Advance Suturing Skills Lab
By: Hans Hurt, MD, GECC Volunteer Physician

Trauma and wound care injuries have been a huge portion of the patients that I have seen arrive to the Emergency Department at Nyakibale on a daily basis. Nyakibale is a small, district hospital in rural southwestern Uganda not too far from the borders of Rwanda and the Democratic Republic of the Congo. What we know of health care in the US is nonexistent here. Families are extremely lucky if they possess the means to see a doctor before things take a turn for the worse.

It has been rare for a day to pass without patients arriving with complex scalp, lip, eye lid, ear, and tendon lacerations from “boda-boda” (motorcycle) or “panga” (machete) accidents. In the U.S., many of these complex wounds would be treated by a consulting an Ear, Nose, and Throat doctor, Orthopedist, or Ophthalmologist – dedicated specialists for these emergencies. But in Nyakibale in rural Uganda, there are no specialists, and in fact there are no emergency physicians whatsoever in the entire country. The closest specialists are three hours away in Mbarara and the majority of patients cannot afford to travel there or pay the additional specialist fees. The ECP’s must develop an amazingly broad skill set at repairing these complex wounds that most Emergency Medicine physicians in the United States would feel uncomfortable closing on their own.

In order to lead the advanced suturing workshop, I had to first broaden my own skill set and fill in knowledge gaps for the procedures I often ask the specialists to perform. I had to look outside of the standard Emergency Medicine literature as a common recommendation was to consult a specialist without giving any details of the procedure.

The Junior ECP’s were excited to learn the new techniques and get the focused time to practice. Later that afternoon they were already implementing the new corner stitch to fix a scalp laceration and were carefully reattaching a partially amputated ear after a machete attack.

"Thanks to GECC, the trauma patients seen by the ECPs have a chance of surviving that is two times better than what is normal for a similar hospital without emergency care."

Written by: Omeed Saghafi MD, GECC volunteer

According to a new report by the World Health Organization (October 19, 2015), road traffic accidents are now the main cause of death in 15-29 year olds in Africa, surpassing malaria. Thanks to GECC, the trauma patients seen by the ECPs have a chance of surviving that is two times better than what is normal for a similar hospital without emergency care. This is not surprising given what many people call the “golden hour” of trauma care. The first hour of care can often completely determine a patient’s chance of survival. Nowhere else in medicine is the adage “the vitals are vital” better highlighted.
 
People ride on boda bodas (motorcycles) without helmets, sometimes with three or four people as well as boxes full of supplies balancing on one boda boda. Groups of twenty or more pack into open flatbed trucks. Speed limits are an afterthought. Flipped trucks and buses full of people are not uncommon. While Nyakibale is not in a major city, RTAs (road traffic accidents) are still a daily occurrence.
 
As an Emergency Physician I have become exceptionally skilled at telling “sick” from “not sick” - determining who needs immediate treatment and who can wait. Often I can do this from the doorway of a patient room within a split second. However, in rural Uganda, the patients are unbelievable stoic and don’t show signs of being sick until it’s often too late.

We saw a 24-year old who had fallen off a boda boda and looked great. No one seemed to be in any hurry to treat him given how great he looked. However, one of the ECP students came running to me, eyes wide, and she said “the blood pressure is very low.” She was right, she was using the new blood pressure cuff to take the patient’s vital signs, and the blood pressure was far below normal.
 
As a result of the low blood pressure, we performed a rapid FAST (focused assessment with sonography in trauma) exam using a donated ultrasound machine, and found a large amount of blood in the abdomen, mainly near the spleen. The patient had a likely splenic rupture.
 
Two IVs were started, the surgeon was called, intravenous fluid was started. The hospital did not have the right type of blood for the patient, but they did have 2 remaining units of O negative (universal donor) blood which we prepared as the patient was transported to the operating room emergently.
 
This patient did not become another RTA mortality statistic that day because of 1) the ability to get an accurate blood pressure, which then led to 2) rapid and effective treatment of a critically ill patient. These things would have never been possible without the tools provided by MDF Instruments and the training in emergency care provided by GECC.

Editor's note: GECC is profoundly grateful to MDF Instruments for donating stethoscopes and blood pressure cuffs to the Emergency Care Practitioners and trainees at Nyakibale Hospital.