trauma update
on Random Uganda (Uganda), 19/Feb/2010 15:13, 34 days ago
Trauma Update: 12 February 2010I’ve been having weekly sessions with our A&E (accident and emergency) nurses for almost a half a year now. We talk about trauma, and emergency medicine, and ambulance transport (most ambulance calls here go out with a non-medical driver and a nurse—there are no paramedics here, although I’ve been agitating to hire some clinical officers and train them to be paramedics), and other topics. Most days I think we’ve come a long way. At least they’ve started to laugh at my jokes.Last Friday afternoon I was looking forward to the quickly approaching weekend and a cold beer at Fuego when Justine, senior sister (compare to nurse manager) in charge of OPD (outpatient dept.) and Linda, my emergency team leader, come and grab me to come see a RTA (road traffic accident—UK medical lingo). I’m a little disappointed that Linda feels it necessary to come with Justine as opposed to taking charge of her team, but I smile and head to the trauma room. Which is empty. (not a huge deal, since I’ve come to accept the fact that the trauma room is really a place to store obsolete, broken and esoteric unusable equipment) The patient is in one of the unmonitored beds in main 5 bed casualty ward. There are 3 nurses standing around him, none of them touching him, all of them watching as one after the other pushes the button for the automatic blood pressure cuff,which won’t seem to give a blood pressure value.The patient was in a car crash earlier in the day in Masindi (about 3-4 hours north of Kampala by car—I've visited Masindi district hospital, see the Sept. 2009 post, it might explain why he didn’t seek care in Masindi). His coworkers tied a big piece of wood to his obviously fractured leg, threw him in the back to truck, and drove him to Kampala where, reportedly his health scheme covered hiscare at Kampala International Hospital.It didn’t take much clinical prowess to see why they couldn’t get his blood pressure. He didn’t have one. He was cold, sweaty, pale (after 8 months, I am finally starting to get the nuances of just how pale a black man can be and what it means) and has no peripheral pulses. One hand on his left upper quadrant tells me that his spleen has ruptured, and the majority of his blood is now pooling inside his peritoneal cavity.By this time there are now 5 nurses around the patient, still none of them touching him. Both the medical officers assigned to casualty have disappeared without a trace.I try to nudge Linda into taking charge by reminding her of the ABCs (airway, breathing, circulation) and asking her what should we be doing first.‘Well, we need to get the vital signs first.’ Sigh.I coax the nurses into putting down the automatic blood pressure cuff and starting an IV line on our man (they look at me like I’m mad when I ask for a second line—‘can’t you see we just started one?’ I make a generally hopeless request for oxygen and a cervical collar. I track down one of our surgeons who agrees with me that the man needs to go to the theatre for a laparotomy.And then the reception staff take over the casualty unit and everybody starts talking very fast in Lugandan. There’s been a slight misunderstanding. The patient’s health scheme pays for care at Kampala Hospital, not International Hospital of Kampala.Suddenly my nurses, who have mostly been milling about for twenty minutes, leap into action and get the man loaded back up into the truck. The surgeon shrugs and says something to the effect that there is nothing we can do. This feeling is echoed by Justine.‘What can we do?’I feel like screaming, but I keep my voice well modulated.‘We can do the right thing, and operate on him and possibly save his life.’‘But he will have to pay cash for it.’‘Can’t we worry about the money later?’Apparently not. I tried to explain to the patient and his coworkers that he could easily die in the 20 minutes it was going to take for him to get across town. But they were having none of it.I called over to Kampala Hospital and, after a number of transfers, spoke to their surgeon. He listened to my story, seemed surprised that I had taken the time to call, and thanked me for the heads up. Understand that in the US, making a call to say that you had just transferred a patient without a blood pressure in need of an emergent laparotomy (not even to mention in the back of a freakin’ truck) would basically be like begging to have your license to practice medicine revoked and all of your personal assets taken from you.The patient survived his surgery.He left the hospital 3 days later. The nurse I spoke with was unable to confirm if he was alive upon discharge.