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Tuesday, 24 February 2015

Nurses in Disasters “A call to Action-Uganda!!”

Nurses in Disasters

“A call to Action-Uganda!!”

www.newvision.co.ug


No one could have imagined the devastation of the July 2010 Kampala bombings. Uganda will always remember that evening when young innocent men and women out to watch the 2010 Soccer World Cup final were heartlessly murdered. The incident sent painful ripples through the country and the World. And in Mulago Hospital where majority of the Victims were managed, we who were there that evening will never ever forget the horror of it and how unprepared we were as individuals, as a hospital and as a country.

In Disaster situations and even Mass Casualty incidents, Emergency Departments everywhere anticipate to be flooded with not only Victims but also volunteers, patient’s relatives, journalists, even idle onlookers. Without proper planning and organisation, this can worsen an already strained situation and frustrate management efforts.



In Uganda, Mass Casualty Incidents (MCIs) are common and often result from Motor Vehicle Accidents (MVAs), Building collapses, homicide, political violence etc. Experiences in these situations, have taught us that the public can and will respond and try to participate in meaningful roles. Thousands of skilled and unskilled responders will often come to Emergency units or other sites willingly offering to help in any way that they can.
In all this, however, what is the role of the nurse? Are nurses prepared to take on and participate in more demanding roles? Are we trained enough? Do we know what is expected of us? Those are questions I often ask myself.


Nurses form the biggest part of the health workforce. When hospitals are suddenly flooded during disaster situations, they can and should play important roles! They can organize and supervise teams, triage victims, plan, implement and evaluate patient care, coordinate response plans and talk to relatives of victims and even the media amongst other roles.



A Nursing Triage Station at the Emergency Ward in a Ugandan Hospital

In the weeks that followed the July 2010 Kampala, terror attacks, the department of Psychiatry at Mulago Hospital organized a review of all staff that participated in the direct managements of patients, of which nurses were the majority. These nurses were responsible for the initial management of the victims and were predisposed to Post Traumatic Stress Disorder. This particular group of nurses discussed the various experiences they had gone through in previous MCIs, and especially the need for regular psychiatric visits, and also more training for nurses in disaster management.


Nurses must, therefore, avail themselves for education and training to ensure that they are knowledgeable about the most current and appropriate care protocols.
Emergency nurse must focus on safety, and must be competent and knowledgeable to function during disaster situations where the number of people affected is so high that the usual community resources available are inadequate to manage the response. With increased awareness of this need, several resources are currently available for nursing education on the role of an emergency nurse in disaster situations including biological, chemical warfare etc…




Call to Action!

As Uganda moves towards developing a National Ambulance system and hospitals increasingly driven to develop Disaster Management Plans, nurses should not sit back.
Our purpose is to help set guidance for the Profession in Disaster Management. As Emergency Nurses plan their Vision, nurses and nursing students must be educated properly in handling Disasters to ensure that they can prepared to participate in the effective management of any such future events.


By Josephine Nabulime
(The writer is a Disaster & Emergency Nurse, And Chairperson of the Disaster Management Committee, Emergency Medicine Uganda)


Saturday, 14 February 2015

A BALL, A RACQUET, A HOPE; AND A DREAM

By Elisha Mullen Okaisu

We all are inspired by something, somebody, some event… at the very least, we all are inspired sometimes. Recently, I have been inspired too, by someone, who against odds upon odds upon odds walked tough roads, tough miles and in making history said:

“I have to congratulate Maria. She gave us a great final, not only for you guys but for women’s tennis. I’m really honoured I got to play you in the final. Growing up, I wasn’t the richest, but I had a rich family in spirit and support, and standing here with 19 championships is something I never thought would happen. I just went on court with a ball, a racket and a hope, that’s all I had. And it’s an inspiration for you guys who want to be the best – you can be, never give up and you don’t know who you can inspire. You never know what can happen. I’m so honoured to be here tonight and to hold this 19th trophy.” –                                   
SERENA WILLIAMS 2015


Generally speaking, it is something that resonates with us, some words, some phrase; for me it was:

Growing up, I wasn’t the richest, but I had a rich family in spirit and support, and standing here with 19 championships is something I never thought would happen. I just went on court with a ball, a racket and a hope, that’s all I had.

So I ponder and I think, what do you really need for success? In your wildest dreams, would you think that a ball, a racquet and a hope could turn into 66,211,528 USDs prize money1 double that of the second highest earner? Would a ball, a racquet and a hope turn into yearly earnings of $15-20 million and a net worth of $ 130 million2? Of course judging success only by the money in your pocket or bank account (or wherever you keep it) is rather narrow minded some would say. So, would a ball, a racquet and a hope turn into 19 Grand Slams, a very top end service and return game etc? Or into a global inspirational figure for what has been achieved? Who would have dared to dream these possibilities 16 years or so ago? I very probably would not; but that is the operative word – WOULD! Because reading this story, I can dare to dream. Of course I am way past playing tennis for that kind of expertise or to earn that kind of money, but I still have a dream.


http://www.tch-trust.org.za/files/2012/05/DSCF0183.jpg


A dream that was birthed in the most difficult of circumstances, of significant pain and loss – not mine (am nearly glad). I travel back in time to about 2005, still at school doing exams, their stress makes me cringe sometimes! This was not my patient she was presented for the exam by a colleague and happened to be the neighbor to the one I had to present. She had an intrauterine fetal demise/death that took a bit longer to come out than what was comfortable for the body. So after induction, the famous DIC (disseminated intravascular coagulation) set in with all its perils and difficulties. From the OBS/GYN ward to the ICU she went, and we followed her, to see how she was doing (long after the exam). I remember it all vividly – she in the ICU, the breathing, the bleeding, the tubes in and out, the strong and distraught husband who had lost a child, now with the real possibility of losing a wife, the healthworkers. Two days later we went back to see her, and she looked, O so much worse than two days before. With my limited knowledge and significantly more limited experience in critical care, this was bad, very bad. This was my labour suite, and it was coming with pain, lots of pain for someone else; a little pain for me too.

This is when a thought came to mind – she would do much better with better resources, especially human resource. I thought then, and I think now, had she been induced earlier, there is a high chance she would not be lying in the ICU. Now that she was this far down, I thought as well that if there were more competent – knowledgeable and skillful healthworkers in critical care in the ICU, more timely decisions and interventions would be made that would pull her out of the jaws of death that were slowly but surely enveloping her. There I stood gazing at her, helpless – with a birthing dream. 

She did not make it in the end, but a dream was born, that could help someone else, maybe, hopefully.

My dream – to live and grow in the high-paced, adrenaline-infested world of critical care – begun to blossom. I would become one of those that help the dying live when they should have died. 

10 years on the dream lives and breathes – BLS/PALS and soon to be ACLS instructor, critical care nursing training, 7 years of a work place that offers some abilities for critical care, with the emphasis on human resource.



Yes the dream lives on and gets better. It’s not only critical care, it is emergency care/medicine. It is the whole continuum from onset of illness to rehabilitation and recovery.

I still have a dream that there are healthworkers who will work to see lives saved rather than “how do I benefit?”
I still have a dream that one day, the one that picks a patient with life threatening illness from their home/accident scene won’t be just a good Samaritan without the faintest idea of how to transport a patient with life threatening illness.
I still have faith that just like a ball, a racquet and a hope can turn into untold success, a dream can turn into a vibrant and effective emergency system.

“Growing up, I wasn’t the richest, but I had a rich family in spirit and support.”

Yes, in 2005 I wasn’t the richest (in knowledge, skill or family) but in 2015 there is a family, a support and rich spirit – Emergency Medicine Uganda. Long may it live to multiply dreams and hopes into realities and lives saved; to create systems that are robust and sustainable; to build a pipelinethat shall draw water from a well of evidence-based practice and all that is rational and noble, where truth reigns (and all truth is God’s truth).

I still have a dream, with a faith and inspiration that this dream shall live! Now let the family speak.

Oh! Happy Valentine's day.


  1.  http://www.wtatennis.com/SEWTATour-Archive/Rankings_Stats/Career_Prize_Money_Top_100.pdf
  2.   http://www.celebritynetworth.com/richest-athletes/richest-tennis/serena-williams-net-worth/
  3. Kiyosaki, R. Hauling Buckets - or Building a Pipeline?Available at: http://www.lifes7yle.com/wp-content/uploads/2012/06/HaulingBucketsorBuildingaPipeline.pdf




Sunday, 1 February 2015

Housekeeping Healthworker

Housekeeping Healthworker

The more things change the more they stay the same. Serena Williams just won her 19th Grand slam title coming to within 3 of the record holder and may you bet that she will change and start losing, failing to surpass that magical 22 number? I wouldn’t dare place that kind of bet. She walked onto the court one day with a racquet, a ball and a hope and won 19 Grand Slams!!!
If you did not already know, this weekend all, but 2 of the big guns in the Premiership won and Arsenal scored 5 goals. Okay, popular opinion seems to suggest that that is a new phenomenon, however, we know they have always beaten up on teams, so nothing has changed there. That is the gist of life, the more things change, the more they stay the same. Or may be not,


That is why when my phone rang at 02h18 a few weeks back from a number I knew all too well, and was conscious of the fact that I would not receive a call from this number at that time save in an emergency, my heart skipped a beat. What could be wrong?
“Hello”
“Hello”
“Elisha, aunt Y’s shop help has had a suspected snake bite, they are in hospital and there is nobody to help them. Can I give them your number and they call you? Do you think you can help? Sorry for waking you up this late”

My mind racing, when did I last deal with something like this? 

"Yes of course, go ahead and this is why I went to school so don’t be sorry”

Meanwhile, I am trying to recall what we do with snake bites and am thinking antivenom and this that or the other. Guess what am not all too sure, don’t think I have had to deal with anything called snake bite!!

My mind races back to school, recalling the visiting “muzungu snake expert.” He talks of snakes being friendly creatures and cowardly, only attacking when feeling truly threatened. He even talked about how they are kind enough to give a warning to the aggressor with a hiss or whatever the species uses. If they could speak a language I understand, guess they could be saying “I don’t want to fight so take a walk or I will strike, and am quite deadly.” Kind of them, a warning before a deadly bite.

Oh! I remember in my ebook library there is a book on snakes, I should check that out, what was the title again? [just checked: Venomous Snakes - Envenoming Therapy].

My phone rings again
“hello” 

“hello”

Long story short, the boy may have been beaten by a snake at about 23h30. The neighbor, as the first responder and local “medic” cut the site up for blood to drain out. We are not sure if there were 2 bite marks because it was cut up, we did not see any snake, the site is very mildly swollen, just a bit of pain and bleeding. He is conscious, breathing well, just a bit anxious and was breathing a bit badly but now is ok. 
"He seems in no imminent danger of systems collapse", I say to myself.
They got to the local district hospital – no healthworker i.e. nurse, doctor or clinical officer has seen the patient.

The Shocker:
Okay, I know this is said to be rather common, but till it happens to someone close to you, it is far-fetched:

“The cleaner (allow me call him housekeeping) was the only one available. He started an IV and has given Normal saline. He has also given gentamicin and X-pen. He has sent us to look for hydrocortisone, we have driven all over the town and finally found it.”

“you see, we are thankful for his help, but we are not sure if this is the best help and are looking for professional advice. He says the medics will come in the morning, but we are not sure if this current treatment is all okay”

“do they have anti-venom there?” I ask
“No, he says there is nothing”

Okay, I have to believe that he knows what he is talking about, he has, in all honesty done a remarkable job with what he has at his disposal, he seems a fast learner. He has given normal saline in case the cardiovascular system begins to collapse. Am not really certain about the antibiotics, and there is an antiinflammatory added for good measure

“O-o-kay, call me back in 10 minutes” I reply.

You can guess where I went – Google, Medscape, and my book above. But the book is 357 pages, I could not read that. I found an article from Gulu online that I glossed over. Hmm, the treatment that this friend from the housekeeping department gave, is similar to what they used.

More research, more questions for me and Google + Medscape. I begin to think, if it was a snake bite, it was not really venomous. I will assume it was anyway, better wrong that way.

The call comes back after the said 10 minutes, the patient is eating, talking and laughing. The wound is not bleeding anymore, he is himself and getting better. So I reassure them that it looks like there is no immediate danger, we can wait till the morning and see where to go from there. Indeed in the morning, the patient was discharged by 8 O’Clock by our housekeeping healthcare worker.

The need for the growth of emergency medicine then hit me hard, the realization that had it been a real significant envenoming snake bite this patient would not have survived on this treatment. Additionally, I was not prepared to deal with something like this and neither was our healthcare system structure if the person starting IV lines has no formal medical training. I guess there is space for apprenticeship, but this is all too fast and furious and scary, and guess not exactly what patient safety experts would call safe practice.

I have no idea where to find anti-venom in this country, my bad, I must research. I had no idea on my fingertips how to treat this, but thank God for very available resources that can change this situation quite fast.

I have questions and more questions. I have fears for emergency medicine in the country, its growth should have started 20 years ago, but we are just starting. How many will suffer preventable harm with significant residual adverse effects? How effective are our treatments?  What if this was a bite by the deadly black mamba, what would the end result be?

What if it was me? I shudder to imagine.

The more emergency medicine changes in Uganda, the more it stays the same.
I have a dream that one day, it will be very different, change for the better and stay better.
I have a dream that one day, within one hour, a patient like patient X will receive appropriate evidence-based care.
I have a dream that one day, Emergency medicine Uganda shall lead the creation of  an effective, efficient system where preventable harm and death are minimized

I have a dream and like Serena Williams, a hope, that one day we, Emergency Medicine Uganda will be Grand Slam winners!!

Elisha M. Okaisu