Volume 6, Issue 3: Bystander apathy and African emergency care

The bystander effect – or more appropriately, bystander apathy – refers to a situation where individuals fail to render assistance to a casualty as long as multiple other individuals are present; apparently the more the individuals present, the less likely assistance is to be forthcoming. There are numerous social experiments based on the bystander effect and the phenomenon has been studied for nearly fifty years. ​

According to psychologists, bystanders who noticed the casualty (recognition is oddly delayed the bigger the bystander group) will weigh up the severity of the situation, the form of assistance required and their responsibility towards the situation (which includes whether they know the casualty, they feel the casualty is deserving of help and they consider their own competence in dealing with the situation sufficient) before acting.

I often struggle to understand what I see as the general indifference of clinicians, non-clinicians and funders (locally and abroad) towards African emergency care. Not consciously indifferent, but rather unconsciously indifferent. Do not get me wrong, there are many that do not conform to this type of group mentality and simply by reading this editorial you are most likely excluded from being the bystander. But the critical mass has not swung towards calling the majority (those that can contribute, but don’t) to action. I cannot help but wonder whether the unrelenting reminders of the African HIV burden, pictures of starving children and decades of foreign aid have not created a sort of bystander effect, that have resulted in involvement-fatigue for many we look to for engagement, both locally and abroad. And yes I would go as far as to say that the bystander effect claims African clinicians, non-clinicians and funders as well. Don’t believe me? Here are two examples: publication patterns indicate a preference of local authors to publish elsewhere (usually subscription journals) rather than local (usually open access journals), and we cannot get local advertisers to support the journal.

But perhaps the problem is not really that of the bystanders’. Perhaps we should be asking ourselves: how can African emergency care advocates present themselves and their plight locally and abroad in different ways, so that the bystander effect is negated, or better yet, reversed? Advertisers have been subconsciously doing this for years, so why can’t we? I don’t really have the answer, but I do know that we need lots of local participation and a reasonable proportion of foreign collaboration if we are to succeed in building a functioning African emergency care system at some point in the future. There are many who contribute already, but I am not wholly convinced we are speeding up the bell curve just yet. Training, conferences and journals all cost money - something that is hard to come by in Africa on basically any day. The African Journal of Emergency Medicine and some of the local emergency care societies for instance have started by looking towards social media (Twitter, Facebook, blogs, etc.) as a means to engage audiences. But more can definitely be done to tip the scales from apathy to engagement and in the process recruit more bystanders.

Issue line-up
Developing metrics for emergency care research in low- and middle-income countries
African emergency care research represents less than 2% of the world’s emergency care output, which is at odds with Africa being home to over a billion (or 16%) of the world’s population. This study essentially showed that we are not doing ourselves any favours, as metrics used in the studies analysed varied widely and showed little consistency. A key recommendation is for metrics to be defined and adopted throughout the continent for use in local research. Such a move will bolster quality, improve the relevance of findings and allow for meta-analyses.

Bedside ultrasound training at Muhimbili National Hospital in Dar es Salaam, Tanzania and Hospital San Carlos in Chiapas, Mexico
Two things stand out for me from this paper. The first is that obstetric ultrasound was included in the training and the second is the confirmation that ultrasound training is feasible within resource limited settings. Obstetric causes of death are a major concern in the African setting and specialists are sparse; emergency physicians should be able to wield a cavity probe. The paper does not go into any depth as to why it was included in the training except by referring to the 1998 World Health Organization’s and the American College of Emergency Physician’s ultrasound policies. If you are keen to set up a training programme in your area or region you should get in touch with the corresponding author.

A Pilot Training Programme for point-of-care ultrasound in Kenya
Our second paper, also about point-of-care ultrasound, makes an argument for the old adage: practice makes perfect. Candidates that went all the way with the course up until the refresher were simply more successful than those that did not. What I also like about this study is how the programme evolved and responded to local challenges ushering in a bit of action research on the go. Following the trend set in Tanzania, obstetric ultrasound was also included in this curriculum. Perhaps this is an East African thing (I wish it was an African thing). This is certainly another corresponding author you should be contacting if you are keen to set up a training programme in your area or region.

Added value of graded compression ultrasound to Alvarado score in cases of right iliac fossa pain
In this study ultrasound appears to add value where it matters – in the middle. Low Alvarado scores (less than five) were associated with excellent rule out value and high Alvarado scores (greater than eight) with good rule in value. But for the real clinical toffees, the rule in value for scores between five and eight were improved to excellent. Naturally we’d like to see this replicated in a larger sample. Still the findings are promising and suggest a clinical decision rule is waiting in the wings to be defined.

Federation matters
Be sure to check out the 2016 African Federation for Emergency Medicine Consensus Conference recommendations on access to out-of-hospital emergency care in Africa.

http://dx.doi.org/10.1016/j.afjem.2016.08.005