Gerard O'Reilly, MB BS, FACEM, MPH (International Health), Grad Dip Biostats, Director of International Programs; Mark Fitzgerald, MB BS, FACEM, Director; Pilane L Ariyananda, MB BS, MD, FRCP, Dean and Professor of Medicine; Sue Williams, Manager; Leanne Smith, CCRN, Nurse Manager; Tamsin Jones, CCRN; Sally Charlton, CCRN, Clinical Nurse Specialist; Simon Young, MB BS, FACEM, Director; Linas Dziukas, MB BS, FACEM, Emergency Physician; Zoe Fisher, CCRN, Clinical Nurse Specialist; Sally Wragg, CCRN, Clinical Nurse Specialist; Eliza Burke, CCRN, Clinical Nurse Specialist.
In the wake of Sri Lanka's tsunami: The Health for the South Capacity-Building Project
Article first published online: 28 MAR 2008
© 2008 The Authors
Emergency Medicine Australasia
Volume 20, Issue 2, pages 175–179, April 2008
How to Cite
O'Reilly, G., Fitzgerald, M., Ariyananda, P. L., Williams, S., Smith, L., Jones, T., Charlton, S., Young, S., Dziukas, L., Fisher, Z., Wragg, S. and Burke, E. (2008), In the wake of Sri Lanka's tsunami: The Health for the South Capacity-Building Project. Emergency Medicine Australasia, 20: 175–179. doi: 10.1111/j.1742-6723.2008.01071.x
- Issue published online: 28 MAR 2008
- Article first published online: 28 MAR 2008
- Accepted 22 October 2007
- developing country;
- emergency medicine;
- multiple trauma;
- Sri Lanka
In response to the Indian Ocean tsunami of December 2004, the Health for the South Project was developed for Sri Lanka. The capacity-building component of this project involves the provision of trauma and emergency care training to the staff of Teaching Hospital Karapitiya (THK) in Galle, Sri Lanka. A principal objective of this training for THK is an increased capacity to respond to future disasters in the south of Sri Lanka. Key elements of the capacity-building programme include the on-site emergency care training by teams of Australian emergency physicians and emergency nurses, working alongside the staff of the Emergency Treatment Unit in THK. It is expected that the programme will continue for at least 2 years, during which time a new Emergency and Trauma Centre will be constructed.
The Indian Ocean tsunami of 26 December 2004 provoked renewed discussion regarding the role of emergency medicine when disasters occur in developing countries. There is some consensus that after a relatively short period of several weeks, the major health-related priority could be described as emergency public health rather than emergency care.1–6
Similarly, whereas the impetus to improve disaster preparedness in developing countries is a natural consequence of disasters such as the tsunami, the role of emergency medicine in this setting also remains variable and unclear. Those disaster preparedness programmes that do utilize emergency physicians tend to focus on the importance of emergency medical system change and emergency medicine development as a specialty.7–12
To date, there are few examples of enhancing disaster preparedness through local ED capacity-building, that is, from the so-called grassroots upward. The recently commenced Health for the South: Emergency and Trauma Centre Project – including the capacity-building component – is an investment in disaster preparedness through training in the local ED setting. This paper aims to describe the origins, development, objectives and features of the capacity-building programme.
As a result of the 2004 tsunami, an estimated 35 000 people perished in Sri Lanka. Galle, as the provincial capital of Sri Lanka's southern province, was the most populous urban centre affected, with more than 4000 deaths.13
Teaching Hospital Karapitiya (THK) is the main teaching hospital and multidisciplinary service provider for the southern province of Sri Lanka. It has 1400 beds and is 116 km south of Colombo. The Faculty of Medicine from the University of Ruhuna is colocated and provides medical training.
Prior to the tsunami, THK had an Emergency Treatment Unit (ETU) of two trolleys. This was adjacent to the Outpatient Department, which had traditionally provided the initial assessment of the vast majority of expected and unexpected presentations. At the time of the tsunami, then, the ETU of THK had an extremely limited capacity to provide an effective hospital response to any disaster.
While the tsunami might have brought attention to the lack of THK disaster preparedness, there was a parallel urgency to develop a facility with the capacity to provide advanced trauma care. Sri Lanka has not escaped the evolving road trauma epidemic. Injuries are the second most common cause of death in Sri Lanka (after cardiovascular disease) and the most common cause of hospitalisation.14–16 The dual needs of improved disaster preparedness and trauma care led to the development of the Health for the South Project.
Programme origins and development
Within several months of the Indian Ocean tsunami of December 2004, the Victorian Government made a commitment to assist with post-tsunami reconstruction in Sri Lanka. An agreement with the Ministry of Healthcare and Nutrition, Sri Lanka, led to the creation of the Health for the South Project.
The initial plan was to build a new Emergency and Trauma Centre at THK and improve the trauma and disaster capacity of the hospital. MF, the Director of the Emergency and Trauma Centre, Alfred Hospital, Melbourne, offered to visit Galle and review the plan from an emergency medicine perspective. His recommendations included: the interim expansion of the current two-bed ETU to a 6–8-bed facility; the supply of appropriate resuscitation equipment for the expanded facility and the provision of training to the ETU staff as well as some modifications to the building programme for the new centre.17,18
Funding for the equipment and the training programme was provided by United States Agency for International Development (USAID) and Australian Agency for International Development (AusAID is the Australian Government agency that manages Australia's overseas aid program), respectively. The Alfred Hospital and Royal Children's Hospital, Melbourne were to implement the capacity-building component of the project. The Health for the South Project was publicly launched in February, 2007.
The overall goal of the Health for the South Project is ‘to establish an Emergency and Trauma service capability at THK’.19
The specific objectives of the capacity-building programme include the following:
- • Improve the initial assessment, resuscitation and stabilization of critically unwell patients
- • Develop THK's capacity to respond to disaster and mass casualty situations
As the Government of Sri Lanka is simultaneously in the process of developing a national trauma system, a key aspect of the capacity-building programme is to ensure consistency with the national approach. Both the national trauma system development and the capacity-building component of the Health for the South Project subscribe to the standards provided by WHO Guidelines for Essential Trauma Care.20
The programme began in April 2007 with the intention of continuing until the new Emergency and Trauma Centre is established in late 2009. During the first year, six Australian teams will visit THK for periods of 3–4 weeks. Five of these teams will be sourced from the Alfred Emergency and Trauma Centre and one from the Royal Children's Hospital ED. Each team consists of at least one emergency physician and two emergency nurses with critical care qualifications. The teams are to obtain Sri Lankan medical and nursing registration enabling them to work effectively alongside the ETU staff.
Over the course of the programme, two teams, each of two staff from ETU, THK, will visit the Alfred Emergency and Trauma Centre for the same duration of 3–4 weeks. These staff will be chosen on the basis of being future champions in the new THK Emergency and Trauma Centre.
As per the objectives given above, the major themes of the programme include trauma care and trauma triage; the development of skills in both these areas will provide the foundation for disaster response training and therefore, the project's raison d'etre, disaster preparedness. Beyond these core themes, all aspects of the management of the critically ill patient will be covered in the training programme. Process changes, such as documentation, will also be implemented.
Prior to the implementation of the training programme, a number of opportunities for change have been noted. In brief, they include the following:
- • Adoption of universal precautions
- • Systematic approach to trauma care
- • Trauma team leadership and role delegation
- • Time-critical approach to management of the unstable patient
- • Trauma triage
- • Disaster plan development
The importance of trauma triage as an issue is illustrated by the existing practice – where almost all major trauma patients have been triaged from the hospital entrance or Outpatient Department directly to the ward.
There is considerable institutional support at THK for such change. The development and continuation of the programme have benefited highly from the leadership of Professor Ariyananda, Dean of Medicine, University of Ruhuna.
Emergency physicians have argued for a paramount role in disaster response. However, where disasters occur in the setting of either developing countries with a limited or fragile infrastructure, or where an extant infrastructure is largely destroyed, the immediate relevance of emergency medicine might be limited, predominantly to triage.1,5,11
The provision of lifesaving care immediately after a disaster or mass casualty incident requires developed hospital resources, including an effective prehospital service, appropriate triage, adequately skilled and resourced resuscitative care (in the ED), and adequately skilled and resourced definitive care (surgical staff and facilities). Trauma triage and trauma care are integral to the hospital response.
Sri Lanka has a well-developed public health system, courtesy of government investment in health. The national initiative includes the preventative approach to reduce road trauma deaths.21 Having progressed along the development scale, the health system is ripe for investment in its hospital-based services.22 Improvements in emergency and trauma care appear to be at the forefront of the health agenda at a national level.21
Within the specialty colleges of Sri Lanka, there is a growing recognition of the importance of emergency medicine as a specialty. Independent of the Health for the South Project, a number of Australasian emergency physicians with Sri Lankan partners have considerably progressed the development of emergency medicine as a national specialty.23
Synergistic to this top-down approach to emergency medicine development is the ‘bootstraps’ approach of the capacity-building component of the Health for the South Project. Previous examples in the literature of such an approach to disaster preparedness are few in number, but examples include the Masters of Medicine (Emergency) programme in Papua New Guinea, where Australasian emergency physicians have also spent contact time with the local staff, working alongside them in the ED.24
The Health for the South Project is unique in a number of aspects. A key is the inclusion of emergency nursing staff as trainers. This recognizes that the delivery of emergency medical care is reliant on a team approach that includes emergency nurses and doctors – and that a sustainable programme requires both (Fig. 1).
In the Asia–Pacific region and beyond, the role of Australasian ED staff in the development of emergency systems, ED development, emergency nursing and medicine as distinct specialties, and disaster preparedness is expected to grow considerably over the decades ahead. The experience gleaned from projects, such as the Health for the South Project in Sri Lanka, will help guide such programmes in the future.
The authors wish to acknowledge the hard work and enthusiasm of the staff of the ETU, THK, Galle, Sri Lanka. The authors also wish to acknowledge the funding provided for the Emergency and Trauma Centre and the capacity-building programme, by the Department of Premier and Cabinet, State Government of Victoria, and AusAID, respectively.
GO, MF, PLA, SW, LS and SY have contributed significantly to the development and implementation of the project. TJ, SC LD, ZF, SW and EB have contributed significantly to the implementation and delivery of the project. All authors have contributed to the writing of this perspective. Specifically, as per the guidelines of the International Committee of Medical Journal Editors, all authors have contributed to each of the criteria outlined below:
- • Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data
- • Drafting the article or revising it critically for important intellectual content
- • Final approval of the version to be published
- 1Medical issues in disasters. In: CameronP, JelinekG, KellyA, MurrayL, BrownAFT, HeyworthJ, eds. Textbook of Adult Emergency Medicine. London: Churchill Livingstone, 2004; 694–702., ,
- 3Refugee health. In: CameronP, JelinekG, KellyA, MurrayL, BrownAFT, HeyworthJ, eds. Textbook of Adult Emergency Medicine. London: Churchill Livingstone, 2004; 706–9.,
- 4Medecins Sans Frontieres. Refugee Health: An Approach to Emergency Situations. London: Macmillan, 1997.
- 13Sri Lanka-Deaths-05Jan05. [Cited 1 August 2007.] Available from URL: http://www.unhcr.org/tsunami/SriLanka-Deaths-05Jan05.pdf
- 14World Health Organisation. World Report on Road Traffic Injury Prevention. Geneva: World Health Organisation, 2004.
- 16India and the management of road crashes – towards a national trauma system. Indian J. Surg. 2006; 68: 237–43., , , ,
- 172005.The development of emergency services at Karapitiya Hospital, Galle, Sri Lanka, post tsunami. Report to the Department of Premier and Cabinet, State Government of Victoria and World Vision Australia, Melbourne.
- 182005.Project report: Health for the South. Report on site visit.
- 19Health for the South – Emergency Trauma Centre Project – Capacity Building Component – Terms of Reference. Melbourne: unpublished, 2006., , , (Capacity Building Steering Committee).
- 20Guidelines for Essential Trauma Care. Geneva: World Health Organisation, 2004., , , ,
- 21Trauma Secretariat Sri Lanka. [cited 20 May 2007.] Available from URL: http://www.traumaseclanka.gov.lk
- 22United Nations Development Program. Human Development Report. New York: UNDP, 2006.