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LIKE it has always been for almost all hospitals in this world, there is rarely a larger, bold, brighter and well exposed signpost as the one above that relatively clouded common entrance to the hospital building(s) where the critically ill, the dying and the dead are delivered. In red, blue and sometimes white it reads, “EMERGENCY DEPARTMENT” or “ACCIDENT & EMERGENCY” or “CASUALTY” depending on the hospital's choice. For the suffering sick, tortured caretaker and exhausted rescue team, this is a heaven of sorts, a place of hope, thus approaching the entrance is never contemplated.
Unlike Heaven where everything is believed to be as expected, the emergency department for obvious and/or unexplained reasons has on occasions exhibited the opposite of its definition and description. This inconsistency can and should only be tolerated if it does not pose a threat to life.
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| Mulago National Referral Hospital Casualty Entrance (pre-renovation): https://jackmilln.wordpress.com/ |
In my country and may be many
developing countries, the excitement and great hope following arrival to the emergency department
is short lived. It disappears in a flash, the moment one steps on the other side
of the large door-less entry to this presumably famous, ever active department.
This is very often the case especially for the first time visitors. For those regularly ferrying
patients to this department, their experience has undergone
adaptation and worst of all inappropriate evolution. The resultant “why hurry, I don't care, death is
normal” attitude commonly seen with these either untrained or inadequately trained and poorly or unsupported good
Samaritans can be traced back to the unacceptable and demoralizing reception given at the emergency department. The poor outcomes of these patients as a
consequence of delay, worsening illness, impromptu and substandard care fosters demotivation.
The ultimate impact of such
experiences is to give up which unfortunately, never solves any dilemma. Human
survival and success is driven and sustained by REWARD. The healthcare
providers trying to implement skills outside their basic training and job
description will not feel gratified but instead experience physical and mental
torture. This facilitates and enhances
moroseness, carelessness and inertia. Expression of such behaviour is
a direct blow to the hurting, dying patients and their relatives. Such
actions are opposite to and against the
principles and practices of emergency
and critical care medicine. For those familiar with the consequences of
psychological derangement on the natural course of disease, you realise the
possible modifications in the clinical manifestations in conscious patients
presenting to a unit full of patients with limited numbers of demotivated,
unskilled, exhausted and helpless healthcare providers at all levels of the
medical “hierarchy”.
In life, everything we do yields
either a reward or a punishment. Positive reward leads to motivation while
negative reward champions demotivation. In extreme situations negative reward
not only hinders self satisfaction but is a punishment or perceived as that.
Currently
the
emergency medicine division in my country is more of a punishment to the
patient, and healthcare provider than a section for prompt, appropriate,
professional rescue for the dying and their relatives. This is a personal conclusion drawn from cross sectional observations
overtime given that I have been to almost all major hospitals (private &
public) in my country. This conclusion is entirely professional.
The unbelievable: Ideally, the existence of an
emergency and critical care service will mean that just a call by a patient or
a witness to life threatening illness is more than enough to trigger a lifesaving
chain-reaction culminating in protected life. This, in my country, seems to be
a big fantasy irrespective of the casualties’ locations and severity of illness. The actual experience is
unbelievably ghastly:
a witnessed collapse within hospital
elicits attention from a cloud of bystanders, mostly non-medical, long enough
for the patient to die without any intervention. Following death the hospital
and/or police will guide transportation of the dead to the mortuary. If this is
the case within the hospital, I shudder to think of what is happening a short or long distance away from the
hospital?
Is this the consequence of ignorance
of the occurrence and the attendant necessary attention and consequences of
inaction by the public and medical fraternity or is it lack of the dedicated
appropriate system, medical crew and services?
I
now believe I have an answer: it is ignorance and lack of independent emergency
and intensive/critical care services.
My failure to withstand the
professional embarrassment posed by the witnessed unattended-to deaths in
hospitals is the absolute reason for who I am today, with a purpose to save the
critically ill who make it to hospital as the responsible parties find
solutions for those who fail to make it there.
The
political bit; The
fortunate side of this complex is the wits of our community never cease to have
erudite discussions and documentation regarding the widely and readily
available, prompt and safe emergency care for all nationals. On the contrary,
the brilliantly documented resolutions are either immediately or later
partially implemented or never at all. That creates a new agenda on the waiting
list for the next expensively held meeting to resolve the failure but not to
ensure implementation. This goes on and on, year after year in circles. After a
long time of such, the ABNORMAL practise mutates to NORMAL, making it the
ultimate practice for the next generation and reinforced by unjustified
statements like “That
is how it has been done for many years”.
CAUTION; “It has been done like that for years” does not make it normal and/or right
until evidence is in support AND lack of evidence is in support of nothing.
The unclearly evident emergency
medicine in my country……
In my country there is a handful of
what we refer to as regional referral hospitals. They are classified as
tertiary healthcare centres for the geographical region allowed to them in
principle. These hospitals are positioned hundreds of miles away from each
other and are sources of referrals to a single national referral hospital
located at the capital. The national hospital is approximately four to ten hours distance away from each of these feeder hospitals. The
emphasised distances herein may not be a major concern provided appropriate
means are available to mitigate the effects of these distances.
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| Arrival of the injured at Mulago: http://www.monitor.co.ug/News/National/-/688334/1153024/-/c25eudz/-/index.html |
As per this year none of these public
regional referral hospitals has the capacity to run internationally and locally
acceptable emergency medicine services. The national hospital and a few private
hospitals are left to battle with the burden of the daily escalating need for
emergency care services.
Additionally, only a few citizens of
my country can afford to pay for basic requirements for their survival, health
care inclusive. That said, it gets obvious that the national referral has to
bear the burden of providing emergency medicine solely.
Light judgement, carelessness and
ignorance regarding emergency medicine
by the nationals may obviate the true significance of such a state of health
care service availability and provision.
Well lets say for any hospital or
country to run emergency medicine services, the following must be customised
and well maintained;
1. Infrastructure
(emergency medicine and intensive care units)
2. Equipment
3. Transport system
(Ambulance system)
4. Communication
(Internal and external, code systems, etc)
5. Human resource
(adequate numbers and skilled, continuous evaluation)
6. Training (New
trainees, CPD, Drills,
7. Referral system
8. Protocols
(standardised processess and implementation)
9. Performance
evaluation systems
All listed are or may seem familiar to any reader but in reality whether they have significance is dependent on the systems design. Unlike other aspects of human survival, in Emergency and critical care medicine time lost is or may equal to a life! For that matter the efficiency and effectiveness of all the above is scored in units of human survival (dead and alive) making it a completely sensitive section of health care.
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| Inside an ambulance that would transport the injured http://www.newvision.co.ug/mobile/Detail.aspx?NewsID=669434&CatID=3 |
What we lack in my country……
The difficulty in appropriate response
to this by many has culminated in failure to resolve the challenges that emergency and critical care medicine are
facing.
As we all know, step one in problem
solving is……….
“KNOW
THE PROBLEM”.
The truth is what my country lacks is
not microscopic that it cannot be seen with naked eyes; too abstract to be
understood, encrypted that it needs special skills to decrypt or written in
ancient language that the current generation cannot fathom. If it was this
complex then the terms “emergency
medicine and critical care” would not be part of the medicine vocabulary! Therefore their
existence means we know what they entail.
A very honest countryman – victim or not – of this evolving subspecialty of
medicine will tell you my country lacks everything mentioned above. This may be
out of frustration and disappointment experienced at the time when they knew
the nature of care that was needed but they could not get it, either because of
complete absence of the service or the unbelievably poor quality services.
Recalling such physical, psychological and emotional torture can exasperate
anyone resulting in baseless responses.
The medical professionals are
obviously divided on this. Some will wholeheartedly declare non existence of
the service, others will choose to accept whatever is available and explain the
non functionality while the minority, hope not the majority (I am not sure of
this one), will maintain a neutral ground.
However, whatever the case is, there is urgency to restructure or
re-establish the entire system of
emergency and critical care medicine in my country.
We must admit there is something in
place. How adequate, appropriate, efficient and sustainable it is, is the gist
of this ill definition.
As already put, service is not defined
by the building and the label or name on it. The activities conducted will
dictate the category while the quality of these activities will give fame to
the service. In most cases services seem to be by infrastructure not by the
activities carried out therein, leaving the population with false hope and
blindfolded. This is routine practice in my country as many well built and
labelled emergency sites barely posses anything to save a critically ill and
dying casualty.
That elucidated, what my country
lacks is the implementation of the activities that define emergency and
critical care medicine. This stems from the non existent and/or partially
established services. These aforementioned components are equally important and
inter-dependent. Perfection of one, suboptimal establishment of all and
ignoring any other of them will all end with complete service failure.
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| The task ahead: Manually Ventilating a Patient http://africamd.blogspot.com/ |
The challenge is widespread, intense
and inescapable. In my country, we have
a handful of each and everything required for emergency and critical care to serve such an immensely growing population.
Because the irreversible increase in demand for such services is coupled with
non matching investment public, this creates
an impression of a non existing service leaving the few professionals
frustrated and demotivated. Their presence with no requirements to deliver the
service makes them look fools. Hence the chronic abandonment of their stations.
`
The most devastating phenomenon as
earlier stated is “the
problems and solutions are known” but the permutations of linking the two are ignored. Multiple meetings have been held and a number of
reasonable strategies documented but implementation is not our decision makers’
forte.
Evidence: In a study by Nathan W, et al. 2011, “Preparedness for mass casualties of
road traffic crashes in Uganda: assessing the surge capacity of highway general
hospitals”,
the findings then are in total agreement with this troubling topic. The study
revealed unacceptably alarming inadequacy in staffing, equipment, skill,
transport system, training and communication(1). The results were made public
but their consequence or impact after this long is untraceable. The reasons for
ignoring in such a catastrophic way this area of medical practice are
unthinkable.
All the above create a non desirable
environment that you are highly likely to encounter when you walk into any
hospital emergency department in my country with the exception of a few private
hospitals. This atmosphere makes you feel lost or misplaced. Inside it will be
congested, overcrowded, bloody and stuffy; patients occupying the few beds and
the floor; an exhausted and unconcerned nursing team; non emergency doctor in
and out if at all present. Shift after shift there will be no one left to
wonder what brings to the emergency department. In fact chances are you will be
on your own long enough to collapse and at that time you will not be
salvageable.
That is how home and “emergency
and critical care” currently interface.
In this era of Emergency medicine
Uganda, we are set for the change for good, success and excellence in emergency
and critical care practice. It is our opportunity to review all evidence that exist
for and against the current practice of emergency and critical care medicine,
form a platform to undertake the challenges at all levels of care and finally
perfect the practice through strategy, advocacy, implementation and sustenance.
We are young focused and determined
implementors. We are dedicated to reveal
the true meaning of emergency and
critical care to our nation.
References:
1. Nathan W. et al 2011. Preparedness
for mass casualties of road traffic crashes in Uganda: assessing the surge
capacity of highway general hospitalsFor day to day survival and satisfaction.
Health Policy and Development Vol. 9, No. 1. January-April 2001, pp. 17-26
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