July uprising shows what's missing in our emergency medical care

Remember the teen with an amputated forearm,  smiling on a hospital bed and saying he was willing to lose another hand for the country?

That boy -19-year-old Atikul Islam - was shot by the police on 5 August, the day the Hasina regime fell. He was then taken to five local private hospitals, but none of them provided treatment to him. Even after the bullet was removed from his forearm, he got no treatment for 18 long hours.

Eventually, doctors at National Institute of CardioVascular Diseases (NICVD) found that his hand had gotten infected, and it needed to be amputated. They sent him to National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), where the amputation was done on 7 August, two days after he was shot.

From 18 July to 5 August, local private hospitals provided basic treatment to thousands of injured protesters, often ignoring pressure from local Awami League goons, mostly free of cost. 

Although their role was much appreciated, the fact that in most cases they failed to treat the severely wounded and instead referred them to government hospitals, rings a warning bell. Their inability to provide emergency healthcare led to the piling up of wounded protesters and dead bodies in a handful of city's major hospitals, making treatment even harder.

It was a stark reminder of how our emergency healthcare service is incapable of tackling national emergencies and disasters. 

The lack of physical facilities and trained personnel, coupled with the fear of mob justice (or injustice), as well as harassment from law enforcing agencies bar accident victims from getting swift emergency treatment, often leading to loss of life and limbs, as they travel long distances to get proper treatment.

Not just city clinics, this extends to upazila and district level hospitals.

"Emergency medical care, EMC, is weak in general in our country. There are emergency departments in local hospitals, especially in 480 Upazila Health Complexes. But they are very basic in all aspects – physical, personnel and equipment," Dr Be-Nazir Ahmed, former Director of Disease Control at DGHS told TBS.

"On one hand, the medical officers are very young with little experience and zero training in emergencies, and on the other hand, there is limited equipment, room, sterilisation facilities etc," he explained.

As a result, managing severe injuries or health complaints there is hard. On top of that, a tendency has grown in the last two decades: if an emergency patient dies there, relatives of the patient become violent and 'mob justice' ensues. Doctors and nurses are attacked, emergency departments are vandalised, etc. 

"So the doctors tend to refer emergency patients to larger hospitals," Be-Nazir Ahmed said.

In case of profuse bleeding, blood transfusion or surgeries cannot be carried out in such medical facilities due to the lack of anaesthetists or surgeons, he further said.

Dr Be-Nazir Ahmed added that smaller private clinics in Dhaka are all the same. They want to control their expenses, ending up employing young doctors. Facilities are also meagre there. But he says larger clinics are better; those have consultants with degrees in emergency care.

One notable obstacle in emergency care in private clinics is that law enforcers often take them to task for treating injuries that involve a crime and for giving the victims injury certificates. As a result, such institutions often avoid such cases and refer them to government hospitals. 

This happens despite the High Court directing the government in 2021 to ensure that hospitals, clinics, and medical practitioners provide emergency medical care to every patient brought to them.

Clinics and hospitals still refuse to treat emergency patients for one reason or another.

Dr Abdul Hamid, who works at a private hospital in Mirpur 10, was on duty on 19 July, when Mirpur 10 and surrounding areas became a hotspot of clashes between the protesters and government elements. 

"We removed as many pellets from the bodies of the victims as we could. Many came with severe head injuries; we had to refer them to government hospitals," he told TBS.

Medical colleges, on the other hand, have improved capacity in emergencies, and also have other departments. So severe patients are referred to these medical college hospitals, or, in some cases, district hospitals. 

For example Dinajpur and Rangpur Medical College Hospitals are common destinations for people of that region. In Dhaka division, people may prefer to visit Dhaka Medical College Hospital (DMCH) as a one-stop solution.

"After the Nimtoli fire tragedy and many other incidents like it, DMCH played the main role in treating the injured. Add to the list Suhrawardy Medical College Hospital, BSMMU, National Institute of Neuro-Sciences and Hospital for head/neurological injuries, Mugda Hospital to some extent and so on," Dr Be-Nazir Ahmed said.

"We need to plan seriously to improve emergency services in Upazila Health Complexes by appointing trained manpower. This way death out of injury, such as road traffic injury, can be reduced to some extent. But more importantly, the security of emergency personnel must be ensured. Posting armed guards in emergencies can reduce the tendency of referral," the expert suggested.

In a nutshell, enhancing capacity and ensuring security can change the emergency medical care scenario in the country, according to the expert. The demand of the service is super high in a country of 17 crore people, he mentioned. Being densely populated, the risks of accidents are also high.

"Increasing the capacity would help reduce mortality and sequelae (consequence of a previous disease or injury). For example, many of the bullet-hit patients of the July uprising lost their limbs – hands or legs. These disabilities could have been avoided if swift response could be ensured. These disabilities have life-altering impacts on the victims," Dr Ahmed said.

Is it required to introduce legal safeguards for private doctors to get protected from harassment from law enforcers? We asked.

Not quite, Dr Ahmed said. 

"If a doctor has a BMDC certificate, s/he is entitled to issue medical certificates to victims. But since they do not perform post mortems, they refer the severely injured who have no chance of survival to government hospitals," he said.

However, Be-Nazir Ahmed says the clinics now handle emergencies more than before. 

Emergency health care needs to be improved even in normal times, so they are always ready to handle disasters, he said.

"If a big earthquake hits Dhaka, there will be a massacre. For such situations, guidelines and preparations should be there as to where to set up field hospitals, who will do what etc. Also, a buffer stock of medical supply needs to be created." 

The armed forces practise these things, but the civil health system doesn't, he said. Health service's capacity to handle disasters is scarce, he added.

The private clinics boast all kinds of services, from cardiac operations, paediatric care, diagnostic services to 24/7 emergency services. They indeed fulfil the needs of local healthcare seekers. Then what's missing?

"Private clinics have indoor and outdoor health services, but they are weak in providing emergency services," said the former DGHS director, adding, " In emergencies, they only offer basic treatment and refer them to other hospitals."