“Management of emergencies is taught but dealing with an emergency theoretically is different from dealing with the emergency in real life.”

Clinical Officer, Zambia 2019.

Matua Rural Health Centre, Siavonga District

THE CASE

The Clinical Officer at Matua clinic contacted us about a 49-year old gentleman with breathlessness. He had been brought in by his family who were very concerned about him. He had been unwell for the last 3 days and was now getting rapidly worse. He had a history of hypertension, HIV and relapsed tuberculosis (TB). He was poorly compliant with his anti-hypertensive and anti-retroviral medication. There were also concerns that he had not completed a full course of TB therapy.

On assessment he appeared unwell. The Health centre does not have a saturation probe for monitoring oxygen levels, but the Clinical Officer is used to relying on his clinical skills and he noted the patient was breathing fast with signs of respiratory distress. On listening to his chest there were widespread crackles, suggesting fluid in the lungs. His heart rate and blood pressure were elevated. No heart murmurs were heard but there was significant leg swelling. He had a mild fever. The Clinical Officer was concerned that this gentleman had acute heart failure.

But the clinic’s oxygen cylinders were empty and they had run out of intravenous diuretics.

The patient continued to deteriorate and the Clinical Officer wisely referred him on to hospital. He subsequently contacted the Virtual Doctors to ask if there was anything else he could have done whilst waiting for the patient to be transferred.

The Volunteer doctor started by supporting the Clinical Officer in his plan to transfer the patient. Although our service does try to help manage patients on site, it is just as important to recognise when this is not possible and to encourage safe practice and prompt referral. He understood that the Clinical Officer wanted advice that he could apply should he have to deal with a similar case in the future. It was not the time to discuss or debate Guidelines for management of Acute Heart Failure or the subsequent diagnostic pathway and workup. The case might be fascinating to us as clinicians (what role was the hypertension, HIV or TB playing in this presentation in someone so young?) but the importance on this occasion was to concentrate on practical management steps.

During the subsequent discussion the Volunteer tried to highlight achievable interventions. Even simple things like helping the patient to sit upright to assist his breathing can help. Intravenous vasodilators, sometimes used in treatment of acute heart failure, are not on the Essential Medicines list and therefore not available in the Health centres. But opiates are available and the Volunteer advised that they could be used to rapidly relieve the breathlessness and distress of the patient. In addition, he recommended that if intravenous diuretics were not available, diuretic tablets could be tried instead; acknowledging that although this would not act fast, it might be helpful.

The Health Centre does not have access to ECHO, X-rays or even ECGs so investigating and treating for a reversible cause of the heart failure would not be possible on site. But the patient had presented with a low grade fever so the Doctor suggested that treating for inter-current infection with antibiotics might have some benefit.

These steps may not have obviated the need to refer to hospital on this occasion but they may have made the patient more comfortable in the meantime and at least bought some time.

THE CLINICS

The Clinics that we support in Zambia are predominantly Primary care facilities. The ‘typical’ rural Health Centre has about 3-4 rooms. Two of the rooms may be used for ‘Screening’ (reviewing patients). The other rooms are used for administration, for storing medication and as a waiting area. Unlike GP surgeries in the UK, some of the centres have in-patient beds (ranging in number from about 2 to 12). These beds can be used if the patient needs a period of observation. Sometimes it may be preferable to assess the patient’s response to initial therapy before making a referral to Hospital. If the patient improves then an unnecessary journey is avoided. The Virtual doctors are often contacted about this group of patients in the hope that together we can alter the patient’s clinical course.

EMERGENCY CARE AT THE HEALTH CENTRE

“Management of emergencies is taught but dealing with an emergency theoretically is different from dealing with the emergency in real life.”

Clinical Officer, Zambia 2019.

Management of emergencies can be so much more difficult in “real life”. And it is only made worse if equipment, infrastructure and manpower are lacking. The Zambian Ministry of Health has laid out its efforts to improve pre-hospital and emergency care provision in its current Strategic Health Plan. Amongst other measures, this has meant over 1,000 health professionals across the country have been trained in Basic life support, paramedics have been trained abroad and the first A&E centre has been built at Kabwe General Hospital.*

The Health Centres are mainly focussed on managing primary care conditions and they do not have a dedicated emergency area. But the staff do have to be ready to deal with emergencies, as they are often the first point of care. Our colleagues have described how they may have to ‘wait long hours’ before an ambulance is available to transfer a very sick patient. The ambulances are usually based at the Hospitals and are sent out to fetch referrals. There is not a national coordinated emergency response service as in the UK. Matua clinic in this case, is just 30km from the nearest hospital. But other clinics within the same district are 130-170km away**.

The observation beds can be used to stabilise sick patients in the meantime. But it is far removed from what we know in the UK. There may only be one clinical officer stationed at a clinic with 2 nursing staff to assist; so the team is small. They do have essential equipment such as thermometers, blood pressure cuffs and intravenous drips. But it is rare for a clinic to be able to monitor oxygen saturations, to check peak expiratory flow rate or to perform an ECG; things that we would consider vital in the UK. More sophisticated equipment such as cardiac monitors or defibrillators are limited to the hospital setting. Some items of emergency equipment that are recommended for the Health centres, such as bag valve masks or suction machines, are often lacking***. We have received cases (such as this one) where basic supplies required for dealing with emergencies such as fluid or oxygen have run out. But there have also been many instances where the Clinical Officers have competently provided immediate care to patients and then turned to the Virtual Doctors for ongoing advice. The cases include not only acutely sick adult medical patients. Examples of other urgent cases we have been consulted on include severe infections in neonates, eclampsia in expectant mothers and trauma. The trauma cases include anything from road traffic accidents to occupational crush injuries or wild animal attacks (including a possible tension pneumothorax inflicted by a lion). The team of Clinical Officers and Volunteers work together to provide the best possible care available for these patients.

The infrastructure of the clinics is limited. Many of the clinics rely on boreholes for their water supply. Our in-country office team estimated that about 70% of the clinics we support use solar power; they noted that this can be unreliable. Other Clinics rely on hydro-electricity; during the drought this year there have been many power cuts. This has implications for the running of a facility; and it affects not just the health centres but the hospitals too. A complicated case we received recently from one of the Hospitals we support, reported that an X-ray would have to be deferred until the morning when the power supply returned. All of the facilities should have refrigerators for storing certain medications; but our colleagues tell us that the unreliable power supply can cause problems with this. Some, but not all, of the clinics have generators to try and counter these difficulties.

We cannot change this but we can support the Clinical Officers. We offer advice on all kinds of cases, but the emergency situations are often those that appear to trouble the Clinical Officers most. Simply hearing advice from someone away from the stress of a situation can be invaluable. We try and help them to focus on steps they can achieve. We can remind them of the “ABC approach” to the sick patient; a logical sequence for assessing a patient so that the priorities of their Airway, Breathing and Circulation are reviewed and managed. We offer up alternative treatment solutions. We can support the decision to transfer to Hospital where appropriate. We have made sure that learning resources (such as the WHO Basic Emergency Care modules) are available to the Clinical Officers through their Virtual Doctors devices and we are supplementing this with some of our own Acute Care education topics on the forum. Sometimes, as in this case, we are consulted after the event and then we can help by mentoring, supporting and debriefing to help build knowledge and skills.

We may not have been able to alter the course of this patient’s journey but we hope that with our continued support the Clinical Officers will become empowered to change more lives in the future.

FOLLOW UP

Sadly the patient died in hospital a few days later.

We are grateful to Shakerrie Allmond, Stellah Chilembo and Pralin Koongo from the Zambia team, as well as all our Clinical Officers, for providing us with helpful factual background for this account

References

*Zambia National Health Strategic Plan 2017-2021

**The List of Health Facilities in Zambia (Ministry of Health, 2012)

***Institute for Health Metrics and Evaluation (IHME). Health Service Provision in Zambia:

Assessing Facility Capacity, Costs of Care, and Patient Perspectives. Seattle, WA: IHME, 2014.

Resources: https://www.who.int/publications-detail/basic-emergency-care-approach-to-the-acutely-ill-and-injured