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.

First Aid Response Training in Mbrarara, Uganda.

Uganda 

Arriving in Rwanda

After a 3 yr hiatus, I am getting back on the road (or plane if you will). Last time I was abroad, I was so anxious to one day be able to go back into the world with a little knowledge under my belt. My year abroad taught me so much, but it was frustrating for me to not have the medical experience to be able to give back. I was a little medical student following the Senegalese/ Laotian resident around. I am now returning as an MD. A little baby MD with training wheels still on, but a Doctor nonetheless.  I am very excited but also nervous to get back on my travel horse. Although I have traveled a great deal, it is still scary to jump on a plane to a unknown land and culture. Here we go once again!

 May 2, 2014

 I started of my adventure with a 21 hour journey from Boston to Uganda (Boston -> Amsterdam -> Rwanda- > Uganda), which was followed by another 13 hours on the ground until I reach my final destination of Mbarara, Uganda. I arrived into Kampala, the Ugandan capital, at 10pm. It was a surreal experience to be setting foot in Africa again. My first hour here, from the airport to the hotel, was one giant flashback. It made me truly miss Senegal. I have kept Senegal very close to my heart since I left. It will forever be my first time in Africa and first time I went out into the world completely on my own. Uganda had big shoes to fill. As I walked out of the airport, all I could see and hear were the Senegalese taxi drivers yelling to get your attention in French and Wolof. I remembered those butterflies in my stomach, the sweat in my palms, and the feeling of my heart racing that I felt when I first landed in Dakar 3 years ago. I was so scared back then. All I kept thinking was to keep walking forward and seem as calm as possible, when all I really wanted to do was crawl in to a little ball and be teleported back home with my Momma. This time it was different. I knew what to expect, and my appearance of calm was not a facade but reality. It made me a little sad.  You only get to have your first kiss once, and you only get to be a 24yr old girl during her first time in Africa once too. As I looked up and saw the million stars in the sky, I smiled and thought to myself, “ Hi

Africa, I’m back!” Uganda is very beautiful. Senegal is in the middle of the Sahara, so it was nothing but desert and Boaboa trees. Uganda is dead center on the equator. It is about 80 degrees year round, so it is very green, a little humid, and filled with valleys.  All the nervous feelings I had as I prepared for my trip disappeared on my way to the hotel. It was like riding a bicycle. I immediately adjusted to the stores on the side of the road, the aluminum roofs, and old concrete or brick. The familiar smell of 1970s cars mixed with fresh air and old world was all around me. I was thinking of how wonderful it was to be able to come back to such a beautiful part of the world, when we arrived to the hotel gates with a security guard holding a machine gun the size of a small child. It was reality reminding me of where I was in the world.   

May 6, 2014

Mbarara

It has barely been 2 days, and I already feel like I have been here a week. Right away it is very obvious that this trip is unlike any trip I have taken. I have always gone abroad to study or work on a project.  Yet, my trips have always been focused on me learning. Even when I have gone abroad to complete a project, no one was depending on my results for anything. The expectation was that I get out as much as I could out of the trip and my experience in order to further my knowledge that specific field or topic. This trip is different because I have very real responsibilities. There are both Ugandans and Americans that are depending on my work and the results I obtain. It feels like the first trip of the rest of my life and career. I feel like my previous trips were done in preparation for this trip and the work I will do from now on. It is both daunting and very exciting.

May 7, 2014

A&E = Emergency Department

Working in the A&E ( accidents and emergencies), which is the Ugandan version of the emergency department is going to be such an incredible learning experience. I have been working hard these last 2 years as a resident to learn as much as I could and gain as much experience as possible as a clinician. It has been a very steep learning curve. Going from an oblivious little intern to now an up-coming PGY-3, the difference in my skills as a doctor are incredible.  On my first day of residency, it took me an  hour and a half to see and complete the evaluation of my first patient. I still remember his face, the room he was in, and his chief complaint. I was so scared to prescribed Tylenol because I knew that if I put in the order, the nurse would actually give it. It wasn’t like medical school, where everything is practice and things have to be approved by your senior resident or attending. Although I had plenty plenty of support and help if I needed it, my orders for medications and interventions would actually be given. Anyway, so I went from getting butterflies from prescribing Tylenol  to being able to confidently treat septic patients,  

Procedure Room

strokes, doing intubation, placing central lines, and ordering medications that could rapidly and drastically alter someone’s physiology as well as having the ability of being responsible of as many as 15-20 patients at the same time on my overnight shifts. I still have a lot to learn, but the difference is mind-boggling. 

Type and Crossing

 Well, I came from that back to step one again. Being here in the Uganda A&E, I don’t know where any of the medications are, how the system works, the extent of the capabilities of the department, or how to simply write a note. My first day, it took me 2 hours to complete the evaluation and admission of 1 patient. Obviously, some of that had to do with how the system works, but the intern had to talk me through how to write a note and work up a patient. I felt like a day 1 intern all over again. I was learning more from the Ugandan doctors and interns than they were learning from me. Me, the American doctor being trained with “advanced” techniques and was here to teach them a few things! Because they do not have the tools and technology we have available to us in the west, they rely mostly on their skills as clinicians and physical exam. It is an art that is quickly fading in the west due to our growing reliance on technology.  

Blood Bank

I needed it, my orders for medications and interventions would actually be given. Anyway, so I went from getting 

It reminded me that I have to always be paying attention. There is no difference between me and the 13yo boy I say in the A&E the other day, who was hit by a boda boda. He came in with a head injury, cuts, and a very large open wound that involved the entire left side of his abdomen. He was lucky because it didn’t involve the part of the body that keep your organs and intestines inside. He was sutured up and discharged home later in the day.

May 8, 2014

I wake up at 630am-7am every morning and have not been able to go to sleep until about 11pm every night, not much difference than my days back in the US. Well, I little different. I don’t think I will have to take-on strings of days/weeks of getting 5-6hrs of sleep per night.

I have already had two amazing experiences. On Tuesday, I tagged along with a field team who deliveries HIV medications to rural communities. We drove out about 1 hour from Mbrarara into the tiny huts and houses that are in the middle of banana plant fields and miles from anything remotely modern. It was awesome!! I was honored to be the guest into their homes and sit in the one chair or bench of their home. The houses are usually made of clay, using old palm tree leaves as the structure backbone of the clay walls. The roof is usually made tin or dry palm leaves weaved together.

View of Mbarara Regional Referral Hospital

Today, I accompanied one of the internal medicine residents who is also here to a rural clinic that was 4 hours away from Mbarara. In order to get there, you have to drive through Queen Elizabeth National park, which is the main game reserve here in Uganda. There we were, making a very ordinary drive out to the clinic while seeing elephants, water buffalo, water bucks, and exotic birds on the way. No big deal. Just another part of our day! I couldn’t help but laugh and smile about the life I am lucky enough to live. 

The clinic experience was eye-opening. These patients are so far away from any major city, that this clinic is all they have for medical assistance.  There is no doctor. There is a chief medical officer, who was trained for 3 years after high school and is responsible for every patient, and a team of nurses. The clinic has a catchment area of about 40, 000 people, so it is no small task. He is able to work with limited medications to treat diseases that would require entire medical teams in the west. It was very humbling.

May 11, 2014

This first week was all about getting to know my environment, the people, the culture. I spent months trying to plan out my project, but it is so different to actually arrive and to start doing it. The beginning stages of organizing the first aid course have started. I have a specific plan of action. The program coordinator, Sarah, has been here for about 2 years so she knows the system very well. I had the curriculum and overall concept of the course planned out in my mind, but she is helping me adjust it to the setting in which I am working. Next week will be very busy. We are implementing the course in 8 days. It is not a lot of time to implement a course that I have never executed before in a setting that I am just getting familiar with. Yet, I know that we will get it done. We are going to start off small. We are planning to have only 40 participants this time around. My hope is that this course will grow and develop to become a city-wide event. 

Central Market

Chickens for sale at market.

Roadside Rest Stop

Elephant on my way to rural clinic.

Lake Bunyonyi

Ugandan kids