Process Mapping in Ghana

After a week of orienting to the Emergency Department, I started in on my project in earnest this week. The objective of identifying opportunities to improve the process, and thus create more capacity, was met with enthusiasm almost uniformly. I was able to complete several process mapping sessions this week � with the accounts staff, medical officers and front line nurses, all of whom seemed excited to engage in the project and interested in the methodology.

Our findings are very encouraging � that there are many areas of the process that � once mapped out and through structured discussion - are redundant, prone to error or un necessary. Each group also offered many creative ideas for how the processes could be improved and solutions for some of the barriers they identified.

I will now work to translate the walls of post-its into Lucid Chart (great process mapping software) and then circle back with each of the groups and see if there area any other areas we are missing. I am working with the clinical coordinator to help vet my findings, and put a report together with some suggestions based on the staff�s ideas, on how to improve the workflow.

Ultimately the hope is that by identifying the areas of the process that can be streamlined, reducing the waste and redundancies, we are able to move patients through the department more quickly, and thus increase the capacity of the (always crowded!) ER and the capacity of the staff to care for their patients.

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Process Mapping in Ghana

Having been here a week, my work is well underway and am sadly realizing a lifetime of dedication to this emergency department couldn't accomplish what I was hoping to do in a few weeks. Ghana itself is amazing � although some things, like the incessant honking from the Ghanaian trotros (shared ride cabs), 80 degree nights (and 95 degree days), and constant call of �obruni� (the Ghanian slang for white lady), are familiar from other travels, there are many things that make west Africa like no place I have ever been. To begin with, I was met by a thick red dust coating the city, which in combination with the stifling heat, felt remarkably unfamiliar. The Harmattan � a dusty trade wind that brings with it the Saharra dessert, coating West Africa between November and March, is apparently at it�s worst in 20 years. This has left everything (including my glasses by the time I got to the hospital) coated in a thick layer of red dust. This, mixed with the somewhat more familiar stench of burning garbage and open latrines, was the first assertion Beantown was far behind.

So although the climate is somewhat unwelcoming, the people couldn't be more friendly. Ghana � an English speaking country roughly the size of Oregon with the population of Canada � is largely lauded as being among the most friendly nations on the continent. Indeed, everyone I have encountered since I arrived have appeared uniformly excited to see me � to show off the city, tour me around the hospital, introduce me to the food or teach me the language (twi is one of many local languages that flows freely in and out of most English sentences).  Having traveled a fair bit in the last decade, I will say that I have been nowhere that I have felt less threatened and more secure than in Ghana.

The hospital however is a less hospitable place. The staff are wonderful and the administrators welcoming, but the state of healthcare here is certainly unfamiliar. The hospital I am working at, Korle Bu, sits surrounded by some of the poorest communities in Accra and has a strong commitment to serving all comers. Despite this principled mission, the infrastructure, equipment, supplies and staffing doesn't exist to support it. I am working primarily in the Emergency Department � on a project aimed at increasing capacity by identifying areas of inefficacy � but recognize the problem is larger than my weeks here will impact.The physician I am working with is truly an inspiration though � a native New Yorker who starting coming here 7 years ago, trained in Emergency Medicine and still supported by NYU and Bellevue Hospital. She has been living here full time for almost 4 years and through incredible relationship building, political navigation and patient care, created the first department of Emergency Medicine at Korle Bu. The department, which she is now the clinical coordinator of, is vital to help resuscitate the hoards of patients that arrive critically ill secondary to a system with almost no preventative medicine, little access to primary acute care, and a mostly fee for service model that leaves people without the medications or diagnostic tests that they need. The acuity of the patients I have seen over the last week arriving in the Emergency Department, is truly unfathomable.

In partnership with the hospital, and incredible local collaborators and colleagues, they have created this department now teeming with over 50 stretchers in various states of disrepair, which admits to an over 2000 bed hospital (MGH has 950  as a point of comparison). The issues remain though: no oxygen masks the day I arrived, a defibrillator that has been broken for over a year, a marked shortage of certain medications and intermittent access to the limited diagnostic tests they have.  With that all said, the commitment is here � the dedication to the patients and belief that through focused work the system will advance � as it already has in recent years.  So that at least, is inspiring.So after a week of observing in ER, meeting the staff, administrators and beginning to understand the cultural communication nuances that will hopefully help me be successful I look forward to digging into the work next week.

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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

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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 ?

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Toward Emergency Department Integration in Ethiopia

In the dark of the night, our plane descended. A galaxy of yellow and orange house lights swarmed below, drifting closer to my pocket of airplane window. Twenty hours of travel (including two brief layovers) was nearly over. Complimentary glasses of red wine (for the circadian adjustment) had done their trick, and our wheels skidded down on cool Addis Ababa tarmac like a reunion of old friends.

Just three years previously (in November of 2011) I made my first trip to Ethiopia, as part of a multinational study assessing medical and nursing students� migration intentions. At that time I partnered with senior educators in Addis Ababa University�s School of Medicine and worked closely with senior and junior students alike, making quick and close friends at all levels. Ethiopia had felt a strange and unfamiliar place to me then�far different in culture, climate, history and language than any sub-Saharan African place I had ever visited. Now three trips later, however, it was almost a second home, my friends here some of my dearest, and the culture and customs no longer new.

As I waited in line for a renewed visa, watching disembarking passengers bolus past outnumbered Ebola screeners, excitement and impatient apprehension both swelled as I began to unlock the mental list of immediate �to-do�s� needed to jumpstart the upcoming three weeks of work. No longer studying health professional student migration (as I had my first two trips) or working clinically in the Emergency Department (as I had my third trip), my goal this trip was to forge a network of Ethiopian Emergency Departments in order to aid in multicenter data collection and analysis, and national and regional policy reform.

As elsewhere across sub-Saharan Africa (and, in fact, throughout low- and middle-income countries), the importance of emergency care is growing. And while most Disability-Adjusted Life Years (DALYs) in sub-Saharan Africa are still lost to lower respiratory tract infections, diarrheal disease, HIV/AIDS, and malaria (by Global Burden of Disease data), the burden of traumatic injury and acute presentations of non-communicable ailments is rising.

Ethiopia, in particular, finds itself in a unique situation. With the 13^th highest population in the world (second in Africa only to Nigeria), it also has both the largest proportion of rural inhabitants (80%) and the highest rate of urbanization (5%) of any of these most populous countries. But that�s not all. Among these most crowded nations, Ethiopia continues to boast one of the highest per capita GDP growth rates. In other words, Ethiopian cities are growing faster than in any other most populous nations (urbanization rate). Additionally, they will likely continue growing for longer than anywhere else, given the proportional and absolute size of the rural population, and they are filling with people who now have somewhat more money than they did, say, a decade ago. This money is often sufficient to afford slightly less healthy lifestyles (diet, cigarettes, etc.)�but not ample enough for medications to control the corresponding resulting chronic diseases. While these trends are familiar across Africa, it is in Ethiopia where a �perfect storm� of demographic and economic realities have rendered them most pronounced in both absolute and relative terms.

 For Ethiopia, the encroaching high tide of emergency care need represents both an immense crisis and an unprecedented opportunity. For a nation so historically rural, the urban health system capacity�including its emergency care capacity�must be rapidly expanded if it is to have any hope at absorbing the influx of demand. But precisely because so much growth is needed all at once, there is great advantage to undertaking it in a coordinated fashion. Indeed, it is in hopes of helping coordinate the emergency care data collection systems that I return to Ethiopia.

My first few days consisted of logistical essentials: buying a phone, buying a SIM card, buying a second SIM card when the first SIM card didn�t work; checking into a cheap hotel, moving to a second hotel with more reliable internet and closer proximity to the hospital; scheduling meetings, preparing documents for said meetings, rescheduling meetings, defaulting to back-up plans when rescheduled meetings fell through�. And finally came the opportunity to sit down with the Head of the Emergency Department (one of the hospital�s busiest men)�in a small hidden conference room tucked behind three bustling ED rooms. I handed him my proposal. We talked. Our meeting was brief; it didn�t need to be longer. We saw eye-to-eye�our mutual appreciation for the importance of this task fueling each other�s excitement. Without delay, he introduced me to an individual who would become over the next several days one of my closest collaborators�a young nurse

manager (A.Y.), recently trained in emergency care and critical care nursing and now working to coordinate referrals between Addis Ababa�s government hospitals.

As week 1 came to a close, I had spent many long days venturing with A.Y. and his team to all of the city�s government hospitals (as they coordinated referrals between them), confirmed data recording systems at each one, and developed a plan with A.Y. to standardize inconsistencies going forward. It was time for the next important meeting�with the Ministry of Health.

Over aromatic black Ethiopian coffee, we sat and pored through an intricate spreadsheet I had assembled on my computer late the previous night, summarizing the full week�s findings. The cool morning air bowed to midday sun, and we switched tables to keep talking. The lunch crowd came, then left. And still we talked through further details. Reviewing variables, considering how to improve collection of still others, discussing which additional ones might even be added going forward�and how, logistically, in a network of government hospitals with universal paper charts, to accomplish these tasks. Our work, at last, was finished. A team was formed. And week 1 in Ethiopia was complete, far more successfully than I could have imagined, thanks in large part to the Partners Centers of Expertise Global Health Grant.

Dave Silvestri, PGY-2

Department of Emergency Medicine

Massachusetts General Hospital

Brigham and Women�s Hospital

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