Immediate diagnostics for trauma patients in rural Ghana

Two dozen relatives of patients are crowded together under an iron roof outside the Accident & Emergency (A&E) center of the Holy Family Hospital in Techiman, taking shelter from the glaring West African sun. It is early March; SARS-CoV-2 has not reached Ghana yet but will soon also impact on this rural part of the country. In between older men chatting and babies crying on their mothers’ backs sits Gladys Nyarko – whose initially joyous visit to the hospital has now changed for the worse. Together with her niece Ama*, she had accompanied a friend in labor. All went well, and the two women stayed a few days to support the mother and her newborn. Then, Ama, a trader by profession, excused herself to travel to the market in Kumasi, Ghana’s second city.

She never arrived. “After dark, a truck crashed into her minibus,” Gladys explains. Ama and her fellow-passengers were rushed to hospital by strangers.

Holy Family Hospital deals with around 10,000 emergency cases every year. “Many of them are road traffic accident victims with severe trauma injuries,” says hospital administrator Christopher Akanbobnaab. Techiman, a relatively small regional capital, is located on Ghana’s main south-north axis. Every year, millions of people and goods travel through this area. The road is narrow, and busses and trucks drive on the shoulder. These are just some of the issues causing a high traffic-related death rate, which is five times higher than, e.g., in Germany.

Ama’s stay in the emergency ward triggers bad memories for her aunt. Four years ago, Gladys had been involved in an accident herself. Her husband had died, she and her sister-in-law were brought to Holy Family Hospital. “My sister-in-law needed to be transferred because they could not diagnose her in Techiman,” Gladys recalls. But her sister-in-law succumbed to her injuries before the transport could be made.

Stories like these were common in Techiman. “Without a CT scanner we were basically blind,” emergency physician Tobias Ninnang, MD, recalls. “It was very frustrating to have to refer serious cases to the Komfo Anokye Teaching Hospital in Kumasi in the south, three hours away by ambulance.” Many patients died along the way, and those who made it were often left with a high debt, having to pay for the ambulance.

Not anymore. At Holy Family Hospital, fast and reliable diagnostic services are now supporting a well-functioning emergency department. In 2017, with help and funding from the German Rotary Volunteer Doctors (GRVD), various Rotary chapters as well as Rotary Germany and the German Federal Ministry for Economic Cooperation and Development (BMZ), the hospital built a new A&E center with improved infrastructure featuring an intensive care unit, and in February 2018 added a 16-slice SOMATOM Emotion 16 eco CT scanner to its radiology department.

Inside the A&E center, Gladys’ niece Ama has gone through triage and has been placed in the orange section for patients that are seriously but not critically injured. Because she suffered trauma to the head, emergency physician Tobias Ninnang orders a CT scan. Two nurses in violet overalls push Ama on her bed out of the backdoor, straight into the radiology department. A few minutes later, the hospital’s radiologist in charge, Edward Ebo Ocran, MD, is already scrolling through the pictures of Ama’s CT scan in his air-conditioned office.

Edward Ebo Ocran oversees more than 3,000 scans a year. Thanks to the new diagnostic possibilities and the improved emergency infrastructure, the hospital can directly treat many more patients. “And in cases where we don’t have the specialist treatment needed, we send the diagnosis ahead of the referred patients.” This is saving many lives, assures the radiologist.

According to hospital administrator Christopher Akanbobnaab, more time is needed before exact numbers can be given. What is palpable, however, is the trust from patients and those referring them. Before the overhaul, the average number of emergency patients was 7,000 to 8,000 a year, 20 to 30 percent less than current numbers. Diagnostic tools in the less developed northern part of Ghana are rare. The nearest CT scanner north of Techiman is 258 kilometers away in Tamale. And it is not always working. “At times we serve a catchment area of 4 to 5 million people,” Akanbobnaab calculates.

On the day of the interview, two days before the first COVID-19 cases are recorded in Ghana, administrator Akanbobnaab is hosting three members of German Rotary Volunteer Doctors (GRVD), an organization that is closely linked to Rotary Germany and comprises 1,100 members, mostly former doctors, who invest themselves financially and as volunteers with the aim to improve health care in developing countries. The non-governmental organization (NGO) has supported Holy Family Hospital since 2011 and has spearheaded the overhaul of the emergency and diagnostic services. Professor Ulrich Vetter, MD, and Professor Ulrich Sprandel, MD, pushed the idea; fellow-GRVD member and former bank director Winfried Nusser enlisted his network in Germany to raise a formidable one fourth of the total funds needed.

According to one of the visitors, Professor Rainer Burghard, MD, a retired pediatrician and coordinator for Ghana at GRVD, “sustainability was on top of the list when we planned the project.” The staff at the hospital is regularly trained by German volunteer doctors and nurses. A training station with demonstration dummy is being established and selected doctors and nurses from Techiman are trained in German intensive care units.

Inside the CT operator room, radiologist Edward Ebo Ocran can confidentially say that Ama has not sustained any permanent brain damage after having analyzed her scan data. He calls in emergency physician Tobias Ninnang to get a second opinion. Then he writes his report and submits it to the emergency department.

When the time came to choose a CT scanner, GRVD and the hospital consulted one of Ghana’s leading radiologists, George Asafu Adjaye Frimpong, MD, who established Spectra Health, a private interventional imaging and radiology center of international standard. “The challenge was to find a basic model that is sophisticated enough while being economic and easy to maintain,” Frimpong says. In the end a refurbished 16-slice SOMATOM Emotion CT scanner fit the requirements best.

Frimpong has had positive experiences with Siemens Healthineers in his own radiology center. “Even more important however is that the company has people on the ground.” Engineers from MEANS Ghana provide technical training to the radiology staff and conduct four scheduled preventive maintenance visits a year to identify issues “before they become real problems,” as Saeed Abdul-Ganiyu, one of the engineers, says.

For Christopher Akanbobnaab sustainability also has to be assured on the economic side. The hospital administrator is especially pleased with the moderate cost of buying, running and maintaining the refurbished CT scanner, as his patients cannot afford to pay as much for a scan as those in Kumasi or the capital Accra.

The upgrade of the Holy Family Hospital has been recognized by the Ghana Health Service. The facility has been lifted a tier to Secondary Level Health Provider. The Health Minister himself, Kwaku Agyemang-Manu, was at Techiman to see the progress and was impressed. Beyond mere recognition, the secondary level designation also means more funding from the government.

Akanbobnaab is extremely pleased with how the project has panned out. “We did what might have seemed unachievable at first, and so others in a similar position can do it too,” he is convinced, “if they are willing to build the necessary networks.” As the hospital in Techiman shows, close collaboration of public, development and private actors is a health care business model that can lead to progress in developing countries where government resources are limited.

Over in the emergency ward, Tobias Ninnang calls Gladys inside. In front of section orange, the emergency physician informs her that her niece Ama will make a full recovery.

The global COVID-19 pandemic reached Ghana on 12 March 2020, two days after our visit to Holy Family Hospital in Techiman. Thanks to strict quarantine measures for people entering the country, frequent testing, a ban of public gatherings and a partial lockdown of its two biggest cities, the virus initially only spread slowly through the West African country – not slowly enough to prevent community transmission however. As of 14 July, Ghana has recorded 24,988 positive cases, over half of which are in and around the capital Accra (Greater Accra Region). The death toll of 139 is comparatively low.

Bono East Region, where Holy Family hospital is located, counts a total of 207 cases. Thanks to its modern emergency facility, the catholic hospital was selected as a COVID-19 treatment center.

Since the first patient tested positive on 15 May, the hospital managed 41 cases, according to administrator Christopher Akanbobnaab. “The A&E center offers us a chance to receive suspected COVID-19 patients without risking infection of other patients, thanks to an isolation room with direct access from the outside.”

After some of the staff tested positive and were sent into self-isolation, the A&E center had to be shut down temporarily but is operational again. Strict security measures are in place. All persons entering are screened, need to wash or sanitize their hands and wear a mask. “Despite this, we might evacuate the entire A&E once we have to handle more severe cases,” says Akanbobnaab.

The A&E center can hold 35 COVID-19 cases plus two patients in intensive care beds. According to Akanbobnaab, the CT scanner helps to manage patients in severe stage of COVID-19. The biggest challenge the hospital faces is inadequate oxygen supply. “We do not have ventilators for long term use,” says the administrator. Patients can be intubated temporarily but will have to be transferred to other hospitals soon after.