Dead after arrival: Terrible emergency services are killing by the thousand

Alex Madaga was walking home on the evening of October 5, 2015 when a car hit him, throwing him head-first onto the tarmac at Thiong’o area on Waiyaki Way, Nairobi.

The casual labourer sustained serious head injuries, but paramedics stabilised him and rushed him to the nearest hospital at Kikuyu.

Doctors at Kikuyu Mission Hospital, however, referred him to Nairobi for specialised treatment.

REFUSED TO ADMIT HIM

Unconscious and the clock ticking fast against him, Mr Madaga would spend the next 18 hours in an ambulance as paramedics rushed him from hospital to hospital, one of which refused to admit him because his wife could not raise the Sh200,000 down payment while another said all its Intensive Care Unit beds were occupied.

Fearing the worst, the paramedics drove to the casualty department at Kenyatta National Hospital.

Nurses told them that they could not attend to him because, again, all their beds were occupied. And thus began the long wait in the parking lot for the still unconscious father of one.

Eighteen hours later, at 5.30pm on Tuesday, October 6, 2015, Mr Madaga was finally wheeled into the Intensive Care Unit at KNH, after spending the night and day inside the ambulance.

It was too late, and three days later, at 1.50pm on October 9, he passed on.

Exactly two years later, on October 5, 2017, a court in Nairobi awarded his family Sh2.5 million as compensation for his death.

Chief Magistrate Peter Gesora awarded the family Sh150,000 for the pain and suffering, and a minimum wage compensation of 20 years amounting to Sh2,068,248. Mr Madaga’s monthly salary was Sh50,000.

He also awarded them Sh189,659 for special damages, all to be paid by the owner of motor vehicle that knocked him down.

It was a small relief for his wife, Jessica Moraa Moasa, whose world had stood still when her husband of one year failed to show up home on the evening of the accident.

However, in the larger scheme of things, Mr Madaga’s accident and ultimate death brought to the fore the state of emergency care services in the country.

Emergency treatment is the provision of initial resuscitation, stabilisation, and treatment to acutely ill and injured patients, and delivery of those patients to the best available definitive care, regardless of ability to pay, according to the African Federation for Emergency Medicine.

LITTLE DONE

But, two years after Mr Madaga’s death, little has happened to change how desperate patients are treated in Kenyan hospitals. Emergency care still remains underdeveloped, underequipped and basic, in both public and private health facilities.

The country does not have an organised national emergency care system, lacks specialised trained emergency care health personnel, and has not developed standard operational procedures and emergency operation plans.

This, unfortunately, exposes victims and survivors of road accidents, droughts, oods, res, terrorism, poisoning, collapsed buildings, disease or epidemics to avoidable death.

Benjamin Wachira, an assistant professor of emergency medicine at Aga Khan University Hospital, Nairobi, says this needs to be addressed right from the training of healthcare professionals.

“We were not trained on emergency care in medical school as the main focus was on in-patient care only,” says Dr Wachira, the first and only emergency medicine specialist in the country.

“This means that sometimes those in the casualties may not be well-prepared. You cannot predict when an emergency will walk through the casualty doors, but you are expected to be ready when that happens. That’s the dilemma in our country.”

The Health Act, 2017 describes emergency care as the necessary immediate healthcare that must be administered to prevent death or worsening of a medical situation.

It includes pre-hospital care, stabilising the health status of the individual, or arranging for referral in cases where the health provider of first call does not have facilities or capability to stabilise the victim.

Hospitals, including private ones, have an obligation, as indicated in the Act, to provide emergency services or be fined Sh3 million.

The Act further says that any healthcare provider “who fails to provide emergency medical treatment while having ability to do so commits an offence and is liable, upon conviction, to a fine not exceeding one million shillings or imprisonment for a period not exceeding 12 months, or both”.

A study published last month — titled Burden of Emergency Conditions and Emergency Care Usage: New Estimates from 40 Countries — shows that a substantial proportion of the world’s leading causes of death can be addressed in an emergency care setting, and that emergency care can no longer be considered a non-essential luxury, especially as low- and middle-income countries such as Kenya experience the mounting double burden of communicable and non-communicable diseases.

“It is the injured who need emergency care to prevent death and permanent disability, not those who die,” adds Dr Wachira. “Therefore, strengthening trauma and emergency care will result in a decrease in injury deaths. There is an urgent need to integrate emergency care into existing healthcare systems because we will at one time or another need these services.”

The World Bank says that the implementation of “effective, prioritised, timely emergency care has the potential to address 45 per cent of deaths and 36 per cent of disability in low- and middle-income countries”.

GAP IN EMERGENCY CARE

As a result, the Kenya Medical Practitioners and Dentists Board (KMPDB) chief executive, Mr Daniel Yumbya, sees the gap in emergency care as an opportunity for county governments to step in to provide the critical services to Kenyans without necessarily having to refer them to KNH or other national referral facilities.

“I challenge county governments to ensure that their hospitals, including the referral ones, are well-equipped with ICU beds and trained personnel in emergency care for their residents,” Mr Yumbya told HealthyNation on phone.

But emergency care, Dr Wachira emphasises, is not defined entirely by location and may be required at home, in the streets, on roads, schools, disaster sites, and ambulances, among others.

For instance, by October 10 this year, over 3,000 Kenyans had been seriously injured on Kenyan roads since January, according to statistics from the National Transport and Safety Authority. In most of these cases, bystanders provided first aid or transportation to the victims shortly after the accident, regardless of how much skilled or unskilled they were to offer emergency care. This is particularly problematic for what is known as the golden hour in medicine — the period following acute traumatic injury or medical emergency such as a heart attack or stroke during which there is the highest likelihood that prompt emergency medical treatment will prevent death.

However, Kenyans lose their lives or are maimed for life within this hour as they may not get the appropriate and timely critical services.

Others who require the life-saving services include survivors of terrorism attacks, collapsed buildings, and fires, as well as survivors of assault or mob justice, pregnant women with complications such as high blood pressure and severe bleeding, and poisoning incidents.

Emergencies are spontaneous, but emergency care shouldn’t be, says Mr Irungu Houghton, the executive director at Society for International Development. More needs to be done to ensure emergency services are an integral component of the healthcare system in the country, he adds.

There is hope, however, that things will change in the near future. The recently passed Health Act strengthens legislation on emergency medical care in Kenya. And in November 2015, a motion that the government immediately develops and implements a national curriculum for training of all medical personnel in the country on emergency medical care, by Ms Susan Musyoka, the Member for Machakos County in the National Assembly, was passed in Parliament.

In the training field, the Aga Khan University, Nairobi, started offering the first post-graduate diploma in emergency medicine, in January last year. Dr Wachira says that so far close to 10 medical officers have graduated from the programme, but “this is still not enough”.

Last month, Kijabe College of Health Sciences started a one-year post-graduate diploma in emergency medicine for clinical officers, while in May the medical board recognised and listed emergency medicine as a medical speciality in Kenya. It also registered Dr Wachira as the first emergency medicine specialist in the country.

In June this year, the National Hospital Insurance Fund entered into a partnership with Emergency Plus Medical Services (E-Plus) to roll out emergency road rescue and evacuation services. This is meant to benefit all NHIF members and their declared dependants — in total nearly 20 million Kenyans are now covered — who can access round-the-clock emergency ambulance services such as on-site evacuation and emergency care in the ambulance as they are ferried to the nearest NHIF-accredited health facility.

To access the service, NHIF members are required to call 1199, which is a toll-free number, or 0700395395.

 This is important because majority of health facilities, excluding national and provincial hospitals, do not have emergency transportation, which means transferring patients under emergency circumstances from these facilities is fraught with delays and possible complications.

Even then, emergency care is not explicitly included in the NHIF out-patient package.

“Part of the reason may be that it has previously been hard to define what emergency care is, and thus it cannot be costed, especially where private facilities are concerned,” Dr Wachira says.

However, the Emergency Medicine Kenya Foundation is working on a project that seeks to include universal emergency care coverage under NHIF.

 The ambitious project seeks to offer a tailor-made emergency cover for predetermined emergency conditions, including the tests and treatment which will be offered at an agreed cost paid by NHIF.

***

ABOUT THE COURT CASE

The Kenya Legal and Ethical Issues Network on HIV and Aids (Kelin), with the assistance of pro-bono lawyers Kimanthi and Associates Advocates, filed Civil Suit No 6426 of 2016 against the driver and owner of the vehicle that fatally injured Mr Alex Madaga.

Ms Tabitha Saoyo, deputy executive director at Kelin, says this about the court judgment awarding damages to the family of the victim: “Whereas no amount of money can replace a life, we celebrate this judgment together with the wife and family of the late Alex Madaga.

They have patiently awaited justice for his death for over two years. Kelin intends to push for immediate payment in this matter and ensure that, ultimately, our healthcare system reforms to afford patients the much deserved emergency medical treatment.”

 

***

CELEBRATING A HERO

Media reporting on the events around Alex Madaga’s death has inspired a movie, 18 Hours, which will be screened for the first time in Nairobi next Friday.

The 70-minute movie has been produced by Roque Pictures Inc and was written by Kevin Njue, a young filmmaker. It tells the story of Brian Odhiambo , the paramedic who stayed with Alex for 18 hours in search of medical help.