The "golden hour"—the first 60 minutes after a major trauma—is often crucial to survival. But how golden that hour will be often depends on how swiftly emergency medical personnel can respond to the crisis, initiate life-sustaining care, and get critically ill patients to the emergency room.
In the United States and other industrialized countries, this type of rapid response is virtually guaranteed. Unfortunately, that’s not true in much of the developing world, including Rwanda, a country in central Africa about the size of Maryland.
There are just 277 ambulances nationwide to service a population of nearly 13 million people. Kigali, the nation’s capital, has just eight of those ambulances and 60 EMS providers to care for roughly 1.5 million residents.
In 2011, Sudha Jayaraman, MD, MSc, now director of the Center for Global Surgery at University of Utah Health, was asked to participate in the effort to address this disparity. At the time, she was a trauma, critical care, and acute care surgery fellow at the Brigham and Women’s Hospital at Harvard Medical School in Boston.
Since then, she has pulled together a group of surgeons from University Teaching Hospital of Kigali, Brigham and Women’s Hospital, and Virginia Commonwealth University. This group determined that Rwanda, like many low- and middle-income countries, needed to significantly upgrade its emergency services.
During the past decade, the project has provided advanced training for emergency responders and hospital staff and established standardized checklists for patient care while en route to the hospital. It also created a patient registry to assess trauma care across several of the country’s main hospitals through funding from the Rotary Foundation, the National Institutes of Health (NIH), and philanthropists.
Overall, the effort has improved the quality and consistency of care prior to arrival at the hospital, according to Menelas Nkeshimana, MMED, head of the Department of Accident and Emergency at the University Teaching Hospital of Kigali, principal on-site investigator of the NIH grant, and vice president of the Rwanda Medical Association.
"The ongoing partnership with the University of Utah is a living testimony to the fact that there is always power in collaboration," Nkeshimana says.
In time, the researchers say these improvements could be implemented in other low- or middle-income countries where more than 90 percent of the world’s trauma-related injuries and 95 percent of childhood deaths from trauma occur.
However, gaps still exist, particularly in communications between dispatchers, ambulances, and emergency room staff.
"Over the last decade, we’ve trained a lot of staff and standardized the way they deliver care," says Jayaraman, who was recruited to U of U Health in 2020 to lead its global surgery efforts. "But having trained staff who can deliver high-quality care won’t help if you can’t find the patient or figure out which hospital has the right resources or the best way to get them there."
Although Rwanda has a national emergency phone number—912—many homes across the country don’t have addresses, and GPS data is rarely available for location information. As a result, pinpointing where an emergency phone call is coming from or where the nearest ambulance is located is challenging.
To help remedy this problem, the next phase of the project, supported by a 5-year, $850,000 grant from the NIH and led by Jayaraman, will focus on creating a more efficient communications system designed to locate patients faster, stabilize them quickly, direct the ambulance to the right hospital, and reduce the percentage of prehospital transport times lasting over 60 minutes.
Jayaraman, the principal investigator for this grant, says that the system will be devised and tested in partnership with RwandaBuild, a group of software developers in Kigali, before replacing the existing system. Among its innovations is the development of GPS-based technology to improve geolocation of patients. The team plans to evaluate the effectiveness of implementing such a large-scale intervention to show its impact.
"In this partnership with the Government of Rwanda, our team has an opportunity to really set the standard for how emergency dispatch systems are set up in Rwanda and other low- and middle-income countries so that trauma care is expedited, and many lives can be saved," Jayaraman says.
In addition to U of U Health, physicians, scientists, software developers, and policymakers from the RwandaBuild program, Rwanda Biomedical Center, University of Washington, University of Rwanda, and the University of Birmingham in the United Kingdom are participating in this project. The team is in the process of receiving a multimillion-dollar award from a UK agency to expand this work across the country.