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Introduction: Every year, >5 million people worldwide die from trauma. In Kigali, Rwanda, 50% of prehospital care provided by SAMU, the public prehospital system, is for trauma. Our collaboration developed and implemented a context-specific, prehospital Emergency Trauma Care Course (ETCC) and train-the-trainers program for SAMU, based on established international best practices. Methods: A context-appropriate two-day ETCC was developed using established best practices consisting of traditional 30-minute lectures followed by 20-minute practical scenario-based team-driven simulation sessions. Also, hands-on skill sessions covered intravenous access, needle thoracostomy and endotracheal intubation among others. Two cohorts participated — SAMU staff who would form an instructor core and emergency staff from ten district, provincial and referral hospitals who are likely to respond to local emergencies in the community. The instructor core completed ETCC 1 and a one-day educator course and then taught the second cohort (ETCC2). Pre and post course assessments were conducted and analyzed using Student's t-test and matched paired t-tests. Results: ETCC 1 had 17 SAMU staff and ETCC 2 had 19 hospital staff. ETCC 1 mean scores increased from 40% to 63% and ETCC 2 increased from 41% to 78% after the course (p

The first 60 minutes after a trauma are described as “the golden hour.” For each minute of prehospital time, the risk of dying increases by 5% (Sampalis et al., 1999). Since 90% of the global burden of injuries occur in low- and middle-income countries and lead to 5.8 million deaths annually, addressing rapid access to emergency services is critical in these settings (Nielsen et al., 2012). In most low- and middle-income countries (LMICs), there are no formal trauma systems, and many lack organized prehospital care (Nielsen et al., 2012). Emergency medical dispatch and communication systems are a foundational component of emergency medical services (World Health Organization, 2005). Yet there are no established recommendations of creating these systems inLMICs.Rwanda, a country of over 12 million people, is a rapidly developing leader in East Africa. The Ministry of Health of Rwanda established the Service d’Aide Medicale Urgente (SAMU) in 2007, recognizing the need for public emergency medical services. SAMU’s national dispatch center receives roughly 3,000 calls per month through a national 912 hotline. It organizes regional transportation with 260 total ambulances located at hospitals throughout the country and provides prehospital emergency services in the capital city of Kigali with a fleet of 12 ambulances. In the city, each ambulance has a driver, nurse and anesthetist dispatched for every call. Emergency department nursing and anesthetist staff are dispatched from hospitals around the country to respond to regional emergencies. No formal prehospital cadre of the workforce exists although the SAMU staffhave extensive field experience in prehospital care. SAMU has several challenges to rapid prehospital emergency care including lack of addresses beyond the capital city, unclear location data in densely populated areas, complex communication processes with little information about health facility capacity, and no established electronic dispatch system. The average response time for SAMU ambulances was 59 minutes in 2018, but 39% of calls were not completed within the golden hour.

Introduction: Although emergency medicine (EM) training programmes have begun to be introduced in low- and middle-income countries (LMICs), minimal data exist on their effects on patient-centered outcomes in such settings. This study evaluated the impact of EM training and associated systems implementation on mortality among patients treated at the University Teaching Hospital-Kigali (UTH-K). Methods: At UTH-K an EM post-graduate diploma programme was initiated in October 2013, followed by a residency-training programme in August 2015. Prior to October 2013, care was provided exclusively by general practice physicians (GPs); subsequently, care has been provided through mutually exclusive shifts allocated between GPs and EM trainees. Patients seeking Emergency Centre (EC) care during November 2012–October 2013 (pre-training) and August 2015–July 2016 (post-training) were eligible for inclusion. Data were abstracted from a random sample of records using a structured protocol. The primary outcomes were EC and overall hospital mortality. Mortality prevalence and risk differences (RD) were compared pre- and post-training. Magnitudes of effects were quantified using regression models to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results: From 43,213 encounters, 3609 cases were assessed. The median age was 32 years with a male predominance (60.7%). Pre-training EC mortality was 6.3% (95% CI 5.3–7.5%), while post-training EC mortality was 1.2% (95% CI 0.7–1.8%), constituting a significant decrease in adjusted analysis (aOR = 0.07, 95% CI 0.03–0.17; p

IntroductionInjuries account for approximately five million deaths worldwide and have high burdens in low- and middle-income countries, where pre-hospital systems are being developed to improve acute injury care. This study compares the characteristics and outcomes between trauma patients transported by formal emergency medical services (EMS), known as Service d’Aide Medicale Urgente, and by private transport to the emergency department (ED) at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda.MethodsThis retrospective cohort study analysed a random sample of trauma patients from of the CHUK ED presenting between 1 August 2015 and 30 July 2016. Non-trauma patients and transferred patients were excluded. The primary outcomes were ED and inpatient dispositions and outcome characteristics of: admission, length of stay (LOS), mortality. Descriptive analyses were performed and differences in outcomes assessed based on transport modalities via Pearson Chi-Squared or Fisher’s Exact tests.ResultsThere were 556 trauma patients analysed, of which 87.1% were transported by private transport and the remainder by EMS. The median age was 28 years (IQR:18-39), 52.1% had serious injuries, based on the triage system at CHUK. Common mechanisms of injury included road traffic crashes (62.7%) and falls (17.1%). Median inpatient LOS for private transport patients was 7 days (IQR:3-16 days), compared to 9.5 days for EMS patients (IQR:4-18 days) (p=0.301). There was a significant relationship between ED disposition and transport method (p=0.005), with a higher number of admissions among EMS-transported patients. The observed mortality of EMS and privately transported patients were not significant different, however there were a higher percentage of deaths in the ED and inpatient setting among those who were privately transported. ConclusionWhile mortality and hospital LOS between EMS and private transport patients were not statistically significantly different, this may not reflect a lack of clinical significance. Future research will be needed to continue to assess the EMS utilisation rate, quality and impact on patient-centred outcomes and should include studies that prospectively investigate larger samples of patients to better evaluate the effects of EMS trauma care in Rwanda.

Introduction: Healthcare systems must be equipped to handle major incidents. Few have been described in the African setting, including in Rwanda. The purpose of this case report was to describe and discuss two major incident simulations in Rwanda with different challenges. Case report: We report two recent major incident exercises conducted in Rwanda, in 2017. The exercises exemplify two different types of multiple casualty incidents requiring the deployment of extra-ordinary resources, one due to the location of the incident (off-shore), and the other due to the large volume of casualties. Both exercises required extensive multi-agency planning and training beforehand, as part of an increasing awareness of the need for preparedness for these types of incidents. Conclusion: The exercises demonstrated the need for a standardised, physiological method of triage based on clinical needs; this is in order to maximise the number of lives saved. Triage training should be an integral part of further major incident exercises, which should be conducted regularly. Keywords: Major incidents, Triage, Rwanda

Pediatric trauma is a significant public health problem in resource-constrained settings; however, the epidemiology of injuries is poorly defined in Rwanda. This study describes the characteristics of pediatric trauma patients transported to the emergency department (ED) of the Centre Hospitalier Universitaire de Kigali by emergency medical services in Kigali, Rwanda.This cohort study was conducted at the Centre Hospitalier Universitaire de Kigali from December 2012 to February 2015. Patients 15 years or younger brought by emergency medical services for injuries to the ED were included. Prehospital and hospital-based data on demographics, injury characteristics, treatments, and outcomes were gathered.Data from 119 prehospital patients were accrued, with corresponding hospital data for 64 cases. The median age was 9.5 years, with most patients being male (67.2%). Injured children were most frequently brought from a street setting (69.6%). Road traffic injuries accounted for 69.4% of all mechanisms, with more than two thirds due to pedestrians being struck. Extremity trauma was the most common region of injury (53.1%), followed by craniofacial (46.8%). The most frequent ED interventions were analgesia (66.1%) and intravenous fluids (43.6%). Half of the 16 obtained head computed tomography scans demonstrated acute pathology. Twenty-eight patients (51.9%) were admitted, with 57.1% requiring surgery and having a median in-hospital care duration of 9 days (range, 1-122 days).In this cohort of Rwandan pediatric trauma patients, injuries to the extremities and craniofacial regions were most common. Theses traumatic patterns were predominantly due to road traffic injury, suggesting that interventions addressing the prevention of this mechanism, and treatment of the associated injury patterns, may be beneficial in the Rwandan setting.

Background Studies from high-income countries (HIC) support restrictive blood transfusion thresholds in medical patients. In low- and middle-income countries (LMIC), the etiologies of anemia and baseline health states differ greatly; optimal transfusion thresholds are unknown. This study evaluated the association of packed red blood cell (PRBC) transfusion with mortality outcomes across hemoglobin levels amongst emergency center (EC) patients presenting with medical pathology in Kigali, Rwanda. Methods This retrospective cohort study was performed using a random sample of patients presenting to the EC at the University Teaching Hospital of Kigali. Patients ≥15 years of age, treated for medical emergencies during 2013–16, with EC hemoglobin measurements were included. The relationship between EC PRBC transfusion and patient mortality was evaluated using logistic regression, with stratified analyses performed at hemoglobin levels of 7 mg/dL and 5 mg/dL. Results Of 3609 cases sampled, 1116 met inclusion. The median age was 42 years (IQR 29, 60) and 45.2% were female. Transfusion occurred in 12.1% of patients. Hematologic (24.4%) and gastrointestinal pathologies (20.7%) were the primary diagnoses of those transfused. Proportional mortality was higher amongst those receiving transfusions, although not statistically significant (23.7% vs 17.0%, p = 0.06). No significant difference in adjusted odds of overall mortality by PRBC transfusion was found. In stratified analysis, patients receiving EC transfusions with a hemoglobin >5.0 mg/dL, had 2.21 times the odds of mortality (95% CI 1.51–3.21) as compared to those ≤5.0 mg/dL. Conclusions No association between PRBC transfusion and odds of mortality was observed amongst EC patients in this LMIC setting. An increased mortality association was found for patients receiving PRBC transfusions with an initial hemoglobin >5 mg/dL. Results suggest benefits from PRBC transfusion are limited as compared to HIC. Further research evaluating emergent transfusion thresholds for medical pathologies should be performed in LMICs to guide practice.

BackgroundFormalised emergency departments (ED) are in early development in sub-Saharan Africa and there are limited data on emergency airway management in those settings. This study evaluates characteristics and outcomes of ED endotracheal intubation, as well as risk factors for mortality, at a teaching hospital in Rwanda.MethodsThis was a prospective observational study of consecutive patients requiring endotracheal intubation at the University Teaching Hospital of Kigali ED conducted between 1 January and 31 December 2017. A standardised data collection tool was used to record patient demographics, preintubation clinical presentation, indication for intubation, vital signs. medications and equipment used, and periintubation complications. The primary outcome was in-hospital mortality. Univariate associations were determined for risks of mortality.ResultsOf 198 intubations were analysed, 72.7% were male and the median age was 35 years (IQR 23–51). Airway protection was the most common indication for intubation (73.7%). Rapid sequence intubation was performed in 74.2% of cases; sedative-only facilitated intubation in 20.6% and non-drug assisted in 5.2%. The most common agents used were Ketamine for sedation (85.4%) and vecuronium for paralysis (65.7%). All patients were successfully intubated within three attempts, 85.4% on the first attempt. During intubation, 23.1% of patients experienced hypoxia, 6.7% aspiration and 3.6% cardiac arrest. Median ED length of stay was 2 days. Outcome data were available for 164 patients of whom 67.7% died. Bonferroni-corrected univariate analysis demonstrated that mortality was associated with higher postintubation shock index (p=0.0007) and lower postintubation systolic blood pressure (SBP) (p=0.0006).ConclusionThe first-attempt and overall success rates for intubation in this ED in Rwanda were comparable to those in high-income countries (HIC). Mortality postintubation is associated with lower postintubation SBP and higher postintubation shock index. The high complication and mortality rates suggest the need for better resources and training to address differences in compared with HIC.

Introduction:Low and middle-income countries (LMICs) bear a disproportionately high burden of sepsis, contributing to an estimated 90% of global sepsis-related deaths. Critical care capabilities needed for septic patients, such as continuous vital sign monitoring, are often unavailable in LMICs.Aim:This study aimed to assess the feasibility and accuracy of using a small wireless, wearable biosensor device linked to a smartphone, and a cloud analytics platform for continuous vital sign monitoring in emergency department (ED) patients with suspected sepsis in Rwanda.Methods:This was a prospective observational study of adult and pediatric patients (≥ 2 months) with suspected sepsis presenting to Kigali University Teaching Hospital ED. Biosensor devices were applied to patients’ chest walls and continuously recorded vital signs (including heart rate and respiratory rate) for the duration of their ED course. These vital signs were compared to intermittent, manually-collected vital signs performed by a research nurse every 6-8 hours. Pearson’s correlation coefficients were calculated over the study population to determine the correlation between the vital signs obtained from the biosensor device and those collected manually.Results:42 patients (20 adults, 22 children) were enrolled. Mean duration of monitoring with the biosensor device was 34.4 hours. Biosensor and manual vital signs were strongly correlated for heart rate (r=0.87, pDiscussion:Wearable biosensor devices can be feasibly implemented and provide accurate continuous vital sign measurements in critically ill pediatric and adult patients with suspected sepsis in a resource-limited setting. Further prospective studies evaluating the impact of biosensor devices on improving clinical outcomes for septic patients are needed.

The 1994 Rwandan war and genocide left more than 1 million people dead; millions displaced; and the country’s economic, social, and health infrastructure destroyed. Despite remaining one of the poorest countries in the world, Rwanda has made remarkable gains in health, social, and economic development over the last 20 years, but modern emergency care has been slow to progress. Rwanda has recently established the Human Resources for Health program to rapidly build capacity in multiple sectors of its healthcare delivery system, including emergency medicine. This project involves multiple medical and surgical residencies, nursing programs, allied health professional trainings, and hospital administrative support. A real strength of the program is that trainers work with international faculty at Rwanda’s referral hospital, but also as emergency medicine specialty trainers when returning to their respective district hospitals. Rwanda’s first emergency medicine trainees are playing a unique and important role in the implementation of emergency care systems and education in the country’s district hospitals. While there has been early vital progress in building emergency medicine’s foundations in Rwanda, there remains much work to be done. This will be accomplished with careful planning and strong commitment from the country’s healthcare and emergency medicine leaders.