Thursday, May 29, 2014

First Aid Response Training in Mbarara, Uganda

The incredible need for such a course was immediately apparent to me on my first day in the Accidents and Emergency (A&E) Ward, MRRH’s equivalent of an Emergency Department. It was clear that the majority of patients were being evaluated for traumatic injuries, most from recent encounters with a boda-boda.  Half of them had their heads wrapped in gauze to either cover their head wound or to secure the post-surgical drain from their recent hematoma evacuation. Upon walking in, you were hit with a wave of a distinct scent of old, crusted blood mixed with the smell of purulent drainage and the natural odor of the human species, when one is unable to take a shower for days, all combined in a hot, humid air that is caught in a building that is located on the equator with no air conditioner. It was a difficult scene to process, at first, especially when a 13 year-old boy comes in with his peritoneum exposed and a deep abrasion to his scalp after being hit by a boda-boda. His eyes filled with fear and confusion as he holds tightly to his mother’s arm and lets out cries of suffering. Unfortunately, you become slightly desensitized after a few days because such a sight is not uncommon. 

I had arrived in Mbarara with nothing but a small set of slides and the knowledge I had obtained from reading about similar courses done around the world in the last 10 years.  Yet, one step into the A&E Ward gave me the motivation required to make any apprehension I had, about my ability to execute such a course, completely disappear. I realized that even though a one-day first aid course for only 40 drivers would be a drop in the ocean, it would still be the first step towards improving prehospital care in a city where that concept was barely being introduced. I had the responsibility of creating the first aid course from the ground up in 14 days.  Along with the mentorship from Dr. Hilarie Cranmer, Director of Disaster Response at MGH Center for Global Health, Dr. Miriam Aschkenasy, Deputy Director of Disasater Response at MGH Center for Global Health, Dr. Anna Baylor, Program Director for MUST Research Collaboration, and Dr. Jon Mousally, EM Faculty at MGH who is working on a similar project in Bangladesh, Sarah Graham, who is the Program Manager for the MUST Research Collaboration, was my main collaborator on the ground.

The first stage of planning was focused on the logistics of the course. We wanted to formulate a small course which did not over-extend our resources and risk the quality of the course. Additionally, we were executing a project that we had never done before to a community that was new to the concept. Our target population were the drives and staff of the MUST Research Collaboration. This was a good group to start with because they were familiar with MGH and had a stable handle on the English language. Preference was given to collaboration drivers. Within the first six hours of opening up the course, all available positions were filled. The demand was so great that we were forced to turn down requests to take the course. Furthermore, after the course, participants were asking when the next course would be available. The primary emphasis of the course was for it to be hands-on with minimal lecture time. Given resource and time constraints as well as the local cultural customs, we elected to make the course four hours long with a 20-minute break in between. In order to ensure participants had adequate one-on-one instruction, the course was implanted over two days in two four-hour sessions with 20 positions for each course. After having the basic logistical skeleton for the course, our attention shifted to finalizing the curriculum, response cards, and first aid kits. 
The curriculum was focused on subjects that had proven to be universally valuable in low-resource settings. It centered on scene safety, universal precautions, airway, recovery position, wound dressing, tourniquets, splints, and cervical spine precautions. Using current literature, I used the small set of slides I had prepared prior to arriving to Mbarara and expanded them to create a four-hour course.  We then created a response card based on the pictures used for the course. Our end-goal was to make this course self-sustaining, so the involvement of Ugandan physicians was critical from the conception of the course. We recruited four Ugandan physicians: three interns and one Mmed, the equivalent of a resident. On average, there was a one to four or five ratio of instructors to participants. The curriculum was taught using materials from a first aid kit that was made from locally-sourced supplies. We spent three days searched for the best supplies available and negotiated for the best price. The only out-sourced portion of the kit was the bag in which the supplies were packaged; it was donated by Global Disaster Response at MGH Center for Global Health. Supplies included: gauze bandages packages – 3 units, gauze Pads – 12 units, elastic Bandage – 3 units, medical tape – 2 units, medical gloves – 10 pairs, scissors – 1 unit, hand sanitizer – 2 units, 1ft wooden dowels – 4 units, crowbar – 1 units, water bottle – 1 unit. The participants were taught using only these materials and resources that would be available to them in case of an accident (e.g., a towel, shirt, sheet). Each kit also included a first aid response card that illustrated each skill taught in the course in addition to the list of supplies and location where they were obtained. Each driver received a first aid kit, a portable water bottle (also donated by Global Disaster Response at MGH Center for Global Health), and a certificate. The participants were made responsible for restocking their kits as supplies were used. A six-question test was completed at the end of the course to evaluate the participants’ knowledge retention. This test showed that scores were lower in the session in which collaboration drivers made up 80% of the participants. In Uganda, drivers tend to have lower education levels than other professionals. The lower test scores of this session could be attributed to lower education levels, language barrier, and less exposure to the medical field.
Although I had originally proposed to execute a 3-week first response training course for about 200 participants and a disaster drill, I was only able to take a small first step towards this grand goal. As you know, international emergency medicine is a very dynamic world. When dealing with communities of low resources, especially abroad, it is difficult to execute a project without the full understanding of the local culture, community, and infrastructure, which is what I was able to accomplish during my 4 weeks in Mbarara. The course laid the foundation for a better product because of community engagement and capacity building of Ugandan physicians. Additionally, my trip also focused on meetings with key stakeholder in the city and medical community of Mbrarara. Dr. Cranmer, Dr. Baylor, and I met with the Vice-Chancellor of MUST, the Dean of the MUST Medical School, the Chief of Police, the Chief of Fire, the heading of nursing for both the hospital and the university, and the Department Chiefs of MRRH. These meetings were integral to the development of disaster preparedness in Mbarara. The intent is to organize and establish a self-sustained, Ugandan-led pre-hospital training course that will culminate in a city-wide disaster preparedness and response plan, including mass-casualty exercises and drills. As the Vice-Chancellor of the Mbarara University of Science and Technology put it, “Our hope is to make Mbarara the model for country and hopefully East Africa.”
In order to start working towards our long term goal, in November 2014, we will conduct a risk and needs assessment focused on formulating a basic first response training course tailored to the specific needs of the Mbarara community. The assessment will address the capabilities of the local Ugandan taxi drivers, fire, police, University and Hospital staff, and healthcare workers. It will quantify the types of injuries they come across and qualify the skills they feel they are able to offer.  The modes of transportation injured patrons utilize to go to the hospital will be measured and reviewed.  By the end of this long-term project, we seek to create capacity in pre-hospital care and emergency health care delivery. Hopefully, in a couple of years, a 13 yr-old boy with an exposed peritoneum will come in at least partially stabilized and with proper wound dressings.

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