confusion. I am pretty sure if should cover the worst effects of their bite. They dont bite many people in comparison to the other elapids anyway.

Meaningful training can only take place if people are interested. There were some really dedicated doctors and medical personnel there but others do not really have a calling but just a "job" and they dont get a bonus for saving lives.

You cannot just walk into a sovereign country and try to take over training. They are rather touchy about that and the ministry still had to approve the training regimen despite them being totally incompetent themselves. You can never learn too much and if any of the personnel at the respective hospitals had been at the SSS I am sure the child's life could have been saved. It is not rocket science. Any enthusiastic person with any post school qualification should be able to pull that off.

[Ian Simpson]

My point is that intubation training is not useful as doctors who are not confident will not carry it out. We have seen this in a great many countries. The more important training is with imrovised devices which doctors or even basic medical staff will use.

Whether D. angusticeps is found in Swaziland depends on which references you check, but the important point is with neurological symptoms do you give the new ASV or not. These are key issues which impact whether a doctor uses or wastes ASV. You mention SAVP, but supposing I have both which would I use? With H.h which also gives neurological symptoms there will be a straight choice SAVP or new...you cannot leave a doctor in that position.

Having introduced training in a number of soverign countries and states, it depends on how you go about it and how experienced you are doing it. One aspect is inviting the right people so they dont all leave after lunch! Many of the developed world experts have not done it and therefore struggle. One even stated he was uninterested when I offered to show him how we had provided it for 10,000 doctors in the State of Tamil Nadu. There are ways to do this and ways that will not work.

The original posting said staff from the hospital were there at SSS.

[zululand]

Unfortunately I was only there for the informal day where a few doctors attended and
they were all very enthusiastic and provided good insight and comments as to the
treatment and suggested procedures Dr Bush presented. Pity they didn’t have the
intubation exercise that day.

If permission can be obtained to bring in 300 vials of antivenom and have it distributed
there shouldn’t be any issue with the same aid organisation to provide training to people
on how to administer it? Or have it done under their umbrella at least?

The debate on whether to use it or not and if so which one to use
I’m not qualified to get into.

From what I saw you have to be confident in what you are doing and have the right back
up in case the patient reacts badly to it. It is not pleasant stuff but a necessary evil in some
cases, especially with the neurotoxic elapids. If the people that treated the patients were
properly trained or at least up to date with treating snake bites those 2 people would
have survived. Look at the two cases outside Durban with D angusticeps bites, both severe,
both survived. I’m with BV on these snakes occurring in Swaziland, unlikely even if some
distribution records show them listed there. Their Grey cousin is the problem in Swaziland.


When we approached the dept of health here and then worked with all the doctors
and hospitals in Northern KZN they were all very interested in what Dr Bush
had to say regarding treatment even though they all treat snake bites on a regular basis so I’m
of the opinion that the mere fact that the subject is snake bite will keep most people interested.
Something like intubation should be a necessary skill out there, it is a procedure that could be
necessary in many emergency treatments, not only snake bites.

[Ian Simpson]

@Zululand
You are right, its a practical approach that is needed. I would put less emphasis on ASV and intubation though. Intubation is complex and you have to provide a deal of training to get doctors at basic facilities to use it. I well rememebr Norris from Stanford's shocked expression when we provided airway management courses in India, when a doctor attempted to place the ET tube in upside down! They may not even have the correct equipment, which is very normal. Simple Nasopharyngeal tubes are much more effective and likely to be used.

ASV is fine but much of the current supply to Swaziland will be wasted, it always is due to poor protocols...ASV does get to Swaziland now. Its also expensive which means that corruption will be a factor. At a single hospital in West Bengal we found a good protocol saved 19,000 vials per year...no typo! The training must come first, its too easy to call for more ASV and then give it to doctors who have no idea how or when to use it. In addition, ASV is unlikely to work against the pre synaptic part of the mamba venom. A good substitute for the post synaptic element is neostigmine. Its very cheap and usually supplied and can be stolen/borrowed from anaesthetists as its used during operations. That can be kept in basic facilities and will work very well against post synaptic species. The best solutions will be cheap and effective, therefore more likely to be used. Thats why we included a chapter on equiping basic facilities to manage snakebite in the protocol I refered to in an earlier post.

It requires a proper approach with the right people engaged and due consideration to the context. Seminars very rarely deliver anything apart from headlines.

[Jen]

Ian - I have to agree with you. I'm a South African doc in anaesthetics and in the average generalist, airway skills are appalling. Airway management is the bread and butter of an anaesthetist, and we get called by other disciplines all the time to assist in airway issues, even from specialists.

The South African system is improving - interns (the 1st two year after qualification) have to spend 2 months in Anaesthesia - much better than the previous 2 weeks. At least these 2 months are equipping our junior docs with better skills.

It must be said that intubating a mannequin and intubating a human are vastly different! Plus, an easy airway is an easy airway - anyone can get the tube down. It's the more tricky patients that scare them. This patient in the thread was a Grade 1pupil - around 6 years old. Intubating a child (which is actually easy) often scares many newly qualified doctors. I completely agree that a lack of confidence plays a big role.

[Ian Simpson]

Hi Jen
Excellent intervention from an expert. This is a typical developing world scenario, doctors cant intubate, call anaesthetist who is always busy, wait ensues and victim dies. The use of simple airway support devices, with good training to make a resus bag more effective is far more effective. Ventilators are always in use, if in the rare case the hospital has them. I have seen a number of developed world experts who asked the closed question "do you intubate victims with airway problems" get the answer "yes sir" which actually means "no sir". When you ask the doctor to show you the intubation equipment they then own up that they do not have one. This confidence question also impacts ASV. A great many times when doctos say, "we have no ASV", what they actually mean is "I have ASV but am worried about using it". They will then fall back on adverse reactions to the ASV, which in fact are trivial and can be managed very easily.

Jen, I am curious, have you seen these newish plastic disposable vetilators that run off air pressure in SA? We have used a couple in India and supported a krait victim with respoiratory failure for 18 hours till recovery, they need some more testing but may present a useful stop gap in the absence of mechanical ventilators.

Most developed world guides to snakebite recommend intubation and mechanical ventilation which is just not practical. Thanks for a very useful post!

[swazi]

Wonderful comments! Everyone is right to a certain degree. We all learnt a lot (well… some more than others) and if I ever arranged another SSS I will most certainly change quite a few things. The death of the young boy was a bitter pill to swallow and the (mis) treatment, of several bites I have been involved with since, not much easier to comprehend.

Ian I am not comfortable with your comment that symposiums do not achieve the desired results. There have been many successful training symposiums, just have a look at the progress David Williams is making! It is very easy to criticize other people’s efforts from a distance.

[Ian Simpson]

Swazi,
Thanks for your comments. I am unsure which 'successes' you are refering too. I notice the mortality rate in PNG is increasing so I am not sure how you are judging success.

I spoke about seminars, of which there have been huge numbers over the past decades, usually given by the same snakebite experts who describe snakebite as 'neglected' and lament the fact that no progress is being made. They have been talking about training since at least the 1980 WHO meeting and are still talking about it. A seminar gives, usually an academic, an opportunity to present a PowerPoint presentation and then leave. If we are to improve training then a comprehensive approach to engage authorities and provide meaningful, locally relevant courses that are practical in nature is required. We have seen this work in the countries with the highest snakebite mortality and I would have thought the lessons would be useful for the smaller countries as well. That was cetainly my approach when Sean Bush sought my advice before the SSS on how to be effective in developing countries. Unfortunately he only availed himself of around 10% of what he needed to know before going ahead.

[Bushviper]

If the doctor is too stupid to intubate and has never bothered to learn he will not suddenly wake up excited and want to learn. These idiots should have their licenses revoked but everyone thinks that they are untouchable. If you cannot do the job (ventilate a patient or know when and how to give antivenom) then you should be fired from the hospital and struck off the roll. It is that simple. Why tip-toe around them because they have a doctors degree or qualified as a nurse. It is a pity so few people actually sue doctors and win. I am so glad there are specialist lawyers who now work on a no win, no fee basis and are calling these incompetent idiots to task and breaking them financially.

[Ian Simpson]

It is too simplistic to say they are "too stupid", if you fire all those who dont intubate or give ASV, you will have plenty of empty medical facilities. Developing country doctors are trained in very basic settings. They probably were in a class of 20-30 that crowded around the only, well used, cadaver, to 'learn' intubation. They then find themselves in a local setting, where they live and are known. The consequences of a 'failed' intubation can have imediate and dire consquences for the doctor. They will always take the safe option. If they do nothing or refer the patient, the patient just dies. If they do something and fail, they are responsible. Its also why most snakebite victims are refered from a local to a main hospital.

The trick is to effectively train them in techniques they CAN perform. Most doctors have unfortunately been scred witless by 'experts' on how reactogenic ASV is, it is hardly surprising they are reluctant to give it even when they have got some. Where we have given effective training, doctos manage patients locally. If they are confident, they will intervene, particularly if they are told ASV reactions are trivial to manage (which they are). Good outcomes raise their reputaion in the community and that incents them. We have seen this time and time again in India and Pakistan, it has also been reported in the literature.

[froot]

The SSS played the role it was expected to with success. I can see why Swazi would do things a bit differently if she holds another one but it brought the necessary parties together in one room and created the awareness needed for the snakebite epidemic in Swaziland. We cannot expect the SSS to be the 'silver bullet' that will suddenly alleviate the problems faced by snakebites in the country. That responsibility was there to be offloaded on the various expertees and authoroties that attended the SSS and left the SSS with parts of it. If the ball was dropped, that's where it happened and nobody followed the progression through. Swazi can surely hold another symposium if she wants but it will only be worth it if people who BUY IN and COMMIT themselves to STRATEGISE and FOLLOW UP on PROGRESS attend.

The theme for the next symposium should be on strategy, IMO much more needed than training in this case. Seriously, it cannot be that difficult. All they need to do is select and train only one doctor up in the snakebite field, have an ambulance with nurses on call. It's a nice small country, bang a small clinic somewhere in the middle of the epidemic, a couple mobile phones, nurses acting on the doctor's instruction and have a national snakebite helpline with an easy to remember number (911 sort of thing) that is advertised in clinics, newspapers, on billboards etc. If a child gets bitten, a family member runs down to the nearest phone and makes the call, the ambulance arrives and finally there's no more guess work.

Get the first aid part of snakebites sorted and the rest will be much easier, and nowhere near as costly.

Once again, it's a people problem.

Edit: Last year I initiated a drive to raise funds for antivenom for Swaziland and IIRC 22 vials were donated. Should I do this again? I would like to hear eveyone's thoughts on this.