Emergency Medicine Uganda

“A pre-hospital emergency service should be implemented, as this study suggests that salvageable patients are dying before reaching hospital. Injury management requires coordination, so that the large volume of minor injuries receive care without impeding the care of the seriously injured, who should be rapidly triaged to tertiary centers. This is particularly crucial for head injuries.”

Kobusingye et al. 2002

“The goal of an effective emergency medical system should be to provide universal emergency care — that is, emergency care should be available to all who need it. However, there are many unfounded myths about emergency medical care, and these are often used as a rationale for giving it a low priority in the health sector, especially in low- and middle-income countries.

These myths include equating emergency care to ambulances and focusing on transport alone while neglecting the role of care that can be provided in the community and at a health-care facility. Perhaps most common is the perception that emergency care is inherently expensive; this myth focuses attention on the high-technology end of clinical care as opposed to the strategies that are simple and effective. Efforts to improve emergency care, however, need not lead to increased costs.”

Kobusingye et al. 2005

Uganda’s emergency service is still very much in its early infancy but it is important to begin somewhere in helping it develop and grow. This is significantly important, an emergency perhaps for Uganda, given that many salvageable patients die before getting to the hospital (Kobusingye et al. 2002). However, the challenges are numerous, including myths which make building an emergency care system seem like climbing Mount Elgon (all of 4320 metres), or Mount Rwenzori (just about 5100 metres) without climbing gear – not worth the hustle.

However, the need is great and this hasn’t changed, with or without emergency care services.

Pre-hospital services:

Pre-hospital services – provided in the community until the patient gets to a health facility – may have an impact in improving outcomes. In the context of resource limitation, building the capacity of these tier-one systems i.e. volunteers and bystanders may be reasonable to form a group of first responders who will contribute to improving outcomes.

EMU and Pre-Hospital Care

Beginning 9^th April 2016, EMU started its contribution to building these tier-one systems. In partnership with Namirembe Diocese, we embarked on training members of this Diocese in First Aid and cardiopulmonary resuscitation (CPR). A group of 20 teachers including Sunday school teachers gathered in a classroom at Kazo, a Kampala suburb to learn what it means to provide simple, yet life-saving interventions in different situations. We hope that we can slowly but surely, within the context of limited resources, begin the process of shifting outcomes through improved pre-hospital care. We hope they will form a nucleus of First Aid first responders that will spread throughout the country.

We also aim to use these experiences to develop a manual that is tailor-made for the needs of our communities.

We will keep you updated as we continue these efforts, as they snowball into a vibrant community first aid service that feeds directly into enhanced emergency pre-hospital services.

Below is a pictorial:

The tier-one system taking shape

Interaction Between Trainers and Trainees

Practicing Adult Compression-only CPR

Infant CPR

More Infant CPR whilst referring to the manual in the making

Infant Choking

Learning with the manual in the making

Heimlich Manoeuvre

More of Heimlich Manoeuvre

Choking in the Infant

The Manual In its Infancy

A Peek Inside The Manual

Learning from a "Real Patient"

References

Kobusingye, C. O., Guwatudde, D., Owor, G. & Lett, R. R. 2002. Citywide trauma experience in Kampala, Uganda: a call for intervention. Injury Prevention. 8:133-136

Kobusingye, C. O., Hyder, A. A., Bishai, D., Mock, C. & Joshipura, M. 2005. Emergency medical systems in low- and middle-income countries: recommendations for action. Bulletin of the World Health Organization. 83:626-631.

A Roadside Reminder

By Annet Alenyo Ngabirano, MD

From nearly 40 m away, we could see her squatting on the lawn right by the roadside, panties pulled down, handbag lying carelessly, forgotten, by her side. A small crowd of curious onlookers was already gathering around, but she maintained her position on the lawn, ignoring the strangers and their stares. Just an hour earlier, the 3 of us had been elected as Executive Officials of Emergency Medicine Uganda, the first-ever emergency medicine organization in Uganda. Our minds were in overdrive with ideas and plans, and we did not have time to join a crowd of curious onlookers staring at a clearly mentally unwell woman. Someone suggested we should perhaps inform the security guard at the main gate on our way out, to take her to the A&E for a quick psychiatric evaluation. Our minds were racing with thoughts of all the many other important things we had to do, and plan for, until we got close….

What we saw from 3 m away made me feel so ashamed of my earlier thoughts and indifference. The lady was young, perhaps even younger than me. The panties she had pulled down were stained with so much blood you could not tell their original color. She was clutching her lower abdomen, face twisted in severe pain as she looked right up at us. Her pleading brown eyes filled with pain, and something else. Something I couldn’t quite identify. Anxiety? Fear? Perhaps even anger. Something was terribly wrong. Instinctively, all 3 of us rushed across the road to her side.

Up close, her posture was odd. Her left knee was on the ground, strategically placed as if to protect or perhaps hide what appeared to be a pile of bloodstained clothes and a polythene paper behind her. We introduced ourselves, assuring her we were doctors and would like to help. Surprise flashed across her face for a few seconds before she gingerly moved her knee, allowing us to see what she was shielding. A lifeless fully formed fetus lay half on bare grass and half on a bloody piece of cloth, the placenta still attached to its protective mother. I understood her pain then, perhaps as only a mother can. I, too, would have squatted bare in front of strangers to protect the dignity of my child, even in death.

What followed was driven by both compassion and passion; this woman’s fierce bravery and quiet desperation were a reminder of why we are what we are. Our discussions and plans could wait, but this could not. This is why we made plans, why we sat in meetings—our patients.

We were nearly a kilometer from the nearest medical care and supplies, but this lioness of a mother had come prepared with a pair of bedsheets and 2 packages of sterile gloves in her bag. Within minutes, Joseph, Fred, and a lady passing by were holding up her bedsheets to form a makeshift privacy screen. The unspoken consensus was that, being a woman and a mother, I was best suited to examine the lady.

She was fully conscious and oriented, with no mucosal pallor. Her pulse was surprisingly full, albeit in the range of mild tachycardia. There was no obvious bleeding per vagina, and the placenta was still in situ. A medical student passing, predictably, thankfully, had a surgical blade in his pocket. Using the rubber cuffs from the gloves as cord ties, there on a lawn by the roadside near the hospital gate, I severed the physical bond between a grief-stricken mother and her dead child. I carefully wrapped the tiny, lifeless body in a cloth and handed the stillborn child to its mother. As there was no active bleeding and she was stable, our best option was to use some of the mother’s clothes to pad her perineum and take her to the maternity ward for more definitive management.

This was her short painful history. She was 29 years old, living with her mother. This was her second miscarriage. The first had been at a similar gestational age, about 5 to 6 months. The pain had started at 1 pm that day, 6 hours before presentation. It had been gradually increasing in intensity, but there was very little blood until just as she delivered the baby onto the lawn. Having no other alternative, she had traveled by Boda Boda (commercial motorbike) all the way from her home, over 10 km away.

By the time we handed her over to the ob/gyn team, a million thoughts had flooded my mind. What could have gone wrong? Was this something we could have prevented? What about the effect of a bumpy ride over 10 km in her condition?

This story is not unique, and neither is it uncommon. The sad stories and preventable deaths are too numerous to count. Time-sensitive illness and injuries take a heavy toll, especially in vulnerable populations such as pregnant and lactating women, and children. The only way this can be reduced is by recognizing, addressing, and improving the inadequacies of our health systems, and emergency medical care must be at the forefront of this effort. Much has been done, but so much remains to do. We can, and should—nay, must—continue our efforts.

As more and more countries begin to design and implement emergency care systems, we should tailor them to address the common causes of mortality and morbidity in our communities.

During a recent meeting with a mentor and patron, Dr. Olive Kobusingye, MD, about emergency care in Uganda, she emphasized this simple but powerful truth: “Commitment is half the task.” For us to see change in emergency care not only in Uganda but also across Africa, we must be committed to creating the change we need to see (http://www.emergencymedicineuganda.com/2015/04/commitment-is-half-task-dr-olive.html).

We must make a commitment today to change emergency medical care across Africa so that we may hope for a brighter tomorrow.