The young patient was wheeled into our emergency centre by the ambulance service. He had sustained what appeared to be a severe head and pelvis injury and possibly also a spinal one.
Our emergency care team leapt into action. They took over his breathing, placing a tube through his mouth into his lungs. We splinted his pelvis and rapidly replaced the blood he had lost. In no time we were heading to the CT scanner with a fully stabilised patient.
Earlier that evening I sutured a three-year-old's face after an unwelcome encounter at home that resulted in a broken window and an unsightly cut. She may recall the accident that led to the injury but not her hospital experience nor any traces of the wound. I gave her a light sedation and used a combination of fine sutures and skin glue to close the wound.
Before that, I treated a would-be mother who suffered a miscarriage. I also slowed down a young man's heart that was beating too fast and treated another person's acute asthma attack.
Each patient could safely go home after the emergency centre treatment. Each had a follow-up arrangement at their usual primary care doctor. My trauma patient couldn't go home – at least not today. But he did get the best chance at a good outcome thanks to the presence of the specialised emergency care team in the emergency centre.
Inadequate training on offer
This scenario can be replicated by very few African emergency centres. But it did form part of my daily routine when I trained and worked as a specialist in emergency medicine at an English hospital. There, this level of emergency care is considered standard.
In contrast, emergency centres in South Africa – including privately operated ones – are mainly staffed by general practitioners and early career medical officers, who are largely non-specialists. Elsewhere in Africa, emergency centres may be staffed by clinical officers, who are not quite doctors but able to provide more advanced care than a nurse.
Undergraduate courses in most of Africa, and certainly in South Africa where I work, largely skimp on emergency care training. And the two- to three-day courses – usually a prerequisite to work in an emergency centre – mainly cover aspects of resuscitation. The result is that emergency centres are staffed with clinicians who either do not practice emergency medicine full-time or are only trained to deal with a small section of specialised emergency care.
There are currently five universities in South Africa that offer specialist training in emergency medicine. The first was established in 2003. But the trickle of specialists produced annually has not yet tangibly filtered down into the health-care system. There are only nine similar offerings on the rest of the continent.
In contrast, emergency medicine as a speciality has existed in developed countries such as Canada, the US, United Kingdom, Australia and New Zealand, and in parts of Western Europe for between 20 and 45 years.
Africa needs emergency care specialists
African countries make up more than half of the top 20 countries that have the highest annual death rates.
The two biggest contributing factors are: a lack of attention to prevention at the one end, and emergency care at the other.
Injury related deaths are projected to overtake HIV-related deaths by 2030. Noncommunicable causes of death such as acute strokes and heart attacks have steadily increased over the past decade, overtaking the slowing tide of infectious causes of death such as HIV, tuberculosis and malaria.
An emergency care epidemic from injuries and noncommunicable diseases has been quietly filling the room just as HIV and tuberculosis were being ushered out. With proper emergency care only haphazardly practiced, health practitioners are ill prepared to cope with the stresses this will place on an already resource-limited and overburdened health-care system.
From what is known internationally about the ideal standard of emergency care, Africans appear to be getting a raw deal. This is the same whether you are attending a dilapidated public “casualty” department or a tidy private emergency centre.
Private medical aid providers admit to this service failure. They point to inappropriate decisions taken by inexperienced doctors working in private emergency centres as one of the key reasons for rising private health-care costs in South Africa. This effect is likely to be similar, if not worse, in public emergency centres staffed by doctors with a similar scope.
Emergency medicine as a speciality involves providing specialist-level care for all acute illnesses or injuries for any age group, whether in or outside the hospital. It means having neurologist, cardiologist, surgical and a whole host of other specialist skills sets available in the emergency centre, with the safety and convenience of not having to wait longer than needed. The knock-on effect is reduced mortality, morbidity and cost.
By providing specialist input early in the patient journey, diagnoses are made sooner, appropriate treatment is started earlier and admissions are made appropriately. This leads to timely care, less complications and earlier discharge – often from the emergency centre.
As shown by multiple studies it is really that simple: by investing in the front end of acute care, savings (in more ways than one) are made downstream for both patients and health-care systems.
It is paramount to incorporate proven local solutions into African emergency care because Western solutions don't face the same resource restrictions.
African countries could, for example, take a leaf out of HIV's success story. As with antiretroviral treatment, emergency care is a front-end solution that has an effect on nearly every part of the health-care system. And stakeholders from every part of the health-care system need to be involved to set up and maintain the service.
But to achieve any of this, health-care leaders in the public and private sector need to be mobilised as advocates.
Stevan Bruijns, Senior lecturer in the Division of Emergency Medicine, University of Cape Town
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