Francis Kyakulaga, a district sanitation manager, and I had finished eating a meal at the ground floor restaurant of the Mwaana Hotel on the Trans-African Highway in Uganda. During the meal, we noticed an increasing commotion in the hotel lobby area, and Kyakulaga asked a man what was happening. He informed us that someone had collapsed upstairs.
We hurried upstairs to find an unconscious man lying in the hallway. A hotel worker had seen him collapse about one hour before and had informed the hotel management. While the hotel staff prepared our food, they had left the unconcious man in the hallway. They did not know what to do to help him.
When I arrived on scene, I checked his breathing and carotid pulse. His cold, hard neck made me think that he must have been dead long before I got there. Still, I wanted to be sure. I began CPR and shouted for an ambulance. I heard his ribs crack beneath my compressions, and soon I knew that my efforts were hopeless.
Kyakulaga personally knew the top healthcare officials in the district, and about ten minutes after he called the head of the nearby hospital, three vehicles arrived, and two medics joined us. They did not bring any equipment with them, although the vehicles were stocked with medical supplies. One medic slowly put on his gloves before checking for the man’s radial pulse. After what seemed like a long time, he hesitantly and incorrectly proclaimed that the man had a weak pulse.
The medic then discussed at length with his colleague what to do next. Still unsure, he decided to call the police ambulance for further direction. After several minutes, someone from the police ambulance arrived and declared the man dead.
The news that a man had died spread throughout the town, and the street outside filled up with several hundred people. The crowd waited for a glimpse of the dead body, and did not disperse until the body was carried off in the back of a pickup truck.
“People want to help, but they don’t know how,” Kyakulaga told me.
Most ambulances in Uganda are not staffed by trained medical technicians. Kyakulaga explained: “the hiring process to staff the ambulance goes like this—they ask if you can drive a car. If you say yes, you are hired.”
Here, as in most low-resource settings in Africa, even if someone is taken to the hospital in a timely manner, there are no guarantees that the patient will receive the necessary medical intervention.
With the already limited government funds for healthcare targeted to treat infectious diseases such as malaria, tuberculosis, and HIV, there is nothing left to improve any phase of emergency medicine. Uganda’s emergency medical system currently depends on the support of poorly-funded non-governmental organizations.
Two weeks after the hotel incident, I heard my neighbor at the home where I was staying shout for help. The neighbor’s maid had collapsed. I assessed her and found that she was unresponsive, but she was breathing and had a pulse. Since the neighbor had no personal connection to the hospital to call for a vehicle, we mobilized a car and drove through the sparsely lit, bumpy dirt roads in the Ugandan night to Iganga District Hospital.
When the driver and I arrived at the hospital compound, I shouted for a stretcher. No one came. Other patients and their families surrounded me. Some laughed at seeing a foreigner making a commotion. I ran into the hospital and grabbed a stretcher, put the unconscious woman on it, and pushed her into the in-patient room. There were no medical personnel in the room, so I called for a nurse and a doctor. The woman’s breathing seemed to become fainter with every second.
Eventually, a nurse ambled into the room and slowly put on her gloves. She glanced at the patient and asked, “Are you her husband?” At this, I raised my voice to request a glucometer, oxygen, and a blood pressure cuff. The nurse gave me a blank look and left the room.
A couple of minutes later, a clinical officer came. He also glanced at the patient from some distance away and said, “She’s fine.” We then transferred her to the casualty ward, and on seeing a foreigner pushing the stretcher with the unconscious woman, the nurses there looked at me blankly. After several seconds of mutual staring, I asked, “Aren’t you supposed to do something?” The three nurses meandered to the stretcher and surrounded it. They looked at the patient without touching her. I asked them if they had a blood pressure cuff or a glucometer, and one of them brought the equipment.
We found that the maid was hypoglycemic. Fortunately she recovered, but I was shocked by the lack of the staff’s emergency medicine training.
I later found that stories like these are common, not just in Uganda, but in most of Sub-Saharan Africa. Emergency medicine is a grossly neglected part of their healthcare systems. In 2004, South Africa established Africa’s first residency training program in emergency medicine. Since then, only four other countries (Ethiopia, Botswana, Ghana, and Tanzania) in the region have followed suit.
Sub-Saharan Africa has one of the highest rates of fatalities from traffic accidents in the world despite having the smallest number of motorized vehicles. As Africa’s economy grows, more people will own cars, and this will result in an even greater need for quality emergency medical systems. According to the World Health Organization, by 2030 traffic accidents will account for 3.6 percent of total deaths in the world, compared to just 0.8 percent for malaria. This translates to an urgent need for functional emergency medical systems.
Accentuating the poor emergency care in most Ugandan hospitals, patients who are fortunate enough to make it to a hospital face a nearly insurmountable challenge to receive any emergency care at all. There are two types of triage in Ugandan government hospitals. One is if other sick patients realize that another patient is really sick, then they allow the sicker patient to go ahead in the queue, and the second is if medical personnel see by chance that a patient in line has a very obvious emergency.
To attempt to help address the emergency-medicine crisis, Global Emergency Care Collaborative (GECC), a non-governmental organization founded by four American physicians in 2009, has employed “task-shifting” (teaching a non-physician clinician to perform tasks formerly delegated to specialist physicians) to train nurses to become emergency medical providers. Task-shifting is employed in settings where there are not enough physicians to meet the healthcare needs of the population. According to CIA’s World Factbook, Uganda has 0.12 physicians per 1000 people. In contrast, the United States has 2.5 physicians per 1000 people.
GECC’s flagship program is a two-year, “train the trainer” Emergency Care Practitioner (ECP) program for nurses, founded in 2008. After the two-year program, currently run in Nyakibale Hospital in Western Uganda, the nurses are qualified to provide independent emergency medical care without a physician. This independence is necessary in physician-limited settings such as Uganda, where patients often have to wait more than one day in the hospital before seeing a physician.
With the ECP program, GECC helped established the first emergency department with internationally acceptable protocols in Uganda at Nyakibale Hospital. Currently, private donors from the West fund GECC, which is collaborating with the Ugandan government and academic institutions to transfer administration of the program to Ugandans. The ultimate goal is to incorporate the nurse training program into the Ugandan healthcare system in order to make the program sustainable without ongoing international investment.
Tobias Kisoke, the program director of GECC at Nyakibale Hospital, said, “This program saves a lot of lives. I think that the idea of training nurses to be emergency medical care providers has a lot of potential throughout Africa. Lack of emergency medicine causes many unnecessary deaths.”
Nyakibale Hospital Emergency Department has served over 25,000 patients in the past five years, averaging between 13 and 14 patients per day. It remains to be seen if the model at this relatively well-resourced private hospital can be applied to under-resourced, under-staffed, and high-traffic government hospitals.
In collaboration with partners from Mbarara University of Science and Technology, the Ministry of Health, and Masaka Regional Referral Hospital, GECC will expand their operations to Masaka Hospital in October 2015. Masaka Hospital is a regional referral government hospital, and it should serve as a good test of the feasibility of their task-shifting program in a more resource-limited setting.
There are notable challenges to having a successful emergency department in a district hospital.
“[The] GECC model could work in a district hospital, but it needs outside help,” Dr. Luyimbaazi Julius, the medical superintendent at Nyakibale Hospital, said. “The government does not usually take responsibility for the full staffing of the hospital. If a department needs ten nurses to function, the government sometimes only has the resources to pay two.”
However, the current benefits of the emergency department at Nyakibale are undeniable. Turyamureeba Claudio, hospital administrator of Nyakibale, said, “Hospital patient numbers are increasing after the GECC came to Nyakibale. Many health centers have opened in this district since GECC arrived in 2008, so the number of patients coming to the hospital should be decreasing, but now, the communities know about the emergency department and that they will be seen right away.”
GECC still faces many challenges. Mark Bisanzo, the President of GECC, stated, “To make this program sustainable, there needs to be investment in emergency medicine. Right now, there is hardly any, but we hope that we can make emergency medicine a part of the Ugandan medical system.”