The death of Dr Kwame Adu Ofori and matters arising

It has taken me a relatively long time to react to the death of Dr Kwame Adu Ofori, a rare breed of Emergency Medicine Physician, who was in transit from the Komfo Anokye Teaching Hospital to a hospital in Accra for management of acute myocardial infarction, precisely ST-Segment Elevated Myocardial Infarction (STEMI).

I have been sad and disappointed because I did not expect that more than 35 years after the establishment of the National Cardiothoracic Centre, this country would still be grappling with state-of-the-art management of cardiac emergencies in almost every part of the country apart from Accra.

There is no serious attempt to establish more heart centres in the country. The National Cardiothoracic Centre itself has not experienced the growth and development needed to make it operate at the global level.

Comprehensive approach
It was reported that Dr Adu Ofori had to be transferred to Accra because of the absence of a Cardiac Catheterisation Laboratory (Cath. Lab.) in Kumasi.

Entrance to Komfo Anokye Teaching Hospital in Kumasi

It was also in the news that the government has promised to buy Cath Labs for Komfo Anokye Teaching Hospital and a few other health institutions.

This is commendable. However, I wish to caution that a Cath Lab, important as it is, cannot guarantee the success of management of cardiac emergencies such as STEMI.

Other facilities, staffing and coordination and discipline of health personnel are equally important.

After all, the first port of call for patients needing emergence cardiac care is not the Cath Lab.

For optimal care, acute myocardial infarction and other heart related emergencies should be managed by an inter-professional team that is solely dedicated to heart disease. In the case of myocardial infarction, besides the cardiologist, the team usually consists of an interventional cardiologist, a cardiac surgeon, intensive care physician, anesthetists, cardiac rehabilitation specialist, critical care or cardiology nurses, pharmacist and pulmonary physician or physiotherapists.

The cardiologist is the leader and is responsible for all final decisions.

Team work is absolutely important and because time is of essence, this special team should be able to assemble within minutes of arrival of an emergency and the initial evaluation of the patient should be executed within 10 to 15 minutes of arrival in the emergency department.

Processes
Blood for general laboratory, as well as heart specific investigations and other non-invasive cardiac investigations such as ECG, pulse oximetry and echocardiography should be carried out within minutes.

This should be achievable because successful outcome of management of STEMI depends on rapid diagnosis and timely reperfusion.

Reperfusion in this sense means restoration of blood supply to the portion of the heart that has been affected by the blockage of the heart vessel(s).

There are two ways of achieving this. First is primary Percutaneous Coronary Intervention (PCI) which should be done within 12 hours in a cardiac cathterisation laboratory by persons skilled in the procedure and supported by experienced personnel.

If the PCI is not possible because of the nonavailability of a Cath Lab then one falls on the second option, which is fibrinolytic therapy that uses drugs to dissolve any clot blocking the heart vessel.

Optimally, fibrinolytic therapy should be done within two hours.

In addition, parenteral anticoagulation, as well as antiplatelet therapy, is recommended for all patients.

On the rare occasion that PCI fails, prompt access to emergency coronary artery bypass graft (CABG) surgery must also be available.

Not enough

This brings me to a very important point. It would not be enough to provide Cath Labs for the performance of PCIs in the selected hospitals as contemplated by the government.
Facilities and personnel for full scale open-heart-surgery must be provided as well.

Here again, the Komfo Anokye Teaching Hospital has been struggling for years to get a good cardiothoracic centre established, but the requisite investments in equipment and training of personnel have not materialised.

As things stand presently, a Cath Lab may be purchased for the Komfo Anokye Teaching Hospital, but without facilities for coronary bypass, surgery patients who experience failed PCI may be in life threatening difficulties.

In considering Cath Lab for Komfo Anokye,I would like to opt for the purchase and installation of a Hybrid Operating Room, which combines a Cath Lab suite with a traditional operating room fixtures.

Such a facility removes the need to move a patient in unstable condition from Cath Lab to operating theater suite which may be in another block.

Also, with a few changes, the inter-professional team that assembled for the PCI can switch over to perform the coronary artery bypass surgery.

As far as I know, the Cardiothoracic Centre in Korle Bu and the University of Ghana Medical Centre (UGMC) have the inter-professional teams that are solely dedicated to heart disease and these teams that can be mobilised within minutes and have proven themselves time and time again.

Sadly, the Cath Lab at the Cardiothoracic Centre caught fire a few months back and it is yet to be replaced.

Poor state
The government’s intervention to acquire a Cath Lab for Komfo Anokye is adhoc and I don’t blame it.

The Institutional Care Division of the Ghana Health Service (GHS), which operates under the broader oversight of the Ministry of Health (MOH), should be blamed, in part, for the rather poor state of hospital care in the country.

This division is poorly staffed to carry out its core functions including developing and implementing quality assurance systems, establishing clinical governance frameworks, providing support and monitoring for quality assurance programmes and developing standards and protocols for quality, efficiency and effectiveness in service delivery.

The Institutional Care Division should at any time appreciate the health challenges of the population, especially in the area of non-communicable diseases, then scan and monitor the health institutions whether they are adequately equipped to manage the burden of diseases.

I wish to give the care of end-stage kidney disease as an example.

In the last three decades there has been an increasing number of patients with end-stage kidney disease, most of them requiring hemodialysis treatment.

By now there should have been active sustainable kidney transplantation programmes in at least four hospitals in Ghana.

In the absence of such a programme only patients who can afford catastrophic spending abroad get the needed surgery and after care.

Needless death
Cardiovascular deaths, such as the case of Dr Adu Ofori, are dramatic and have the potential of eliciting dramatic responses.

However, there are many other departments, such as neurosurgery, Ear Nose and Throat, Ophthalmology, Urology, Hematology, Cancer Care and Laboratory Medicine and many more that are screaming for assistance.

It is rather unfortunate that blood and tissue samples of Ghanaians are shipped abroad for investigations.

The scanning of health institutions should not be limited to GHS institutions.

The Catholic Hospital at Battor in the North Tongu District of the Volta Region under the leadership of Dr Kofi Effah has put Ghana on the world scene as far the management of gynecological oncology is concerned.

It would not be out of place for the MOH to tap into the experience of Dr Effah to build a state-of-the art hospital to manage gynecological oncology cases.

The needless death of Dr Adu Ofori could have been prevented had we been a bit more proactive in equipping existing medical centers appropriately.

Health is wealth and time is long overdue for Ghana to invest in well planned and fit for purpose health facilities to cater for our population and also prevent capital flight resulting from medical treatment and laboratory investigations abroad.

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