When will emergency medical services system be improved?

On the afternoon of December 29 last year, Teddy Kanyunyuzi Erukwaine, was wheeled into the theatre at Jinja Regional Referral Hospital.

She had developed pre-eclampsia, a pregnancy disorder which sees an expectant mother either develop high blood pressure or has large amounts of protein in her urine or sees her organs fail to function normally. In her case, it was high blood pressure.

Medics there thought it would in the circumstances be too risky for her to give birth the natural way. They opted to aid the birth by way of an operation.

It was meant to be a routine operation that should have saved both the mother and baby, but the operation went awry. The baby was saved, but Erukwaine became another statistic of women who die while giving birth.

Uganda has quite a high and very worrying maternal mortality rate. The CIA fact book puts the number at 343 deaths for every 100,000 live births. The tragedy is that many of these deaths could have been avoided.

Some of the medical workers at Jinja Regional Referral Hospital believe that Erukwaine’s was an anaesthetic death – the result of an anaesthetic error.

Dr Peter Waiswa, an associate professor in the Department of Health Policy, Planning and Management at Makerere University’s School of Public Health, says anaesthesia errors occur mostly as a result of negligence on the part of the anaesthesiologists or surgeons.

Also, they are manifest in for example failure to guide patients on what to eat or drink prior to surgery; administration of too much or too little or administration of a wrong type of anaesthesia.
“In this case there is a very big possibility that the drugs may have been mishandled. First, it is highly likely that they are out of stock and therefore have to be bought from a pharmacy. Others may need refrigeration and a particular way of handling during storage, which may not have been adhered to. There is also the possibility of expiration,” Dr Waiswa says.
“Besides, there is also a question of training of the few available anaesthesiologists. Some of them were trained very long ago and are practising obsolete methods,” he adds.

Dr Waiswa says where they do not result into death, anaesthesia accidents can leave one in a coma or with a brain injury. They can also result into heart attacks, a stroke or birth defects.

On June 13, 1992 the World Federation of Societies of Anaesthesiologists (WFSA) adopted standards to guide anaesthetists, hospitals and governments to maintain safety of anaesthesia care. Revisions were conducted in 2008 and 2010 and updated in May 2018 on behalf of WFSA and the World Health Organisation (WHO).

The guidelines are premised on the principle that safe anaesthesia for essential surgery is a basic human right, which should be available to all irrespective of ability to pay for it.

They provide for, among others, continuous presence of a trained and vigilant anaesthetist, intermittent monitoring of blood pressure, use of the WHO safe surgery checklist and a system for transfer of care at the end of anaesthesia, but implementation in Uganda is near impossible, at least for now.

Uganda is unable to have “continuous presence of a trained and vigilant anaesthetist” at every theatre. The country has been suffering from an acute shortage of anaesthetists for more than 25 years now.

As of August 2003, there were only 12 anaesthetists, five of them foreigners. Nine of the 12 were in Mulago National Referral Hospital, but that number was not good enough for the facility.

Earlier in 2002, the Ministry of Health had tried to bridge the shortage by training 144 clinical officers, medical assistants and midwives to work as anaesthetists. It also trained 21 doctors based in upcountry hospitals, but the shortage has persisted.

According to the Association of Anaesthesiologists of Uganda (AAU), Uganda is suffering from an acute shortage of anaesthetists, with more than 70 per cent of the posts in government institutions unfilled. The result has been that there is only one anaesthesiologist for every 100,000 people, which is miles behind the WHO and Lancet Commission on Global Health’s goal of having between five and 10 for every 100,000 people by 2030.

“I am away from the office. That is technical information that would require me to look at the records, but we have been trying to recruit and also provide scholarships for people to train so that we fill the gaps in the key cadre positions,” Prof Pius Okong, the chairman of the Health Service Commission, said when asked what is being done to address the problem.
However, information obtained from the Commission’s website indicates that it recruited two principal anaesthetics officers and four anaesthetics officers in September 2018. Too little.

As part of an effort to address the problem, last year the Ministry of Health gave 10 people scholarships to study anaesthesia at Makerere and Mbarara universities. Another 40 people were also offered scholarships to study diplomas in the same field at different nursing colleges across the country. The year before, scholarships were given to 182 people, some of who are studying anaesthesia.
However, this points to an even much bigger problem surrounding Uganda’s emergency medical services (EMS) system.

Challenges
70 percent: The percentage of health facilities without anesthesiologists in Uganda.
1:100,000: Ratio of anesthesiologist to patients in Uganda.
Challenges: “In other cases, the ICUs are locked up for security reasons. Those in-charge lock them up out of a genuine desire to secure them and the expensive equipment in there, but that complicates situations in times of emergencies. Matters are not helped by the fact that some of those in-charge of them do not reside on the hospitals’ premises,” Dr Peter Waiswa, a lecturer at School of Public Health, Makerere University, says.

Flawed emergency medical service (ems)
An Emergency Medical Service (EMS) system should ordinarily have the capacity for rapid response, extrication of patients in case of accidents, providing basic and advanced life support, radio communication and transport. It should also have trained paramedics and emergency workers to handle the injured or the acutely ill.

In other words we are talking of a system that has a highly organised ambulance service system, a well-oiled referral system and good hospitals with functional intensive care units, but those seem to be out of reach for Uganda.

Research that the Ministry of Health and the University Hospitals of South Manchester and Health Education North West carried out culminated into the unveiling, in January 2014, of the Uganda National Ambulance Service Project. Government was meant to have purchased 100 ambulances over a five-year period beginning in the financial year 2014/2015.

The ambulances, which government had said would be fitted with modern technology where surgeries could be performed, were meant to be reached by way of a toll free emergency telephone number. They had been planned to reach those in need with 10 to 20 minutes.

The then Permanent Secretary in the Ministry of Health, Dr Asuman Lukwago, said the ambulance service was the first step in the move towards operationalisation of Uganda’s EMS, which would also entail the provision of specialised healthcare at designated emergency units and intensive care units (ICUs) at different health centres across the country.

This was meant to be backed up by recruiting and training of medical and paramedical workers, drivers and making the referral system work better. However, besides the training of 100 people to work as drivers and emergency staff, the ambulance service has never gained ground and the much hyped operationalisation of the EMS has not happened.

The referral systems remain in shambles and most of the ambulances at public health facilities are grounded due to lack of among other things fuel, tyres or simply because of small mechanical problems. Some are parked because they overshot their maintenance service limits. The health centres often have no money to service them in time.

It is important to note that most of the public health facilities do not have intensive care units. Where such units are in place, the staff are not skilled to provide appropriate care or handle the medical gizmos there, a situation which the Permanent Secretary in the Ministry of Health, Dr Diane Atwine, indicates government is aware of.

“Right now the Health Service Commission is in the process of recruiting medical workers for most of the ICUs across the country,” she told Sunday Monitor during a previous interview.

However, lack of trained personnel is not the only problem at ICUs. Most of them often run out of oxygen, which happens on account of either inadequate funding or poor planning on the part of the facilities’ administrators. Whatever the causes, the shortages have often resulted into deaths that could have been avoided.

In other cases, there are no standby generators to keep the machines running or help out during surgical procedures.
“In other cases the ICUs are locked up for security reasons. Those in charge lock them up out of a genuine desire to secure them and the expensive equipment in there, but that complicates situations in times of emergencies. Matters are not helped by the fact that some of those in charge of them do not reside on the hospitals’ premises,” Dr Peter Waiswa says.

The initial batch of ambulances that were imported for the Uganda National Ambulance Service Project were not placed at Mulago where they should have been supervised by the Ministry of Health. They were instead placed under the Kampala City Council Authority (KCCA).

Dr Atwine said the rest of the country would be catered for under a different project that was in the works.
“We are instead working on a National Emergency Care Strategy. That strategy is still being discussed, but it entails a lot more than the ambulance service,” she said.

Ugandans are waiting for the national emergency care strategy to take off, but the question is, how many more lives will it take before we see any meaningful improvement in the EMS?