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?
