Ghana’s broken Emergency Medical Service: Time for EMTALA to fix it

Ghana’s broken Emergency Medical Service: Time for EMTALA to fix it
Source: Dr. Issaka Yakubu Akparibo | Flight surgeon (Aerospace Medicine Specialist), Member of the Aerospace Medical Association | twitter: | @akparib
Date: 30-04-2018 Time: 09:04:16:am

I will begin this article with an NBC news item:

 LAS VEGAS, NV (NBC) December 9, 2009 -  What killed Angel Nicole Dewberry? It's a question the Las Vegas Coroner's Office is tackling after the baby girl died following an at-home delivery.

An attorney for Angel's mother, Roshunda Abney, says Abney was in full labor last week when two local hospitals failed to help her. Less than an hour later, the baby was born at home and then died. Abney's attorney believes the case highlights what's wrong with healthcare today.

 This lady did not know she was pregnant and started having abdominal pain and presented at the University Medical Center in Nevada and was turned away. She went home and delivered and the baby died. The hospital fired six employees involved in this case the following day and launched an investigation.

 The question I ask myself is what killed this 52year old female teacher?

A doctor’s delight is to see the patients we treat get better, just like a mechanic takes delight when he fixes a broken car.

This teacher’s story has two angles and highlights two serious problems of Ghana’s emergency healthcare.

April 19, 2018, whilst on locum duty at a private medical facility in Accra, the capital city of Ghana, a young man brought his 52-year-old mother to the hospital in a taxi (note: not in an ambulance). The nurse called me to attend to an emergency, I stopped seeing all patients and attended to this teacher. In her serious medical state, I saw a very intelligent, humble and calm woman.

The lady was admitted to a different private medical facility and when her condition deteriorated she was referred to the Korlebu Teaching Hospital, the premier tertiary hospital in Ghana. According to the patient’s son, he took his mother to the emergency room (ER) of Korlebu Teaching Hospital and he was turned away because there was no bed. They went to the police and 37 military hospitals and the story was the same hence they presented at the facility I was on duty. This patient was having a myocardial infarction (heart attack) and her blood pressure had crashed.

This is the most serious medical emergency an adult can suffer, and what did our public hospitals financed by this teacher’s tax do? turn her away at a time that she needed her country most. I attended to the woman until around 11 pm past my shift time when I handed over to the night doctor and went home. I returned at 2 pm the next day to begin my shift only to meet a colleague doctor at the entrance of the hospital and I quote her: 

Dr. Akparibo, I heard you left the hospital late last night. Your patient died after you left. Unquote: I was very sad, heartbroken but not surprised.  Not surprised because the lady needed to be transferred to a CATHLAB for reperfusion surgery and I knew there was none in our referral centers.

The first problem of our emergency healthcare system exposed in this patient’s case is the culture of turning patients away in our referral hospitals ER on account of no bed.  This is often done by security men standing at the emergency room entrance and wearing white coats as if they are medial persons.

This is where EMTALA (The Emergency Medical Treatment and Labor Act) is needed urgently to fix this problem. This canker is not peculiar to this patient. Several families have suffered a similar fate and its time parliament passes this law as a matter of urgency to solve this problem.  What does this law entail?  

In summary, in the United States and other developed countries, no hospital can turn away a patient that turns up in the emergency room for treatment. If the patient is even within 250 yards from the hospital compound, the hospital is responsible for the patient. Hospitals that violate this law are fined up to $ 50,000 and may be blacklisted by the Center for Medicare and Medicaid. There is no law that deters hospitals in the US than EMTALA.

The key points of this law include:

  • Hospitals must detain and evaluate any patient on its premises who present for an unplanned visit and seeks care, regardless of ability to pay.
  • Those ERs that are under the legal definition of a dedicated emergency department are fully bound by EMTALA, while those that are not are required to have policies and procedures on how the unit is to respond to a patient presenting with what a prudent non-medical person would consider being a condition requiring immediate assessment and care.
  • The term emergency medical care (EMC) is much broader under EMTALA than under typical medical usage. The term includes any condition that is a danger to the health and safety of the patient or unborn fetus, or may result in a risk of impairment or dysfunction to the smallest bodily organ or part if not treated urgently.
  • The initial assessment of the patient reporting at the emergency must be conducted by a physician and not a security man wearing a white coat.

Fixing this problem does not require donor aid or rocket science. It is just the duty of our legislators doing their work as reposed to them by the citizenry. My introductory case was an isolated case that occurred elsewhere and was big enough to have been captured by NBC news, six employees fired the next day, whilst my teacher patient and 100s of her kind that happen on a daily basis have become a norm in Ghana.

Simply unacceptable! Our hospitals may complain that passing this law may put undue pressure on them (just like the complaints that emanated during the implementation of the free SHS) in that patients with minor conditions may turn up at their ER. By this law, a physician is required to examine the patient and make a decision as to whether the medical condition qualifies as an emergency.

Passing this law may even help the hospitals in decongesting their ERs in that patients will not be detained at the ER based on whom you know or with minor problems but will depend on whether you really require admission; this way there will always be a bed for my 52-year-old patient and others like her.

The second problem with our emergency health care delivery system highlighted by this patient is a lack of a catheterization laboratory (CATHLAB). A CATHLAB is a facility that is capable of relieving the blockade (reperfusion surgery) in the arteries of the heart. It is this blockage that causes the heart attack. Ghana currently has a single interventional cardiologist that is resident in the country that I know.

There may be more, so why not tap the expertise of this person? In a well-developed society, people with scarce expertise are regarded and used properly and that’s why these countries are great. Let me cite another scenario I experienced last month and compare and contrast the two situations. Whilst ridding with CareFlight (An air and ground medical transport division of Miami Valley Hospital in Dayton Ohio USA), March 27, 2018, we received a call that a 69year old female was having a heart attack in a smaller hospital that is about 25miles from Dayton.

The weather that day was not good so all CareFlight’s helicopters were grounded. Myself and two critical care nurses and a driver hopped onto the MICU (Mobile Intensive Care Unit) and moved to Troy to pick the patient and transported her to Samaritan Hospital in Dayton where the CATHLAB is available. Immediately we entered the hospital the interventional cardiologist was already waiting to talk to the patient. We sent the patient to the CATHLAB and she had the procedure done.

This 69year old woman survived with reinvigorated heart arteries that may take her another 20 or more years. Compare and contrast this with my patient in Ghana a month apart. A 52year old female with a heart attack that could not survive to enjoy her pension, and she had paid tax all her working life to the same country that could not help her at the time she needed her country most.

A CATHLAB does not also require donor funding, neither does it require rocket science and did I hear the University of Ghana Medical Center has a CATHLAB? Progressive thinking by our policymakers is the key here. Ghana’s Airforce helicopters are used as hearse and people pay up to 5000USD to engage them to carry their dead relatives to their villages for burial, meanwhile the same family will not pay the same amount to engage a helicopter to medevac their relative for emergency care in a tertiary facility, “I cannot think far”.

For now, our country cannot save us if we get a heart attack; my humble advice to you is: live a healthy lifestyle by doing regular exercises, eat a Mediterranean diet, quit smoking if you do and avoid fast foods. This is the only way to beat a heart attack in Ghana. What our country can do for us is for parliament to enact a similar law like EMTALA urgently.Civil society groups, the media, and NGOs in healthcare should take this up and put pressure on both the legislature and executive to get this law enacted.


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