Travel Report from Uganda November/December 2018

The Arrival

It's a pretty cool November night when we land in Entebbe. Already on the way to the airport building the first known faces of airport employees greet us. I try to find a few minutes time for each of them to inquire about their condition and family in the country-specific way. The usual control measures are quickly done, you know each other and everything goes its way, in the typical East African calmness.

The way from Entebbe to Kampala, we can now start for the first time on the just finished Entebbe-Kampala Expressway. Modern radar bridges for speed monitoring were built on the most important highways. For a moment you feel transported back to Europe before sand tracks and red dust bring you back to reality. A mountain of forms, permits, applications and certificates awaits me for processing. The ubiquitous traffic jam in the capital Kampala makes even the smallest appointment a test of patience - everything runs like slow motion.

Quieter winter months

November and December were rather quiet in our catchment area this year, without any more serious accidents. Only once, at the end of November, in the middle of the night, we were called to a discotheque in Entebbe. One girl feared to have been poisoned and was taken by our emergency doctor to the public hospital in Entebbe and carefully examined there, but the fear was not confirmed. It was only a feverish virus infection.

Ship accident claims large number of victims

A shipwreck in Lake Victoria off Entebbe in December caused a long night mission for our emergency ambulance. We provided the leading emergency doctor and a psychologist, who stood ready at the pier, where the dead and injured were delivered by the water rescue. The accident occurred within sight of the port of Entebbe, so that rescue measures could be initiated quite quickly. The cooperation with the various rescue forces involved was fortunately less complicated than we had expected. Ultimately, however, our main task was to determine the death of the victims and to reassure and care for the bewildered relatives of the deceased.

Sadly, there is no getting around criticising the training of Ugandan rescue workers in this instance as well. Especially in the case of drowning accidents with younger people who have not been in the water for a long time, one should not lightly make a death diagnosis without having tried re-animation. I had already pulse and self-breathing again after only one heart pressure massage interval with a patient delivered to me for the "death assessment". We are aware that our criticism stirs up emotions, yet urgent reforms are needed.  In particular with the procedure of the medical personnel.

Number of victims can be drastically reduced with simple measures

The high death toll is partly due to the fact that not even ten percent of people in Uganda can swim. The 35 degrees warm water would provide sufficient protection against rapid cooling, but the lack of swimming skills and life jackets meant that only about 35 people out of 150 passengers survived. On the other hand, there is a complete lack of knowledge of CPR among rescue personnel, the army and the police! This year we will start to offer special target group-oriented compact courses for this circle of people.

Environmental toxins are still a problem

The careless handling of formalin in large quantities for the preservation of the deceased, which is customary throughout the country, will become a further problem over time, as too much formaldehyde enters the biological cycle. Here alternatives have to be considered, as often there are no technical possibilities for cooling the dead bodies.

The ubiquitous burning of plastic brings another avoidable environmental toxin - dioxin - into the biological cycle. The use of uncoated aluminium cooking vessels on gas cookers or charcoal fires with very high flame temperatures leads to an accumulation of aluminium compounds in the liver, which can be problematic in combination with other environmental toxins! This often leads to the unconscious or inadvertent absorption of toxins, which lead to clinical symptoms that are often not detected.

The lack of training opportunities cost lives

Another national problem is the complete lack of emergency training for hospital staff and doctors. This often leads to fatal misjudgements, which often lead to the death of the patient.  The so-called anamnesis and body check after accidents and acute illnesses is in most cases carried out only minimally. Serious, life-threatening injuries such as bleeding between the meninges, cerebral hemorrhages, tension pneumothorax or abdominal bleeding are simply overlooked.

The simplest basis and differential examinations or haemostasis are not performed. In the facilities we look after, we try to train doctors and nurses bit by bit in the essential measures of emergency and trauma care to such an extent that no such errors occur there. We also try to raise the standard of hygiene to a good level. These measures will contribute to a better control of haemorrhagic fever and other highly contagious diseases.

The list of needed things is long

There is a great need for first aid equipment, vacuum rails, Sam Splin rails, quick bandages and support ruffs. Recovery cloths and rescue equipment in the form of lift bags, sheet metal shears, crowbars, bolt cutters and flex are only available on our rescue vehicles. Except in Kampala City, no fire brigade is sent to assist at the scene of the accident. There are no trained helpers available for accident recovery, so most accident recovery operations end in chaos. We do our best to provide as many aids as possible.

Also in for the patients free public hospitals the medicaments must be brought along or fetched from the pharmacy. These are often not available in the ambulances or treatment rooms. For emergency patients, this often leads to avoidable, life-threatening situations because the required medication - even if it is available - is not administered until the patient or his relatives have procured the money for it. This is anything but fast on overcrowded and congested roads and costs valuable time that an emergency patient often does not have!

Poverty must not be an obstacle to humane treatment

Some can't afford the drugs, or can't reach the relatives who can afford them quickly. These patients simply remain untreated and often die while waiting. It is one of our main tasks to try to provide as many impoverished people as possible with vital medications quickly and free of charge!

This is one of the main tasks of our small agile SUV. The vehicle brings specialists, missing medical equipment and essential medicines as quickly as possible to the hospital or the corresponding health station. In the urban area of Kampala we often organize the transport with a motorbike to get to the place of action faster.

Gross negligence is a daily occurrence

We have also found that doctors on call in public hospitals are not present during their time on duty, even though they have been "stamped". They treat private patients outside the hospital during their working hours, on their own account of course. In the evening they only appear again for "stamping out". For this reason, only a few people are treated at all. In Europe this wpuld be a clear case of negligent physical injury, or even negligent killing, in Uganda however it is very common.

We are in the process of developing solution models with the district managers in order to support better care. We try to have sufficient pharmaceuticals on our vehicles to provide immediate care to emergency patients and also to ensure the necessary drugs and equipment for hospital treatment. For this purpose, our vehicles carry more than 420 different medications and all equipment in double stock.  At the moment, we are handing over the medicaments free of charge, but it remains to be seen to what extent this will be possible in the future.

Infrastructure is barely in place

In many areas there is a lack of any means of transport for patients and cases of emergency. Sometimes not even a motorcycle is available.  One of the reasons for this problem is the lack of expertise and competence of those responsible for vehicle procurement in the public sector. A lot of money is invested in unsuitable vehicles that are not adapted to the circumstances, which then break down after a short time and rust for years on the courtyards of clinics and institutions.

Often there are only small causes which are not repaired and after a short time a vehicle becomes a scrap heap. The low competence of the mechanics does the rest to aggravate the situation. If all existing vehicles that are not ready to drive were ready for operation, there would be almost enough transport capacity in the country. In many places you can see suitable vehicles that are left to their fate after minor defects. This is one of the reasons why we remain the sole owner of all the vehicles we use and do not hand over vehicle management to the supported clinics and health stations.

Wrong investments are the norm

In a community in western Uganda where there is not a single asphalted road, the street version of the new Toyota Hiace model - without all-wheel drive, without a bad-road package, without an additional air filter but with fuel-consuming automatic transmission and street tires - was purchased as an ambulance vehicle. For the same price one could have got a simple Land Cruiser with manual gearbox, air filter package and all terrain tires.

As a consequence, the vehicle gets stuck in all bad passable places during rainy weather. In Addition, there is no fuel for the thirsty automatic vehicle and after a short time the engine fails because of the sharp-edged red dust. Due to high prices for replacement engines the vehicle will be taken out of service and become a goal for part thieves. This is just an example for the misorganization and the lack of competence when it comes to procurement and maintenance of vehicles.

No more money for fuel

At first glance there are sometimes surprisingly good looking vehicles. At second glace, however, the medical equipment and the training level of the personal is more than insufficient. For some reasons automatic vehicles are very popular in Africa, although they consume considerably more fuel than an identical vehicle with manual transmission. So it happens that many people own a vehicle, but have no money for the fuel.

This is also an acute problem for many local police departments where there is no fuel available for the expensive vehicles. Alternatively, the police officers then use 125ccm motorcycles without any warning signals to reach their place of action. This in turn leads to missing transportation possibilities and unsecured accident sites because of missing blue lights.

No functioning coordination of operations

Millions of dollars have been invested in a modern digital radio network which would work quite well if there would be a proper control centre with all the necessary information and contact numbers. The GPS location of various vehicles is also missing here. A better solution would have been a modern, well-developed analogue radio network to which all auxiliary services are connected.

In Europe, the introduction of digital radio for police and rescue services was intended to ensure that only the targeted users received the information designated for them and were not bothered with irrelevant radio conversations. In Uganda, where a coordinated control centre and GPS location of the vehicles is missing, the consequence is that available forces around the accident site are not aware of the emergency.

We hope to be able to put an integrated control centre into operation in the near future. We are advertising the connection to this radio network to all local organisations.

Training for police officers are unavoidable

Unfortunately, Ugandan police officers receive no first aid training, although they are in the most cases the only ones who treat and transport injured people at an accident site. Our offer to train all police officers in a one week basic course in western measures is not accepted by all districts due to the time to be paid.

However, what all districts have in common is the lack of equipment to salvage and care for accident victims and to secure accident sites. The further away one is from the capital, the clearer the deficits become.

For reasons of fuel savings, engines and lightning, including blue lights will be turned off at the accident site. As a result, the night blue vehicles without reflective bonding cannot be seen by night or rain. Same applies to the black or dark green uniforms of the police officers. The only well visible uniforms are those of the traffic police. Now, more and more warning vests are being used at night, which significantly improves visibility.