Andrew Moscrop: Emergency training in Pakistan

Every night, every half-hour, the whistle and stick man visits. We’ve never met, but I know his work. His job is to walk the streets of our neighbourhood between sunset and sunrise, blowing a whistle and tapping a stick to keep the local security guards awake (as if the barking of automatic rifle fire was not enough). Toot toot, tap tap. Night shifts in any setting are challenging it seems, but hospitals have a particular need for 24/7 alertness.

Many paediatric hospital deaths in developing countries occur within 24 hours of a patient’s admission and these deaths might be avoided if sick children can be identified and treated promptly. Acknowledging this, the World Health Organisation in 2005 drew up the Emergency Triage Assessment and Treatment (ETAT) guidelines and training programme. ETAT is orientated toward the management of immediately life-threatening conditions seen in the developing world, with emphasis on diarrhoea-induced dehydration and severe malnutrition. The guidelines are based on research conducted in Malawi and adapt the Advanced Paediatric Life Support (APLS) course that is familiar in the west.

“The baby in front of you has stopped breathing.” Dr B was calm, but emphatic.
“Stopped breathing?” The paramedic from the Afghan border looked uncertain and stroked his moustache.
“Yes, the baby is not breathing. What are you going to do?”
“Er…” Still the paramedic moved only to shift awkwardly from one foot to the other and poke his thumbs into the pockets of his waistcoat. Time seemed to tick on interminably.

Thankfully it was only a plastic baby, and this was only the first morning of the Emergency Triage Assessment and Treatment training.

With a combination of discussions, demonstrations, power point presentations, and practical sessions over four days, Dr B and I taught the ETAT principles of a systematic approach to emergency patient management. Our twenty-three course participants included male and female doctors, nurses, and paramedics from MSF projects in Quetta city, the nearby health centre at Kuchlak and the distant town of Chaman on the Afghan border. Given our disparate origins and languages, a translator was on-hand to work between my English, Dr B’s Urdu, and the Pashtu or Baloch of attendees.

Did it work? It worked for me: having previously shied away from teaching on account of a sense that, actually, I might not have any knowledge worth imparting; and having felt myself afflicted by a public speaking voice as skittering and cracking as an incompetent skater on thin ice; for me, conducting the ETAT training and watching the group members develop knowledge and skills during the course was a rewarding experience. And by the time we were examining participants on the final day of the course, the moustachioed paramedic from the Afghan border was bag-and-masking, wielding interosseous needles, and figuring out emergency intravenous fluid doses with the best of them, so it seemed to have worked for him too.

But does it work? In principle, ETAT works: the assessment algorithm and treatment instructions have been proven to effectively identify emergency cases and guide medical management. But does the training work? Does the education change knowledge, does the knowledge change behaviour, and does the behaviour change patient outcomes?

Following Advanced Paediatric Life Support training, an Israeli study has shown short-term knowledge retention among participants; a UK telephone survey found long-term knowledge improvement; and a study in Ohio has demonstrated positive behaviour change in emergency situations among those who had undergone training. However, actual improvements in patient health outcomes have been difficult to demonstrate. Nonetheless, a study conducted at the Malawian hospital where ETAT was developed, managed to show that improved triage and emergency care for children reduces inpatient mortality in a resource-constrained setting; which seems like the final link in the chain of education-knowledge-behaviour-outcomes.

Presumably, these improvements are to some extent operator-dependent and culturally contingent: the efficacy of ETAT training will depend upon the trainers (who may vary in teaching ability) and trainees (who may vary according to their background levels of basic schooling and medical education). Furthermore, the effectiveness of any provision of emergency medical care will be limited by factors beyond the health care setting: such as a community’s help-seeking behaviour, and the ability to transport sick people to health care providers.

The ETAT training also assumes the value of emergency care in the developing world, which, given its relatively high cost compared to preventive medicine or primary healthcare, has not been beyond question. Still, if we accept the World Health Organisation’s premise that health services are not simply about improving the overall health of the population, but also about responding to people’s expectations and providing financial protection against the costs of ill-health, an emergency service capable of meeting demand for urgent care and of limiting life or limb-threatening illness or injuries, surely has a role in most settings.

Anyone who has lived, worked, or travelled in the developing world will be familiar with the fact that many things do not work; but training or education is not one of them. Nor, potentially, is emergency medical care.

Andrew Moscrop qualified as a GP last year and will be working with MSF in Pakistan for six months.