Emergency cases burden a struggling health system

The number of road crashes is damning.

The incidents, if not fatal, leave lifetime scars. And the blame game, a constant feature. It’s almost a chicken and egg situation.

Some say, would the driver have been more careful, the accident would have been avoided. Others feel authorities should take the blame for lack of alertness.

This is the sad story of Kenyan highways. But, what becomes of the victims?

For orthopaedic surgeon Francis Mbugua, the high fatalities are a reflection of the health system. “It’s scary to hear the number of people who die in road accidents. I don’t think Kenyans look at those issues through the eyes of survivors,” he tells HealthyNation.

One such survivor is truck driver John Mchicha, and he has pondered over these issues.

He can only speak of indescribable pain when he recalls the circumstances that confined him to a wheelchair.

FINANCIAL BURDEN

On that October evening in 2018, he went about his routine, kissed his wife and children goodbye and left his home in Nairobi’s Kayole for Busia.

Had he known what awaited him barely 40 minutes into the journey, he would have held his family a little longer.

Just past Kimende, a vehicle rammed his truck and this moment changed his life forever.

He was taken to AIC Kijabe Hospital, where he stayed for more than eight months as he fought for his life, oscillating between ICU and operation tables.

Now, seated on the floor of his house, John’s says the memories are tormenting. “I used to be very energetic. My life was full of sporty, fun-filled activities with my children. Now, I cannot walk or earn a living for my family and I depend on people to help me even with the most personal things,” he says.

Every day he watches helplessly as his wife struggles to look after him and their three children. He needs knee replacement surgeries which he cannot afford. “People get tired of fundraising calls,” he says.

TRAUMA CASES

John is grateful to have lived, but out of his bill of Sh2.4 million at Kijabe, he has only been able to pay part of it and it is giving him sleepless nights.

Orthopaedic surgeon Chege Mwangi attributes the high cost treatment to the state in which patients are when they go into the hospitals.

“Fractured spine, broken limbs, trauma in the head,” he says, are some of the cases they deal with. “They often stay with us here for a while, and sometimes never leave.”

The most traumatic cases Mwangi receives are from motorbike accidents with patients often succumbing to the injuries.

Those who live pay a heavy price majorly borne by them, their families and, if they’re a lucky, hospitals ease the burden.

As soon as an accident victim is taken to the hospital, they are rushed to the operating table. The work however begins after surgery and with this comes the cost.

For those with fractures, nails have to be used to join the bones. The cost of each nail ranges from Sh25,000 to 40,000.

Fixators needed to grow the bone back are often expensive. The healing process is not complete until therapy is done. “The number of metals will depend on how many bones have been broken,” says Chege.

SCARCE RESOURCES

In most cases, hospitals such as Kijabe have to foot the bills. According to exclusive financial records at the hospital, the facility incurred a Sh12.8 million debt in January this year alone — nearly four times the amount patients paid in that month.

The debt has increased by nearly 40 percent since 2018, with a likelihood it will go up even further.

A new study on the capacity of Kenya’s hospitals to handle emergencies paints a dark picture of the country’s ability to respond to a rising public health threat of accidents, other forms of trauma and any medical issue that would require instant life-saving attention.

Exclusive data from Project 47, a nationwide study on the county hospitals’ capability to offer emergency care, shows that less than half of Kenya’s hospitals (46 percent) have a dedicated emergency department that can attend to accidents among other emergencies.

Of the facilities that have the department, 31 percent do not have a triage system. The triage system enables healthcare workers to judge the seriousness of injuries. Another 21 percent lack a functional X-ray machine.

TRIAGE SYSTEM

Head of the emergency department at Kenyatta National Hospital, Alice Maingi, says patients are categorised depending on whether they go to the hospital bleeding profusely or whether they are breathing. These are marked as either green, orange or red.

Green is for patients who can wait up to an hour as their lives are not hanging by a thread. The wait time for an orange is a few minutes and a red has to get immediate attention.

Wachira Wambugu of Aga Khan University, Kenya’s only emergency medicine specialist, tells HealthyNation that a trained emergency health worker monitors the queue closely as a green could easily become an orange and move to red.

In a matter of minutes, an orange can also move to red and it could mean death.

According to the report, there was not much hope in terms of medical equipment that are considered basic by the World Health Organisation. While two in five of the hospitals (40 percent) had a functional theatre, they lacked blood banks.

Even more worrying is that more than a third (32 percent) of the hospitals did not have resuscitators which, according to Wambugu, is necessary to save a person who is not breathing.

STAFF SHORTAGE

In terms of healthcare workers, equipment and funding, slightly more than half (57 percent) of the hospitals can perform the live-saving procedures such as opening up of the stomach (laparotomy), caesarean delivery and treatment of an open fracture.

Even when the healthcare workers are willing to act, they are either overwhelmed or ill-prepared to handle the type of patients who walk into the emergency care department.

It is hardly newsworthy that Kenya suffers chronic healthcare worker shortage.

The WHO approved ratio of health workers to the population is 45 physicians, nurses and midwives per 10,000 people.

Kenya has 13.8 health workers per 10,000 people, and this includes clinical officers.

Physicians at Nakuru Level Five Hospital, Thika Level Five in Kiambu County and Makindu Hospital said whenever there are accidents, they can work for more as 16 hours a day.

At Makindu, a clinical officer, who spoke on anonymity as he is not authorised to speak to journalists, said: “Sometimes we decide which case is the most critical, but we would still be too few to handle the cases. We end up playing God. You give your attention to a patient and hope they survive.”

Similar concerns were raised in Mombasa County’s referral hospital and Kisumu’s Jaramogi Oginga Odinga Training and Referral Hospital.

POOR TRAINING

The trouble is compounded by the fact that Kenya’s medical schools do not offer training in emergency care beyond the basic first aid.

Until 2016, the Kenya Medical Practitioners and Dentists Board did not have emergency medicine as a specialty, leaving hospitals such as Kijabe and Aga Khan to train their staff in-house for an 18-month course.

The board’s chief executive officer Daniel Yumbya confirmed to HealthyNation there are no specialists on emergency medicine. The mismanagement of patients — in most cases unintended — is costly.

Chege explains: “Patients are taken to facilities with an exposed bone, which if not properly managed, begins to rot when it gets infected. When they come here, they may have lost portions of the bone that must be grown back, 1mm each day.”

Clinical officer David Aliba has undergone the training, and he is now able to handle patients in critical care until the doctors arrive for surgeries.

For instance, he is now able to place the central line, through which the patient breathes, triage and isolate the patients who should be attended to first.

LOW FUNDING

Yet, despite the pressure emergencies, especially trauma, exert on the health system, no money is explicitly allocated to hospitals for these emergencies.

A study published in the journal Elsevier showed that in Kenyatta National Hospital, emergencies — mostly road crashes and falls — take up the majority of its, but money is allocated mostly to diseases such as malaria, tuberculosis and HIV.

Yet, the majority of patients (61 percent) that walked into KNH were treated in the emergency centre, observed and discharged, while another 33 percent were admitted into the hospital. Six percent died, mostly due to head injuries.

This study and other recently published data showed that the majority of the people treated in the hospital were due to non-communicable diseases such as heart problems or traumatic injuries.

Seeing the neglect of emergency care, now experts are questioning the prioritisation.

ROAD CRASHES

WHO records show that road crashes claim 1.2 million people globally, 90 percent of which take place in sub-Saharan Africa.

This has baffled experts because Africa has only two percent of the world’s vehicles, but the deaths in roads are 24 per 100,000 deaths compared to 10 in Europe.

Dr Wambugu attributes this to, among other things, roads without sidewalks and a broken emergency response system in hospitals.

In the study, only 33 percent of the patients triaged and found to be in need of ICU admission received that care due to limited availability of equipment and resources.

This story does not end well. “They also found the mortality risk to be significantly higher in those patients admitted to the general ward as compared to the ICU,” the authors wrote.

In 2015, a road crash victim Alex Madaga died after waiting in an ambulance for 18 hours because Kenyatta National Hospital did not have a free ICU bed.

Contacted, Wekesa Masasabi, the acting director-general at the Ministry of Health, acknowledged the lack of a specific fund allocated to dealing with emergencies and left the decision to the hospitals. He said there was money for public health emergencies.

Masasabi however remained non-committal on when the fund policy would be launched, only commenting that “there is movement”.