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| Prof. Iribhogbe |
Statistics
has it that the chances of survival when emergency medical conditions sets in
here in Nigeria is 10.4 to 100,000 death
as against 24.1 to 100,000 deaths in Europe. Worst, most of these deaths could
have been avoided if help had gotten to the victims early enough through the
EMS. What’s the scope of EMS?
Emergency Medical Services (EMS) is a highly
sophisticated level of care that entails pre hospital and in hospital care give
to victims of medical emergencies.
Whenever trauma sets in, these victims are expected
to receive some level of care before they are taken to the hospital. This
increases their chances of survival.
Simply put, EMS encompasses the 3R. It means getting
the right patient to the right place in the right time.
It needs a team including paramedics, emergency
nurses, emergency physicians (unfortunately, they are not in Nigeria
currently), trauma surgeons, FRSC, Fire service, police, NEMA and NAMA.
EMS as obtainable in foreign countries operates like this; whenever an emergency medical condition sets in, people at the scene know a specific number to call that puts them across to the EMS control center. On receiving the call, the control centre immediately checks the screen and looks for the ambulance closest to the site of emergency and informs the paramedics to move to the place and begin rescue mission. The paramedics move the patients into the well equipped ambulance and begin the process of transporting the victims to the hospital. On their way, they put a phone call through to the Emergency room (ER) of the hospital they are taking the patient to. The doctors in the ER begin to set up the equipment needed to care for the patient because they already have an idea of the kind of patient the paramedic are brining. Upon arrival at the hospital, the doctors take over the care of the patient. This whole set up is to give the patient a greater chance of survival because the chances of a patient surviving an emergency lies in the time interval between occurrence of emergency and the time help arrived.
However in Nigeria, we do not have an EMS, such that
when emergency medical conditions set in, people go and look for vehicle to
transport the person to the hospital. Some of them go to several hospitals
before they get to a facility that has equipment to cater for their condition.
The system in Nigeria is time wasting and at such the chances of persons
surviving during emergency conditions is very slim.
There
is the general notion that Nigerian Health workers do not respond to
emergencies early enough when people arrive at the ER. How true is this? Also,
what is the standard procedure for attending to patients in the ER?
The notion is not true. Nigerians must understand
that in the ER, we attend to patients based on the severity of the case and not
on the first come first serve basis because we are talking of life here.
First, we have to define what an emergency is. In
Trauma, an emergency condition is a condition that is a threat to life.
Worldwide, in every ER, there is a team we call the triage team. They are the
once that first see the patient and classify the condition based on the
severity of it. Such that we have the immediately group comprising those who
will die in few minutes time if care does not get to them. An example is a patient
that is choking. There is the urgent but not immediate group; an example is
someone who is bleeding. Finally we have the delayed group. This group entails
patients who can talk and will last long even if help doesn’t come as soon as
possible. Example is someone with fracture.
Upon arrival, the triage team identifies the patient
and care begins.
For example, a woman might notice a breast lump in
her breast and start running down to the ER, if in 2 minutes time another
patient is brought in with heart failure, the doctors will abandon her and
start attending to the patient with heart failure because she is in the
immediate group and life matter here.
Last year at the Accident and Emergency room (A/E), a
patient was brought in choking. There was a large piece of meat hanging in her
throat which was compressing the trachea (wind pipe) leading to difficulty in
breathing. At the same time, an accident victim was brought in who had fracture
of the femur and was bleeding. We left the accident victim and began attending
to the one that was choking. The relatives of the accident victims were busy
shouting and causing trouble that they arrived almost the same time and we were
showing favoritism that our medical team does not know how to attend to emergency
conditions.
That boils down to the ignorance among Nigerians.
They need to understand the working of the A/E. There is no A/E where doctors
attend to patients on first come first serve basis. Such doesn’t exist in the
world.
The fact that Nigeria does not have a functional EM
is complicating our troubles in the A/E. If there were a functional EMS, the
paramedics could have called informing the ER that a patient with fracture and hemorrhage
was coming. We would have known how to strategize to accept both emergencies at
the same time.
However I can’t speak of other hospitals but I am
the head of Accident and Emergency department here in UBTH and daily I monitor
what goes on here. Here, those in the immediate group do not need to take card
and fulfill other hospital protocols before we begin treatment. Immediately
they arrive and our triage team identifies them, the trauma team start
attending to them while a member of staff guide the relatives on how to go
about the registration. For those in the delayed group, we tell them to go and
take card and begin attending to them when we see that there is no other
immediate group of emergency to attend to. In the ER, every minute matters. It
could determine if a person will stay alive or not.
If only Nigerians understand the workings of the
A/E, they will stop the rumor that health workers are not fast in responding
during times of emergency.
Basically,
what’s the effect of not having a National EMS on Nigerians and Nigeria as an Economy?
The effect is that we keep losing precious lives at
golden hours. Our human resource is depleting. Persons with potentials needed
to develop the nation are dying when they develop medical emergencies because
help came late.
Developing Nations in Africa with the exception of
South Africa do not know what EMS is all about and that include the giant of
Africa-Nigeria. Over the past 10 years, I have been at the fore front of
advocating for an EMS and have held series of interviews on televisions. I have
spoken to senators about it and they laugh when I am done. They don’t seem to
get it but when they move around in convoy, you see them moving with ambulances
incase of any emergency. No one cares if the ordinary man in the street needs
an ambulance and medical care in case of emergency.
Currently, the whole concept of EMS is misunderstood,
Nigerians Ignorant about it and no structure in place to run it which has lead
to increase in mortality and morbidity rate among Nigerians because people keep
dying pre hospital and few hours upon arrival in the ER. The goal of EMS is to take the hospital
through Paramedics to the patient.
If a person collapses now in Nigeria, the person is
on his own. People around do not even know how to resuscitate the person. All
they know is that they have to get a car and start transporting the person to
the ER. What if such person dies on the way? What if there is no vehicle at the
spot? Why not have a system of care such
that the person is receiving care on the way to the hospital as obtainable in
foreign countries. We are busy talking about taking the person to the hospital,
we have forgotten that a person that develops an emergency condition needs some
level of care on his way to the hospital in a well equipped ambulance. In
advanced nations, the care of the person including those that sustained
accident on the road begins from when the emergency sets in. this emergency
could be epilepsy, choking, epistaxis (severe bleeding from the nose), asthma
etc.
Nigeria should have a structure in place to care for
people in times of emergency because the chances of survival have to do with
the time between when the emergency sets in and arrival of help.
Ems is a chain of health care and many persons come
into the picture. If a man develops heart attack, his wife should have some
knowledge of Basic life support (BLS) and Advanced Trauma Life Support (ATLS)
protocols which entails some level of knowledge on what t do before arrival of
paramedics and transportation to the hospital. If there is an earthquake in
Benin now, peoples around do not even know what to do to rescue these persons
and increase their chances of survival because they lack BLS and ATLS skills
which every human being on earth is expected to have. Having BLS and ATLS does
not have to do with being a heath worker or not.
Take the case of Israel, in the late 90s when the
Palastians were attacking them, they began teaching every Israeli BLS such that
by 15 years they had knowledge of BLS and by 18yars they went to serve in the
military voluntarily and were taught ATLS. This helped the country in times of
trouble and bomb blast. Every citizen knew what t do before the arrival of the
Paramedics.
This is something the government has to do with the
National Youth Service Corp (NYSC). They should work on the scheme and include
space for a mandatory teaching of BLS and ATLS protocols to the Corp members.
NYSC should be beyond the Cdc, Pop and parade they o. with the emergency of
insurgencies, every Nigerians should be taught BLS and ATLS. It is vital and
will help reduce mortality during bomb blast.
Over
the years, FRSC and Red Cross have been rendering EMS to victims of road traffic
accident (RTA) and Bomb blast. Some states like Lagos state and Ondo state have
keyed into the scheme as well as Flying Doctors instituted by Dr Ola Orekunmi
to provide air ambulance to victims during emergency conditions. Are you saying
this is not enough?
Their services are not enough at. How many parsons
are aware and can pay for the services of Flying doctors. What I am saying is
that the government should constitute a national EMS not what the states are
doing. We must first commend the states for what they are doing but more need
to key into it. We should have a national structure for it from the national
level.
Like I said initially, EMS does not only respond to
victims of RTA but any medical emergency.
The FRSC has a duty of accident prevention not rendering
EMS to Nigerians. Their job description is to ensure that Nigerian behave well
on the road. It is a good idea but the bad part is that the medical representatives
in FRSC are almost zero. Where are the
paramedics, Emergency nurses, physicians, trauma surgeons and other emergency
workers in the FRSC? Do they go to scene for rescue mission? Have you watched
how they carry accident victims? You will marvel. For example a person that developed
a spinal cord injure must never be made to seat in a car. Such persons must be
made to lie on a flat surface. There are ways we carry people with multiple
traumatic injury and there are some medical interventions we do for them on the
scene and the FRSC officials do not know about this. Outside the country, there
are people specially trained to handle emergencies and they are the paramedics.
I have friends that are medical doctors in the FRSC and their duty is to sit in
the office. They do not go to scene for rescues mission. It is the nonmedical
workers that go here. You cannot attend to an accident victim with just 2-3
days training on rescue missions. People attend schools to learn these things.
Paramedics undergo three years of intensive training on this. Their duty is to
take the hospital to the patient. But the situation in
Since 2008, UBTH has been training Paramedic s and
us the only hospital that odes that in Nigeria currently. We approached the
FRSC years back and told them to employ our graduates to add the medical touch
to their rescue mission and as we speak I am not aware if they have accepted
that bargain. But we will keep putting
pressure on them because we know that this is something that will benefit all
Nigerians.
What we have resolved is that we send down our
paramedics to do attachment with them during ember period and help in rescuing
accident victims. FRSC do not pay our paramedics transportation. This they are
doing because of the love of for Nigerians.
As a medical doctor that specialized in trauma
surgery, I cannot leave the hospital to accident scene, so we send down the
paramedics who represent us there. They are under instructions to help revive
and keep the patients alive until they get to the hospital for the trauma
surgeons to take over management f the patient.
You know o the immigration job saga? If we had
emergency paramedics on scene, the casualty level would have reduced. Years
back Rehand Bonkie held a crusade in Benin and there were 16 deaths. If people
are having a gathering that will involve crowd like church crusade, political rally,
aside having an ambulance, they should have paramedics on the spot as it is the
tradition oversees. Even companies like shell, NNPC and multinational company
should employ paramedics to help handle their casualties before they bring
their workers to the hospital for continued management. It’s rather sad that
Nigerians do not get the entire concept.
As for the Red Cross, we must first acknowledge the
fact that it is an international movement of volunteers. We can’t say Red Cross should take care of our
EMS, it is not done anywhere in the world. If there is a war in Benin now, they
could come and assist me here in UBTH and they are under instructions. Assuming
someone collapse along the Ugbowo Lagos road, will the Red Cross go there to
rescue? By the way, how will you even know those that are Red Cross members, do
they have a dedicated line that we can call for emergency conditions. Their
duty is to volunteer during times of natural disasters. Never forget that the
Red Cross member could be anybody- a banker, engineer, lawyer and other
volunteers. They are not trained to handle emergency that’s why they work under
instructions. Paramedics are trained for that duty and should be given their
place of pride in emergency response.
Red Cross and FRSC cannot substitute for our EMS.
If
the government decides to run an EMS today, what are the modalities to be put
in place?
We must establish the fact that EMS is expensive and
needs a whole lot of logistics but the good news is that Nigeria I rich enough
to run it. a government only interested in looting fun cannot run it because
you will have to pay workers and equip the ambulances. You can’t send the
paramedics to the street with empty ambulances to go and rescue people.
There will have to be a control centre from where
paramedics are dispatched to respond to distress call. We will need a central
control centre, semi control centre, communication gadget, well equipped ambulances,
emergency workers comprising more of paramedics’ and advocacy. The control
centre must have gadget that can receive and send call beyond GSM and radio.
Every Nigerian should be informed of the number to
call whenever there is an emergency condition.
Whenever a medical emergency occur, people there
will have to call the control centre who receives the call and inquire of the
location. Upon receiving the call, the person at the control centre reassures
them that the paramedics will be with them shortly. All the ambulance in the states is supposed
to be visible on a computer screen. He immediately checks the screen and
searches for the one closest to the scene of emergency and informs the
paramedics manning the ambulance. All theses happen within 4 minutes in the USA.
It means we will have lot of ambulances manned by paramedics spread across
strategic locations in Nigeria and a functional GPS system.
Who
pay for these services?
Payment depends on the country. The National Health
Insurance Scheme (NHIS) can be a part of it. If a person has a medical
insurance, his company can pay for it. Assuming
the Edo state Government wants to run an EMS, he can mandate all UBTH staff to
insure themselves with a certain amount of money such that their pre hospital
care in times of emergency is well catered for.
Sadly, many Nigerians do not have a health
insurance. Those not having health insurance can be asked to pay in cash but
the risk is that we will have to rescue them first before talking about payment
and might be running at a loss.
The government should start running it first as a
social service and then start charging people to pay either via insurance or cash.
We must have to rescue everyone first because the financial part can be settled
at any time. Government can even make the calculations such that the rich end
up paying for the poor.
Our message to the government is that they should
develop a national structure first. EMS can even be run by the police, fire
services and private individual. Here at UBTH, we have started a flagship
programme but it is still on a low key and we are making it private. Few
persons know the phone number to call but we are facing the challenge of
funding. Our politicians can key into it. What we see here is that when
elections are coming, they will run down to UBTH and donate few bed sheets to
the hospital and be projecting it on television that they are helping the poor.
I laugh when I see them do this. Health care should be more than those bed
sheets and toiletries they come here to donate. They should invest heavily in
it. It shouldn’t be because of elections to earn cheap popularity that they
remember the hospital exists. That’s what most of them do. EMS is something
that will benefit everyone.
Considering
the disharmony in the health sector coupled with persistent strike, don’t you
think it will affect the smooth running of EMS?
The incessant strike has nothing to do with the
running if EMS. Infact, it won’t affect it at all. Rather, it will help in
redirecting patients.
There was a time we had a strike here in UBTH and
they brought in a man that was seriously sick. When the relatives saw the
emergency room empty and were told that UBTH is on strike, they had to take the
man away but unfortunatly, the man died before getting to UBTH gate and they
returned immediately to deposit the body in the mortuary. Whenever there is strike,
the paramedics who man the ambulance know the hospitals that are on strike and
will not take patients there. EMS will help in redirecting patients to
hospitals not on strike. The Paramedics could even take the patient to the
private hospital of the physicians that are on strike.
It’s however pathetic the way strike has become
recurrent in the health sector. Major art of the problem lies in the
government. They fail to keep to their promises and some persons are trying to
change the way things are supposed to be done.
Have we not wondered why the doctors in Ghana, South
Africa and Egypt do not go on strike just the way our health workers do here?
Over there everyone knows their job description and has a stipulated amount of
money they earn. Nigerian health workers might not earn exactly but the international
ratio must be maintained. The scenario in the heath sector can be likened to a
boss and his assistant. The boss earns #100,000 as monthly allowance and his
assistant goes to negotiate with the government who increase that of the assistant
from #50, 000 to #150,000 more that of
the boss. As the boss, you can get angry and go on strike. The pathetic part is
that government doesn’t respond to these issues until workers have downed
tools.
Everyone
should know their job description and work in the tenet of it. There is nothing
called Nigeria Medicine. Medicine is universal, we shouldn’t try to invent one
here.
I believe in team work. As a trauma surgeon, I respect
my nurses and they respect me too. Same applies to the other hospital staff. I can’t
do their work and they can’t do mine. Everyone should do what they are supposed
to do. Know your role in the health sector. Failure to recognize your role
means the person is a stupid person. I
come daily to the hospital, do the work that is expected of me and my nurses do
theirs too. Everyone of us is happy here in the A/E.
As a Professor of Traumatology, there is a Chief
Medical Director (CMD) governing this hospital. I leave him to do his work
while I do mine so peace will reign. I can’t be CMD. There is supposed to be
only one at a time. Anyone that wants to head this place should get the
necessary qualification that the law requires not trying to follow short cut and
change the way things are supposed to be done.
In a ship or plane, there is only one pilot but
there are other workers like the air hostess, auto engineers etc. All of them
have a role to play to avoid the flight from crashing. They know that the pilot
is the head of the team. They respect him and he respects them too. They give
the pilot the opportunity to perform his duty and everything goes well.
Same applies to the university. We have a single
vice chancellor. Everyone can’t lead at the same time.
The government allowed the health sector to be bastardized by some people that have selfish interest and do not mean well for
Nigerians. These persons have to be kicked out if not, the government will keep
batting strike.
On a final note, everyone is a stakeholder in having
a functional EMS. We should always look beyond our pockets and work for the
common good of all.
Not until government set up a national EMS,
Nigerians will keep dying during emergency conditions before help reach them.
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