Emergency Medicine Editorial

BULLETIN of the NETHERLANDS SOCIETY for TROPICAL MEDICINE and INTERNATIONAL HEALTH

N O 0 1 / m a r c h 2 0 1 9 - v o l u m e 5 7

EMERGENCY MEDICINE EDITORIAL

EMERGENCY MEDICINE

e are so familiar with For the medical staff, working in such health emergencies; an environment is challenging; one CONTENT when someone suffers must quickly become used to taking on from cardiac arrest, a lot of responsibility. A (junior) expat REVIEWS Wdiabetic coma, acute abdomen, a calam- doctor may have to perform emergency The importance of Emergency ity in pregnancy or trauma, we call 112 operations particularly on trauma pa- Medicine in Africa - 3 or 911 (whatever applies in our area) and tients that he would never have been an ambulance with skilled staff is on its allowed to do in countries like the Neth- Establishing a paediatric way to the scene and should arrive with- erlands, with little if any supervision. intensive care in a low income in a specified time to provide first aid. setting - 6 Resuscitation may have already been Emergency Medicine (EM) has devel- started by bystanders who have been oped into an increasingly recognized Burden and pattern of injuries trained in cardiac massage in publicly speciality with improved access to in an Ethiopian referral available courses. Skilled staff awaits the specific training for all staff and the hospital - 9 patient at the emergency department availability of protocol-based manage- and major life-saving interventions can ment. Designated emergency units ARTICLE be done immediately with further care and intensive care units have been Burn injuries in Africa with a in an intensive care unit if needed. established. EM has been integrated focus on management in the into the medical curricula, and medi- acute phase - 14 Not so in most low- and middle-income cal and nursing staff do rotations in the settings. Bystander response or any Emergency Department. The impact of INTERVIEWS form of emergency service such as EM cannot be overemphasized: besides Emergency Medicine training in ambulance transport or hospital-based saving lives, it reduces the burden of Africa - 5 facilities is absent in many places. How- inappropriate admissions to the wards ever, this is slowly changing. In 2018, and reduces overcrowding and overbur- The Adult Emergency and the WHO launched the Global Emergen- dening of nursing and medical staff, Trauma Centre (AETC) at Queen cy and Trauma Care Initiative to provide which in turn benefits all admitted Elizabeth Central Hospital, a structured framework to address this patients. And last but not least, in- Blantyre, Malawi - 12 issue. In Africa, there is now an African creased awareness, better staff training, Federation for Emergency Care (AFEM) and improved infrastructure in overall LETTER FROM THE TROPICS that has produced the Oxford Handbook health facilities result in better care Lessons learned from an of Acute and Emergency Care with and a more rational referral pattern. internship at an Emergency protocols for all common conditions. Department in It is gratifying to see yet another South Africa - 18 In Malawi, the adult trauma and important component of the medi- emergency centre at Queen Eliza- cal spectrum coming of age. CASE REPORT beth Central Hospital in Blantyre has A rabid pregnant woman in transformed emergency care dramati- ED ZIJLSTRA Tanzania: Obstetric dilemmas cally based on triage and a well-defined JOSEPHINE VAN DE MAAT and considerations - 20 patient approach. In the same hospital, a paediatric intensive care unit was suc- IN MEMORIAM cessfully established, boosting health NO ONE SHOULD DIE Ankie Borgstein van Wijk care for children in general and offering FOR THE LACK OF 1925-2018 - 22 specialized care for those who need it. ACCESS TO EMERGENCY CARE, AN ESSENTIAL Patients with burns form a special category, and the emergency man- PART OF UNIVERSAL agement faces many challenges in HEALTH COVERAGE which cultural beliefs, poor infra- WHO DIRECTOR-GENERAL structure, poor training and lack of DR TEDROS ADHANOM specialized care play a role with a GHEBREYESUS [1] Disclaimer direct negative effect on outcome. All views expressed in this journal are of the authors­ only and are not ­necessarily shared by the editors of MT. Letters and articles may be edited for purposes of clarity and space. 1. World Health Organization (WHO). Global Emergency and Trauma Care Initiative [internet]. Geneva: WHO; 2018. Available from: https://www.who.int/emergencycare/global-initiative/en/

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The importance of Emergency Medicine in Africa

Many acutely ill or injured adults 2013.[5] These chronic lifestyle diseases This is up to international standards and children in Africa seek care such as cardiovascular disease, lung especially considering there were no ­every day. Frontline providers man- disease and diabetes typically present cases of shockable rhythm observed. age patients with acute problems as life-threatening acute exacerbations Disappointingly, none of the patients like injuries, infections, stroke, such as diabetic ketoacidosis, asthma/ survived to discharge. The main asthma and complications of preg- COPD exacerbation, stroke and heart contributing factor was the lack of post nancy. These acute presentations attacks. The third burden is perhaps cardiac arrest care, as only about half of unfortunately contribute to a high the most characteristic of the continent: the patients were admitted to ICU.[8] mortality and morbidity. Health- accidents, violence and war. Specifically, care provision on the continent has trauma as a consequence of road traffic FRAMEWORK PROPOSED BY WHO historically focussed most on the accidents (RTAs) and interpersonal vio- Any regional or national approach classic burden of disease such as lence causes almost double the amount should be customized and take into con- elective chronic care e.g. HIV/AIDS of disability adjusted life years (DALYs) sideration the specific burden of disease, programs, nutritional care, elec- in Africa compared with the rest of the gaps in the health care system and re- tive surgery etc. It seems a growing world.[6] Other major causes are burns sources available. For instance, emer- burden of emergency presentations and drowning.[7] Africa is the only WHO gency care in Southern Africa is slowly is not being provided for sufficient- region where the percentage change in taking off while in Central Africa there ly. In response, in 2018 the WHO age-standardized road injury DALY rate is virtually no emergency care provision. launched the Global Emergency and increased over the period 1990–2013.[7] These different areas need different so- Trauma Care Initiative to provide a lutions. The ‘WHO emergency care sys- struc-tured framework to address LACK OF ACCESS TO EMERGENCY CARE tem framework’ is a tool to identify gaps this issue.[1] There are many obstacles to healthcare in care delivery and to create context- access in an emergency, especially relevant priority action plans for system THE PROBLEM in the rural areas of the continent. It improvement. The framework is based Health and well-being in Africa is starts with a lack of bystander response, on three distinct levels as illustrated in characterized by a unique and evolv- and there is usually no coordinated Figure 1. The levels include the scene, ing triple burden of disease as well provider dispatch carried out by a call transport and the facility. All three have as a lack of access to healthcare. centre. Subsequently, there is a lack the same key components to function: This combination contributes to the of emergency medical service (EMS) human resources, protocols and equip- fact that it is the continent with the ambulances to bring patients to a ment. Some context relevant examples of lowest life expectancy by far.[2] hospital or clinic. Attendance may be these components are described below. further delayed by lack of triage and/or THE TRIPLE BURDEN[3] emergency department facilities. Ulti- HUMAN RESOURCES Communicable diseases, poverty and mately, there is often a lack of admission As scarcity of appropriately skilled malnutrition characterize the first facilities such as high or intensive care providers is an issue, a realistic approach burden of disease, classically repre- units (ICU) or early operative care. to the attainable level of training as senting the majority of years of life well as task shifting is required. A good lost in Africa.[4] These conditions can All the links in this chain rely heavily example is the introduction of specialist lead to acute life-threatening presenta- on each other and need to be in place nurses such as Emergency Care Provid- tions such as sepsis and dehydration, in order to be successful. Research ers (ECPs) in rural Uganda. Since 2009, which have a very good prognosis if conducted at a large Emergency Depart- they have attended to 80,000 patients, treated adequately and in time. The ment in Botswana identified a clear gap. which resulted in favourable mortality second burden is non-communicable This unpublished prospective obser- rates. This suggests that task shifting diseases (NCDs) and mental health. vational study observing the outcome can be successfully applied to acute NCDs in Africa almost doubled the of witnessed cardiac arrest revealed care in order to address the shortage percentage of total deaths attributed that 27% of patients (n=71) regained of emergency care.[9] In South Africa, to them in the period from 2008 to return of spontaneous circulation. there is an overwhelming demand for

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doctors with skills in emergency care researchers to share research in their tic training of human resources, and in numbers that the national residency peer-reviewed journal and by publish- selecting evidence-based pro-tocols program cannot provide. A Diploma in ing the ‘AFEM Clinical Handbook of applicable to the African setting. Primary Emergency Care (DipPEC) was Acute and Emergency Care’. Addition- introduced, a one-year core curriculum ally, free online open-access medical program, which is now graduating education (FoaMED) blogs like #badEM MICHIEL VAN VEELEN, MD, emergency 150-180 candidates per year, providing (brave Afri-can discussions in Emer- physician, DTM&H an immediate solution in a responsible gency Medicine, www.badem.co.za) Institute of Mountain Emergency Medicine, and affordable way.[10] South Africa, contribute by discussing current issues. EURAC Research, Bolzano, Italy. Botswana, Rwanda, Tanzania, Ethio- [email protected] pia, Egypt, Sudan, Malawi and Ghana EQUIPMENT AND IT have developed their own emergency Resources are required at all levels to medicine residency programs. Local function at a minimum level. A call REFERENCES

EM specialists are now ready to fill key centre with a national alarm number, 1. World Health Organization (WHO). Global Emergency and Trauma Care Initiative [internet]. coordinating roles in EMS and disaster equipped EMS ambulances, and EDs Geneva: WHO; 2018. Available from: https://www. management, guideline development with equipped shock rooms supported who.int/emergencycare/global-initiative/en/ 2. Central Intelligence Agency (CIA), The World [11] and research as well as teaching. by 24/7 radiology, laboratory and blood Fact Book [internet]. Wash-ington; 2017. Available from: https://www.cia.gov/library/publications/ bank. Bedside diagnostics in the ED the-world-factbook/rankorder/2102rank.html CONTEXT BASED PROTOCOLS such as ultrasound and portable blood 3. Our World in Data, Burden of Disease [internet], Univer- sity of Ox-ford/Global Change Data Lab, 2018 Available Clinical protocols are evidence-based gas machines are quick wins; they from: https://ourworldindata.org/burden-of-disease 4. World Health Organization (WHO). Disease but rely heavily on studies performed in make the provider independent, are burden by Cause, Age, Sex, by Country and by the Western setting. There are strong quickly accessible and generally cheap. Region, 2000-2016. [internet]. Geneva: WHO; 2018. Available from: https://www.who.int/healthinfo/ examples that demonstrate that it is global_burden_disease/estimates/en/index1.html 5. U.S. Department of Health & Human Services, The not possible to extrapolate appropriate CONCLUSION Burden of Non-Communicable Diseases in the Devel- management to African settings. These There is still a lot to gain by introduc- oping World [internet]. Washington; 2015. Available from: https://www.ahrq.gov/professionals/education/ include the increased mortality after ing or improving the emergency care curriculum-tools/population-health/baldwin.html 6. Norman R, Matzopoulos R, Groenewald P, Bradshaw D. fluid boluses in children with severe chain in Africa. Looking at Africa’s The high burden of injuries in South Africa. Bulletin of infections found in East Africa as well specific and dynamic burden of disease the World Health Organization. 2007. 85(9):649-732. 7. Haagsma JA, Graetz N, Bolliger I, Naghavi M, as the observed increased mortality and its access issues, emergency care Higashi H, Mullany EC et al. The global burden of injury: incidence, mortality, disability-adjusted life after an early resuscitation protocol in is likely to be in high demand. Ap- years and time trends from the Global Burden of adults with sepsis in Zambia.[12,13] Both plication of the WHO emergency care Disease study 2013. Inj Prev. 2016 Feb 1; 22(1):3. 8. Lekang K, van Veelen MJ, Cox M. Return of studies contradict current Western system seems to be a useful framework Spontaneous Circulation dur-ing Cardiopulmonary Resuscitation (CPR) in Patients with Cardiac Arrest guidelines. The African Federation for in an African set-ting, especially when at Princess Marina Hospital Emergency Depart- Emergency Medicine (AFEM) is closing scrutinizing specific issues such as ment, (PMH ED), Gaboro-ne, unpublished data. 9. Chamberlain S, Stolz U, Dreifuss B, Nelson SW, this gap by providing a platform for local weak links in the access chain, realis- Hammerstedt H, et al. Mortality Related to Acute Illness and Injury in Rural Uganda: Task Shift-ing to Improve Outcomes. PLoS ONE. 2015. 10(4): e0122559. 10. The Colleges of Medicine of South Africa (CMSA), Diploma in Primary Emergency Care of the College of Emergency Medicine of South Africa: Dip PEC(SA) [internet]. 2018. Available from: https://www.cmsa. co.za/view_exam.aspx?QualificationID=60 11. African Federation of Emergency Medicine (AFEM), Doctors in Emergen-cy Medicine & Leadership Training in Africa [internet]. 2015. Available from: https://afem.africa/project/doctors-in-emergency- medicine-leadership-training-in-africa/ 12. Maitland K, Kiguli S, Opoka RO et al. Mortal- ity after fluid bolus in African children with severe infection. N Engl J Med. 2011;364:2483-2495. 13. Andrews B, Semler MW, Muchemwa L, et al. Effect of an Early Resuscita-tion Protocol on In-hospital Mortality Among Adults With Sepsis and Hy-potension: A Ran- domized Clinical Trial. JAMA. 2017;318(13):1233–1240.

Figure 1. WHO Emergency Care System Framework Source: www.who.int/emergencycare/emergencycare_infographic/en

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Emergency Medicine training in Africa

Heike Geduld is one of the first emer- together around specific needs in EM can Journal of Emergency Medicine) has gency physicians trained in Africa,­ and shared materials. Our strength was received Pubmed registration, and the and she is currently a leader in emer- fostering this network and validating AfCEM conferences held every two years gency medicine (EM) in the region. In the work of partners in their respective attract hundreds of participants. As an this interview, Heike shares her story, countries.’ For Heike this was one of the educator, Heike holds great pride in experiences and vision on this new and main successes of AFEM: the creation having been an implementation partner fast-growing specialty in medicine. of a network and bringing committed of the WHO in their Basic Emergency people together around a shared vision Care (BEC) course. The course is for FROM FIRST RESIDENT T0 HEAD OF of emergency care for all across Africa. providers having to deal with emergency DEPARTMENT care in limited resource settings. There Heike Geduld, born and raised in Cape THE RELEVANCE OF DATA have been pilots in Uganda, Tanzania, Town, was among the very first group Education has been very important and Asia, and the course is open-source of residency trainees in emergency in reaching this goal, Heike recalls. available.[2] Heike was one of the editors, medicine on the African continent. This is considered ‘low-hanging fruit, and it was one of ‘those personal dreams Though the medical system in South as it is measurable and it allows you to be involved in something way bigger Africa in those days (in 2004) was fairly to prove that you made a difference. than the things that I can do day to day.’ advanced, EM as a speciality tended There are thousands of educational to lag behind. For Heike it was quite a projects in Africa, so one of our primary DEALING WITH EM IN THE COMMUNITY challenge being in that first group. ‘We focus areas has been to bring people In places where emergency medical had no idea what we would get into, together, facilitate their collaboration, service (EMS) is not formalised, it is but I felt that EM was really important, and harvest the educational projects.’ important to educate the lay person and particularly in the African context with enable people to respond to emergen- a high burden of HIV, TB and trauma. This harvesting was done by themselves, cies in a sensible way. To support this, That was the area in which we could as they always ensured that the authors AFEM developed the Community First make the biggest difference, we thought. and collaborators were Africans and not Aid Responders (CFAR) project in which And in addition, for me personally, I re- only visitors from high-income coun- the community is trained in firstly ally liked the idea that emergency medi- tries. The personality of people working recognizing emergencies, and secondly cine allows you to fix things quickly.’ in EM helped to get things done, as knowing what to do when they occur. according to Heike ‘We are people who Building a good EMS is building a good From there, her career took off, as Heike are often quite willing to push ourselves, community response system. The CFAR – after many years of presiding the Afri- take chances and give things a go.’ curriculum includes basic components can Federation for Emergency Medicine on safety and personal protection, on (AFEM) and the College of Emergency This attitude was important and proved how to stop bleeding, and basic splinting Medicine of South Africa – embarks useful in publishing on EM in Africa, with things that are lying around. The on a new position as Head of Division because as Heike underlines ‘One of context is important, as Heike explains. of EM at Stellenbosch University. the things we were very aware of from ‘When we started educating taxi drivers the start is that you can’t build and in Madagascar, the taxi drivers asked if SHARED VISION advocate for a system unless you have we could also teach them how to deliver Over the past 15 years, the speciality of data. That is what ministries want, and babies. Because there is no prehospital EM has matured vastly although it is this needed to be produced by people system, they are the ones driving pa- still fairly new. In her job with AFEM, on the ground. So when you train tients to hospitals, and they were some- Heike was responsible for training and people to take on this role as EM nurse times delivering babies themselves! systems development in emergency or pre-hospital provider or emergency medicine. She also devoted much of physician, you have to teach them how her time to advocating for having to do the research and to present it in a an emergency physician in a medi- way that actually allows them to provide cal facility and for training nurses in advocacy. For EM to develop, everyone emergency medicine. ‘Emergency care who is a new trainee is a future leader.’ appears quite costly to health manag- ers, especially building supporting AND THE HARVESTING CONTINUES… systems (from the community to the In a relatively short time span, AFEM hospital), which makes advocacy quite has published two handbooks on acute challenging. We managed however to and emergency care – geared to LMIC bring key partners from across Africa settings,[1] their Journal (AFJEM, Afri-

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That never crossed our mind!’ Besides to see more education programmes are quite a lot of places that actually the context, culture and acceptance of across Africa – particularly franco- need people to come and teach.’ emergency care matter, but also much phone countries. In addition, ‘There is depends on the system and resources. a need to focus on formalising train- With these words, and an invitation An example is how to deal with car- ing of nurses and other care providers to participate in the upcoming confer- diopulmonary resuscitation (CPR) in a in EM, alongside improvements in ence on EM in Cape Town in November low-resource setting, or if there is debate prehospital care, and of course we need (www.emssa2019.co.za), we concluded on the issue, for example on whether consolidation of the existing systems.’ an interesting conversation about to perform CPR on an elderly person. emergency medicine in Africa. Those In some cultures, ‘People will actually A WORD OF ADVICE who cannot wait until November and say it is important that you do CPR on One of the tips Heike would give Dutch are interested in any of the programmes elderly patients as they are the soul of MDs coming to work in emergency Heike is involved in, can contact her the community.’ Examples like this medicine in Africa is to be culturally directly ([email protected]). show the relativity of ‘common views’ sensitive and aware of the context. ‘I do when considered in a specific context. think that there are fantastic experi- ences you can have as an emergency JOSEPHINE VAN DE MAAT THE FUTURE OF EMERGENCY­ care provider in an LMIC. We have very PhD student Sophia Children’s Hospital, MEDICINE IN AFRICA complicated cases, but there is also this Rotterdam Emergency medicine training took off experience of being part of something [email protected] over the past decade, with ten countries that is both challenging and incredibly across Africa now providing this train- uplifting. EM in Africa is very uplift- ing (South Africa, Botswana, Tanzania, ing, because there is the chance to do REFERENCES

Ethiopia, Egypt, Sudan, Ghana, Rwanda, something in a space where very few 1. AFEM handbook of Acute and Emer- gency Care, Oxford University Press Uganda and Mozambique). This is a people are involved. So the things you 2. WHO Basic Emergency Care course: www.who.int/ good development, though Heike hopes do can make a big difference. There emergencycare/publications/Basic-Emergency-Care/en/

Establishing a paediatric intensive care unit in a low income setting

Childhood mortality in low- and come from improved curative services. ally done in high-care wards or paediat- middle-income countries (LMICs) ric intensive care units (PICU), a concept has dramatically decreased over the Reducing in-hospital mortality means which is relatively new to sub-Saharan last two decades.[1,2] In the 1990s, improving care of critically sick chil- Africa. Even in western settings, sepa- nearly one in five children living dren, or in other words developing rate paediatric intensive care units were in sub-Saharan Africa died before critical care medicine in low-income only established in the 70s and 80s. In their fifth birthday. The under-five settings. The WHO acknowledged the sub-Saharan Africa, these units are not mortality for sub-Saharan Africa importance of critical care in paedi- common but are slowly appearing.[6] has since more than halved and is atrics by developing the Emergency currently estimated at 7.6%.[1,2] Triage and Treatment (ETAT) guide- In Blantyre, Malawi, we opened the first lines in the previous decade.[4] These paediatric intensive care unit in July Childhood mortality in LMIC settings guidelines, developed for healthcare 2017. In this article we describe some however remains an unacceptable eight workers in LMICs, help to timely of the issues we faced and progress times higher than in high-income coun- detect critically sick children, priori- that has been made that may be of try (HIC) settings and needs further tise their care, and improve the qual- use to others with similar interests. reduction in the coming decades.[2] The ity of resuscitation and save lives.[5] question is of course how to achieve SETTING this. So far the largest reduction may Although this may be seen as the in- Malawi is one of the poorest African have been due to preventive medicine, troduction of critical care to LMIC, still countries and has a current health an area that may still have room for much has to be improved in the care we expenditure of 30 US dollars per capita improvement.[3] However, we now may deliver to children following the acute per year.[7] Blantyre, the second largest have entered an era where further event. Focussing attention, resources, town in Malawi, is home to the country’s reduction of mortality should (also) and efforts on the sickest children is ide- only medical university, the College

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Entrance of the Mercy James Centre building. Interior of the PICU or paediatric intensive care unit. of Medicine, which was founded in support staff is unmistakably one of the The unit is currently run by two in- the early 1990s. The Queen Elizabeth most important aspects in developing a ternational paediatric intensivists that Central Hospital is a third-line govern- PICU. In collaboration with the govern- perform the clinical work and build up ment hospital affiliated to the college. ment, 20 nurses were hired to staff the the unit. With the help of visiting inten- Its paediatric department is one of the six-bed PICU, a relatively low number sivists from the collaborative projects largest departments and hosts on aver- compared to western PICUs in HICs, and a Malawian paediatric anaesthetist, age 200-350 in-patients, with wards spe- but a very high number compared to the clinical work of the unit is covered. cialising in general paediatrics, neonatal normal hospital wards in LMICs. Some During out of office hours most of the care, malnutrition, oncology, orthopae- of the nurses had paediatric experience work is performed by Anaesthetics dics, neurosurgery, burns and general whilst others were newly registered Clinical Officers, who have been trained paediatric surgery.[8] The paediatric nurses. All nurses were trained in over the past 18 months in PICU-related surgical unit was rebuilt and re-opened the weeks prior to opening the PICU topics. These physicians can rely on in 2017 as the ‘Mercy James Centre for with support from an American PICU a growing number of local protocols Paediatric Surgery and Intensive Care’. nurse trainer, input from Cape Town developed over the past months which As part of the improved care, three new University, and the involvement of are accessible through a website.[9] In the operating theatres, a four-bed high-care the paediatric, surgical and aesthetic long run, the unit should be staffed by a and six-bed paediatric intensive care departments and the college of nurs- paediatric intensivist from Malawi; the was included in the building plans for ing. The two lead nurses of the unit had first one is currently being trained in this new paediatric surgical hospital. spent a six-month period in the PICU Cape Town, South Africa. A six-month of Oslo and a Norwegian PICU nurse fellowship in paediatric intensive care CHALLENGES was present to deliver bedside training. and anaesthesia was developed to en- Setting up a new high-tech facility in an courage interest among young doctors. LMIC faces several challenges. Some of Since the opening, nurse training has these challenges may not be different continued on site, and after a year most The care for critically sick patients from setting up a new health facility nurses have developed from beginner relies on many more persons than doc- or even a business in a low-resource to a good basic level of PICU nurs- tors and nurses alone, including ward setting. However, the consequences ing. In the next year, the level should assistants, cleaners, technicians, store of suboptimal functioning are poten- be further improved to also be able managers, lab technicians, pharma- tially lethal as critically sick children to make an impact on the vulnerable cists, physiotherapists and data clerks. are involved. Unmistakably the most neonates which require a very high The performance of all these persons important challenge has been obtaining level of attention to detail and care. is essential but demands (very) differ- funding, embedding it in the existing ent skills in the critical care setting and infrastructure, and obtaining sustain- During the first year, new nurses joined requires extra training. Most train- able involvement of the government. To our team, which emphasised the need ing, once again, was provided in the achieve this, several important collabo- of having our own PICU nurse train- ward by our own staff or by external rations have contributed essential equip- ers to deliver the curriculum developed specialists who were sent by one of the ment and other resources to the develop- for our new staff. Two nurse teach- collaborative partners, as many of these ment of our PICU (Figure 1). The paper ers were selected to receive further areas involve expertise that cannot focusses though on more practical chal- training in Oslo and have been linked be provided by nurses and doctors. lenges we faced during the first year. up with American and Dutch nurse trainers. By involving the College of CONSUMABLES, DRUGS AND LOGISTICS STAFF Nursing in Malawi, we aim to boost The permanent availability of essential Staffing the unit with sufficient and the development of a critical care consumables and drugs is essential to adequately trained nurses, doctors, and curriculum for nurses in Malawi. outcomes of PICU patients. A list of

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essential equipment and drugs was com- and require permanently available staff suffering from an acute illness which is piled together with our management to perform urgent repairs. Training and detected in time, and after a short and team, and we are setting up reliable sup- appointment of a qualified and motivat- intensive treatment, the child fully re- ply lines and a solid store management ed technician has been essential to keep covers. The ICU is then a bridge towards system. This process in itself is quite the donated items running, and we aim a healthy future. We have written a complex in our settings for several rea- to move towards preventive maintenance guideline that can help in making these sons. We require new items and drugs and an indexed system of equipment. difficult decisions as we gather outcome data from patients we admit to PICU.[9] HYGIENE Intensive care also means clustering The timing of admission is essential as patients who are severely sick, often due detection of clinical deterioration and to infections, with patients most vulner- timely intervention and PICU admission able to infections. Infection prevention can prevent morbidity and mortality. and treatment is therefore even more Creating a PICU has demonstrated the important than in other parts of the need for a unit that can more closely hospital. Even in high-income settings it monitor patients who may need more is not uncommon that (multi-resistant) intensive care or do not need to be in bacteria rapidly spread in ICUs and PICU anymore but still need moni- cause temporary closing of units. In our toring. The paediatric department is hospital, multi-resistant gram-negative currently developing such a high-care Figure 1. A summary of some partners involved bacteria were and are present and have unit, which is essential to improve the in developing the ­Mercy James Centre Paedi- not ignored our PICU.[10] The role of an full chain of care for our patients. atric Intensive Care Unit (MJC PICU) active and multidisciplinary infection prevention committee, medical bacte- CURRENT DATA that have not been routinely available in riology support, appropriate antibiotic In the first year since opening, we ad- health services in Malawi. Some items drugs / guidelines, and a proper supply mitted 296 patients to PICU who spent cannot be bought locally and delivery line to prevent re-using equipment 1185 bed days in our unit. The number can take weeks to months. We partly are essential but also a challenge. depend upon donations, which may not always provide the right items. We are PATIENTS AND ETHICS trying to improve this essential aspect Possibly the biggest clinical challenge by simultaneously involving hospital is deciding whom to admit (or reject) pharmacies at a local and national level, to PICU. Even in settings with high re- preferably sourcing items through lo- sources this is a recurrent dilemma, but cal commercial suppliers rather than in settings with high numbers of severe- Figure 2. Admissions during the first year of the PICU depending upon international dona- ly sick children and limited beds this tions, by developing a computerised ethical dilemma is even more pressing. stock system, and by appointing a An important element of critical care is of admissions per month is displayed in stores and procurement manager. to focus resources on those in whom we Figure 2. Most admissions consisted of can positively change the course of dis- children with surgical conditions (80%). EQUIPMENT AND FACILITIES ease. Deferring a patient from PICU will The majority of our patients (151/296 Intensive care medicine involves a likely mean the patient will not survive, = 51.0%) was less than one year of age large quantity of essential equipment whilst admission of a patient who will and 29.3% (n=87) less than one month. including ventilators, monitors, syringe not survive indirectly means that (sev- Newborns are generally overrepre- drivers, special intensive care beds, eral) other children with a potentially sented in PICUs, as this age group is mobile imaging machines and basic lab good outcome may not get a PICU bed. commonly affected by either congeni- machines. These items were donated tal (surgical) conditions or infectious as refurbished equipment or purchased The decision is further complicated diseases. The percentage of patients as new equipment with the help of since a) PICU-care is new to all physi- who were ventilated during admission donors. To be able to run these sensitive cians involved and thus there is little increased from 40% in the first month machines non-stop, several essential experience and data aiding these deci- to approximately 80% at the end of the facilities were incorporated in the design sions, b) presentations are often delayed, year. The overall mortality was 25% of the hospital including a generator and and c) information on the course (n=75), which was higher in neonates Unlimited Power Supply (UPS), a plant and cause of disease is more difficult but was not different amongst surgical to concentrate oxygen, air and create to obtain. The latter two both delay or medical patients (data not shown). vacuum and a buffered water supply. prompt and adequate treatment and These systems are all equipped with reduce chances of full recovery. Ideally, FUTURE DIRECTIONS AND CONCLUSION alarm units to detect malfunctioning intensive care is given to a healthy child The development of a paediatric inten-

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sive care in Malawi has been a major REFERENCES achievement that was realised by the JOB CALIS 1. UNICEF 2018 https://data.unicef.org/topic/child- commitment and collaboration of many survival/under-five-mortality/ . [accessed 21-jan-2019]. Mercy James Centre for paediatric surgery 2. WHO 2018; https://www.who.int/gho/ individuals, institutes and governmental and intensive care, Blantyre, Malawi. child_health/mortality/mortality_un- der_five_text/en/ . [accessed 21-jan-2019]. and non-governmental bodies. Embed- Department of paediatrics and child health, 3. WHO 2016; Health in 2015: from MDGs to SDGs; https://www.who.int/gho/publications/ ding the PICU into the current system College of Medicine, Blantyre, Malawi. mdgs-sdgs/en/ . [accessed 21-jan-2019]. and obtaining government and hospital 4. WHO 2015; Emergency Triage Assessment Department of paediatric intensive care, and Treatment (ETAT) course; https://www. support and resources has been es- Emma children’s hospital, University who.int/maternal_child_adolescent/docu- ments/9241546875/en/ . [accessed 21-jan-2019]. sential. However, much more time and Medical Centers Amsterdam, the 5. Kapoor R, Sandoval MA, Avendaño L, Cruz AT, effort will be needed to fully embed the Netherlands. Soto MA, Camp EA, Crouse HL. Regional scale-up of an Emergency Triage Assessment and Treat- PICU in paediatric healthcare services. [email protected] ment (ETAT) training programme from a referral hospital to primary care health centres in Gua- Challenges to be faced involve develop- temala. Emerg Med J. 2016 Sep;33(9):611-7. ing reliable supply lines and stocks, 6. Punchak M, Hall K, Seni A, Buck WC, et al. Epidemiol- Co-authors ogy of Disease and Mortality From a PICU in Mozam- maintaining and replacing essential bique Pediatr Crit Care Med. 2018 Nov;19(11):e603-e610. P. WEIR, T. KAPALAMULA, E. THOMSON, 7. equipment, development of a critical WHO 2016, Country statistics for Malawi, S. CHIKUMBANJE, M. MPUNGA, S. DAYO http://apps.who.int/nha/database/country_pro- care curriculum for nurses and doctors, file/Index/en; accessed 21-jan-2019. AND E. BORGSTEIN; all from the Mercy 8. Harris C, Mills R, Seager E, Blackstock S, et al. Paedi- and finally improvement of high-care James Centre for paediatric surgery and atric deaths in a tertiary government hospital setting, Malawi. Paediatr Int Child Health. 2018 Nov 19:1-9. facilities in our medical wards. intensive care, Blantyre, Malawi. 9. Protocols for the pediatric intensive care; www. mercyjames.info/picu . [accessed 21-jan-2019]. Q. DUBE; Department of Paediatrics and 10. Musicha P, Cornick JE, Bar-Zeev N, et al. Trends Critical care has brought a new dimen- Child Health, College of Medicine, Blantyre, in antimicrobial resistance in bloodstream in- fection isolates at a large urban hospital in sion to paediatric healthcare in Malawi Malawi. Malawi (1998-2016): a surveillance study. Lan- and has made a promising impact on G.K. BENTSEN; Division of emergencies cet Infect Dis. 2017 Oct;17(10):1042-1052. the outcomes of several children. The and critical care, Oslo University Hospital, opening of a PICU will boost these Norway. developments and will undoubtedly further improve paediatric healthcare and survival in Malawi and other sub-Saharan African countries.

Burden and pattern of injuries in an Ethiopian referral hospital Results from data collection in the Hawassa University Referral Hospital Ethiopia

Injuries account for 10% of deaths to rapid growth of motorized trans- EXPERIENCES FROM AN worldwide. This is higher than port and expansion of industrial ETHIOPIAN HOSPITAL the total number of deaths from production without adequate safety We performed a retrospective cohort malaria, tuberculosis and HIV precautions.[2] Only little attention study in Hawassa University Referral combined. Road traffic accidents is given to this problem and thus Hospital in Ethiopia. All trauma patients are responsible for 23% of these, there is insufficient monitoring of who presented in either the surgical followed by intentional harm the pattern and burden of injuries. or the paediatric emergency depart- from suicide (15%) and homicide In 2012, 11% of the total disability ment (ED) in 2013 were included. We (11%). Low- and middle-income adjusted life years (DALYs) lost in collected their file numbers from the countries (LMICs) suffer the brunt Ethiopia were due to trauma.[3] Our logbooks in the emergency and paedi- of these, with injury death rates aim is to describe the causes and atric department. Using a structured ranging from 45-55 fatal injuries type of injuries in Hawassa Uni- checklist, socio-demographic and injury- per 100,000 population in Western versity Referral Hospital in 2013 related facts were recorded. In case of Europe and North America up to 99 (2006 Ethiopian calendar) and to multiple injuries but no poly trauma, to 126 in LMICs.[1] These numbers make recommendations for possible we selected the most severe injury. are rising in sub-Saharan Africa due interventions.

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THE HOSPITAL that more data would be crucial for Hawassa University Referral Hospital health policy makers to guide their is a large tertiary hospital (79 surgi- decisions on in-hospital care as well as cal beds, 8 intensive care beds) for the on preventive measurements. Compared southern region of Ethiopia that serves a to recently published data collected population of 19.1 million people. At the elsewhere in Ethiopia, we found similar time of research, there were eight gen- rates of road traffic accident victims: eral surgeons, one of them also special- 34% in our study, 35% in Bulto et al. ized in urology and one in plastic and versus 14% in Amdeslasie et al.[4,5] We reconstructive surgery. None were for- found slightly less victims from inten- mally trained as trauma or orthopaedic tional harm (28%) than Bulto et al (43%) surgeon. The hospital serves as a train- and Amdeslasie et al (31%). Mainly ing facility for medical students and re Cae of traa of atent young men are affected. Most common re Dtrton of te of nr of provides postgraduate training for surgi- reentn at Haaa Unert Referra atent reentn at Haaa Unert cal residents and emergency physicians. Hota n Referra Hota n Residents or emergency physicians are usually the first responder in the ED. T No structured triage system is in place O L and trauma cases are not structurally D assessed via Advanced Trauma Life Support (ATLS) principles. X-ray and ultrasound possibilities are available. No CT scan was available at the time. Those T who could afford it were sent to a private O A hospital with CT facilities. We should mention here that, contrary to the situ- A ation in most high-income countries, these, severe head injuries were seen there is a possibility of keeping patients in 21% of the cases, 22% had moder- E re Cae of traa of atent in the ED for several days, and these ate head injuries and 57% only mild re Dtrton of te of nr of reentn at Haaa Unert Referra patients did not count as admissions. head injuries. Only 2% of the patients atent reentn at Haaa Unert O Hota n were poly trauma patients. Location Referra Hota n RESULTS of injury is provided in Figure 2. T In 2013, in total 1318 patients presented O with trauma in either the emergency or Head trauma was a major reason for L D paediatric department of our hospi- presentation at the ED. Half of these tal. We excluded 14 patients from our (187) needed admission. From this study due to missing files. Finally, 1304 group, 29 needed burr holes. A total patients were included, of which 30% of 45 head injury patients died dur- T were referred by a lower-level facility. ing admission. This was the lead- O Two-thirds were male, median age ing cause with 66% out of the total A was 28 years (ranging from 0 to 90 in-hospital deaths after trauma. years). Unintentional harm accounted A for 70% of the injuries: mainly road Because of a lack of orthopaedic sur- E traffic accidents (36%), occupational geons, 57 patients (4.4%) were referred accidents (19%) and domestic acci- to another hospital. Almost half of dents (15%). Fighting, sexual abuse those patients (24/57) were sent for O and other intentional harm accounted orthopaedic treatment of lower or upper for 28% of the cases, while suicide extremity fractures or dislocations, 14 attempts were seen in less than 1%. were referred because of head injuries, 6 are soft tissue and head injuries, with The remaining cases were mostly because of complicated poly trauma, and the latter type accounting for both most from animal attacks (e.g. hyena-, dog- 12 for the treatment of other injuries. admissions and in-hospital deaths. We and snakebites). See also Figure 1. found an in-hospital mortality of 5.4%, DISCUSSION mainly after head injury. This is compa- In terms of injury types, the most fre- We described the causes and types of rable to the 4.2% in a recent study about quent were wounds and burns (N=395, injuries in a large tertiary hospital in trauma in a tertiary hospital in Malawi. 36%), although most of these cases were Ethiopia during one year. Unfortunately, [6] Head injury accounted for most of only mild (85%). Second most frequent little epidemiological data is available our admissions, similar to the studies were head injuries (N=381, 29%). Of on injuries in Ethiopia.[4,5] We believe by Bulto et al and Amdeslasie et al.[4,5]

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We hypothesize that we underestimated training.[7] Also, the scarce availability of the true trauma related morbidity and diagnostics that are essential in trauma FLEUR DE VRIES, MD, PHD mortality. Firstly, not all patients reach care such as ultrasound and CT should Department of Surgery, Hawassa University the hospital alive. There are no compre- be improved and made readily avail- Referral Hospital, Hawassa, Ethiopia. hensive statistics about victims who died able. Furthermore, the limited treat- Department of Surgery, Albert Schweitzer on the accident scene or while being ment options, especially for traumatic Hospital, Dordrecht, the Netherlands. transported to the hospital. Another cat- bone injuries, play a major role in the egory that do not make it to our tertiary outcome of trauma care. Often conserva- Co-authors referral hospital are those that are seen tive treatment via plaster of Paris (POP) TOM GRESNIGT, MD in a local clinic but cannot afford the or skin or bone traction for fractures are travel costs. Thirdly, we only looked at the sole options available. The option Department of Surgery, Hawassa University admissions. Patients seen and treated of plating or intramedullary fixation is Referral Hospital, Hawassa, Ethiopia. in the ED, even if for an overnight absent and there is only limited avail- Department of Surgery, Treant Scheper observation there, were not included. ability for external fixation, even in a Hospital, Emmen, the Netherlands. Another limitation is the retrospective tertiary referral centre. Inadequately [email protected] nature of this study. The coding system treated fractures in young patients used in this study was not standardized may lead to disability, more DALYs and W.W.E. NOLET, MD in the hospital admission forms. This hence less productivity for Ethiopia as a Masanga Hospital, Sierra Leone. means that the files had to be reviewed whole. Some (mission) hospitals provide and interpreted by the researchers, orthopaedic care via expatriate trauma/ D. VAN DER VELDE, MD, PHD sometimes with incomplete data. orthopaedic surgeons. However, there Department of Surgery, Hawassa University The earlier mentioned lack of trauma is a lack of trained Ethiopian trauma Referral Hospital, Hawassa, Ethiopia. skilled personal was confirmed by the surgeons, especially in remote areas. Department of Surgery, Trauma Unit, lack of structured trauma screening St Antonius Hospital, Nieuwegein, the found in this retrospective study. Secondly, prevention of trauma remains Netherlands. key. This prevention should primarily Our data cannot directly be extrapo- focus on traffic safety by addressing N. VAN DER NAALD, MD lated to other low-resource settings poor road structure, poor adherence Department of Surgery, Trauma Unit, but gives a mere indication of the to traffic rules, and the use of poorly St Antonius Hospital, Nieuwegein, the trauma burden in a referral hospi- maintained motorized vehicles and Netherlands tal in an Ethiopian rural area. lack of use of safety equipment like helmets. Also, substance abuse (qat, alcohol) should be strictly controlled REFERENCES

MULTILEVEL especially in traffic. Burns by cooking 1. WHO. Injuries and violence: the facts. https:// www.who.int/violence_injury_prevention/ INTERVENTIONS ARE fires at home or kerosene lights pose a key_facts/en [accessed on January 6th, 2019]. significant risk in relation to the high 2. Nordberg E. Injuries as a public health problem in sub- NEEDED TO DIMINISH Saharan Africa: epidemiology and prospects for control. burden of burns we have encountered East Afr Med J. Kenya; 2000 Dec;77(12 Suppl):S1-43. THE HIGH BURDEN OF 3. WHO. Global Health Observatory data re- (36%). Occupational incidents could pository. Estimates by country: Age-standard- TRAUMA VICTIMS IN be prevented by better regulation of ized DALY rates Data by country. 2012 4. Bulto LN, Dessie Y, Geda B. Magnitude, causes and SOUTHERN ETHIOPIA, personal protective equipment at work. characteristics of trauma victims visiting Emergency and Surgical Units of Dilchora Hospital, Eastern INCLUDING A FOCUS Ethiopia. Pan Afr Med J. Uganda; 2018;30:177. CONCLUSION 5. Amdeslasie F, Kidanu M, Lerebo W, Ali D. Patterns ON PREVENTIVE CARE of trauma in patients seen at the emergency clinics In 2013, 1304 trauma patients were of public hospitals in Mekelle, Northern Ethiopia. Ethiop Med J. Ethiopia; 2016 Apr;54(2):63–8. admitted after being seen in the 6. Tyson AF, Varela C, Cairns BA, Charles AG. Hospital RECOMMENDATIONS emergency and paediatric department mortality following trauma: an analysis of a hospital- based injury surveillance registry in sub-Saharan As we consider the burden of inju- of Hawassa University Referral Hos- Africa. J Surg Educ. United States; 2015;72(4):e66-72. 7. Tumwesigye NM, Ingham R, Holmes D. Condom ries to be high, we propose that mul- pital, most often due to road traffic use at first and latest sexual events among young tilevel interventions are needed to accidents. Traumatic brain injury was people: Evidence from a rural and peri-urban setting in Uganda. Afr Health Sci. 2013;13(2):407–14. diminish the high burden of trauma the predominant reason for admission victims in southern Ethiopia, includ- and for in-hospital death. Improve- ing a focus on preventive care. ments could be made in the training of medical staff with the principles of In the first place, the hospital staff is not ATLS or the presentation of multiple trained in trauma care and resources casualties. Policy makers should focus are limited. Although there is no formal on enhancing the in-hospital trauma training available in Ethiopia, we recom- care and the referral system but above mend inclusion of the principles of all should invest in preventive measures. ATLS during medical and postgraduate

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The adult emergency and trauma centre (AETC) at Queen Elizabeth Central Hospital, Blantyre, Malawi

This summary was compiled after a the Wellcome Trust, the Anadkat Family ized in Emergence Medicine and offer discussion between Mulinda Nyirenda, and other private donors. QECH is a oversight and expertise. Nurses are expert in the subject, and Ed Zijlstra on tertiary referral hospital and serves the trained in triage and basic life sup- behalf of the Editorial Board of MT. adult population of Blantyre district with port skills and basic trauma care skills a catchment area of 1.2 million people. that allow them to initiate life-saving BRIEF CV The AETC provides emergency care for emergency care and treatment as Mulinda Nyirenda completed her adult patients with medical, surgical, patient awaits clinical evaluation. medical education at the College trauma or obstetric/ gynaecological con- of Medicine, Blantyre, Malawi and ditions; a paediatric Emergency Depart- The departments of Internal Medicine, graduated in 2001 (MBBS). She then ment had existed at QECH from 2001. Surgery and Obstetrics/Gynaecol- trained in Internal Medicine in Malawi ogy each have interns and registrars (University of Malawi, MMed, 2010) The staff consists of generally trained responsible for medical, surgical and and South Africa (Witwatersrand, medical and nursing staff supported gynaecological admissions and for offer- 2012, MMed; FCP (SA) in 2010). by ancillary staff. The medical team ing consultation for other specialties. She is now finalising a Masters of is composed of clinical officers, medi- Philosophy in Emergency Medicine at cal interns and medical officers. All ORGANIZATION OF PATIENT CARE University of Cape Town. In 2010 she require in-house training in emergency The AETC operates on four pillars: joined the OPD/Emergency/casualty and trauma care skills at the begin- ­1. proper initial assessment using a tri- section that later became the AETC ning of their rotation. There are three age system to reduce delays for patients at QECH. She is a section editor of senior consultants who are all special- who need treatment urgently; 2. early the African Federation of Emergency Medicine (AFEM) handbook. EMERGENCY PRIORITY TO BE SEEN IMMEDIATELY TO BE SEEN WITHIN 1 HOUR INTRODUCTION

Before 2011, it was not uncommon to signs signs find a patient in the adult medical wards AIRWAY BREATHING of Queen Elizabeth Central Hospital • Airway compromise • Difficulty breathing (QECH) during the daily morning • Respiratory rate > 20 or < 12 BREATHING • Pulse oximetry < 93% ward round who was admitted dur- • Severe respiratory distress ing the night because of headache and • Respiratory rate > 30 or < 8 CIRCULATION fever. Quick assessment would show • Pulse oximetry < 90% • Systolic blood pressure < 90 or > 180 • Wheezing or stridor • Diastolic blood pressure > 110 that the patient was probably suffer- • Central cyanosis • Pulse > 110 or < 50 ing from acute bacterial meningitis, a • Very pale appearance CIRCULATION • Moderate dehydration medical emergency condition. How- • Systolic blood pressure < 80 or > 220 • Temperature > 38 0C or < 35.5 0C ever, no adequate clinical assessment, • Diastolic blood pressure > 130 • Pulse > 130 or < 40 DISABILITY including diagnostic procedures such • Heavy bleeding • GCS < 14 as lumbar puncture, had been done, • Weak or thready pulse • RBG < 4 mmol/l and appropriate (or empirical) treat- • Severe dehydration • Temperature > 40 0C or < 34 0C symptoms ment with antibiotics and IV fluids • Active bleeding had not been started. Precious time DISABILITY • Chest pain • Active convulsions • Focal neurologic deficit was therefore lost which often contrib- • GCS ≤ 10 • Fracture / dislocation uted to a poor outcome in this serious • RBG < 2 mmol/l • Head injury with loss of consciousness • History of convulsions disease. This was not a standalone symptoms • Moderate burn example, but a common occurrence that • Facial swelling • Poisoning painfully showed the lack of a well- • Major burn • Pregnancy with abdominal pain • Major trauma • Recent faint or severe weakness functioning emergency department • Pregnancy with seizure history • Severe pain with a 24-hour service and skilled staff. • Severe shortness of breath • Sexual assault • Snakebites • Visual changes • Violent behavior INFRASTRUCTURE AND STAFF The Adult Emergency and Trauma Cen- ALL OTHER PATIENTS MAY BE TRIAGED AS GREEN tre (AETC) at QECH began its opera- tions in October 2011 with support of Figure 1: The Triage parameters utilised in the AETC three-tiered triage

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TABLE 1: CHANGES OBSERVED IN TIME REQUIRED TO ACHIEVE SPECIFIC INDICATORS FOR CARE OF ACUTE MENINGITIS PATIENTS BEFORE AND AFTER THE OPENING OF THE ADULT EMERGENCY ­DEPARTMENT

INDICATOR BEFORE AETC OPENING After AETC opened 2012 Difference noted 2009 Mean (SD)* in hr:min Mean in hr:min Mean (SD)* in hr:min clinical assessment and treatment, Registration to Triage** 02:50 (1:00-4:55) 00:05 (00:04-00:13) 01:10 with proper consultation and evalu- 02:31 ation of treatment response; 3. avail- Registration to First ­Clinical 03:07 (00:45-4:57) 00:38 (00:15 - 01:19) review ability of senior ­consultants (medical expertise) to provide early diagnosis Registration to Lumbar 03:30 (01:00-04:51) 01:25 (00:47 -02:31) 02:05 recognition and implementation of Puncture appropriate care packages for patients; and 4. early diagnostic ­pathways lead- Registration to antibiotics 02:42 (01:42-06:00) 01:52 (01:03-03:00) 0:50 administration ing to initiation of treatment­ before admission to the wards and reducing­ * (SD) = standard deviation. ** Triage in 2009 had no clearly defined criteria but was based on nurses' acuity assessment. unnecessary hospital admissions­ and follow-up visits for patients. who present for example with asthma care packages offered at health centres. The triage system was developed locally exacerbations, non-severe malaria with from the South African Triage System, gastrointestinal disturbances, gastro- ACHIEVEMENTS AND CHALLENGES the Manchester Triage system, and the enteritis requiring IV rehydration as The impact of transforming the adult World Health Organisation (WHO) well as patients requiring observa- patient care pathway is illustrated us- QUICK check tools.[1,2,3] Its implementa- tion after minor surgical procedures ing the acute care pathways indicators tion was guided by the local experience in the emergency department. in providing care for the acute men- of the WHO paediatric Emergency ingitis patient displayed in Table 1. Triage Assessment and Treatment OUTREACH (ETAT) implementation, which has been In addition to care at QECH and in col- The admission rate of the adult patients adopted by health workers in Malawi.[4] laboration with the district health officer decreased from 32% to 9% of all acute The triage parameters include a present- (DHO), the AETC reaches out to the presentations in the hospital (Figure ing complaint and core vital signs (respi- health centres (HC) in Blantyre district 2). A shift in the pattern of admitted ratory rate, oxygen saturation, pulse rate, by helping to strengthen the care given patient load was observed; for example, blood pressure, Glasgow Coma scale at HCs and by designing access path- there was a significant reduction in (GCS) and temperature). It is a three- ways and identifying nearest gateway the number of patients admitted to tiered continuous triage system coded clinics. The Family Medicine speciality internal medicine wards from 68% with traffic light signs: red (emergency) has also taken on the role of improv- to 28%, whereas 21% of adult admis- indicating ‘to be seen immediately’, yel- ing delivery of care in Blantyre District sions were diverted to the emergency low (urgent/priority) ‘to be seen within Health Centres. Supervision by special- medicine short stay ward for observa- 1 hour’ and green (queue) ‘to be seen ists and the DHO have been strength- tion and stabilisation. The outreach within 4 hours of arrival’. (Figure 1) ened. Overtime and decentralisation of activities in Blantyre District that care, particularly of chronic conditions, aimed at primary care strengthening Senior medical expertise has improved have also helped in improving primary yielded a reduction of 19% in visits to resuscitation care for the unstable patient resulting in prompt recogni- tion of respiratory and circulatory failure, shock, and altered mental state presentation that require stabiliza- tion. Airway management, oxygen supplementation, circulatory support and relevant intensive care monitor- ing are initiated and provided in the 4-bed designated resuscitation room. Patients from this area are often admit- ted later to the high dependency and intensive care units of the hospital.

The short-stay ward reduces unneces- sary hospital admissions for patients Figure 2: Impact of change in adult emergency and trauma care pathways.

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the adult emergency and trauma center between 2011 (n= 596,536) and 2012 (n = 482,571), reducing Burn injuries in overcrowding and optimizing the care for critically ill patients. Critical care in various specialties has Africa with a focus improved with the establishment of the AETC, result- ing in better selection of patients admitted to high on management in dependency units. The 4-bed intensive care unit of the hospital has also diversified its patient profile, the acute phase which especially benefits non-surgical patients.

The AETC is an educational hub and a unique model of adult acute/ emergency care in Malawi. Medical and nursing students in undergraduate and post- Burn injuries are a common cause of trauma graduate programs are exposed to the AETC as part in Africa. The injuries are often severe and of their curriculum. Since November 2017, medical contribute to major morbidity and ­mortality. interns have been doing a formal rotation in emer- Children are most vulnerable to sustaining gency medicine which is unique in the country. burns. The World Health Organization (WHO) estimates that between 15,000 and 30,000 Current challenges include high turnover rates in children under the age of 5 years die of fire-re- staff that affect standards of care. Overcrowding lated injuries in Sub-Saharan Africa annually.[1] in the AETC occurs due to delays in processing of medical and surgical admissions. In addition, the Burn care is complex even in well-equipped centres AETC is still utilized for primary care and follow-up in high-income countries (HIC). Lack of prevention outpatient care. Limited funding from the Ministry of programmes, poverty, co-morbidity, ignorance, and Health with minimal external partnerships compro- cultural beliefs all influence the incidence of burn mises the emergency care package at various levels. injuries as well as the outcome. In many African countries, an individual with an epileptic fit who CONCLUSION falls into a fire is thought to be bewitched and will The AETC has transformed medical care in not be pulled from the flames until the shaking Blantyre district and in QECH, both conceptu- stops resulting in devastating burns.[2] (Figure 1) ally and practically, in terms of understanding the concept as well as the delivery of emergency care. This has also resulted in the restructur- ing of primary health care in the district lead- ing to improved care at the health centre level.

MULINDA NYIRENDA Adult Emergency and Trauma Centre (AETC), Queen Elizabeth Central Hospital, Blantyre, Malawi. [email protected]

ED ZIJLSTRA Rotterdam Centre for Tropical Medicine, the Netherlands. [email protected]

REFERENCES

1. https://emssa.org.za/wp-content/uploads/2011/04/ SATS-Manual-A5-LR-spreads.pdf 2. Mackway-Jones K, Marsden J, Windle, J. Emergency Triage: Man- chester Triage Group, 3rd Edition. Wiley-Blackwell. 2014. 3. World Health Organization (WHO) quick check and emergency treat- ments for adolescents and adults. Available from: https://www.who. int/influenza/patient_care/clinical/IMAI_Wall_chart.pdf?ua=1 4. World Health Organization – emergency triage assessment and treatment (ETAT) course. Available from: https://www.who.int/ maternal_child_adolescent/documents/9241546875/en/ Figure 1: Full thickness burn with necrosis of the toes (black ­tissue) and signs of infection (yellow tissue) in a patient who had an epileptic fit. The patient presented with a delay of 1 week.

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Burn care is usually poorly organized and suffers from shortage of supplies, poorly educated staff, and lack of com- mitment from the health authorities.[1] In general, health facilities are under- equipped for adequate management. Although in recent years more burn centres in Africa have been established, for example in Ethiopia, Kenya, Ghana and Malawi, these are at a central level and people from the rural areas often do not have access because of cost and lack of transport. Instead they visit a traditional healer first, causing further delay and increased risk of adverse outcome such as infection. Therefore, Figure 2. The Rule of Nines. © Dutch Burns Foundation; Coraldesign patients with burn injuries often pres- ent late in local hospitals and do not receive proper first-line treatment.[1,2,3] practitioner to follow the right pro- HOW BIG IS THE BURN? cedure in treating burn patients. It is important to estimate the percent- THE ACUTE MANAGEMENT OF BURNS age of the Total Burned Surface Area Burn injuries require special care COOLING (TBSA) with regard to the risk for by well-trained health workers. The The Dutch Burns Foundation started an hypovolemic shock due to increased Early Management Severe Burns awareness campaign many years ago: fluid loss. The Rule of Nine is most (EMSB) course is now widely accepted ‘First water and the rest comes later’. commonly known but difficult to use, as the standard of required training This slogan has become well known in especially in children because of body for nursing and medical staff.[4] the Netherlands. Guidelines all indicate changes with increasing age and growth that cooling the burn with lukewarm of the child (Figure 2). Therefore the This one-day course has been estab- water for a period of not more than 10 1% hand rule has been introduced. The lished in Australia to help with triage minutes is the first management (longer closed hand with the palmar surface and transfer of a victim with severe cooling may induce hypothermia) that of the patient represents 1% TBSA and burns to a burn centre. It is based on the should be started immediately.[5,6,7] In gives a reliable estimation of the TBSA. ABCDE (Airway, Breathing, Circulation, Africa this is not common knowledge. In Africa, a TBSA of more than 30% is Disability) primary assessment. After Instead of water, other substances are life threatening because of hypovole- this, ‘Exposure’ follows where tempera- used such as flour, soil, mud, tooth- mic shock, sepsis and anaemia, and in ture, assessment of the total burned sur- paste, crushed snails, egg yolk, butter, extensive burns with TBSA > 50%, the face area (TBSA), depth and site of the palm oil, cow dung, tea leaves and outcome is invariably fatal and comfort burn are reviewed. Other topics include forms of traditional medicine. There care in the patient’s own environment effective resuscitation, early transfer to is an increased risk of tetanus with the is advised.[7,9] In contrast, patients in a specialist burn centre, intensive care use of cow dung or soil.[8] In practice, HICs with TBSA > 50% are managed for inhalation injury, skill stations and because of ignorance and delay in with ICU admission and this condition interactive discussion groups. In the presentation, cooling is often not done, is not necessarily life threatening. Netherlands and in South Africa for with an increased risk of a deeper example, this course is very success- burn and secondary infection leading HOW DEEP IS THE BURN? ful and led to a dramatically improved to higher morbidity and mortality.[7] The depth of the burn determines if outcome.[4] In most African countries a surgical or conservative approach this course has not yet been introduced. WHERE IS THE BURN? should be initiated. Furthermore, a Deep burns covering the joints may circumferential deep burn may lead FIRST AID AND ASSESSMENT result in contractures and early surgi- to loss of a limb and urgent escha- First aid of burn injuries follows the cal management may prevent disabil- rotomy is indicated to relieve the same procedure worldwide: stop- ity. Facial burns are often associated pressure.[5] (Table 1, Figure 3 a,b,c) ping the burning process, removal of with inhalation injury and may need clothing and cooling the burn.[5,6] artificial ventilation; eyelids are fragile EARLY MANAGEMENT – KEY POINTS and an ectropion may develop. Peri- Thereafter assessment of the in- neal and genital burns may require a FLUID RESUSCITATION jury is performed: where is the burn, urinary catheter and proper nurs- If the TBSA in an adult is >20% (or how big is the burn, how deep is ing care to prevent infection.[7] >15% in children), intravenous (IV) the burn? These questions help a treatment with normal saline or

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TABLE 1. BURN DEPTH CHARACTERISTICS

Epidermal (e.g. sun- Superficial dermal burns Deep dermal burns Full thickness burn, flash burn) (Partial thickness) (Deep partial thickness)

Pathology Involves epidermis Epidermis and upper Epidermis and part of dermis Epidermis, dermis only dermis

Appearance Dry and red Pale pink, wet. Wound Blotchy red or pale deeper White waxy charred base blanches with pres- dermis where blisters have sure ruptured

Sensation May be painful Increased, very painful decreased -

Circulation Normal Rapid capillary refill Sluggish capillary refill -

Colour Red, warm Pink White/pink pale/botchy red White/ charred/ black

Blisters - + Early, large blister which rup- - ture rapidly

Healing time Within 7 days 7-14 days Over 21 days Does not heal spontane- ously

Scarring No scar Colour match defect, low High risk of hypertrophic Wound contraction. risk of scarring scarring Heals by secondary intention

Ringer’s lactate should be started. If this is not available, Oral Rehydration Salt (ORS) may be given instead. Similarly, ICU monitoring of severe burns is not available in most settings. Nurses on the unit should insert a catheter and moni- tor the urine output. If patients arrive with a delay of a few hours, IV treatment should be started. If there is a delay of more than one day, the patient is first reviewed and treated accordingly.[5,6,7]

Figure 3a: Partial thickness burn. PAIN MANAGEMENT Pain management is often a problem in LMICs. Burn injuries can be extremely painful and adequate pain management is needed. Opioids are not widely avail- able and medication is often restricted to paracetamol, 3-4- times daily.[5]

PREVENTION OF HYPOTHERMIA To prevent hypothermia, especially in children, nursing in a warm room, without fan or air-conditioning is indicated until the wound is covered. Bed cages are used to prevent sticking of the blankets or sheets to the wound. Extra blankets should be distributed especially if the wounds are exposed.[5] Figure 3b: Deep partial thickness burn.

16 MT BULLETIN OF NVTG 2019 MARCH 01 ARTICLE

THE WAY FORWARD Emphasis should be on prevention campaigns such as safe cooking and first-aid measures. Resources for educa- tion and improved care are needed.[12] Research in the traditional medicine for burn care such as banana leaves, honey and papaya seems warranted.

Telemedicine may fill a gap in commu- nication between the field and special- ized centres, even abroad.[13] It is then essential that the health professional consulted should be aware of the limita- tions of working in burn care in LMICs. Figure 3c: Full thickness burn.

HELMA HOFLAND WOUND CLEANING PAIN MANAGEMENT If there is a delay in referral, clean- Optimal pain management should be Senior Nurse Researcher, Burn Centre Rotterdam Maasstad Ziekenhuis, ing the wounds, with (boiled) water, continued, particularly during change Rotterdam, the Netherlands. or normal saline or a fluid with anti- of dressings. Ketamine is often used septic is advisable. Experience shows for sedation, with careful monitor- [email protected] that nurses in LMIC clean the wounds ing of the airway and breathing.[7] very thoroughly; however, this can be REFERENCES very painful. After cleaning, the burn NUTRITION 1. Albertyn R, Numanoglu A, Rode H. Pediatric burn care in Sub-Saharan Africa. Afr J Trauma 2014; 3: 61-67. should be dressed. Leaving the burn High energy and high protein intake 2. Baskind R, Birbeck GL. Epilepsy-associated stigma open, ‘exposure treatment’, is not widely are necessary from admission. Peanut in sub-Saharan Africa: The social landscape of a disease. Epilepsy Behav 2005; 7: 68-73. performed although it prevents a lot of butter, high-energy milk or porridge 3. Stevenson J, Borgstein E, van Hasselt E, Falconer I. The establishment of a burns unit in a develop- pain; the exposure is continued until with extra oil and sugar may be used. ing country - A collaborative venture in Malawi. J the crust of the burn cracks, usually 4-5 Vitamin supplements (particularly Plast Reconstr Aesthet Surg 1999; 52: 488-94. 4. Rogers AD, Allorto NL, Wallis LA, Rode H. The [1,7] [7,11] days, which should then be removed. A, C and D) are recommended. Emergency Management of Severe Burns course in South Africa. S Afr J Surg. 2013;51(1):38. 5. ISBI Practice Guidelines for Burn Care. IDENTIFY CO-MORBIDITY SURGICAL INTERVENTION Burns 2016;42 (5): 953-1021. 6. Nederlandse Brandwonden Stichting: Richtli- In LMICs, co-morbidity such as Deep burns need early excision jnen opvang en behandeling brandwondenpati- enten. Available at: https://brandwondenzorg. malnutrition and HIV infection are but due to lack of surgical capac- nl/voor-zorgprofessionals/richtlijnen/ typical risk factors for slow wound ity and blood transfusion or in case 7. Van Hasselt EJ. Burns manual, a manual for health workers. Dutch Burn Foundation 2008, 2nd edition. healing and increased risk of infec- of wound infection operations are 8. Kattan K, Alshomer F, Alhujayri A, et al. Cur- [1,7] rent knowledge of burn injury first aid prac- tion or sepsis and should be managed often cancelled or postponed. tices and applied traditional remedies: a nation- appropriately from the start.[7,10] wide survey. Burns & Trauma. 2016; 4: 37. 9. Tyson AF, Boschini L, Kiser M, et al. Survival after HYPERTHERMIA burn in a sub-Saharan burn unit: Challenges and opportunities. Burns. 2013 Dec;39(8):1619-25 AFTER EARLY MANAGEMENT Burn patients often have raised tem- 10. James J, Hofland H, Borgenstein E, et al. The perature (typically 38-39 0C); this may prevalence of HIV infection among burn pa- tients in a burns unit in Malawi and its influ- WOUND DRESSING be due to wound infection, or a concur- ence on outcome. Burns 2003; 29: 55-60. 11. Prelack K, Dylewski M, Sheridan R. Practical As silver-impregnated bandages are rent infection (e.g. malaria), or due to guidelines for nutritional management of burn often not available, traditional rem- the evolving burn wound or hyperme- injury and recovery. Burns 2007; 33 : 14- 24. 12. Van der Merwe A, Steenkamp WC. Preven- [7] edies are used including the use tabolism induced by a large burn. tion of burns in developing countries. Ann Burns Fire Disasters. 2012; 31; 25: 188–191. of plants such as banana leaves for 13. Klingberg A, Wallis LA, Hasselberg M, Yen P, wound dressing. Other plant materi- AFTERCARE Fritzell S. Teleconsultation using mobile phones for diagnosis and acute care of burn injuries als include papaya (Carcia Papya), Aftercare is of utmost importance among emergency physicians: mixed-methods honey and palm oil. Basic burn dress- for scar management (e.g. pressure study. JMIR Mhealth Uhealth. 2018; 6: e11076. ing can be done with petroleum jelly garments, pruritus treatment) and gauzes. The vaseline gauze does not psychosocial support, but this is not stick to the wound, not interfering commonly available in LMICs. Typi- with the wound healing and maintain- cally, patients seek follow-up only in the ing a moist wound environment.[1,7] case of contractures or keloid develop- ment (which is common in Africans).

MARCH 01 2019 MT BULLETIN OF NVTG 17 LETTER FROM THE TROPICS

Lessons learned from an internship at an Emergency Department in South Africa

KHAYELITSHA hospital, including a very striking case foreign doctor the responsibility to treat The last decade, crime rates have of a victim with a lacerated trachea. a patient completely independently. This increased in Cape Town, while in the means that you provide the indication to bigger South African cities, including DUTCH EMERGENCY PHYSICIAN start a procedure, know the contraindi- Johannesburg and Durban, a downward I spent the final phase of my residency cations, understand the preparation and trend can be seen. In Cape Town, 69 in South Africa. For me as a Dutch deal with complications, even if a patient inhabitants per 100,000 were murdered Emergency physician (EP) in training, is in haemorrhagic or obstructive shock. in 2017, a significant and astonishing an internship in Khayelitsha District increase when compared with 2010, Hospital in Cape Town was valuable for During my visit, the number of patients when it was 42 per 100,000.[1] Violence gaining skills in resuscitative proce- in serious shock was high. This was takes place mostly in the townships dures because of the extensive exposure an unexpected challenge that I never and the informal settlements east to traumatic injury, in particular the thought about before starting this in- of the city centre. The biggest town- treatment of penetrating traumatic ternship. To be responsible for the initial ship in Cape Town is Khayelitsha. In injuries (i.e. thoracocentesis, intercostal treatment of a life-threatening injury 2011, this fast-growing township had drainage of a pneumothorax or hema- takes more than the capability and approximately 400,000 inhabitants. tothorax, pericardiocentesis, airway competency of performing a lifesaving Khayelitsha is also known for its large management, paediatric trauma, trau- procedure. It is quite an experience to be proportion of unemployment (38%), matic arrest and ultrasound in trauma). faced with the most severely injured pa- and the majority of the people live However, the practice in Khayelitsha is tients from stab wounds, shootings and in shacks, with 74% of households different from Dutch practices. I learned burn wounds in large numbers within existing on a monthly income of less three major lessons at this hospital. short time spans. It is mentally chal- than $220.[2] Khayelitsha is considered lenging. Treating one patient while two a dangerous township because of the SHARED RESPONSIBILITY? other patients are rushed into the resus- activity of gangs, murders, robberies, The first one is about responsibility. citation room with comparable injuries and the use of alcohol and drugs such An important difference between the requires a coping strategy. You need as ‘tik’ (amphetamines) and ‘whoonga’ practice in the Netherlands and in South someone at home to share your experi- (cheap heroine which is smoked).[3] Africa is the degree of independence ence after a hectic shift. And maybe you Approximately 16% of traumatic injury of a doctor working in the Emergency should share the experience again later. is caused by gang-related violence.[4] Room (ER). In the Netherlands, the decision to perform a major interven- For me it also helped to realize that the Khayelitsha has one district hospital tion will be discussed in larger teams causes of the patients’ problems can be that was founded in 2012. The hospi- with representatives and supervisors sought in the greater social problem that tal is equipped with a 24-hour level-3 from different acute specialties such as exists in the townships of Cape Town. It emergency service. Almost 40% of the anaesthesiology, intensive care medicine is part of daily life. On a medical level, patients in the resuscitation room have and surgery. Responsibility is shared it was also challenging. I remember a trauma-related problems.[5] Trauma with supervisors, who are medical patient in the resuscitation room who occurs mostly during the nights in the specialists. The Dutch EP is accus- was visibly distressed and excessively weekends and especially when it is ‘pay tomed to sharing responsibility, and sweating after a stab wound of the chest. day’, the day that salary is handed over this is often documented in protocols. The patient had a precordial sucking and people start drinking alcohol, using chest wound located on the sternum drugs and stealing. The busiest shifts in In South Africa these decisions are without signs of decreased breathing the year take place during the weekend made by the individual doctor work- sounds in the left or right lung. Vital before Christmas, when the number ing in the resuscitation room, and this parameters remained stable without of patients arriving can increase to requires thorough knowledge, skills and signs of haemorrhagic shock. After 50 cases in one night, the majority of competence. An EP or senior resident point-of-care ultrasound a hemoperi- which consist of penetrating trauma in emergency medicine available at the cardium was excluded. An immediate of the thoracic region. This includes ER for direct supervision. These are decision on management of the patient many stab wounds as well as gunshot involved only in complex cases, and was required. Is it acceptable to perform wounds.[6,7] I was personally a lot more they expect the doctor working in the imaging of the chest with the accompa- exposed to out-of-hospital cardiac arrests resuscitation room to solve the major- nying delays, or does immediate inter- in children and infants than in my own ity of the cases by himself. They give a costal drainage need to be performed

18 MT BULLETIN OF NVTG 2019 MARCH 01 LETTER FROM THE TROPICS

at the injured site or on both sites? for subsequent cases.[8] In Khayelitsha, context, daring to make a decision by the views on trauma and massive blood yourself, and taking responsibility for WHO GETS THE BLOOD? loss are very modern. No crystalloid this decision. The transition from the The second lesson is about dealing with fluids like normal saline are given to the Dutch situation to the South African is a scarce resources. The number of emer- patient. Instead, tranexamic acid (TXA), big one, but in view of the large number gency blood units is limited. Intraosse- emergency blood, and plasma are sup- of critically injured patients, the contri- ous needles are present in small num- plied. During a traumatic arrest there bution made by foreign doctors is very bers. Syringes can suddenly be used will be no thoracic compressions, but important. In the first half of the intern- up. EPs have to deal with out-of-stock the acronym ‘HOTT’ (i.e. hypovolemia, ship, I needed more support and super- running medication and medical equip- oxygenation, tension pneumothorax and vision, but after treating more patients ment. An unlimited supply cannot be cardiac tamponade) is used. Hypovo- I became more independent. In cases taken for granted, and health care work- lemia due to blood loss is treated with where I felt the need to consult a senior ers need to be thrifty with the amount mass blood transfusion. Oxygenation clinician/EP, there was always the pos- of equipment and medication. There are is treated preferably with bag mask sibility to do so. After a few weeks, I was six units of blood ready for use while in ventilation. Tension pneumothorax able to work on my own with help from some situations more blood is needed requires direct relief or intercostal the nursing staff, who were very suitable for traumatic injuries. Limited resources drainage. And cardiac tamponade is and well educated for the job at hand. put limits on medical treatment. treated by a resuscitative thoracotomy.[9]

The third important lesson to learn is During mass blood transfusion, we MAIK BERENDSEN, MSC related to the first and second lesson: used a maximum of two units of Emergency Medicine, Khayelitsha District critical decision making with these emergency blood, and more units of Hospital, Cape Town, South Africa. limited resources in mind. The idea is freeze-dried plasma could be supplied [email protected] that wasting a limited supply on a hope- until an acceptable state of perfusion less case with little chance for survival was reached. After a haemothorax, negatively impacts other patients with blood that was collected by an intercos- REFERENCES better chances. In such situations, the tal drain was returned to the patient 1. Crime statistics 2017/2018 South African Police servic- es. Available at: https://www.saps.gov.za/services/long_ individual EP plays a prominent role in immediately. The chest tube drainage version_presentation_april_to_march_2017_2018.pdf deciding to stop treatment, causing the system contained an intravenous access 2. Strategic Development Information and GIS Department. City of Cape Town; 2011 Cen- patient to die. These decisions also differ point. This makes autotransfusion sus – Khayelitsha Health District. 2013. 3. 3May PA, Blankenship J, Marais AS, et al. Approach- from Dutch practice. In the Netherlands, possible. And with the help of a glove ing the prevalence of the full spectrum of foetal treatment is never stopped due to lim- and the longest and thickest intrave- alcohol syndrome in a South African population-based study. Alcohol Clin Exp Res. 2013;37(5):818–30. ited equipment, and blood products and nous needle, you can prepare a one-way 4. Meijering VM, Edu S, Navsaria P, et al. Spectrum of intentional injuries in the juvenile population vital resources must be available. The valve thoracocentesis device to relieve treated at a level one trauma centre: a South African process for stopping treatment if there a tension pneumothorax. In case of a perspective. S Afr J Surg 2017;55(2):61-62. 5. Hunter LD, Lahri S, van Hoving DJ. Case is little chance of success is also more sucking chest wound that was caused mix of patients managed in the resuscitation area of a district-level public hospital in Cape elaborate. As a Dutch doctor, it was diffi- by a big laceration in the thoracic wall, Town. Afr J Emerg Med. 2017;7(1):19-23. cult to see drastic decisions being taken we applied a plastic sheet which was 6. Schuurman N, Cinnamon J, Walker BB, et al. Intentional injury and violence in Cape Town, South in such a short period of time, especially cut to the size of the wound. The plastic Africa: an epidemiological analysis of trauma admis- sions data. Glob Health Action 2015;8:27016. if it involved a young patient. And it was sheet used was from the package of an 7. http://www.stemlynsblog.org/englishman-south- precisely the age group around 18 years adhesive plaster. After that, we applied africa-robert-lloyd-st-emlyns/ . [Accessed: 7 Jan 2019.] 8. Van PY, Holcomb JB, Schreiber MA. Novel con- old that were brought in after stabbing. the adhesive bandage on three sides so cepts for damage control resuscitation in trauma. Curr Opin Crit Care 2017;23(6):498-502. that during inspiration no free air was 9. Smith JE, Rickard A, Wise D. Traumatic ar- ROOM FOR INNOVATION sucked into the intrathoracic space. rest. J R Soc Med. 2015;108(1):11-6. But my experience in South Africa also opened up opportunities for smart CONCLUSION ideas and innovation. Instead of using In conclusion, it seems that the most expensive blood products such as fresh important learning goal is not the skill frozen plasma, freeze-dried plasma is itself but the bigger picture. Practic- used in South Africa. This limits the ing a resuscitative skill in South Africa use of blood units so they can be used also involves understanding the clinical

MARCH 01 2019 MT BULLETIN OF NVTG 19 CASE REPORT

A rabid pregnant woman in Tanzania: Obstetric dilemmas and considerations

CASE HISTORY Prophylaxis (PEP) with the anti-rabies sensory nerves until it reaches the A 38-year-old pregnant woman vaccine, with or without rabies im- spinal cord and brain, causing acute was admitted with vomiting and mune globulin (RIG); see Table 1.[1,2] encephalitis.[3] Time of incubation var- general body itching in Ndala ies from one week to six months.[2] hospital, Tabora region, Western The woman we presented did not receive Tanzania. The fundal height PEP although she was bitten by a dog, PASSIVE AND ACTIVE IMMUNISATION corresponded to a gestational maybe due to lack of knowledge or Post-exposure immunisation reduces age of 30 weeks. Malaria and money. We will focus on some dilem- the risk of rabies when the treatment syphilis tests were negative, the haemoglobin count was 12.4 g/ [2] dl, and urinalysis showed only TABLE 1. SUMMARY OF MANAGEMENT OF RABIES FOR EXPOSED INDIVIDUALS. haematuria. Following admission, she was unable to eat and CATEGORY I No treatment drink with excessive vomiting touching or feeding animals, licks on the skin and shortness of breath. She progressively suffered from CATEGORY II Wash wound with running water and soap for 15 minutes. tremors and was becoming increasingly restless, febrile and nibbling of uncovered skin, Administer antirabies vaccines: minor scratches or abrasions ›› 0.2ml (ID) in divided doses of 0.1 ml on deltoid on afraid to drink water. When asked, without bleeding, licks on one hand and another 0.1ml on the deltoid of the a bite of an unknown animal broken skin second hand on days 0, 3, 14 and 28 OR five months before was reported, ›› 1 ml (IM) on deltoid muscle for days 0, 3,7,14, and 28 increasing suspicion of rabies. The Note: Children are given the same doses but vaccine should be patient was treated with diazepam administered on the lateral part of the thigh. and promethazine. The first

dose of antenatal corticosteroid CATEGORY III Wash wound with running water and soap for 15 minutes. therapy was administered to single or multiple transdermal promote lung maturation of the • Administer Rabies Immunoglobulin (RIG) on day 0 bites or scratches with bleed- • 40 IU/kg body weight for Equine (ERIG) foetus in anticipation of possible ing, contamination of mucous • 20 IU/kg body weight for Human (HRIG) preterm birth. While staff and membrane with saliva from • Administer antirabies vaccines licks; exposure to bat bites or ›› 0.2ml (ID) in divided doses of 0.1 ml on deltoid on relatives were still contemplating scratches one hand and another 0.1ml on the deltoid of the whether to perform a caesarean second hand on days 0, 3, 14 and 28 OR ›› 1 ml (IM) on deltoid muscle for days 0, 3,7,14, and 28 section to try and save at least • Note 1: Children are given the same doses but vaccine should the baby, the mother died, be administered on the lateral part of the thigh. together with her unborn baby, • Note 2: The World Health Organization recommends ID route of vaccination administration because it is cost effec- two days after admission. tive.

BACKGROUND mas regarding rabies in pregnancy. is given before clinical signs of rabies Around 30,000 to 70,000 people Will the foetus benefit from premature develop. Prophylaxis should be given worldwide die of rabies each year, most delivery by caesarean section or would as soon as possible after exposure. The often acquired by bites of rabid dogs vaginal delivery be better? What is rabies vaccine induces protective virus- causing transmission of the virus from known about the risk of the baby also be- neutralising antibodies within approxi- the dog’s saliva. If left untreated, infec- coming infected? Moreover, how safe is mately 7-10 days (active immunisation). tion rates vary between 38% and 57% PEP in pregnant women and newborns? The rabies immune globulin (RIG) and depend on the severity and loca- provides immediate virus-neutralising tion of the wound and virus titre in the THE RABIES VIRUS antibodies until protective antibodies saliva. When symptoms start to develop, Rabies is caused by several different are generated in response to the vaccine mortality reaches 100%. Human rabies species of viruses (Genus Lyssavirus). (passive immunisation), which may deaths are preventable through local After amplification near the site of be necessary when contamination of treatment of the wound, followed by contamination, the virus migrates the virus is near to the central nervous prompt administration of Post Exposure centrally to the peripheral motor and system, resulting in a short incubation

20 MT BULLETIN OF NVTG 2019 MARCH 01 CASE REPORT

period.[4] In Ndala hospital, human neonatal outcome. It cannot be excluded RIG is not available; only rabies vac- that the foetus can be contaminated Co-authors cine is. Rabies PEP is safe for pregnant by the placenta, vaginal secretions of CHOBO STEVE PAUL, MD and breastfeeding women as well as infected maternal tissues although St. Joseph’s Mission Hospital, Ndala-Tabora, for newborns.[1,5,6] Studies found no many reports conclude that the neonates Tanzania. increased risk of spontaneous abortions, remain healthy after receiving PEP. premature births or foetal abnormalities ROB MOOIJ, MD among pregnant women after receiving PRACTICAL DILEMMAS Medical doctor international health and PEP. [1] If the diagnosis is correct, the mother tropical medicine, gynaecologist in training, will surely die. This raises concerns on Jeroen Bosch Ziekenhuis, ‘s Hertogenbosch. MOTHER-TO-CHILD TRANSMISSION the (long term) chances if the neo- Former medical officer (2010-2013) Ndala The exact risk of vertical transmission nate is born without rabies, especially Hospital, Tanzania. of rabies is unclear, but mother-to-child in case of suspected prematurity. In transmission has rarely been reported. general, the prognosis of a neonate after REFERENCES

The most important risk for the baby maternal death is poor. An analysis 1. Nguyen HTT, Tran CH, Dang AD, Tran HGT, Vu TD, Pham TN et al. Rabies vaccine hesitancy is the death of the mother before in Ethiopia indicated that in case of and deaths among pregnant and breastfeeding labour. Rabies virus is not present in maternal death, the infant was much women – Vietnam, 2015-2016. MMWR Morb Mortal Wkly Rep. 2018 March;67(8):250-252. [13] the blood, and risk of contamination of more likely to die than to survive. 2. The United Republic of Tanzania, Ministry of Health and Social Welfare. Standard treatment the baby’s mucosa by maternal infec- guidelines and national essential medicines list for tious fluids and tissue seems limited.[7] After symptoms of rabies appear, Tanzania Mainland. July 2013, fourth edition. 3. UpToDate. Clinical manifestations and diagnosis death by rabies will follow in a few of rabies. [Internet]. Available from: https://www. uptodate.com/contents/clinical-manifestations-and- There are multiple reports describing days. Vaginal delivery might not be diagnosis-of-rabies. [Accessed October 1st, 2018]. cases of healthy babies being born, quick enough. Caesarean section is 4. UpToDate. Rabies immune globulin and vac- cine. [Internet]. Available from: https://www. irrespective of mode of birth, from quicker but exposes health care work- uptodate.com/contents/rabies-immune-globulin- [1,5,6,7,8,9,10,11] and-vaccine. [Accessed October 1st, 2018]. pregnant women with rabies. ers to a higher risk of rabies infection. 5. Huang G, Lui H, Cao Q, Lui B, Pan H, Fu C. Safety of In most cases, either the mother, the post-exposure rabies prophylaxis during pregnancy: a follow-up study from Guangzhou, China. Hum baby or both received PEP (vaccine Prevention of rabies is a superior Vaccin Immunother. 2013 Jan;9(1):177-83. 6. Sudarshan MK, Madhusudana SN, Mahendra BJ. and humane RIG when available). strategy. The use of PEP and RIG ap- Post-exposure prophylaxis with purified vero cell rabies pears to be safe in pregnant women and vaccine during pregnancy – safety and immunoge- nicity. J Commun Dis. 1999 Dec;31(4):229-36. However, in one study four pregnant newborns. If a pregnant woman might 7. Aguèmon CT, Tarantola A, Zoumènou E, Goyet S, Assoute P, Ly S et al. Rabies transmission risks women with rabies and their babies have been exposed to rabies, prophylaxis during peripartum – Two cases and a review of the appeared to not have received PEP due needs to be administered as soon as pos- literature. Vaccine. 2014 Apr 4;34(15):1752-7. 8. Iehlé C, Dacheux L, Ralandison, S, Andrianarivelo to fear that PEP might harm the foetus. sible. Health education campaigns need MR, Rousset D, Bourhy H. Delivery and follow-up of a healthy newborn from a mother with clini- Three of these women delivered success- to focus on education of pregnant wom- cal rabies. J Clin Virol. 2008 May;42:82-85. fully by caesarean section, and one baby en and local health workers to inform 9. Qu Z, Li G, Chen Q, Jiang P, Liu C, Lam A. Survival of a newborn from a pregnant women with rabies infection. died due to non-rabies related complica- them of the importance of timely pro- J Venom Ani Toxins Incl Trop Dis. 2016 April 1;22:14. [1] 10. Figueroa Damián R, Ortiz Ibarra FJ, Arredondo García tions. Some studies also described phylaxis and its safety. In our case, the JL. Post-exposure antirabies prohylaxis in pregnant the status of the mothers after delivery. prognosis of both the mother and the women. Ginecol Obstet Mex. 1994 Jan;62:13-6. 11. Mondal PB, Char D, Mandal D, Das S. Rabies in In every reported case, the mother had foetus was poor because the rabies was pregnant woman and delivery of a live fetus. Int [8,9,11] J Gynaecol Obstet. 2014 May;125(2):171-2. passed away. . An interesting Turkish already symptomatic and prematurity 12. Sipahioğlu U, Alpaut S. Transplacental rabies in article mentioned a term woman who was predicted. Retrospectively, a caesare- humans. Mikrobiyol Bul. 1985 Apr;19(2):95-9. 13. Moucheraud C, Worku A, Molla M, Finlay JE, Leaning J, [12] was bitten by a dog 34 days earlier. an section would have put health staff at Yamin AE. Consequences of maternal mortality on in- fant and child survival: a 25-year longitudinal analysis in 40 hours after vaginal delivery the baby risk with little chance of saving the baby. Butajira Ethiopia (1987-2011). 2015 May 6;12(Suppl 1):S4. died suddenly. Rabies was confirmed in both the mother and baby. This is the first case reporting human rabies KARLIJN JONGEN acquired by placental transmission. Medical student Rijksuniversiteit Groningen; Isala Hospital, Zwolle, the The above indicates that the delivery of Netherlands. a healthy neonate from a rabid mother is possible. The route of delivery does [email protected] not seem to be a determinant for the

MARCH 01 2019 MT BULLETIN OF NVTG 21 IN MEMORIAM

Ankie Borgstein van Wijk 1925-2018 by JOHANNES BORGSTEIN

his untimely death at the age of 52, hungry children and only buttered toast though she outlived him by 39 years. and tea available from room service. They were married in 1951, and made plans both for a large family (7 sons in Jan was soon immersed in the busy the space of 9 years), and for moving work of surgical specialist at the Queen out of Europe. Chile as a first choice was Elisabeth Central Hospital (QECH) discarded due to administrative restric- in Blantyre, leaving the running of tions, and their interest turned towards the house to Ankie. Their youngest Africa. In early 1960, having finished child was born several months later at his surgical training, Jan requested home in an ancient government house an appointment with the Undersecre- in the Sunnyside suburb of Blantyre. tary for Colonial Affairs in London. Jan delivered all his own children. Ankie Borgstein van Wijk lived on to just beyond the age of 93 and The Foreign Office must have assumed Several years later Malawi became dedicated at least 60 years of her life he was a representative of the Dutch independent, and fearing violence most to paediatrics and her small farm government, and they were slightly of the British doctors left for Southern just outside Blantyre in Malawi. taken aback when he asked them for Rhodesia (not yet Zimbabwe). Jan took a job as a surgeon in Africa. But with the unprecedented decision to remain Born in 1925, an only child of an the inimitable politeness and sangfroid in Malawi and try to keep the hospital eminent citizen from Gouda, Neth- of the British civil servant, the Un- going. He was to look after the surgi- erlands, she grew up a solitary dersecretary called in a minor official cal and obstetrics/gynaecology depart- child, rarely accompanying her who dealt with postings, and they were ments, while Ankie had to take over the parents on holiday, being sent in- able to offer him a choice between a medical wards (she was then not yet a stead to various summer camps. district hospital in Nigeria or a central specialist). A paediatric department as hospital post in what was then still such did not exist yet, the ill children be- After high school, she went on to study known as Nyasaland. He immediately ing admitted with their mothers to the medicine in Utrecht, starting dur- took the central hospital, though he female medical ward. They ran the 1000 ing the Second World War. Towards admitted later that he had only the bed hospital for several years between the end of the war, the university was vaguest idea where Nyasaland was. them, with the help of the nurses and closed but some of the lectures contin- medical assistants, until gradually the ued clandestinely, and she had to sit After a brief preparation, the couple specialist positions were filled again. for exams at the professors’ homes. loaded their worldly possessions, their 6 children, and their Citroën station wag- Throughout this time, Ankie would Meanwhile she worked for the resis- on (with small camping trailer) onto a make sure she was home when the tance, ferrying messages concealed cargo boat bound for Cape Town. There seven of us returned walking from under the saddle of her bicycle be- were eight of us in a car for 3 passengers school. But after dinner, when we were tween various resistance cells. Had with two small folding seats in the back. asleep, she would often walk back to the these been discovered, she would have hospital alone to see some patients or been summarily executed. Her father The 12-day boat journey was followed chat between cases with Jan, who, as the spent several years during the war as by an epic road trip from Cape Town only surgeon in the country, frequently a German hostage incarcerated in the to Johannesburg, Salisbury (Ha- had to operate far into the night. local jail. Ten hostages were randomly rare), Bulawayo, Tete in Portuguese selected and executed for every Ger- East Africa (Mozambique) where In her ‘spare time’ and to keep us man soldier killed by the resistance, so we climbed up to see the recently entertained in those days before televi- her resistance work must have occa- discovered ancient rock paintings, sion, she would also write and direct sioned a great deal of soul-searching. and on into southern Nyasaland. plays for us to perform on controversial subjects such as drug smuggling and After the end of the war, she met fel- From there it was a day’s drive to Blan- gold fever. She never threw anything low medical student Jan, who was to tyre where my parents were to spend away, and I recently came across some become her husband and the love of the rest of their lives. We arrived there of the original scripts while cleaning her life. She never fully recovered from late at night at the Ryall’s Hotel with six out some of my old schoolbooks that

22 MT BULLETIN OF NVTG 2019 MARCH 01 IN MEMORIAM

were still gathering dust had very little previous making a note of the meaning. Oth- in my room of the house experience in farming. erwise her life style was determinedly she lived in for the rest stoic: no unnecessary luxuries, with of her life. Ankie had played the Her daily routine was up by dawn, most of the food from her own farm violin since she was at school, and in prepare home-grown coffee, supervise and gardens. To her delight, the farm Malawi all the family members were the milking of the cows… then off to was mostly self-sufficient, energy being ‘encouraged’ to learn a musical instru- the hospital in her trusty Landrover, drawn from a batch of solar panels on ment. Jan took up the clarinet, while delivering milk to friends along the way. the roof and used to power both water the sons played piano, guitar, flute, pumps and light in the house. Cooking trumpet accordion and various other Morning ward-rounds were followed and hot water came from an Aga stove in instruments. Musical evenings were by a quick coffee then out-patients the kitchen, fired by wood carefully and usually organised once every few weeks until lunch. A snack in her office or a sustainably harvested from the farm. with other musical enthusiasts. visit to a friend’s house was followed by further clinical work on the wards She worked until the age of 87, Having dedicated several years to largely and, increasingly, teaching and su- completing 50 years of service self-taught paediatrics, she felt it was pervision. Returning home at the end for the Malawi health ministry time to obtain some official qualifica- of the afternoon, she would have tea in 2012. Laterin her career she tions, and she travelled to London to with whoever of her sons happened to received numerous awards: sit for the Diploma in Child Health be around at the time, and check on of the Royal College of Physicians in their schoolwork. Years later when I - a knighthood from the ­Netherlands 1969, and subsequently passed the very spent some weeks writing up my PhD in 1990 stringent fellowship exams of the South dissertation, she would still check if I - an honorary doctorate from the African college of medicine in 1975. had spent the morning working and not Mzuzu University of Malawi in 2006 lounging in a hammock in the garden. - the lifetime award of the Medical She singlehandedly set up the paediatric Association of Malawi in 2008 department at the QECH in Blantyre, After tea she would hold a free clinic - and the order of ‘Grand Achiever and gradually built it up as one of the for all the ill children of the surround- of the Malawi Order of National­ top departments in the hospital. In the ing villages; often between 20 and 30 Achievement’ in 2013. early years of Malawi independence, she children were seen before dark. One persuaded South Africa to offer 10 car- of her gardeners would tag along with She continued teaching until she retired, diac operations per year for patients with a box of medicines, ointments and and although a progressive hearing loss congenital heart problems, all expenses bandages provided by various donations. must have made the paediatric cardiac paid. With only a chest x-ray and a sounds particularly difficult to identify, stethoscope accurate diagnoses had to be Gradually, over the years, her sons she rarely made errors of diagnosis. made (echocardiogram was not even on all drifted off one by one to medical the horizon then), but I did not hear of school in Europe, some returning to She disliked her increasing depen- any patient being returned without treat- various jobs in Malawi, before mov- dency as old age gradually began ment because of an error in diagnosis. ing off again for specialisation. Once to take its toll, but remained living a year she would embark on a whirl- on her own. She maintained a keen Our medical education started as soon wind tour of the family, spending a interest in all the activities around the as we were able to follow the endless few days with each of her sons in the farm and those of friends and fam- patient discussions at the dinner table. various countries they were living in, ily as well as international politics. before returning home to her farm. After Jan’s untimely death while climb- She died some months after her ing the Mulanje mountain range, she She lived in the old house filled with 93rd birthday, body completely worn was so utterly devastated that she was books and memories. She read vora- out, mind as sharp as ever. unable to talk about him for many ciously, often 40 to 50 books per year, years. She threw herself into her work keeping careful notes in her diary, and continued running the farm as she always eager to discuss any recent book BMJ Publishing Group Limited thought he would have liked. She had she had read. She looked up any unfa- Adapted with permission from BMJ grown up as a city girl in Gouda and miliar words in an ancient dictionary, 2019;364:1233.

MARCH 01 2019 MT BULLETIN OF NVTG 23 Membership of the Netherlands Society for Tropical Medicine and International Health (NVTG) runs from 1 January to 31 December and may commence at any time. Membership will be renewed automatically unless cancelled in writing before 1 December. Membership includes MTb and International Health Alerts. An optional subscription to TM&IH carries an additional cost. Non NVTG members can subscribe to MTb through a student membership of the Society for euro 40 per year by sending the registration form via our website www.nvtg.org/lidworden or by sending name and postal address by e-mail to: [email protected] Please submit your contributions and announcements to the editorial office by e-mail: [email protected]

Netherlands Society for Tropical Medicine and International Health

president A.A.L.J. (Ankie) van den Broek

secretary M.G.P. (Marieke) Lagro

secretariat J.M. (Janneke) Pala-Van Eechoud P.O. Box 43 8130 AA Wijhe | The Netherlands | +31(0)6 156 154 73 | [email protected] | www.nvtg.org

COLOPHON MT Bulletin of the Netherlands Society for Tropical Medicine and International Health ISSN 0166-9303

CHIEF EDITOR Leon Bijlmakers

EDITORIAL BOARD Jan Auke Dijkstra, Nicole Fiolet, Esther Jurgens, Annefleur Langedijk, Josephine van de Maat, Andrea van Meurs, Ed Zijlstra

OFFICE Hein Dik Barentsen

LANGUAGE EDITING Eliezer Birnbaum

COVER PHOTO Hanneke de Vries

DESIGN 24 MT BULLETIN OF NVTG 2019 MARCH 01 Mevrouw van Mulken