Advancing Emergency Care partnership in Ethiopia

Nov 14, 2014 � Three weeks and dozens of meetings later, still much remains to be done. For those who missed my earlier post, I have been in Addis Ababa, Ethiopia, working during my combination vacation-elective to help forge a network of Ethiopian Emergency Departments (EDs) in order to aid in multicenter data collection and analysis, and national and regional policy reform.

Right off the airport tarmac, it seemed, my early meetings proved even more successful than I had hoped. My desire to fashion a collaborative multicenter ED research network in this rapidly developing nation found strong buy-in from local leaders both in the Department of Emergency Medicine at the country�s flagship government hospital as well in as the Ministry of Health. By the close of week 1, we had assembled not only a team, but a detailed plan for how to collect existing standardized ED and hospital data at all government hospitals in Addis Ababa, as well as how to enhance ongoing data capture and analysis.

United Nations Conference Center, amidst
ubiquitous construction in Addis.

 It was fitting, then, that these early successes forging relationships across a capital city would be followed at the heels closely by the chance to observe how partnership is taking place across Africa�s Emergency Medicine community�at the Africa Conference on Emergency Medicine�s (AfCEM), a biannual event hosted this year at Addis Ababa�s United Nations Conference Hall. I had conveniently planned my trip to Addis to overlap with this four-day event. With great excitement, some 600 individuals from across the world crowded into the hall: researchers and clinicians, faculty and some of Africa�s earliest Emergency Medicine residents. All corners of the continent were represented. Old friends reunited, but just as many new hands were being shaken as well.

Plenaries and poster sessions provided much food for thought, and bold Ethiopian coffee additional mid-morning stimulation. Research samplings ranged from pre-hospital care and emergency medical dispatch, to components of emergency medicine residency education development in Africa, to assorted estimates on the burden of emergency disease in the region and world. Interesting as they all were, it struck me�as I volleyed from room to room as between buffet tables�that much of the research presented was the fruit of bilateral institutional partnerships, planted years ago through ad hoc personal connections and nourished over time into formal agreements between two institutions (one African, the other often US or Canada). Not discounting the importance these collaborations have had on advancing our specialty across this continent, I wondered whether the bilateral model is most indeed the most effective one for building cohesive systems of emergency care going forward. Indeed, while these partnerships have yielded tremendous gains for the hospitals involved�particularly in the formalizing of Emergency Department infrastructure and training of specialized practitioners�those majority of government hospitals outside the contracted bounds of bilateralism have been left to evolve asynchronously and independently. I had observed this in Addis Ababa the prior week, in my tours of ten government EDs, and I saw it at AfCEM in the subtle dis-ease expressed by current and recent highly-skilled emergency medicine residency graduates from across Africa as they anticipated careers in facilities without the financial, technical, or research support of their training institution. It is no wonder all of them want to stay at their hospital of training!

AfCEM coincided with the graduation of several
of Addis Ababa University's second batch of
Emergency Medicine residents, many of whom I
first met two years ago. The future leaders of EM
in Africa, whom I am privileged to call friends.

It is my hope that our work in Ethiopia may yield not only data useful to the profession of Emergency Medicine in this oldest African nation and across the continent, but may also serve as a model for how collaborative research networks can be built and managed by the African public sector, to the benefit of the entire system of facilities. Moreover, I hope that as this network grows in both the number of facilities and volume of patient data gathered, we might be able to open it for use by local residents and faculty�the future of African Emergency Medicine leadership�so that even as they spread to disparate facilities they might continue to work together as a team to advance the specialty through collaborative inquiry.

Conference drew to a close, and amidst all the hand-shaking and finger-foods I picked up a nasty upper respiratory virus that left me febrile and bedridden for two days, and submersed in my sinuses for the rest of that week. Week 3, therefore, started far slower than I had hoped, and government speed bumps cast further delays. And yet, even if slowly, progress continued to move forward. Much of what we had hoped to accomplish would need to be postponed until after my departure, but perhaps that was not a bad thing. After all, if this is to be a truly effective partnership�indeed, if it is to be an ultimately locally-run venture�most progress will need to continue even when I am gone. I can think of no more competent a team than my local collaborators (now quite close friends!) whom I have left behind. Their enthusiasm, their curiosity, their ambition for this project has fueled my excitement.

One of the ten hospitals visited in Addis

 Now back to good health, these final days have seen the development of several updated data collection templates that will now need to be mass-printed and distributed to all government hospital sites. Together, we have analyzed existing holes and quality gaps in current data collection and designed improved systems to fill them. We have talked with some hospital leaders, and will extend the invitation to others. We have pored through variables, designed research questions, and drafted study protocol. We have laid the groundwork so that this network can be disseminated even outside Addis.

As I sit in the airport now, reflecting as I make my way back to Boston, I must reiterate my immense gratitude to the Partners Centers of Expertise for their largesse in funding my travel on this exploratory venture. Although I came to this nation with merely a vision, a dozen and half contacts, and some scattered words of Amharic, three exhilarating (and exhausting) weeks later I feel I am leaving with much more. It is my hope and that of my collaborators that this trip is merely a prologue to a much longer story. Thanks for reading!

Dave Silvestri,

Department of Emergency Medicine

Massachusetts General Hospital

Brigham and Women�s Hospital

Read More

Point of Care Ultrasound in Rwanda : A few interesting cases.

Case 1:  Last week, we had a patient who presented to the emergency room booked as heart failure.  He was transferred from a district hospital with hypoxia.  The team there had started treating him with a beta blocker and Lasix but he was not improving.  His oxygen saturation was 76% on RA and 90 on a NRB.  His HR was in the 60's ( B-blocked), and he was midly hypotensive with SBP in the 90's.  His chest xray was clear without pneumonia or pulmonary edema.  Given his Hypoxia, the resident suggested we perform a point of care Ultrasound ( I was so happy he initiated this Ultrasound ).  A formal ultrasound could take up to 2 days to obtain, and with the rate of patient turn over at this hospital, who knows if patient would last that long.  His Bedside Cardiac Ultrasound showed  a severely dilated RV and a large dilated non-collapsing IVC ( sorry the other videos won't download, so only one cardiac view).  We of course suspected a pulmonary embolism in this patient.  We performed bilateral point of care 2 zone DVT studies which were negative.  Emergency team decided to heparinize this pt given these findings.  This week I checked on him and he was off oxygen and sitting up breathing comfortably waiting for a bed on the medical service.  Never got CT PE...family could not afford to pay ( you pay for everything at this hospital...including the gloves that clinicians use to care for the pt).  No money, insurance = limited care. 

Case 2:  Young male in his 20s who had a motorcycle accident presented from District hospital with minor pelvic fracture.  It took him about 2 days from his trauma before he presented to our referral hospital.  He complained of severe abdominal pain with us.  He was scheduled for a CT scan of his abdomen but it was taking a while.  We performed  FAST ( Focused Assessment with Sonography for Trauma) on him and saw this.  Yeah....That's a ruptured bladder.  He got antibiotics and a Urology consult. They requested a CT scan which happened 2 days later and confirmed a bladder rupture.  He was then discharged with antibiotics, a foley and was scheduled for outpatient cystogram...This basically motivated the residents to do FAST's on all traumas even if transferred 3 days after injury!!!!!  This helps form habit....and the residents get to perfect their Ultrasound skills.  







Case 3

This is a necrotic leg...This woman's leg has been like this for a few months...why did she not appear that ill???...Well Doppler U/s of the vessels of her legs showed a femoral arterial clot but also incidentally bilateral DVT's which probably prevented severe systemic illness.  She had bilateral DVT's due to large pelvic mass. She ended up having her leg amputated and last time I checked she was doing well on the surgical service.  Unclear what work up she would have for her pelvic mass.    

Soooo Much Pathology here...Because CHUK is the referral center in Rwanda and has the only public CT scanner ( other one is at a private hospital and you need lots of dinero), we get everything at this hospital.  On any given day we have many positive FAST's, large pericardial effusions, and cardiomyopathies.  Great learning cases!!  These were just a few. Thanks for Reading

~Phindile Erika Chowa MD

Emergency Medicine Residency, MGH/BWH, PGY3 ?

Read More