Rwanda Field Report: 2015

Published on July 16, 2015
After a year of clinical and training work at an ED in Kigali, Rwanda, Dr. Rahman returns to his former ED in England and here reflects upon the great importance of the greater health system contexts in EM development.

Emergency care in Kigali, Rwanda

I parked in my usual spot, walked down my usual route to the ED, through the ambulance bay, got changed into my scrubs, and walked into the office for handover. The Matron who was sat there gave me a sideways look. “Where have you been? Pinderfields?” she said, referring to a hospital about 8 miles away. I asked her to guess again, and, after being mistaken for the fourth time, reminded her that I had been in Rwanda over the past year. And so began my first shift back in the familiar setting of the Emergency Department at Leeds General Infirmary after having spent the better part of the year working and developing Emergency Medicine (EM) at the University Teaching Hospital of Kigali, colloquially known by it’s French acronym, CHUK.

The first patient I reviewed on my first day back was an overweight teenager, who had given birth to her first child 10 weeks prior. After having endured a spinal anesthetic during delivery, she had been suffering with persistent back pain, despite consulting her General Practitioner a number of times, and being prescribed analgesics. Nothing had changed on the day of her attendance except that she couldn’t get an appointment back at her GP’s, and the receptionist advised her to attend the ED. She looked well, and was soon on her way home after being reassured that there were no critical findings, and advised regarding use of painkillers, as well as back exercises and losing weight.

The next patient was of the type I had not seen for over a year: • Male • Fifties • Smoker • Chest pain for 20 mins • Now resolved • Normal ECG • Normal clinical exam

Almost like riding a bicycle, I completed the protocol documentation to get him admitted to our Clinical Decisions Unit to await results of his Troponin blood tests as well as repeat ECGs, not to mention the valuable period of observation and therapeutic cup of tea that he no doubt received while on the unit—an essential part of healing here in Yorkshire.

During the time I was seeing these 2 of the 55 patients in the department, I was aware of a trauma case that had been admitted to our resuscitation room following a motor vehicle accident. The Trauma Team had been activated and the bay was saturated with specialist staff who promptly whisked the patient to the CT scanner, less than 50m away, and then back to our resuscitation room for continuing care and to await the CT findings.

Flashback to Kigali

As I took stock of this first hour of my first shift back, I reflected on some of my experiences in Kigali, where we (my colleagues, both Rwandese and expats) faced numerous and significant challenges in supporting the growth of EM in a resource limited setting. By extension, those challenges included delivering emergency care to a severely resource limited population, in terms of both finances and population.

There is an admirable model of health insurance now established in Rwanda, but the system is tested severely with the challenges of delivering modern emergency care, which regularly makes use of expensive primary clinical interventions or imaging modalities to guide critical decision making.

Whereas in developed nations public EDs are open to all, in Rwanda the current system to access the ED at CHUK (which serves as a referral hospital to the nation) was usually by means of transfer from a district hospital. Patients may also be brought in by SAMU, the prehospital service that currently functions only in Kigali, although this occurs less frequently than transfers.

There are appropriate justifications for the development of such a referral system in this setting, although this system can (and often does) lead to significant delays—typically days as opposed to hours—in the transfer of the acutely ill, which results in patients often arriving in such a critical state that they are usually beyond recovery.

There is an admirable model of health insurance now established in Rwanda, but the system is tested severely with the challenges of delivering modern emergency care, which regularly makes use of expensive primary clinical interventions or imaging modalities to guide time critical decision making, particularly in cases of trauma. This results in delays to patient care while family members try to gather together the 10% co-pay of an investigation in question. For a CT head scan, this is $7 too much for most families. Reassuringly, there are continuing attempts, directives, and waivers issued to address this recurring problem, despite barriers to implementation.

Our current model of care delivery relies upon clinical practice guidelines to improve the safety and efficacy of care, and legal instruments protect staff and patients, and hold institutions accountable. Against this backdrop, I am reminded of how we tried our best to manage patients in Kigali who suffered from a range of complex injury and illness for which there is no great body of evidence, and for which the only clinical tools within reach were adaptation, experience, and opinion. Such a patient would include one with greater than 50% burns who remained in our ED for days, isolated from no one, without the focused monitoring, fluids, nutrition, dressings, early institution of appropriate antibiotics, surgical debridement and grafting required for survival and recovery. Or others presenting with hyperglycemia, along with other features more consistent with autoimmune etiology, as opposed to insulin resistance. There were also tragic encounters of managing palliation of the severely brain injured (secondary to trauma or cerebrovascular accident), or terminally ill, where medico-legal implications affected decision-making.

Additional similar clinical challenges were compounded by lack of access to laboratory tests, basic medication and consumables owing to stock shortages, or risk to patients and staff for lack of running water, faulty equipment and environmental hazards, or an inability to get the patient the right care in the right place at the right time due to human resource and personnel issues, or simply a lack of space at the hospital.

Improving emergency care is now a focus of many global initiatives, and all recognize the need for specialist training. For those involved in such programs there is often a sense of urgency in accelerating the infancy of EM to its running stage, before it has learned to walk.

Conclusions

I felt great pride and privilege working among and training the remarkable individuals who are tasked with being the pioneers of EM in Rwanda. I am also reminded of the fragility of establishing EM as a specialty, which, by design, is set to exploit the best of any existing health system in the interest of its patients. It therefore follows that developing EM in resource-limited countries is exposed and at risk of bankruptcy—despite comprehensive education and training programs—if steps are not taken to ensure that the health system is robust enough to perform, whether it be in terms of policy, funding, infrastructure, improved interspecialty and interdisciplinary work, information management, and a culture change that values professionalism and prioritizes the needs of the patient. Surely one would recognize that such an effort is akin to an Ironman endurance race as opposed to a brisk walk in the park.

Back in Leeds, I walked out of the ED at the end of my shift, grateful for the familiarity of the work, the place, and the people. I like the parks in my neighborhood, and I can’t remember that last time I endured a race of any sort. I also miss Rwanda.

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