A Merry Christmas from EMU

The Spirit of Christmas-EM

It is only 2 months and 13 posts since we started this Blog, and already the year is coming to an end.

This year, however, we are happy the Christmas spirits in Uganda have a new friend-The Spirit of Emergency medicine.

Thank you for Reading Our Blog this year and helping us awaken the spirit of Emergency Medical Care in Uganda.

Tubagaliza amazalibwa agesanyu n'omwaka omujja ogwemirembe!!

(We wish you a merry Christmas and a Happy New Year!!)

Till next year, stay safe!!!

To our colleagues continuing the Fight against Ebola, stay strong and stay safe! You are our heroes. 

From All of us at EMU

A Tipping Point

A Tipping Point

Building Uganda’s Emergency Care System-A milestone in our Baby steps!!

“A tipping point is that critical point in a process or system beyond which a significant and often unstoppable effect or change takes place.”

(Malcolm Gladwell; The Tipping Point: How Little Things Make A Big Difference)

For Emergency Medicine development in Uganda, that tipping point was on 5^th December 2014-A visit from the African Federation for Emergency Medicine (AFEM) President, Prof Lee Wallis.

Our special guest was here to observe and support Uganda’s progress in developing our Emergency Care system. A short impactful visit!!

L-R: Dr.Joseph Kalanzi, Prof. Lee Wallis, Prof. Harriet Mayanja, Dr. Tony Stone Luggya

The evening of 4th December 2014

In the One hour it takes from Entebbe Airport to Kampala City, we discussed the development of Emergency Care systems in low resource setting and shared various experiences from the Residency Grant program in Tanzania; the establishment of a communication system for an ambulance service in Zambia; the establishment of a training center for Emergency Medicine short courses in Ethiopia; to a One million South African Rand EMS service in the Western Cape. Our pace and mood for the next few hours was set!!

8:00 am:         Speke Hotel Kampala

The breakfast that morning was nearly half as enjoyable as what we discussed while we had it– Emergency Medicine Uganda, its formation, and impacts. I explained to our guest the social media campaign we embarked on 2 months ago and its impact on advocacy, networking and partnerships for a stronger Health system. He on the other hand, offered much needed and appreciated guidance. 

10:00 am:       Rubaga Hospital

First stop after a hearty breakfast was a Private Not for Profit hospital in Kampala-Rubaga Hospital. 

We visited the Emergency Department and the enthusiastic staff working there. Among other things we discussed improved trauma care through a streamlined data collection process, developing major incident plans for hospitals and improving the emergency care capacity for nurses working in the Emergency Department

11:00 am: Makerere University College of Health Sciences:

Lessons from Countries with already established Emergency Care systems show that the process has been a direct result of efforts by National Emergency Medicine Specialty³ groups. Makerere University is one of the oldest Universities in Africa, and has trained majority of Uganda’s Doctors. It will be the academic spine for training and capacity building for Emergency Medical Care. 

Prof. Lee Wallis, Dr. Tonny Stone Luggya, Prof. Nelson Sewankambo

Key points discussed: Masters in Emergency Medicine program, creation of an EM skills training center as well as development of research capacity in EM for the university.

1:00 pm:         Mulago National Referral and Teaching Hospital:

Prof. Wallis and Dr. Cornelius Ssendagire: Mulago Hospital ICU

Mulago Hospital is Uganda’s largest and National referral Hospital. Our guest had the opportunity of meeting some members of the Hospital Rapid Response Team-A brain child of the Anesthesiology department.  

This team of dedicated and self driven Junior anesthesiologists and Residents have taken it upon themselves to fill this much needed gap in patient care- and they are just a phone call away. 

2:00 pm          Ministry of Health

Emergency care like all other aspects of health requires government support and strategic planning and for sustainable development. The Ministry of Health was therefore an important place to visit.

In addition, Uganda is in the process of developing our National Ambulance Service (UNAS), a process being led by the Ministry of health. 

At the UNAS office

5:00pm           Total Uganda

We rounded up thie day with a visit to Total Uganda; a private company that is in the process of building its capacity in Emergency medicine. Private Companies have the resources to invest in capacity building for their own Staff or for others through Corporate Social Responsibility initiatives like individual scholarships or even funding an entire Emergency Medicine training Program in a University, like the case of the ABBOTT Fund at Muhimbili University in Tanzania. For any Company interested in investing in Health Care, Emergency Medicine is a truly worthy choice!!

5:00 am           And just like that…..we were on the road back to Entebbe.

This time the discussion was about funding. How do we get funding for a system that is, like we say in Uganda, “having birthing pains”

We brainstormed many options from Mass campaigns like the telecommunication companies to sitting back and hoping for that Philanthropist. An interesting attempt at answering a difficult question in 45 minutes!! Well, Emergency Medicine Uganda (EMU) has taken up this challenge.

A final note:

Thank you Prof. Lee Wallis for coming down to Uganda and always being an inspiration.

We are thankful for the support from AFEM and all our friends building the Emergency Care system with us. Together we are tasked to create order out of the chaos (Linchpin, Seth Godin).

The Formation of EMU- a key group of individuals was inspired from regional meetings^{4, 5} that illustrated the need for focused meetings on emergency care development. Our journey of a thousand steps has started.

References:

1.      Kobusingye, Olive C., et al. "Emergency medical systems in low-and middle-income countries: recommendations for action." Bulletin of the World Health Organization 83.8 (2005): 626-631.

2.      Anderson PD, Suter RE, Mulligan T, et al. World HealthAssembly Resolution 60.22 and its importance as a health carepolicy tool for improving emergency care access and availabilityglobally. Ann Emer Med 2012;60(1):35–44

3.      Elizabeth L. DeVos , Vicken  Y. Totten , Lisa Moreno-Walton , C. James Holliman , Terrence Mulligan ,Gabrielle A. Jacquet , Gautam Bodiwalla. How to start and operate a National Emergency Medicine specialty organization.African Journal of Emergency Medicine Volume 4, Issue 4, December 2014; Pages 200–205

4.      The first East Africa Regional Meeting on Acute and Emergency CareReynolds, Teri A.Sawe, Hendry, Kalanzi Joseph et al.African Journal of Emergency Medicine , Volume 3 , Issue 4 , 155 – 156

5.      AFEM consensus conference 2013 summary: Emergency care in Africa – Where are we now?Reynolds, Teri A. et al.African Journal of Emergency Medicine , Volume 4 , Issue 3 , 158 - 163

By Dr. Joseph Kalanzi

THE FIRST 5 MINUTES: Resuscitation strategies in a children’s hospital for better outcomes

THE FIRST 5 MINUTES:

Resuscitation strategies in a children’s hospital for better outcomes

……………….Uganda with scarce expert human resource. We realized we can get a nurse to the patients’ bedside in 5 seconds, whereas it may take 5 minutes or more to get a doctor ……………… So it is imperative that they are competent enough to initiate appropriate management …………………

The dream of many a health worker-in-training seems stereotyped – fast paced, adrenaline-full, life-on-the-edge moments where the life of another is in your hands, big or small though they may be. Here your knowledge and skill comes to the fore and oh how good you are at this. Knowing that one wrong move and they are gone, one great heroic decision and you pulled this life back from the ever welcoming clutches of death and his mate, the grave! It all makes for a greatly significant contribution to the lives of mankind and you are right in the middle of it. Of course, we are always the heroes and everyone looks with great admiration like it is the famous Hercules riding back home triumphantly from one of those fierce battles and subsequent great Greek victories that required the supernatural to intervene.

Reality is somewhat different, I found; Okay, majorly different: Knowledge chooses this exact moment to desert you and your hands somehow lose that fine-motor skill they seemed to be good at just a few hours ago. Sometimes it is a shouting and/or screaming match, other times it is a frenetic running around – not knowing where many things are – the mask, ambubag, laryngoscope blade, defibrillator or the inability to get a team together to save this life for a myriad of reasons.

And then there are those times when it is just not clear what it is we are doing – we may shock asystole/PEA or fail to shock VF (ventricular fibrillation). Just sometimes, one or two of us in the team may run away from the sight of that defibrillator (yes we do get scared sometimes after all it shocks the patients and if used improperly, the user/resuscitator too). Well, the defibrillator may have stopped working or UMEME chose this moment to load shed and we are unable to start the backup generator (okay this is because there is no fuel).

Or worse still, epinephrine is out of stock, and amiodarone has not been stocked in the last 6 months (we had other priorities; it has nothing to do with poor planning!).

Many things can go wrong, and one of the key determinants of a successful resuscitation is the competencies (knowledge, skill and attitude) of the resuscitation team. Survival from any emergency (life threatening illness) is dependent on a well-oiled team that knows what and when to do what needs to be done. The team is well-prepared and mostly ready for any eventualities like a Formula One servicing team. Training in life support courses i.e. basic and advanced life support will give these teams the knowledge they need to be able to perform appropriately¹.  Additionally odds of survival from a cardiac arrest seem to increase if the health worker who discovered the patient is actually trained in Life Support².

Unfortunately, these skills suffer significant attrition a few weeks after training³ and thus the care that is usually offered to those patients who have “coded” (had a cardiopulmonary arrest) is laden with many worrying problems – delays and deviations from recommended guidelines⁴. We start compressions late (say 1.5 minutes after this was indicated) or request defibrillators late (4.3 minutes after defibrillation was needed). As Hunt et al. (2008) state, “future educational and organizational interventions should focus on improving the quality of care that is delivered during the first 5 minutes of resuscitation, emphasize BLS and early defibrillation”.

Life Support Training to Improve In-Hospital Cardiac Arrest Survival:

With this in mind, it therefore makes sense, that the team that would be instrumental in improving in-hospital survival from cardiopulmonary arrest is the nursing team, especially in the context of Uganda with scarce expert human resource. We realized we can get a nurse to the patients’ bedside in 5 seconds, whereas it may take 5 minutes or more to get a doctor to the said patients’ bedside. So it is imperative that they are competent enough to initiate appropriate management for these patients teetering on the edge of life and death.

This therefore became part of the strategy at our hospital – to build a nursing team that can provide appropriate resuscitation care in the “first 5 minutes”, before the arrival of other members of the team.

Consequently, since 2008/2009 a requirement for continuing work at the hospital is a minimum certification in BLS (the American Heart Association’s Basic Life Support) and additionally mandatory PALS (Pediatric Advanced Life Support) certification for those who work in what we call ICU.

Also, attending mock code is a requirement – each of our nurses are required to attend at least one a month; where we will practice BLS, effective teamwork and communication, knowledge of AHA algorithms and management of common Ugandan illness and disease in a typical neurosurgical patient at our hospital and whatever is necessary to ensure that the first 5 minutes are clockwork effective.

How will this have helped?

Anecdotally, we can say the incidences of “the patient changed condition and died” are a “Never Event” and so are those deaths that seem to occur mostly in the middle of the night that make you ask the question “what happens in the night?” The team available is competent enough to keep these little children alive.

Additionally, we see the incidences of sudden, unplanned admission to ICU from the ward going down (I should have gotten numbers for this).

Besides, with this improved knowledge and skill, we find our nurses able to detect the deteriorating patient much earlier than the alert from a cardiac and/or respiratory arrest. That is the first link in the pediatric chain of survival i.e. prevention, is greatly enhanced.

So if you want to improve survival in your hospital – you may need to look at the first 5 minutes and you will see a nurse at the bedside. Improve their competencies to provide high quality and safe care and you just may see much better outcomes – almost guaranteed.

References

1. Grant, E. C., Marczinski, C. A. & Menon, K. 2007. Using Pediatric Advanced Life Support in pediatric residency training: does the curriculum need resuscitation? Pediatric critical care medicine. 8:433-439.
2. Dane, F. C., Russell-Lindgren, K. S., Parish, D. C., Durham, M. D. & Brown Jr. T. D. 2000. In-hospital resuscitation: association between ACLS training and survival to discharge.  Resuscitation. 47:83-87.
3. Soar. J., Monsierus, G. K., Balance, J. H. W., Barelli, A., Biarent, D., Grief R., Handley A. J., Lockey, A. S. et al. 2010. European resuscitation council guidelines for resuscitation 2010. Section 9. Principles of education in resuscitation. Resuscitation. 81:1434-1444.
4. Hunt, E.A., Walker, A.R., Shaffner, D. H., Miller, M. R. and Pronovost, P. J. 2008. Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes. Pediatrics. 121 (1):e34-e43.

By Elisha Mullen Okaisu

A Critical Care Nurse and Resuscitation skills trainer