Stories From the Field:

UGANDA

Emergency Care in a Resource Limited Setting

Dr. John Eicken, a third year resident in the Department of Emergency Medicine at Mass General Hospital, was granted a Center for Global Health Travel Award to assist in the development of emergency medical care at Mbarara Regional Referral Hospital in Uganda. 

As a third year resident in Emergency Medicine, I have seen a fair share of the common presentations and conditions which lead patients to seek care in the Emergency Department (ED) including chest pain, trauma, abdominal pain, fever, and stroke, to name a few.  As a resident you work long hours caring for numerous complex patients, oftentimes in highly stressful and high stakes scenarios.  While each shift and patient present unique challenges, you know that you can always rely on tremendous resources such as nurses and specialty consultants, in addition to seemingly unlimited supplies, tests, and procedures that are readily available at Partners-affiliated hospitals.  Through the course of one’s life I imagine there are only a handful of truly life-changing events - I experienced one of these events during my month long visit to the Mbarara Regional Referral Hospital (MRRH) in Mbarara, Uganda when I experienced what it means to provide emergency care in a resource limited setting.

The first patient I encountered at MRRH remains quite vivid in my memory.  He was a young gentleman, in his 30s, and was sitting upright on a mat placed on the ground of the Accidents and Emergencies ward, also known as A&E.  The A&E ward is similar to ED’s in the United States, prior to the specialty of emergency medicine, where the department is divided into a medical side and a surgical side. Given that there are only six beds available in this area of the A&E, patients oftentimes have to stay on mats placed on the ground.  The patient had been evaluated by the intern overnight and a ring of white-coated individuals on morning rounds, including the attending, multiple residents, a few interns, and myself, now surrounded him.  He had presented earlier in the evening with difficulty breathing and currently seemed to be in mild respiratory distress and it appeared as though he had not slept overnight.

As the intern gave the detailed history and physical exam all the typical thoughts began to run through my emergency medicine mind.  What is his oxygen saturation?  What did his electrocardiogram and chest x-ray show?  What were his laboratory results including his white blood cell count, hemoglobin, creatinine, brain-naturetic peptide, d-dimer, and troponin?  Was an ultrasound done at the bedside to assess for poor cardiac output, pericardial effusion, pleural effusions, pulmonary embolism, or signs of pulmonary edema?  Just has I had complied my differential diagnosis and care plan in my mind the intern revealed that the only diagnostic tests which had been completed included a point-of-care malaria and HIV test, both of which were negative.  Although his oxygen saturation was mildly low (which was not determined until morning rounds given that only a few of the residents possess pulse oximeters), the only oxygen available in the A&E was being used for a patient who appeared much more ill.  The patient did not have the money required to obtain more comprehensive laboratory tests, imaging studies, or an electrocardiogram and therefore, these studies were not going to be performed.  As I heard this I thought to myself, how are we going to determine the cause of this patient’s presentation?  At this moment it became crystal clear to me how reliant I have become to diagnostic testing in the ED. 

Luckily, the resident who performed the physical exam during the intern’s presentation was not deterred by the lack of diagnostic data.  He systematically examined the patient head to toe including checking for signs of anemia, evaluating for cyanosis, percussing the liver and spleen, and carefully looking for any other physical exam clues that may reveal the cause of the patient’s symptoms.  He reported hearing crackles in the lungs and noted an elevated jugular venous pulse, both suggestive of heart failure with pulmonary edema, and he suggested initiating therapy with diuretics to treat heart failure.  While the cause of this young patient’s heart failure remained unknown, he was admitted to the medical team where he could receive further care and monitoring.  The reason this patient, and story, are so poignant in my mind is not because of the patient outcome, but rather because it became clear to me at that moment how I would need to drastically alter the framework I used in the evaluation of patients presenting to the A&E. 

Prior to arriving at Mbarara Regional Referral Hospital I had done my best to prepare for working in a resource limited emergency care setting.  However, until one is immersed in such a setting, one does not truly come to appreciate the ramifications associated with high patient volumes and acuity in conjunction with limited staffing, minimal diagnostic and therapeutic resources, and the degree of uncertainty in practice in which you must become accustomed. 

Medical and surgical interns who are a part of the general medicine and surgery ward teams run the Accidents and Emergencies Ward by alternating taking call. There is only one emergency medicine trained physician at MRRH who is visiting from another country and has been there for about a year and a half.  Unfortunately there are very few emergency medicine trained physicians in Uganda and the specialty of emergency medicine is not yet recognized at a national level.  The interns staffing the A&E were responsible for triaging patients, placing IVs, obtaining vital signs, compiling patient charts, administering medications, determining correct dosing, and writing all admission orders - tasks which are completed in the Mass General Emergency Department through the collaboration of several individuals in a multidisciplinary team.  Most of the residents and interns possess extraordinary work ethic and are extremely knowledgeable about the pathophysiology of various diseases; however, they work in an environment that limits their ability to practice medicine to the fullest of their abilities.  The local providers are fully aware of the resource limitations of the hospital and they do not hesitate to teach the less experienced providers what the optimal care plan would be if the patient had access to a more resource-rich hospital such as Mass General.  Every day I was impressed with the providers’ skill and determination to provide patient care to the best of their ability despite the resource limitations they faced.  

During my time at MRRH I was asked by the leadership of the A&E to assist with strategic planning.  I created a gap analysis of the current A&E to assess what resource limitations were preventing the delivery of basic emergency medical care to the patients.  The goal of this analysis was to assist with emphasizing to hospital leadership what important resources were lacking or absent in the A&E.  I was also fortunate enough to form relationships with the residents and interns who allowed me to take part in medical education.  My contributions to the team varied daily, depending on the conditions and needs of the ward and the A&E.  I assisted interns with thinking through the differential diagnosis and management of patients with unclear presentations to the A&E, I helped with patient triage, and I worked with the surgical interns on the approach to trauma in the A&E through the use of a mannequin for simulation.  I was also able to become involved with medical education through didactic “chalk talks” for medical students, precepting medical student patient presentations at the bedside, and presenting a case I had seen in the Mass General ED as part of a presentation to the medicine residents during a morning conferences. I truly feel that the activities above were beneficial to all involved and I hope that they have a lasting impact well beyond my return home to Boston.

I cannot thank the MGH Center for Global Health enough for their assistance in enabling me to travel to Mbarara and contribute to the education of local providers and to assist with the development of emergency medical care at MRRH.  My experience in Mbarara not only fostered my development as a physician but also impacted me greatly as a human being.  The life lessons I learned from my Ugandan colleagues will not only improve my ability to care for my patients in Boston but will also help me maintain perspective on the medical care disparities that remain in the world and motivate me to assist in closing these gaps.