Becoming proficient at low resource medicine

18 Jul 2008
5 minute read

agk’s Library of Low Resource Medicine

Reading a book or a web page is not how you become proficient at providing medical care. I have great respect for the Merck Manuals, and Where There Is No Doctor, but these are really intended as references or brainstorms for people who already have the basic training acquired somewhere else. It isn’t whether you can guess that someone who wakes up with shakes and leg cramps after a day of sweating in the hot sun has low potassium, it’s whether you can rule out a stroke or high calcium or something else first.

Similarly, taking a class and getting a card isn’t enough either. No class can prepare you for the enormous range of cases you will eventually see. At best, your class can orient you towards a life-long learning experience, and connect you with people who can help you along the way.

Finally, it’s important to give up on the idea of being the only, or the highest trained, person available. Medicine is now and always has been a team sport, so recognize that you will only ever occupy a single useful place in a wide constellation of skilled people, some of whom will look up to you and others of whom will be your personal lifeline.

So, person-to-person training, hands-on experience, cooperative practice.

I first tried going over different options and rating them. I’m rewriting this as learning goals. Please, send comments on it.

  1. Constant engagement with different people from all walks of life with a wide range of issues and problems. Doctors have done quite well for themselves by specializing, but unless you only spend time with specialized people, you need to get away from overly particular training. Obviously, if you want to become a midwife, all your patients will be pregnant (and then their brother has a headache… but anyway) but you want the widest range of pregnant people possible. You can’t just confine yourself, as many people unconsciously do, to people between sixteen and forty with good childhood nutrition and minimal functional impairments.

  2. Mental and emotional discipline. I joke that I see EMS as a devotional calling, like becoming a monk – we wear drab, uniform clothes and mediate between ordinary people and the most frightening aspects of life and death. Its true – I see people born, and I see them snap their necks five years later. I see old people who are ready to die, and I see old people kept lashed to their lives by terrified families and friends. My neighbors have learned not to ask for details of what they are convinced must be a very exciting job.

    Most of what I carry with me on calls, though, is just this aura – the sense that someone who has seen birth and death and pain in between is here, and is not worried, and is taking control of the situation. I may actually be worried, or I may be distracted, or I may be ready to strangle my partner, but I have to keep this sense of spiritual calm or I fail in my job. Folks, this is hard work, and I’m still learning to do it well. I’ve said many times that people in med school should have to spend six months shadowing a religious official – a pastor, a rabbi, a priest or as appropriate to their background – on their rounds through the community. Otherwise you come out with a hundred ways to change a heart rhythm and no way to tell someone its okay to die. Which are people guaranteed to need?
  3. Patient assessment skills.
  4. Familiarity with musculoskeletal injuries. This is the cuts, broken bones, sprained ankles, sore back etc thing – there’s a lot of it to be done, it takes some learning (can you reset a dislocated shoulder?) and it builds you trust very quickly among patients. The fact is, people with a broken arm are no more likely to have other health problems than the general population (unlike, say, diabetes) and therefore if you can only fix one thing, it might make them all the way better.
  5. Good underlying science knowledge. This kind of goes with #6, because it’s easy to get lost in the ritualistic aspect of health care. You give this for that, okay, but why? You should always be asking yourself “why?” in your head, and you should be able to answer the question, otherwise you’ll miss something. Why this treatment? Why is this sign associated with this condition? Why does someone in liver failure have swollen legs? Etc.
  6. Improvisational engineering skills. To take an example from my own bag of stories, lets say someone has a severe hunchback, and also may have hurt their neck. If you put them in regular spinal immobilization, which is made for people who can lie flat, you will cause more damage than you’ll prevent. What can you rig up to keep their neck still without injuring their back? How can you carry someone down a flight of stairs? What can you use to rectally rehydrate someone? You have to know how something works to replicate it, but you also have to have a good sense for what’s around you to work with. Putting stuff together that works is almost the definition of thriving in a low-resource environment.

  7. Connections with a wide network of people doing similar work with whom you can share ideas, stories, and advice. This speaks for itself, no?

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from HUCK FINN ON ESTRADIOL ©                                        .
My friend Anne's old blog, available via http at
tagonist.livejournal.com
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