Strides in improving emergency care

Martha Osiro was declared a high risk pregnancy case after losing five pregnancies to pre-term birth. She eventually gave birth to her first born at 25 weeks (six months) and because of the good care she received at a hospital in the US, the baby survived. Following her medical history, Osiro was worried for her health when she found out that she was pregnant shortly after returning to Uganda in 2010.
“My first thought was to return to the US. However, my husband assured me that we would find a good hospital to take care of the baby and I,” she says.
At 16 weeks, Osiro went to hospital after developing a headache. She got a bad reaction to the medication she received and before long she was fighting for her life. At one point while drifting in and out of consciousness, she heard the nurse say, “afudde’ (she is dead). However, her family did not give up deciding to have her airlifted to South Africa.
She recalls arriving at the airport to a waiting ambulance with paramedics and a doctor who rushed her to hospital. “At the hospital, I was checked by an obstetrician and admitted for the remaining months of my pregnancy after discovering that I was eclamptic and had to be closely monitored. Eventually at 32 weeks, she gave birth to a healthy baby boy.

Osiro is still mesmerised by the timely care she received. She, however, notes that this is not a chance many women get.

Returning home
Motivated by her near death experience, Osiro actively sought an opportunity where she could directly contribute to reducing mortality resulting from life threatening emergencies.
She has since joined the Ministry of Health as a technical advisor under the emergency care department and is working with the team developing the policy and framework alongside other structures needed in place for a quality emergency care system countrywide.
Emergency care is a continuum of care that addresses time sensitive injuries and illnesses. It comprises pre-hospital care as well as health workers such as nurses, clinical officers, and doctors.
Dr Andrew Sekitoleko the executive director of Rubaga hospital in Kampala describes an Emergency Medical Service (EMS) system as ordinarily having the capacity for rapid response, rescue of patients in case of accidents, providing basic and advanced life support, communication and transport. “It should also have trained personnel to handle the injured or the acutely ill,” he adds.

Elements
Dr Sekitoleko says the components of an emergency care system include the first responders who are at the scene of an emergency and include trained first aid personnel. “The country has very few of these who are limited to the scouts, girl guides, Red Cross and such movements. However, for every 100 persons, there should be at least 10 first aid providers,” he explains.
There is also pre-hospital ambulance care which is offered by trained personnel often moving on an ambulance with the aim of stabilising the patient and transporting them to definitive care. The target should be that they reach the critically ill person in less than 15 minutes of the call.
Dr Sekitoleko adds that the third component is the emergency departments at the different hospitals which must operate around the clock and be well-equipped with trained personnel on duty (not on call). The departments must also be strongly supported by other services such as laboratory (especially for blood) and radiology (useful in determining the need for immediate surgery).
He adds that there is also need for Intensive Care Units (ICU). “We have observed that several patients will be referred from the emergency department to another hospital simply because there is no ICU to provide onward care. There is an effort to increase the number of ICU beds in the country to improve access to critical patients.”
Dr Annet Alenyo Ngabirano, an emergency physician and president of the Emergency Care Society Uganda (ECSU), says emergency cases cut across all age groups and the emergency care providers should be able to address them accordingly.

Strides
Dr Sekitoleko says the status of emergency medical service in Uganda is evolving from a largely neglected area to a rapidly growing discipline. “Not more than 10 years ago, several hospital facilities maintained emergency rooms that were largely dysfunctional,” he says. However, in the past five years, he says, more attention was put in the area of medical emergency with the creation of a department of Emergency Medical Services in the Ministry of Health. This led to the development of an EMS policy. “With the policy came several training programmes for emergency care professionals and a dedicated country short code for medical emergency calls although it has not been made public as yet because we are still setting up the infrastructure for its use,” Dr Sekitoleko shared.
“Dr Alenyo adds that practitioners have formed the ECSU where emergency care professionals are grouped and equipped. She adds that there is also training for nurses to make them Emergency Care Practitioners at Mbarara University of Science and Technology in partnership with Global Emergency Care.
Also, Rubaga Hospital Training Institute offers a certificate course for Emergency Medical Assistants and will open a diploma course for emergency medical technicians in the course of next year. “This completes the range of professionals required to build an EMS system,” Alenyo says.
She adds: “When medical practitioners can recognise a need early enough, they will give the necessary help hence saving a life.”
More to that, Dr Alenyo believes that there is need for more people to learn about emergency care. “Treatment is not only done in hospitals but starts from home and then in the ambulance as pre-hospital care. Therefore, anyone can learn emergency care because then those at home can ably give first aid depending on the need as the ambulance arrives,” she adds.

The future
Dr John Baptist Waniaye Nambohe, the Commissioner Emergency Medical Services at Ministry of Health, says all regional referral hospitals and national referral hospitals are implementing emergency care processes but at different stages.
He notes that to streamline the different interventions being put in place to bridge the gaps, a national EMS policy has been developed collaboratively with key stakeholders including the Office of the Prime Minister, Ministry of Works and Transport, Ministry of Internal Affairs, Ministry of Defence and Veterans Affairs, district local governments, regional referral hospitals, civil society organisations, ambulance service providers, and development partners.
“This is to guide the implementation, set standards and regulate the practice of EMS,” Dr Waniaye says. He adds that a regulatory impact assessment was conducted, the Ministry of Finance, Planning, and Economic Development issued a Certificate of Financial Implications and the next step is to have the policy presented to the cabinet for approval.
Additionally, a costed five-year EMS strategic plan has been developed and approved by the MOH and is ready for implementation, he said.

Cost
Dr Waniaye says the total cost of establishing an emergency care system is $435 billion for five years with the first year requiring more than Shs110 billion and Shs130 billion for the second year.

Initial costs will involve infrastructure development such as ambulances (land, water and air), accident and emergency departments, diagnostic equipment, communication system and referral trauma centres as well as improvement of emergency department at national level.