No emergency in emergency care

Close to Dhaka's Moghbazar intersection, the Insaf Barakah Kidney and General Hospital is a striking edifice, multi-storied and covered by curtain wall glass in front.

The hospital has specialised physicians in internal medicine, cardiology, orthopedics, gastroenterology, gynecology, nephrology, urology, pediatric, ENT, neurology, dermatology, dentistry and so on, but if it is emergency services you require, that is a different story altogether. 

You have to walk up an unusually high ramp that starts off from the road and traverses the sidewalk. And there is no sign about where the emergency unit is.

Walk a few yards past the entrance gate and to your right, a narrow 4ft wide  corridor will lead you to the emergency unit. 

The cramped space can handle two patients at a time. Physician Md Siraj Uddin, the Deputy Superintendent of the hospital, was leading the unit during a recent visit.

Some people were crowding the small room, but they were not there for emergency needs. They were blood donors donating blood samples for existing patients.

"Every emergency patient can seek service from a general hospital," said Dr Siraj, "as long as there is no police case involved. As much as possible, we provide the patients with first aid [care] and refer them to public hospitals".

The day we visited the hospital, one rickshaw puller showed up with acute abdominal pain. After a paid ultrasound investigation, he was referred to Sheikh Russel National Gastroliver Institute and Hospital.

"The patient's liver was swollen. For treatment, he needs indoor service [at this hospital] for some days, which would be expensive for him. That's why we referred the rickshaw puller to a government hospital where treatment is free or cheaper," said the senior physician. The hospital charges Tk1,000 for a single blood transfusion, a fairly common need of emergency patients. If the patient requires intensive care, he or she will have to pay Tk6,000 and an additional 10% service charge for every day at the ICU.

There are 5,577 private and 638 public hospitals in Bangladesh. On 12 September 2021, the High Court (HC) issued a directive for the government to ensure that hospitals, clinics and medical practitioners provide emergency medical services to every patient when brought to them.

Nonetheless, besides a few fully-equipped private hospitals like Square, Evercare and United hospital, most private hospitals in the country have nominal facilities under the emergency section - a small room, few beds, one or two nurses and a duty doctor on call. While the country's cities and towns are dotted with hospitals and clinics, people requiring emergency attention - such as after an accident - are almost invariably forwarded to a government hospital. 

As a result, the emergency units at government hospitals - be it the Dhaka Medical College Hospital (DMCH) or the National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR) - are overburdened with patients, handicapping their ability to provide adequate attention to most people. 

A large part of the motivation for private hospitals to ignore emergency units is financial. Most patients who need emergency services are people like the rickshaw puller who cannot afford to pay for indoor services. Furthermore, private hospitals are wary of taking on any patient who sustained injuries in an event that might involve law enforcement. 

"Private hospitals show reluctance to admit emergency patients as these types of service make smaller profits. Moreover, they don't want to deal with patients who have been assaulted fearing political consequences," said Dr Raghib Manzoor, the founding Secretary General of the Bangladesh Society of Emergency Medicine. 

A comparatively spacious emergency unit with a five-bed capacity of Better Life Hospital at East Rampura was empty of patients. Three nurses were chatting inside the unit. They said the duty doctor will come if 'called'.

Nafiza Akter, Duty Manager at the hospital, said their emergency unit has the necessary equipment to treat an emergency patient, but they don't admit some patients fearing litigation. However, locals with minor injuries often come to the hospital during the night. 

Photo: Noor-A-Alam

"Providing minimal treatment, we release them. If the injuries are severe, we refer them to specialised hospitals. Most often, we admit emergency patients as regular patients of our specialised doctors," Nafiza said.

A choice between life and money

At the DMCH's 'One-Stop' emergency and casualty unit, we found construction worker Robi, who sustained severe injuries while working at a Mohammadpur site. His colleagues carried him there; one held Robi by his hands and another by his feet. They could not find any stretcher. 

With a blood-stained face, Robi lay unconscious. 

At 1:15pm, Robi was finally moved to an emergency bed. After 15 minutes, a CT Scan revealed his nose was broken and his eyes were bleeding internally. 

The duty doctors referred him to the ENT Department on the 2nd floor of DMCH. 

Robi's colleagues managed a trolley, after bribing a DMCH ad-hoc staff, to take Robi to the ENT Department. Robi lay on the bed, in that state, for one hour before being moved. 

A few nights later, Indira Road resident Didarul brought his pregnant wife Rahima to the nearby Square Hospital, soon after her water broke. Her delivery date was at least two months later. 

Rahima was given an expensive (life-saving) injection and when her vitals stabilised, a C-section was administered. She gave birth to a premature boy less than three hours after her admission. 

Both mother and infant were in critical condition. So, the ICU was their last resort. Fortunately, they survived and gradually recovered. 

Didarul was billed more than Tk1 lakh by the hospital. 

"The emergency response was expensive, but thank God my wife and son have survived," said Didarul. 

Woefully ill-equipped

Bangladesh Society of Emergency Medicine organiser Dr Raghib said emergency treatment should start with an Emergency Medical Support or EMS ambulance equipped with every life-saving instrument like emergency medicine, oxygen cylinder, ventilator, cardiac monitor, saline, syringe pump, pulse oximeter and so on. 

"There must be trained paramedics in the ambulance. Before reaching an emergency unit, the patient's health condition needs to be examined. In the developed world, EMS ambulances start treatment of critical patients from the accident spot," Raghib said.  

Unfortunately, there are not more than 10 EMS ambulances in this country of around 170 million population. 

Stressing the formation of EMS Voluntary groups at the grassroots, Raghib recommended that Bangabandhu Sheikh Mujib Medical University and Bangladesh College of Physicians and Surgeons start MD and FCPS degree courses to educate, train and create a substantial pool of emergency medical consultants that the country lacks. 

The Directorate General of Health Services (DGHS) is currently implementing a project to reform the emergency services of Kurmitola General Hospital, Mugda General Hospital, Mitford General Hospital and Suhrawardy Medical College Hospital, with the One-Stop Emergency and Casualty (OSEC) model of DMCH.

Additional Directorate General of DGHS, Professor Dr Ahmedul Kabir said the OSEC model will facilitate patients with the necessary health examination tools under the same roof. "If we can expand such services at the grassroots, doctors-attendants conflict will be minimised," he added. 

While inaugurating the OSEC model at Kurmitola General Hospital on 5 December, Health and Family Planning Minister Zahid Maleque assured that OSEC will be introduced at every government hospital in phases. 

The minister said, "Modern emergency medical services could reduce mortality. If the survivors of a stroke or road accident receive emergency treatment within a short time, their lives would be saved."