Wednesday, September 6, 2017

Ambulance crisis: when taxis fill in the gaps

A taxi arrives at the emergency medicine

A taxi arrives at the emergency medicine department.PHOTO|SYRIACUS BUGUZI 

By Syriacus Buguzi @buguzi sbuguzi@tz.nationmedia.com

It’s a cool sunny afternoon at the Muhimbili National Hospital (MNH). Many people are flocking in for health services but my attention is quickly drawn to a taxicab that arrives in haste at the facility’s emergency centre—Tanzania’s first full capacity Emergency Medicine Department(EMD).

When the taxi finally comes to a stop, Mr Said Bakari, the driver, hurriedly steps out to open the hind door. No passenger alights off. The door is left ajar.

When I get closer to the taxi and peep through, my eyes land on an old man in his 70s, seated like any other passenger. He’s mute, motionless and breathless. He is very ill, yet there is no one inside the taxi to assist him.

I later learn that he’s suffering from chronic kidney failure and his condition had suddenly changed while at his home in Mbagala suburb. Bakari is still wandering around at the EMD for about 15 minutes, not knowing what to do with the patient.

Two sides of the coin

Bakari picked the patient about 12.8 km away from MNH, which is supposed to be about 39 minutes drive away, according to estimates from Google Map. But he drove for about 3 hours.

“I was called on phone to drive this Mzee from Mbagala. Thank God we’ve arrived here. I had to rush him. His relatives will be arriving soon in another vehicle,’’ he explains, when I enquire.

Soon, one of the EMD crews arrives and quickly assesses the patient, instructs Bakari to drive the taxi closer to what I came to learn later, was the right place—the ambulance bay. This is where all critically ill patients must be taken to, says the EMD crew member, Mr Jella Omary.

“Quite often, drivers of taxicabs or other private vehicles bring critically ill patients or accident victims and don’t know what to do on arrival,’’ says Mr Omary who is a nurse at EMD.

“There are cases where some drivers simply dump the patients outside the EMD and leave. This creates unnecessary delays and at times a patient may lose life before being attended to,’’ says Omary.

But Bakari, the taxi driver, has his side of the story too, as he vents off his frustrations. He says what mattered most at that time was the timely arrival and handing over the patient to the EMD.

“It has been a tough three hours on the road,’’ he says. “I have taken several detours to avoid traffic jams but it wasn’t easy, we still got stuck on the roads,’’ says Bakari.

Not a lone case

The story of taxicabs or private vehicles being used to transfer patients to Muhimbili’s EMD is not limited to Bakari’s case alone.

More than 50 per cent of emergency patients arriving at the EMD get there in private vehicles, mostly taxicabs, says the EMD’s Head of Department, Dr Juma Mfinanga.

“You see, in our country’s ambulance system, a patient who is in an emergency situation is transferred from a health facility to another. It’s called inter-facility transfer,’’ explains Dr Mfinanga.

“Outside this system, it means that people arrive at EMD in private vehicles, mostly those taxicabs you are talking about. This poses many challenges and increases the risk of mortality due to delays and lack of pre-hospital care,’’ he says further.

Taxicabs can’t substitute ambulances

Currently, the EMD receives between 200-300 emergency patients per day, data obtained from the facility authorities show. Taxis and private vehicles are the order of the day at the EMD. I camped there for over 6 hours and counted 40 arrivals. But 30 cases arrived in taxis and private vehicles.

At the EMD ambulance bay, the nurse, Mr Jella Omary further explains that certain emergency patients such as those diagnosed with high heart disease must be positioned in such a way that their breathing is not compromised.

“I know several cases where heart patients, who were supposed to be placed in what we call a prop up position, were instead brought in a taxi while seated wrongly. In certain cases, the patients died on the way. Their death could be attributed to wrong positions,’’ explains Mr Omary.

“If such patients came in ambulances, it means that a nurse(s) on board would help position them properly, give the necessary first aid resuscitate the patients where necessary,” he says in an interview with Your Health.

But for this to be achieved, Omary says, there is need for the country to increase access to ambulance services so that more lives are saved through early interventions. “We know our government has invested in emergency services but I think this requires more attention now,’’ he suggests.

A study done in Tanzania two years ago revealed that the health system lacks adequate public resources in the transportation and other infrastructure for first-responder Emergency Medicine Systems (EMS).

Published in the British Medical Journal (BMJ), the study, titled: The Tanzanian trauma patients’ prehospital experience: a qualitative interview-based study, it detailed cases of patients, exposing the current gaps in health delivery that exist with the existing referral system and what should be done.

There were cases of missed diagnoses, delays in care and transfer, and poor patient outcomes which could have been avoided, due to limited capabilities at pre-referral centres, the study shows.

It’s here that the EMD Head, Dr Mfinanga suggests, “In the long-term, it will reach a point where the country needs a centralised system of public ambulances, meaning that a person somewhere in an emergency can call an ambulance by simply dialing a number,’’ he suggests.

Currently, Tanzania’s referral system for emergency patients ideally includes free ambulance services from peripheral to higher level facilities. But, practically, this system is challenged by delays that may occur due to the limited number of ambulances and the cost of fuel.

What researchers say

An Emergency Medicine expert who has been researching on the state of emergency services in Tanzania, Dr Hendry Sawe, says the government has invested resources in ensuring that the emergency services are improved but, there are still big gaps to bridge.

“There is need to strengthen pre-hospital services. This is very crucial’’ says Dr Sawe who is also lecturer at the Muhimbili University of Health and Allied Sciences.

Increasing the number of ambulances in hospitals may not be the perfect idea. He says, “You can have a large number of ambulances but that’s not enough. They should be manned by trained drivers, installed with the necessary equipment.”

But, Dr Sawe says, the most important area of investment that we now need to look into is on ensuring that the public is well informed about how they can be good first responders. This should be complemented with having good pre-hospital services, away from the referral facilities, he says.

“There is a belief among the people that when a person is injured in an accident, he/she must be rushed to a referral hospital immediately,’’ he points out.

“In fact, the nearest facility—however small it may be—is more useful in saving lives,’’ says Dr Sawe who is also the Head of the Emergency Medicine Residency and Research Program Head at Muhas.

Importance of first aid

The Medical Officer in Charge of Amana Regional Hospital, Dr Mesha Shimwela believes that many lives would have been saved if the public understood the importance of first aid.

“Saving a life of an accident victim relies very much on how the first responders will intervene,’’ points out Dr Shimwela during an interview with Your Health.

“I know a case of a person who was hit by a motorcycle somewhere in Vingunguti but instead of being rushed to a nearby health centre for first aid, he was put on a tricycle and brought to Amana Hospital,’’ he recalls.

“All the way to Amana, he was bleeding profusely. By the time he arrived at our casualty department, he had already lost a lot of blood and his kidneys had been acutely affected,’’ he says.

“He died, despite efforts to resuscitate him. This can be attributed to the delays in getting first aid., although there could be other factors. You can see here that this didn’t require sophisticated health infrastructures; he simply needed first aid to stop the bleeding. This could be handled at the nearby facility,’’ says Dr Shimwela.

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