INJURIES ARE PART OF US BUT WE STRIVE TO REDUCE THEIR IMPACT!

By Tony Luggya Stone

“If you can’t fly then run, if you can’t run then walk, if you can’t walk then crawl, but whatever you do you have to keep moving forward.”  This quote by Martin Luther King Jr

Ring ring…., ring, ring, ring, the rather unwelcome sound of my alarm going off,  on the 12^th day of January 2015, at 6am to the dot. I hit on snooze to catch some more minutes of sleep seeing that previous night was my mates pre-wedding send off  and I was on leave. An hour later I awake in excitement and haste as I remember I have to be in Munyonyo by 9am. Why?

Because the Main risk factors for road traffic accidents, that have become a public health concern, include the following:

•      Demographic factors (explained with the UBOS statistics below)

•      Rapid motorization

•      Transport, land use and road network planning

•      Increased need for travel

•      Choice of less safe forms of travel

With our national statistical analysis showing exponential population growth with expectations thought to be at 100 million by 2050 (see Figure 1 below).

Figure 1: Population projections Uganda

Furthermore Uganda Bureau of Statistics 2012 analysis showed that the majority of our Ugandan population is the youth below 18 years making up  56% of the total population The above population explosion comes with various challenges to societies, governments and resources. But in this case primarily they will need to move to many places, from and to work, from villages and to urban centres, plus other movements such visiting, functions etc.

Total Population	100%	35,356,900
Children (below 18 years)	56%	19,799,864
Adolescents and youth (10 – 24 years)	34.7%	12,268,844
Orphans (for children below 18 years)	10.9%	3,853,902
Infants (below one year)	4.3%	1,520,347
Children below 5 years	19.5%	6,894,596
Women of reproductive age (15 – 49 years)	23%	8,132,087

According to Uganda Revenue Authority new vehicle registration Imported Motor cycles in 2012 were 12,000:5,000 cars however over the past 10 years now the motorcycles are 85,000:6000 cars shown below

  

Figure 2: New vehicle registration (URA)

 

Figure 2: New vehicle registration (URA)

With this large young population comes grave challenges for the stake holders in attempting to have them mature so as to accomplish their full potential. Consequently, focus has been placed on the infectious diseases plus maternal and child health and kudos to them as they are making progress. However, this 56% of the Ugandan population has still been left at risk.

With haste I finally arrived at Munyonyo for the second annual Uganda Injury Forum, a brain child of Makerere University School of public health (MUKSPH) and John Hopkins University. This  joint collaboration brings together stake holders in government, private and private not-for-profit organisations that are leading to discuss local statistics, ways of improving emergency services, fostering inter-organisational partnerships and among other things all in trying to reduce the burden of trauma and injuries which make for an alarming statistic in mortality – almost  epidemic proportions.

The ministry of health represented by Dr Mubikire accompanied by Uganda National Ambulance Service (UNAS) group with Dr Kalanzi Joseph discussing what national policies and injury prevention the ministry of health has embarked on. This was followed up with their approach to significantly improving trauma care and injury data collection including but not limited to including trauma on the Health Management Information Systems (HMIS).

MUKSPH gave a detailed presentation about the statistics and significant epidemiological issues road traffic accidents are causing and significance of good data to keep track of developments. They also highlighted need for partnerships in this endeavour. The first TRAID trauma track masters research was presented and of significance was a Jinja study on capture recapture data of accidents that showed a significant gap or missed data between what the traffic police had and what was recorded at hospitals for admitted injury patients.

Next up was Uganda police represented by Dr Kasiima (PHD) who gave their annual statistics with updates on road use, abuse of drugs and how the police is trying to curb the perpetrators, including a planned police study tour to Australia where a breatherlizer is used for non-alcoholic drug abusers on the road. 

Quite remarkable was the fact that the Uganda Police had signed an MOU with Nakasero Hospital, a private for profit hospital, to stabilize accident victims for free for the first few hours before transfer to a free facility. Kudos to Uganda Police and NHL!

Fire preventions officer Mr Piriyo Robert supplemented this with the Police emergency numbers which are:

1. 0421222 (yes correct number and no digits missing here)
2. 0711042193
3. 0712144799- director

KCCA was represented by their director of health services who explained the authority’s plans for a better Kampala with mapping of streets by hovering helicopters that we may have seen, to ease pick emergency pickups by ambulances. Emergency evacuations, even by putting helipads and HDU beds, have been catered for in the two upcoming hospitals in Kawempe and Kirudu.

We had meal breaks in between and after lunch a breakaway into working groups of three to we could discuss:

1. Preventing Road Traffic Injuries chaired by Police
2. Emergency Response for Road Traffic Injuries chaired by  MOH and Red cross
3. Road Traffic Data Quality and Use = MUKSPH, MULAGO

After this, we emerged for the penultimate plenary sessions which had all the stakeholders representatives as below:

1. Mulago = Dr Alex Bangirana, Head Accident and Emergency
2. Police = Mr Emoit Anthony, head traffic operations
3. Makerere University college of health sciences= chair Dr Sempepwa
4. MOH= Mr Stanley Mubikire
5. Red cross
6. John Hopkins

Each stake holder gave commitment from their respective organisations to bring this burden of mortality down with full length discussions and questions from the house.

Before long it was 4.30PM and the day was ending just as fast as it had began, with Dr Olive Kobusingye giving closing remarks highlighting the primary take home message as:

• What data is there and how is its quality?
• We should receive updated knowledge on status of Road traffic injuries
• How do we all move forward to digest and implement these out comes in our various organisations.

With that brought the close of the 2015 Uganda Injury Forum conference.

But like Martin Luther King Jr said ‘…. whatever you do you have to keep moving forward.” 

Using Bedside Ultrasound: A Medical Students’ Perspective

By Jerome Semakula

Last month I was one of a group of fourth year medical students who attended a short training on use of ultrasound in emergency medicine at Makerere University College of Health Sciences. This was organized by emergency medicine enthusiasts at the College together with visiting Emergency medicine residents from Yale University, USA. This training was meant to introduce clinical year-students to the use of ultrasound in diagnosing emergency conditions. 

There were two sessions, the first of which was a short lecture on the basics of using ultrasound, its indications and interpretation of ultrasound images. This was then followed up with a bedside practical demonstration which was done at Mulago Hospital and involved a real patient with real signs and symptoms. 

This particular patient to be examined presented with fever and general body weakness. He had been sick for a while and for almost a fortnight he was being treated for Malaria at a clinic but his relatives had chosen to bring him to Mulago hospital because of his continuing deteriorating condition.  It was not clear what the exact cause was but quick history and examination revealed a high possibility of septicemia. He had a high fever, tachycardia (fast heart rate) and tachypnea (fast respiratory rate) but no identified focus of infection. His chest X-Ray was unremarkable and the attending intern doctor had already requested for a blood culture and started the young man on antibiotics and intravenous fluids.  

Ultrasound was required to study his abdominal organs and peritoneum and rule out any abdominal focus of infection. For each major organ, the ultrasound viewing was done by medical students present including me. 

We used a portable ultrasound gadget about the size of a mobile phone. We were tasked with applying the general principles learnt in the previous week to study the different organs and give a description of each as seen on the screen of the gadget. Different planes were applied such as sagittal, coronal and transverse to appreciate the different anatomical structures of the abdomen. Ultrasound scanning was done for the spleen, kidneys, liver and peritoneum. All organs appeared normal with no signs of pathology and no free fluid in his peritoneum. In addition to the abdominal organs, viewing of the abdominal aorta and inferior vena cava as well as examination of the heart and its chambers was done. The patient awaited for blood culture results as he was started on broad spectrum antibiotics to manage any possible infection. 

"This teaching session not only allowed me to appreciate radiological aspects of human anatomy but also more importantly taught me how to identify quickly danger signs in a severely ill patient using ultrasound."

Ultrasound is an oscillating sound pressure wave with a frequency greater than the upper limit of the human hearing range (greater than 20kHz). An ultrasound device and probe produces such sounds that are generated from the probe and travel through the tissues of the patient and then return to the probe as they encounter tissues of different densities. The intensity of the returning echo determines brightness of the image on the screen. Strong signals produce white or hyperechoic images as seen with bone. Weak echo signals returning to the probe translate into dark black, or hypoechoic images on the ultrasound screen as seen with fluid. 

The use of ultrasound in medicine started more than 50 years ago when it was mainly used in cardiology and obstetrics to investigate patients without the unwanted exposure to dangerous radiation that was encountered with the use of X-ray. Whereas there have been advancements in radiological devices such as the CT scan and MRI, ultrasound remains one of the most commonly ordered radiological investigations in most hospitals in Uganda because its effective, quick and cheap.

In many high income countries, there has been a shift in medical training toward supraspecialization, where diagnostic imaging and intervention procedures are increasingly performed by physicians with no formal radiology training as a result of which the concept of “point-of-care ultrasonography” (PCUS) where limited, problem-directed bedside ultrasound is performed by hospital specialists has arisen[1]. Currently, this has become an established practice in vascular access, abdominal aortic aneurysm screening, rheumatology, critical care, and emergency cardiac function assessment. The more liberal use of ultrasound by non-radiology specialists has been facilitated by the introduction of portable hand-held ultrasound devices, as well as the development of more affordable and user-friendly ultrasound equipment. Surgeons and emergency physicians have adopted focused assessment with sonography in trauma (FAST) scanning to determine the presence or absence of free fluid in the abdomen, pelvis, or pericardium to guide further assessment with computed tomography or to expedite surgical exploration.

The current growing interest in Emergency medicine in the country, Uganda,  (see milestones) and future establishment of emergency medicine as an expanding specialty in Makerere University and possibly other medical schools in Uganda will depend on training of medical school graduates (doctors) but also equipping medical students early in their training with skills such as Ultrasound use in emergency settings. A recent study comparing the diagnostic accuracy for various forms of cardiac disease between first-year medical students with 18 hours of ultrasound training and board-certified cardiologists armed with their stethoscopes demonstrated a large advantage for the students. [2]

The potential use of portable ultrasound bedside examination is vast in the Uganda setting not only for the emergency (casualty) units but also for the many obstetric facilities especially in upcountry health centers where running of heavy equipment can be a problem due to shortage of skilled staff and power shortages. 

Ultrasound technology has progressed greatly over time. It is predicted that ultrasound equipment will become more compact and will be the new stethoscope of the future [3,4]. It can therefore be argued that it is important to introduce ultrasound and its significance in undergraduate teaching in the early years of their education. As emergency medicine enthusiasts continue to work on establishing the roots of emergency medicine in Uganda’s health care system, it is of utmost importance that medical students as well as those in the field are trained in such areas as diagnostics in emergency medicine to increase effectiveness and efficiency of emergency care in health care centers in the country.

References

1. Beaulieu Y, Marik PE. Bedside ultrasonography in the ICU. part 1. Chest. 2005;128:881-895.

2. Kobal SL, Trento L, Baharami S, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol.2005; 96:1002–6.

3. Heilo A, Hansen AB, Holck P, Laerum F: Ultrasound ‘electronic vivisection’ in the teaching of human anatomy for medical students. Eur J Ultrasound 1997, 5:203–207.

4. Hoppmann R, Michell WE, Carter JB, McMahon C, Lill PH, Brownlee NA, Carnevale KA: Ultrasound in second year pathology medical education. Journal of the South Carolina Academy of Science 2008, 7(1):11–12

Jerome is fourth year medical student at Makerere University College of Health Sciences and is very passionate about all things Emergency