Emergency Medicine Uganda: FWAAAAAH!!!

Emergency Medicine Uganda: FWAAAAAH!!!: A letter to the blog editor by a concerned Acute Care Advocate If you are Ugandan or know something about how we communicate, then you ...

FWAAAAAH!!!

A letter to the blog editor by a concerned Acute Care Advocate

If you are Ugandan or know something about how we communicate, then you will understand why I have taken time to actually blog about this conversation. If you are not familiar with some of our #SoUg (So Ugandan) words you will definitely learn one here.

Definitions of Key Words relevant to this post

The Author: An Emergency Medicine Registrar with a lot of Passion for Acute Care.

The Pharmacist: A Pharmacist with no knowledge of Acute Care.

Setting: A tertiary hospital in a country with no functional Acute Care system. 

Emergency Medicine:  IFEM Definition of Emergency Medicine- Emergency medicine is a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioural disorders; it further encompasses an understanding of the development of prehospital and in hospital emergency medical systems and the skills necessary for this development.

Fwaaah: So many contextual meanings ranging from diarrhea to cosmic sounds made by the universe ( I just leaned this one). In Uganda, however, it means to do something without any thought into what you are doing carelessly and without any insight into the implications of your actions. The more “A’s” in the word, the stronger the emphasis. So, Fwaaaaaah is worse that Fwah!!

Sometime last week:

Cruising like I usually do in the corridors of Mulago (or any hospital for that matter), I was stopped by someone calling me by my Surname!!  That is official-implication: Must stop immediately and respond!!

Pharmacist: Hello “Surname”

Me: Hello (trying to flip through names and faces in my mind. No Results- but then I am abit of an extrovert, will figure out name and place as we chat).

…then the usual Ugandan banter: too hot, too cold, rainy, lost weight, gained weight, tired, too many sick people etc… 

Pharmacist: So, what are you doing now?

Me: With all the pride I can muster “Emergency Medicine!!””

Pharmacist: Clearly not impressed. What is that?

Me: Acute Care medicine. I am training to be able to effectively manage all Emergencies across all specialties in Medicine.

Pharmacist: scoffs!! Hmmm… Some of you people are now doing Courses Fwaaaaaah!! How will that help us?

Me: You must have never had an emergency or known someone with one? That is the specialty that will change our health statistics!!

Pharmacist: well….. okay!! Clearly not convinced.

I have to run help with a patient in casualty so I cant stay long. On the way, I am furiously flipping pages in my mind!!

·         Page 1: Advocacy

·         Page 2: Advocacy

·         Page 3: Advocacy

·         Page ……. ADVOCACY!!

I have spent a good number of hours since that conversation, finding out what people think about the specialty of Emergency Medicine in Uganda.

In Part 2 of this Blog post, find out what Ugandans (Healthworkers and the public) think about Acute Care in Our country.

On my part I believe Acute Care is the change that Uganda and Africa needs!! It is what will change our Health statistics.

The Author is Affiliated with the African Federation for Emergency Medicine

Supporting Acute Care Across Africa

http://www.afem.info/

BY THE TIME...

BY Emergency Medicine Uganda

It has been a while since we posted. Of course a lot has been going on behind the scenes and we will begin the updates pretty soon. 

A synopsis: there has been an EMU meeting and of course there have been experiences and trainings.

We leave you with this piece that is too much of a reality. Cannot think of how many times I have read, heard, seen this scenario as a reality around the next corner, in my neigbourhood. Sometimes, it is my friend, my relative etc. And that is part of the reason we hope for a very vibrant and successful EMU.

This is from various sources online, we just repost:

http://www.theguardian.com/global-development/2015/mar/08/international-womens-day-fight-better-maternal-health-care-uganda

Mrs Y died while giving birth. It was her fifth delivery. She was not from a far off village but lived in the city itself. She set out on time to go to hospital. But ...

... by the time they had found a vehicle to go to the hospital,
... by the time they struggled to get her an admission card,
... by the time she was admitted,
... by the time her file was made up,
... by the time the midwife was called,
... by the time the midwife finished eating,
... by the time the midwife came,
... by the time the husband went and bought some gloves,
... by the time the midwife examined the woman,
... by the time the bleeding started,
... by the time the doctor was called,
... by the time the doctor could be found,
... by the time the ambulance went to find the doctor,
... by the time the doctor came,
... by the time the husband went to buy drugs, IV set, and drip,
... by the time the husband went out to look for blood bags all round the city,
... by the time the husband found one,
... by the time the husband begged the pharmacist to reduce the prices since he had already           spent all his money on swabs, dressings, drugs and fluids,
... by the time the haematologist was called,
... by the time the haematologist came and took blood from the exhausted husband,
... by the time the day and night nurses changed duty,
... by the time the midwife came again,
... by the time the doctor was called,
... by the time the doctor could be found,
... by the time the doctor came,

THE WOMAN DIED!

May this story line change completely, absolutely

http://www.cehurd.org/2012/06/ugandan-women-go-to-court-over-maternal-mortality/

Reflections of Mulago Hospital: a new EM perspective

 Launch of aero med evac service by Acute Care & Emergency Response consortium

As healthcare providers we assume that every patient is entitled to high quality emergency care. No one knows when an emergency may happen to them, whether from a motor vehicle accident, heart attack, or severe infection. With modern medicine in the 21st century everyone should be able to access emergency care. 

Elizabeth (final year student Makerere) leads a trauma
code simulation on patient (Dr.Bradley Dreifuss)

Emergency Medicine (EM) as a specialty is in its infancy in Uganda and much of Africa. A small group of dedicated healthcare providers have seen the vision and laid the ground work for starting the first EM training program at Mulago Hospital.  EM in the USA went through a similar development over 30 years ago, and is now a respected and expected medical specialty in every hospital in America. 

I was asked the question while I was at Mulago "Why do we need EM and how does it fit with medicine, surgery, critical care, and all of the other specialties". The simple answer is that every hospital needs emergency medicine specialists to be able to rapidly treat any medical condition that walks through the door 24/7. Especially, at a big, busy hospital such as Mulago, emergency physicians play a key role in providing high level care in a time sensitive manner to stabilize the trauma patient who is waiting to go to the operating theatre or the critically ill medical patient who is waiting for an ICU bed. 

Josephine and Dr.Harries conducting introduction to emergency
medicine CME with nurse trainees at Mulago hospital.

During my two months in Uganda, I was given the opportunity to give EM lectures to various medical specialties and levels of healthcare providers. Additionally, I was able to provide  bedside teaching in the medical and surgical A&E and ICU. Working together as a team, we proved to each other that emergency care can be provided despite limited resources.  While treating both medical and trauma patients, we focused on addressing critical issues during the primary and secondary surveys and making timely, life saving interventions. For example, sepsis patients received time sensitive IV fluids and antibiotics, and occult shock trauma patients received appropriate emergent resuscitative  interventions, as needed. 

Dr.Harries conducting an ATLS simulation with medical students at College of Health Sciences Makerere

It is an exciting time for emergency medicine in Uganda with the reconstruction of the new A&E ward currently underway and hopefully soon the first class of emergency medicine specialists training at Mulago Hospital/Makerere University.  I am grateful for the opportunity to have been able to work with all the great doctors, nurses, and staff at Mulago Hospital.  A special thanks goes out to all those who supported me during my two months in Uganda. 

Emergency medicine CME with medical officers and surgeons at Nsambya Hospital

Dr. Aaron Harries

UCSF EM Global Health Fellow

CARETAKER PARAMEDICS: Yes We Need an Emergency Response System in Uganda!!

Elisha Okaisu

For me emergency medicine has, until quite recently, always been synonymous with high speed, blazing loud sirens, screeching tyres grinding to a halt, ambulance doors flying open even before a complete stop. Teams then, working with clock-work accuracy, wheel the gurney off the ambulance and to a waiting ED party to receive whoever is the focus of all this; whoever is teetering towards deaths insatiable doors. That is my mind, of course being heavily influenced by what is seen on the screens, as well as dreams held dear, dreams still being chased.

Of course here patient transport is by a well-trained team (let’s call this Team 1) of paramedics and other healthworkers depending on the patient’s needs. Precautions are taken to minimize any adverse events from cervical spine injuries; if the need for advanced airway support develops along the way, the team will deal efficiently and effectively with that; should the blood pressure choose to take a downward (or upward) trend, the team will be on hand to help; should the pressures intracranial change, somehow this same team will know what to do. In short, you will get a chance for yet another shot at life – if you don’t, then it really was not possible, it was time for you to leave, your work on planet earth was done!

Additionally, once you get to the ED/A&E/Casualty (depends on where you are), you will find a team (let’s say Team 2) that had prior knowledge of your arrival, that knew what your needs were and had readied the resources at their disposal to continue the process of giving you this opportunity to live again. Additionally, Team 2 always utilizes the best available evidence in your care ensuring your complete recovery with very minimal if any preventable complications.

Then you will move on to Team 3 who will ensure that you recover ever more appropriately, then to Team 4 and on and on (as may be necessary)

In this world, a world of idealism, evidence-based practice reigns supreme. Teams are actual teams with all the elements of an effective healthcare team i.e. good communication, mutual respect, constructive interventions, knowledge sharing, clear messages, roles & responsibilities etc. Resources are readily available, organized in a way that makes them easily accessible…

However the world of realism is much different from this, especially in a developing world setting – resources are barely there, evidence-based practice lives in a world of hope rather than reality, teams are dysfunctional (reasons are really varied and numerous and we all could give 5 and not produce a conclusive list).

That is why when not so long ago I was (un)fortunate to witness the role of “CareTaker Paramedics” in emergency care, I was shaken back to reality, stark cold reality. You see just like we have Housekeeping Healthworkers – who indeed have their role – I was able to witness and recognize that Caretaker Paramedics are another cadre and do play a significant role in health care, emergency care inclusive.

The Scenario

A patient who had been involved in a road traffic accident (this I mostly assume since I did not ask the questions), was admitted for a while in the local hospital from whence he was sent for advanced imaging, very possibly for a more accurate diagnosis. An ambulance transported the patient (a very positive thing) with the only paramedics available being the patient’s caretakers. To the best of my knowledge, the ambulance driver had significantly limited EMS (and medical) knowledge as well. The journey was about 100km half of which was along a rugged non-tarmac road with lots of bumps and bangs. Now looking at him, there was no cervical collar or any monitoring equipment and the “paramedics” had no knowledge of how to deal with anything in case this patient deteriorated enroute.

Long story short – somewhere along the way, in an attempt to manage this patient, he suddenly stopped breathing immediately after being moved.

“Post-Mortem”

Figure 1

This patient was found to have had a cervical spine (C-spine) injury. No doubt movement along this lengthy bumpy journey without adequate protection for that delicate part of the spine was a significant problem that our “paramedics” could not have been thinking about. EVER. Could the sending hospital have dealt with this problem before sending the patient? What was the possibility that this patient would have come back alive? Ideally, this patient would have to be transported immobilized and protected – maybe something like this (See Fig. 1).

Alas, this was not the case and the patient’s injuries suddenly became incompatible with life.

A Few Questions Then

I always ask me, what if that was me in that ambulance? Again, I shudder to imagine! Would my Caretakers be able to protect me from this preventable harm? Would I be able to survive this journey or would it be the last that I make?

How many of these cases happen that we never know about? How many lives – sons, fathers, mothers, daughters – would we be able to save with more standards of care?

Very importantly, what can we do about all this?

What if there were standards for ambulance services that spelt out how patients are transported – high or low acuity – transported by teams that had the necessary competencies to ensure their safety throughout the sometimes tortuous journeys? Of course then these standards would have to be followed to be of any effect.

What training is necessary to improve these pre-hospital/EMS services?

Questions and questions and some more questions. Surely there must be an answer somewhere…

Surely Uganda must have some things going right in emergency services:

We have seen many ambulances riding the roads, many times with sirens blazing away. Could we harness these services to provide EMS services through a dispatch center among other things?

It all starts with that first a step in the right direction.....

We have questions, but rather than wait for an answer, we can make the answer (as we have started here). Who will join us?

EMU AT THE WORLD CONGRESS ON DISASTER AND EMERGENCY MEDICINE 2015 - A pictorial

EMU AT THE 19th WORLD CONGRESS ON DISASTER AND EMERGENCY MEDICINE

21-24th April 2015

CapeTown, South Africa

A vast body of knowledge is very key for the growth and development of any profession and/or specialization.  Research and dissemination thereof are consequently very important for this process. 

Those that have followed us on this blog, must by this time know that EMU is just beginning it's long road in leading the push for the development of Emergency Medicine in Uganda. 

Not to be left behind, we were very ably represented at the World Congress on Disaster and Emergency Medicine 2015 in Cape Town, South Africa. Here we present some happenings through our eyes for those who could not make it. 

Uganda's Delegation: L-R: Bradley Dreifuss (GECC), John Bosco Kamugusha ( Nakivale Hospital Rukungiri), Stone Luggya (EMU/Makerere University), Annet Alenyo Ngabirano ( EMU/UCT-SUN), Alfonsi K. ( Nakivale Hospital Rukungiri), Joseph Kalanzi (EMU/AFEM), Mark Bisanzo (GECC)

MEETINGS AND DIALOGUES

The AFEM East Meeting: Kenya, Tanzania, Rwanda, Ethiopia, South Sudan and Uganda

The AFEM Uganda Meeting

The AFEM East Update meeting

The EMU ( Emergency Medicine Uganda) and GECC ( Global Emergency Care Collaborative) meeting on the developement of Mid-Level Emergency Care Providers in Uganda. L-R: Bradley Dreifuss, Tonny STone Luggya, John Bosco Kemisgisha, Annet Alenyo Ngabirano, Melissa, Langevin, Mark Bisanzo, Alfonsi K.

First Meeting of the AFEM-Residents Association. 

The AFEM Consensus Meeting 2015 at the CapeTown Waterfront

RESEARCH AND PRESENTATIONS

EMU: Driving the Need for Emergency Care in Uganda.

OTHER POSTERS WE LIKED...........................

 

 ORAL PRESENTATIONS............

John Bosco Kamugisha: Factors Associated with Domestic Violence in Rukungiri Disatrict, Uganda

Annet Alenyo Ngabirano: Effects of Intra-operative Low dose Ketamine on Cost of postoperative pain managemnt after major surgery in a low-resource environement ( a collaboration between Makerere University Anaesthesia Department, CRIMEDIM at Universita Dei Piemonte Orientale)

Joseph Kalanzi: An analysis of Health Facility preparedness for Major Incidents in Kampala, Uganda

And the Other pictures................

       

EMU President: Jospeh Kalanzi

Crystal Bae  (AFEM Intern)n and Tony Stone Luggya ( AFEM Support a Delegate Recipient)

L-R Joseph, Annet and Stone ( A very selfie moment)