Crash Course

According to the World Health Organization, nearly one in ten deaths worldwide are due to injuries, which now kill more than 5 million people each day -- more than AIDS, tuberculosis, and malaria combined.
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At the University Teaching Hospital in Kigali, Rwanda, a nurse brings in a young woman on a stretcher who is obviously pregnant, with a large protruding abdomen. The nurse calls to a young Rwandan physician standing nearby, ready to receive the patient. "Doctor, this patient was in a road traffic accident! She is pregnant, and now has severe pain in her abdomen."

The young Rwandan physician, also pregnant herself, jumps into action. "Madam, what is your name?" she asks, bending over the patient, who only moans in response. "Nurse, please check the patient's pulse and blood pressure," she requests as she puts the buds of her stethoscope to her ears and listens carefully to the patient's chest. "The air entry is good on both sides," she announces a moment later.

"Doctor, the patient's blood pressure is low -- 80/40 -- and her heart rate is very fast -- almost 120," the nurse states in an anxious voice.

The doctor nods in response, pauses for a moment, then motions for the nurse to help her. "We must lay the patient on her left side, to take the pressure off of her vena cava," the doctor explains as they turn the patient, a simple technique that can prevent worsening shock in an injured pregnant patient. "Please nurse, let us also place two 18 gauge intravenous lines and give this patient two liters of ringers lactate. And let us also order blood for this patient."

"What type of blood?" the nurse asks.

Again the physician pauses for a moment. "O negative," she responds correctly a moment later. I turn to one of my fellow emergency medicine faculty standing nearby, observing the situation, and we give each other a knowing smile, proud of how well this generally quiet and shy young physician is managing the resuscitation so far.

Luckily, the patient in this case is in no real danger -- in fact, she is not a patient at all, but an actor, with a rolled up cloth beneath her clothing to help her portray a pregnant woman. Our location is not the actual hospital emergency room, but a squat building a few hundred feet away that has been turned into a low-tech simulation center for medical and nursing trainees. The shy, pregnant Rwandan woman managing the trauma resuscitation is a real physician, though -- a member of Rwanda's very first class of ten emergency medicine trainees.

It may seem odd to have her and her fellow trainees spend the afternoon managing fake trauma cases when just a few hundred feet away, in the actual hospital emergency room, dozens of injured patients present each day. There are young children struck by cars or motorcycle taxis while playing in the road; construction workers with poor safety harnesses who fall from one of the many new buildings going up in the rapidly expanding city; farmers from rural areas gored by their bulls; young drunken men beaten into unconsciousness during bar fights; and many, many more. As in most of the developing world, these types of cases now represent a large and growing cause of death and disability in Rwanda. According to the World Health Organization, nearly one in ten deaths worldwide are due to injuries, which now kill more than 5 million people each day -- more than AIDS, tuberculosis, and malaria combined. Yet until now, few resources have been put into training physicians, nurses, and pre-hospital providers in low-income countries to manage injuries correctly and develop the types of trauma systems that have so drastically reduced mortality in North America and Europe over the past several decades. Some have even gone so far as to say that injury has now become the most important of all neglected tropical diseases.

Which explains why we have Rwanda's first class of emergency medicine trainees running one simulated trauma resuscitation after another, practicing their technique and skills under the watchful eye of our emergency medicine faculty from Brown and Columbia Universities, who have been working to develop this new emergency medicine training program in Rwanda. Just over the past two months since they started their training, we have witnessed tremendous progress in their communication skills, knowledge base, and ability to manage complex resuscitations in a very resource-limited setting. Over the next several years of training, as they continue to sharpen their skills on patients both real and simulated, we expect them to improve to the point where they are prepared to not only provide high-quality care for individual emergency cases on their own, but also to run an entire emergency care system for this rapidly developing country. And given the expected increase in need for emergency and trauma care in Rwanda and other developing countries over the next several decades, it will be none too soon.

Adam Levine is an Assistant Professor of Emergency Medicine and Director of the Global Emergency Medicine Fellowship at Brown University. He currently serves as the Clinical Advisor for Emergency and Trauma Care for Partners In Health/Inshuti Mu Buzima and as a member of the Emergency Response Team for International Medical Corps. His research focuses on improving the delivery of acute care in low-income countries and during humanitarian emergencies. The views expressed in this blog are his alone and do not necessarily represent the views of any of the organizations mentioned above.

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