Improvise and Overcome: Bringing EMS to Kenya, Part 2

Just over 10 years ago, a small group of paramedics set out to teach prehospital emergency medical care skills to a group of nurses, clinical officers, physicians and police officers in the small lakeshore village of Homa Bay in western Kenya. The idea of a prehospital care system, which began as a small program in a rural village, has since turned into an initiative for an entire country. More than three-quarters (78%) of Kenya’s 32 million people live in rural communities; delivering prehospital emergency medical care to those with otherwise-poor access to healthcare has and will continue to save countless lives.

As a continuation of the first part of Bringing EMS to Kenya, which appeared in the October issue, this article will highlight the most recent journey of SHARE EMS paramedics and the sweeping changes that have taken place within the country, and also describe current and future collaborative projects between Kenya’s Ministry of Health, SHARE and Kenyan and U.S. teams of healthcare providers.

The Society for Hospital and Resources Exchange (SHARE) is a non-governmental organization (NGO) with a primary goal of improving the health and well-being of disadvantaged children and communities throughout the world. SHARE personnel have been traveling to Kenya for the past 15 years, working on short- and long-term projects like safe drinking water initiatives, immunizations, HIV and AIDS education, and tropical disease prevention and treatment, to name a few. SHARE EMS has been going to Kenya for the past 11 years, assisting in the development of a comprehensive and quality prehospital emergency medical system.

The most recent trip occurred in May 2004. The U.S.-based team consisted of four volunteer providers/educators from New York: David Violante, Heidi Maguire, Chris Summers and George Contreras. Violante, a 15-year EMS provider and educator, is the SHARE EMS coordinator. He currently serves as assistant director of EMS for the Arlington Fire District and co-coordinator of the Dutchess Community College Emergency Services programs. Maguire is a former paramedic and currently a firefighter/EMT for the City of Kingston. Summers is a nine-year veteran of the U.S. Coast Guard and an eight-year NYC paramedic. Contreras has 12 years’ experience serving as a NYC paramedic, former director of EMS, and an instructor in various areas of EMS and emergency management. All of the participants on this trip had been on previous missions, exemplifying SHARE’s desire to help Kenya’s medical community—and ultimately the people of Kenya—take care of their own.

The Setting

In Kenya, daily concerns differ quite a bit from those we are used to in the U.S. Factors contributing to poor health include unclean water supplies, poor sanitation, lack of immunizations, high transmission rates of infectious diseases, and natural disasters such as floods and droughts. Accidents such as vehicle crashes, falls, fires and drownings also contribute to the poor statistics, as does violence. Poor infrastructure exacerbates healthcare concerns, but that has been steadily improving. With a little work and assistance, many of these problems are preventable.

Table 1 highlights statistics from the World Health Organization’s 2004 World Health Report. The data are from 2002.

In addition to the aforementioned issues, other problems exist, but are improving. Most of these have been related to communications, road conditions, safety and security within major cities at night and along roadways after dark, and safety of public transport. The U.S. State Department’s 2003 Consular Information Sheet describes some of these conditions so that travelers can make informed decisions about travel to and within the country. Last year alone, many changes occurred that drastically improved conditions in Kenya: Cell phones are readily available, inexpensive and reliable; Internet connections, the availability of information and the ability to communicate have exponentially increased; road surfaces are improved within cities and along major thoroughfares; transportation is safer and more reliable; facilities are improving; and the police force has been expanded and its salaries increased.

Disaster awareness and readiness changed for Kenyans in 1998. Previously, disasters were natural in origin and consisted primarily of floods and droughts. Rural areas occasionally needed food and water or specific medications due to outbreaks of tropical diseases. That all changed on August 7, 1998. Terrorists bombed the U.S. Embassy in the capital, Nairobi, killing 213 people and injuring many more. On November 22, 2002, there was a car bomb attack at a hotel in Mombasa in which 15 people were killed and simultaneously an unsuccessful attempt to shoot down an Israeli charter plane.

Disaster preparedness, emergency management and response took on new meanings following these events. New plans had to include Incident Command structure, integration of services, and different types of preplans and responses.

Recent Changes

Kenya has eight provinces and about 250 districts. Each province has a large provincial hospital and several smaller district hospitals.

For the rural population, there is no method of access to the healthcare system other than going to the hospital by bus or other private transport. In large cities, there are small ambulance services that are hospital-run, but they are primarily used for interfacility transfers. The delay in the delivery of lifesaving medical care in the rural setting, where a majority of the population lives, can be fatal. Those with phones can dial 9-9-9, and will most likely reach a police dispatcher who will send police to the scene, call for an ambulance’s availability from local hospitals and, if needed, send the fire service. Police and fire personnel may not be able to provide care; if they do, it’s at the first aid or first responder level.

According to hospital reports from around the country, injuries from road accidents have dropped significantly as a result of recently passed traffic and safety laws, as well as better road maintenance and widespread road improvements. These laws are strictly enforced and include requirements for public transportation vehicles that include the availability of seat belts, lower maximum seating capacities, speed governors and identification of drivers via photo badges and uniforms. While these regulatory changes and improvements to roads have decreased injuries from traffic accidents by an astonishing 50%, there has been an almost proportionate rise in blunt and penetrating trauma. According to hospital administrators, one reason is that since matatu driv­ers can no longer make as much money by rushing overpacked and unsafe vehicles down poorly constructed and washed-out roads, they have begun supplementing their incomes in other ways: The numbers of assaults, stabbings, beatings and shootings have increased. Even though traffic accidents have decreased, the need for trained prehospital medical providers is still great.

The Training

The training sessions on this trip were conducted in a manner similar to past sessions. The town of Thika, about an hour north of Nairobi, was the site of the first week’s efforts; the second week’s training was in Kisumu, the country’s third-largest city, about eight hours west of Nairobi by car.

In Thika, the course was intense and well-received. It was conducted at Thika District Hospital, where there were 32 participants, including physicians, nurses, clinical officers and even some police officers. The program consisted of Basic Cardiac Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Prehospital Trauma Life Support, Mass Casualty Incident (MCI) Management, Incident Command System (ICS) structure, and a field exercise incorporating all of the components.

The program ran from 9 a.m.–6 p.m. Monday through Friday. The participants were eager to learn and incorporate the information into their everyday practice. They all spoke and understood English, making the teaching process much easier. A lot of information was presented in didactic sessions, practical sessions and even some downtime, as the students continually wanted to improve their abilities.

Each class had designated students in charge of various functions to make things go smoother. There were two people assigned to each area they felt were important in maintaining the learning environment: leading morning and evening prayers; talking directly with the instructors on matters of business; keeping the class on schedule; summarizing the previous day’s lesson in the morning and the current day’s lesson in the afternoon; and entertaining us when we all needed a break.

The evaluations in Thika came from 27 healthcare practitioners and five police participants. (The categories were summarized separately because the police officers received less-advanced clinical sessions.) The healthcare practitioners consisted of 13 physicians, nine nurses and five clinical officers (equivalent in training to U.S. nurse practitioners).

Of the 32 participants, 97% found the course to be excellent or very good, 97% found the instructors to be excellent or very good, and 100% stated they would recommend the course to a colleague. Some of the suggestions were more class time, more equipment and more regular refreshers.

In Kisumu, the course was more tailored to a specific audience. The training was conducted at Kisumu District Hospital, where there was a group of 15 nurses and one clinical officer. Several of the participants had already participated in previous BLS training conducted by SHARE. The class structure and program were similar to those of the Thika course. The overall program consisted of BCLS, ACLS and PHTLS (due to logistical reasons, pediatric training could not take place during this session). This class was taught by Kenyan instructors under the supervision of the U.S. team. They proved to be quite capable and were able to continue on their own in our absence.

Of the 16 participants, 97% found the course to be excellent or very good, 97% found the instructors to be excellent or very good, and 100% said they would recommend the course to a colleague. Some of the general suggestions were more class time, more equipment, more regular refreshers and more pediatric training. These suggestions will be addressed in future classes held in Kisumu.

In addition to the classes, quite a bit of equipment was donated to several programs for use in teaching and delivering care: Lifepak 10 monitors/defibrillators and battery chargers, EMS bags and supplies, BLS and ALS manikins, and BLS and ALS teaching gear. Reference materials such as books, curricula, handouts and CDs of presentations were also donated for use in hospital libraries and educational programs.

Following Up

In addition to the training sessions conducted on this mission, the team evaluated the continuing programs in areas we had previously visited. We assessed them in the following areas: oversight, original and continuing education, operations, equipment, data gathering and community involvement.

SHARE had conducted training in the small town of Embu for the past two years and was interested to see what work had been done in terms of that town’s prehospital care. The news was a bit disappointing: While their intentions and desire to build a functional EMS component to their hospital services were great, there was not as much progress as had been expected. Several obstacles had contributed to this impeded development, and a lack of funds was certainly one of them. Excess funds are returned to the Ministry of Health to be redirected where needed, and new items requiring funding are difficult to receive resources for in a timely manner. Although Embu participants were working to increase their numbers of trained personnel, there was still a lack of properly trained staff to conduct orderly emergency responses.

An opportunity for our Embu students to practice what they’d learned presented itself when a local politician suffered chest pains. He was brought to Embu District Hospital, treated and then transported via ambulance to Nairobi Hospital by members who had received SHARE EMS training. They were not only recognized for their lifesaving actions, but saw for themselves the importance of such training.

Additional obstacles included which students actually received the training. For the most part, initial training included higher-ranking people within the hospital who then did not have the time or capability to develop the program as needed. A solution to that issue was to train clinical officers who had a good foundation, worked in the casualty or outpatient wards and had the time and energy to devote to the development of the program.

The Embu team had made some great strides as well: They had begun holding CMEs for staff in the casualty and outpatient departments who would be working on or around the ambulance; they modified a donated portable suction unit to work on ambulance power and become part of the ambulance equipment; they rigged an onboard oxygen delivery system on the ambulance (making theirs one of only a few ambulances in Kenya with such equipment); they created and used response bags according to protocols they set up; and they began tracking patient data for their emergencies and transfers.

Kisumu students had received a great deal of training and equipment over the past few years, and so our expectations were higher for them, but a visit to Kisumu District Hospital revealed issues similar to those in Embu. Although the staff had trained personnel in their hospital and people from the community, ongoing training seemed sporadic due to funding issues, as well as a lack of trainers. A problem with teaching lower-ranking providers within the governmental healthcare system is that they may then be moved by the Ministry of Health to other areas of the country. While this does spread trained people around, it also changes the instructor base. In Kisumu, due to a lack of support from their administration, the improvised EMS response teams were less motivated to continue their efforts. Again, a lack of funds was the major issue.

About a year ago, the EMS team from the hospital mobilized for a tragic plane crash in the neighboring township of Busia. They responded to the site, set up Incident Command and followed the MCI training they’d practiced in class. Their efforts were recognized by the president of Kenya, Emilio Mwai Kibaki, and the hospital received a letter from him to thank and praise the team and the hospital for their response and dedication. Overall, the staff in Kisumu faced obstacles similar to the ones in Embu, and were trying to handle them in similar ways.

Future Projects

Although some great work has been done in Kenya in recent years, there remains a strong need to develop the healthcare infrastructure to accommodate prehospital needs and cultivate a nationwide EMS system.

During our recent visit, the SHARE EMS team met with senior Ministry of Health administrators to start thinking of new ways to create a system of emergency medical services in the country. There is a newly created Division of Emergency and Disaster Management, which will need guidance and assistance to help the people of Kenya respond to emergencies and disasters, both natural and manmade.

Some of the immediate projects discussed were as follows:

• Creating a pilot hospital-based EMS system in Thika;
• Creating a core of properly trained staff who can respond to emergencies;
• Working to develop the newly formed Division of Emergency and Disaster Management within the Ministry of Health;
• Immediately training new staff on ICS and emergency management issues;
• Creating an EMS training center in Thika;
• Creating the job title of EMT so that there can be new positions for people to work in at hospitals;
• Creating partnerships with local training centers and colleges and universities to offer EMT training as a career;
• Collaborating with other agencies and international NGOs that already operate in Kenya, such as the African Medical Research Foundation (AMREF), the Kenya Red Cross, St. John’s Ambulance and other private hospitals.

The SHARE EMS team will be working closely with administrators from the Ministry of Health, in addition to other medical communities and businesses, to create a plan for implementing the EMS system Kenya needs so badly. Once the pilot initiative in Thika begins, SHARE can assist in its evaluation and facilitate its reproduction at a national level, and can contribute in areas such as communications, training, equipment, quality management and certification. SHARE will continue to offer its training courses until the needed knowledge base is established.

The goal of SHARE is to assist the people of Kenya in developing a sustainable program that can effectively reach the majority of the population when they need help. In the future, the paramedics of Kenya may even be treating patients in a way that we ourselves have not yet thought of, addressing all aspects of their healthcare system, not only emergent ones.

SHARE can be found on the Web at www.shareinternational.org.