Emergency Medicine in Rural Mali

By AHHB
Monday, 31 October, 2016


Emergency Medicine in Rural Mali

In Koutiala, in southern Mali, severe acute malnutrition, malaria, diarrhoea, respiratory tract diseases and other so-called opportunistic infections are creating havoc in children aged six months to five years. Dr Lisa Umphrey describes how Médecins Sans Frontières/Doctors Without Borders (MSF) is working to prevent infant mortality in a region that has very few health professionals.
Five years ago MSF approached the Ministry of Health (MoH) in Mali with a plan to combat endemic illness and mortality in children under five in the southern Mali. The key was to integrate community-level care and high-quality hospital services, via a continuum from prevention through to treatment for even the sickest children.
Early diagnosis and treatment by skilled staff in the community are essential to preventing severe sickness. The closer the healthcare, the earlier the contact, the better the results. But inevitably some children will become severely sick or develop complications, so it’s important that the approach be networked, spreading primary care as widely as possible but linking it in with secondary-level care in the hospital.
Emergency Care in Koutiala Hospital
The Koutiala Reference Hospital paediatric department has emergency and resuscitation rooms; a newborn unit; an intensive care unit (ICU) and general ward for non-malnourished children; and an ICU and intensive therapeutic feeding centre for acutely malnourished patients. We sometimes describe this 210-bed facility as “the accordion hospital”, because it has to almost double in capacity to respond to the malaria peak which results in a sudden rise in cases from the middle of each year.
When sick kids arrive at the admission area of the hospital we need to assess quickly to identify those patients with life-threatening conditions.
We use a system called ETAT (Emergency Triage Assessment and Treatment), one of several systems which forms the backbone of training for the Malian nursing and medical staff working with MSF. If a child is a “red” or critical case, this means they have a life threatening condition or are in need of emergency resuscitation.
These patients are taken next door to the resuscitation room. Here they receive life-saving treatment, like cardiopulmonary resuscitation or rapid IV infusions to treat shock. If they survive, which unfortunately despite our best efforts not all do, they will remain in this resuscitation room until they are “stable” enough to move to the ICU.
If the child is critical but not in need of resuscitation, they receive initial care, such as IV placement, first dose of medications and lab tests in the emergency room before being transferred to the ICU.
In southern Mali, children struggle with endemic malnutrition, the heavy toll of seasonal malaria, and other preventable diseases such as diarrhoea and lower respiratory tract infections. Since 2009, Medecins Sans Frontieres is partnering with the Ministry of Health to link prevention and treatment across community and hospital levels of care for the best outcomes for children under 5, in Koutiala. Koutiala is MSF’s most comprehensive paediatrics project, committed to strengthening prevention, early detection and diagnosis, as well as improving the quality and scope of care to treat the sickest children. It builds on the community-level “paediatric package”, addressing nutrition, vaccination, hygiene and health education via outreach and community health centres (CSCOM; currently 5) with the MSF-run paediatrics department within the Ministry of Health regional general referral hospital, Centre de Sante de Reference de Koutiala, or CSREF. In 2014 the hospital expanded to 200 beds.
Tiemoko – Severe Acute Malnutrition
Acute malnutrition can easily and rapidly develop into a medical emergency. One-year-old Tiemoko is such a case. He weighed just 5.5kg when he presented at the community health centre. His health had deteriorated after a bout of diarrhoea followed by the onset of vomiting and fever.
He was in shock, with his body in semi-shutdown mode to protect his most vital organs. He had lost an extreme amount of fluid, and this is was interlinked with his severe state of acute malnutrition.
Under the outreach doctor’s supervision, Tiemoko was stabilised on IV fluids before he could be moved to Koutiala hospital.
Kids with severe acute malnutrition are incredibly sensitive to fluid shifts and cannot receive too much fluid at one time. Giving them too much can quickly push them into heart failure. In “normal” kids, you would often see a quick and positive response to your fluids, but for the malnourished child, they will decompensate in front of you with no apparent reason. Therefore critical management of these kids, in addition to the usual treatments, includes painfully slow and restricted fluid resuscitation or blood transfusions, very close glucose monitoring, and prevention/treatment of hypothermia.
On admission in the hospital Tiemoko’s shock and malnutrition category classified him as ‘red’.
In severe acute malnutrition you can see any type of shock and treatment will depend on correctly identifying the type of shock, which can be incredibly difficult in the MSF setting. Life-saving treatment for one type of shock can have an adverse affect for another type. The first step is to check and recheck that you understand what is happening to the child to cause the shock. The second step is to go slowly ahead with your treatment plan, changing immediately if the child starts to decompensate. Support would include (careful) IV fluids, antibiotics and/or antimalarials, oxygen therapy, control of blood sugar and haemoglobin and reintroduction of therapeutic milk as soon as possible after the child has stabilised.
Tiemoko needed to start therapeutic feeding but was too sick to feed orally. So a naso-gastric tube was inserted. On his second day at Koutiala, Tiemoko was able to move out of ICU into the next two phases of the therapeutic feeding program.
Into his second week, Tiemoko was much closer to recovery. He eventually made the transition from milk to therapeutic peanut paste, started breastfeeding, and gained weight. He could hold his head up, and sit upright— which were key milestones. A few days later he was able to be discharged back to the community nutrition program so that he could complete treatment for full nutritional recovery.

Fatoumata – Severe Malaria and Severe Anaemia
Simple malaria is treatable at community level here in southern Mali. But left untreated, or in severe form, malaria is nothing less than the number one killer of under-fives. Three-year-old Fatoumata first started showing signs of malaria at home, including fever, vomiting and diarrhoea.
At the community health centre Fatoumata tested positive for malaria, but had many of the indications of the severe malaria associated with this disease, such as panting when breathing, a fast pulse rate, and extreme pallor. Unsurprisingly she was very anaemic. Without a transfusion, she had only a few hours to live.
We immediately classified Fatoumata as an urgent case at hospital admissions. Most patients who present to the hospital with severe malaria will need rapid checks of their haemoglobin and blood glucose levels (and appropriate responses such as glucose boluses, transfusions and IV fluids), oxygen support, urgent administration of antimalarial and antibiotic medications, and close observation in the hospital. These patients can decompensate quickly and die from preventable complications even in the hospital.
Fatoumata was examined in ER and started on IV artesunate for her malaria. For her anaemia, she was blood matched via the lab, and then taken into ICU where we began her transfusion.
Blood transfusions are often the difference between surviving malaria and not. It doesn’t take long before it’s too late even for a transfusion. I’ve had too many patients die during the first hour of a blood transfusion despite doing everything right simply because the anaemia was too advanced by the time they reached the hospital. But the transformation for the many patients that survive is exemplified by Fatoumata—full of three-year-old personality and energy again, and on the cusp of discharge, within two days.
A Comprehensive Paediatrics Program
While emergency cases in Koutiala are inevitable, thanks to the integrated community and hospital care with vaccination, regular health monitoring and the focus on preventing malnutrition and malaria, mortality has been halved.
Life-threatening emergencies in Koutiala


  • Cerebral Malaria with Seizures

  • Severe or Cerebral Malaria with Severe Anaemia

  • Hypovolemic Shock from severe dehydration caused by Gastroenteritis

  • Sepsis and Septic Shock

  • Meningitis

  • Neonatal Sepsis

  • Severe Malnutrition

  • Severe Pneumonia with Respiratory Distress


You can read more about Médecins Sans Frontières’ paediatric program in Koutiala here: http://childhealthmali.msf.org/



Dr Lisa Umphrey, MD. - Medical Advisor - Paediatrics, Médecins Sans Frontières
Dr Lisa Umphrey is a paediatrician and medical advisor with MSF Australia's Medical Unit (OCP).
Dr Lisa Umphrey, MD. Medical Advisor - Paediatrics, Médecins Sans Frontières Australia. Having qualified as a paediatrician in the US, Dr Umphrey moved to Uganda for three years where she worked with a number of international NGOs in roles including medical director, running their health clinics. Dr Umphrey joined Médecins Sans Frontières in 2013 and has completed two field placements in large hospital projects in southern Mali and in northwestern South Sudan. Lisa currently advises on paediatric, and particularly neonatal care, in projects in countries including Haiti, Mali, Nigeria and Papua New Guinea, as well as for emergencies.
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