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Growing Pains: Status of Emergency Medicine

in Nicaragua

Mauricio Gaitan, MD*

Wilber Mendez, MD*

Nour E Sirker, MD*

Gary B Green, MD, MPH‡

Nicaragua is one of the poorest nations in the Western Hemisphere.The health of the population suffers as a result of poor nutrition,epidemic diseases, natural and manmade disasters, sporadic vio-lence, urban industrial growth, and inadequate government fund-ing for even basic medical equipment and supplies. Within thisenvironment, emergency services development has been recog-nized as an important and cost-effective public health interven-tion. In recent years, government and nongovernmental agenciesworking together have had a dramatic positive impact on the qual-ity of emergency care provided.

[Gaitan M, Mendez W, Sirker NE, Green GB: Growing pains: Statusof emergency medicine in Nicaragua. Ann Emerg Med March1998;31:402-405.]

I N T R O D U C T I O N

Nicaragua is centrally located on the Central Americanisthmus, bordered by both the Atlantic and Pacific oceans,as well as by Honduras to the north and Costa Rica to thesouth. It has an area of 132,000 km2 (roughly the size ofthe state of Arkansas) and a population of 4.2 million.1 Al-though Nicaragua is blessed with a tropical climate andabundant natural resources, the vast majority of its popu-lation is poor. An estimated 70% unemployment rate anda per capita gross domestic product of US$457.70 indicatethat it is the second most impoverished nation in the WesternHemisphere (after Haiti).2,3 The health of the populationsuffers as a result of poor nutrition, epidemic diseases, fre-quent natural and manmade disasters, sporadic violence,urban industrial growth, and inadequate government fund-ing even for basic medical equipment and supplies.

Similar to other countries in Central America, the majorhealth problems of the population reflect the country’s vari-able transition from an agricultural to an industrial economy.Outside the major population centers, the climate, malnu-trition and poor sanitation all contribute to the spread ofinfectious diseases, with diarrhea and pneumonia the lead-

From the Department of EmergencyMedicine, Baptist Hospital, Managua,Nicaragua*; and the Department ofEmergency Medicine, Johns HopkinsUniversity School of Medicine,Baltimore, MD.‡

Received for publication April 1, 1997.Accepted for publication July 9, 1997.

Copyright © 1998 by the AmericanCollege of Emergency Physicians.

is staffed by three physicians, one to four medical students,and four nurses.

Before 1994, the EDs of the two tertiary care hospitalsfunctioned without cardiac monitors or ventilators and onlyone variably functioning defibrillator. Additionally, the EDswere staffed only by residents and general practitioners. Thefunction of the general practitioners was to evaluate andtreat patients with minor illnesses and to classify others, onthe basis of perceived need, for specialty services. Onceclassified, these patients were assigned to the intern for thatparticular service under the supervision of that service’s on-call resident. Thus the ED was completely partitioned intovarious specialty areas, with no physician having overallresponsibility for patient care or for flow through the ED.Furthermore, the salary for these general practitioners wasset at only $140 to $190 per month, compared with the$1,000 to $2,000 per month typically earned by internistsor surgeons in private practice. As a result, this job wasviewed only as a supplement to private practice rather thanas a career in itself.

The provision of prehospital care in Nicaragua is not man-dated or financed by any government or nongovernmentorganization. Hence there is no EMS system and no centralemergency communications center. In Managua, commonmeans of transport to the ED include taxi, private car, andwalking. Although three agencies accept responsibility forthe provision of prehospital care in Managua (the Red Crossand the municipal and volunteer fire departments), there isno formal coordination of services between these agencies.At this writing, we know of only five ambulances operatingin Managua. Two are owned by the Red Cross, two belongto the municipal fire department, and one belongs to thevolunteer fire Department. However, all are inadequatelyequipped for prehospital treatment, and ambulance person-nel (firefighters) have no formal medical training. Therefore,when functioning, these ambulances provide prehospitaltransport but little if any prehospital care.

R E C E N T D E V E L O P M E N T I N I T I A T I V E S

In recent years the nation’s steadily declining health carebudget has led to increasing competition between the vari-ous sectors of the health care system. However, widespreadattention has been given to increasing rates of morbidityand mortality due to injuries and other treatable emergen-cies. In response to this phenomenon, in 1993 the Ministryof Health named emergency services and critical care devel-opment its highest priority. As a result, during the past 5years the ministry has coordinated and provided supportfor several private and government initiatives aimed at im-

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ing causes of death in children.4 Although infectious dis-eases remain a major cause of morbidity and mortality inthe capital, Managua, and other urban areas, recent indus-trial growth has led to dramatic increases in the number ofautomotive and industry-related injuries. This trend, as wellas increasing violence due to crime and occasional civilunrest, has made trauma the number-one cause of years ofproductive life lost in Nicaragua. Diseases of the First Worldsuch as coronary artery disease, stroke, and diabetes are alsogrowing causes of death and disability in Nicaragua.5,6

It is estimated that 80% of the country’s population re-ceives its medical care from the centrally funded public healthsystem (Nicaraguan Ministry of Health, unpublished data,March 1997). This system is supplemented by several smallprivate hospitals and clinics that provide care to those whocan pay. The government provides preventive health servicesthrough a system of local primary care facilities (Puestos deSalud), staffed mainly by general practitioners and nurses.In addition to preventive services, these centers were de-signed to decrease the need for hospital-based care throughextended hours and limited specialty care at some sites.Unfortunately, budget cuts have led to decreased hours ofoperation, frequent medication and supply shortages, andpoor staff morale. Consequently, increasing numbers ofpatients turn to the urban EDs for primary care, furtherstressing an already overburdened system.

The government hospitals (Centros de Salud) are themajor providers of inpatient care, as well as outpatient spe-cialty services and emergency services. Managua (popula-tion 1.5 million) has five of these hospitals, with an averageof 100 inpatient beds each. There are also four private hospi-tals, each with 40 to 90 beds. The most common diagnosesamong adults in Managua’s EDs are respiratory infections,diarrhea, cardiovascular diseases, and injuries. Among pedi-atric patients, the most common diagnoses are diarrhea,respiratory infections, and skin diseases.7 Two of the Centrosde Salud, the Manolo Morales and Lenin-Fonseca hospitals,are designated tertiary care hospitals and also function asthe major trauma and emergency care centers, each withapproximately 75,000 emergency visits per year.7

Lenin Fonseca Hospital serves as the primary providerof emergency care for the western sections of Managua, aswell as the critical care referral center for the surroundingregions of the country. As the only hospital in Nicaraguawith full neurosurgical capabilities, this facility also receiveshead-injury patients from throughout the country. TheLenin-Fonseca ED has 24 beds, including 2 resuscitationbeds. The ED typically handles 200 to 300 patients per day,with approximately 15% requiring admission. A typical shift

proving the quality and capacity of the emergency servicesprovided.

In February 1993, Baptist Hospital, a small private hos-pital in Managua, established the specialty of emergencymedicine in Nicaragua by starting a small emergency medi-cine residency program. The project was initiated by DrNour Sirker, a Nicaraguan physician (and a co-author ofthis article) who is certified by the American Board of Emer-gency Medicine and who previously practiced emergencymedicine in the United States. The training program devisedby Sirker requires 3 years of clinical practice with escalatinglevels of responsibility during rotations through the EDs andICUs of Baptist Hospital and the Centros de Salud. While inthe ED, residents typically work 24-hour shifts every fourthday. The residents spend 2 hours each day on didactic studyto complete a series of 20 academic modules. A 3-monthrotation as an observer in US EDs is being integrated intopostgraduate year (PGY) 3. In the residency program’s firstyear, a qualifying examination and interviews were usedto select four general practitioners to start as residents. In1996, there were five residents: two in PGY3, two in PGY2,and two in PGY1.

Recently the National Autonomous University ofNicaragua agreed to award the Diploma of Specialist to thosewho have completed the emergency medicine residencyand have passed written and oral examinations. In additionto this academic pathway to specialty certification, a second,practical pathway has been proposed. The practical pathwaywill allow any physician already involved in the full-timepractice of emergency medicine to complete the 20 educa-tional modules to qualify for the certification examinationwithout entering the residency program.

In the past 4 years the Ministry of Health has also acteddirectly to improve emergency care through a developmentprocess initially focusing on Managua’s two large publichospitals, Lenin-Fonseca and Monolo Morales. First, emer-gency services was given full departmental status in bothhospitals. Administrative control and primary patient careresponsibility was then transferred from the various special-ties to the department of emergency medicine. The EDs werealso restructured to designate separate physical areas forcritical and intermediate care patients in addition to thealready existing 10-bed observation units. A separate fast-track area was set aside in each hospital for patients withminor complaints. Both hospitals were given funding toappoint full-time ED directors and to create positions forfull-time emergency physicians with a competitive salaryof approximately $350 per month. Specific training for thenew emergency physicians, as well as for other ED staff, wasalso initiated. As a result, Lenin-Fonseca hospital now has

13 full-time emergency physicians and Manolo-Moraleshospital has a staff of 14 emergency physicians.

In addition to these administrative and staffing changes,the ministry obtained a loan from the Spanish governmentspecifically for the purchase of new equipment for the EDsand ICUs of these two public hospitals. Consequently, theEDs each have four cardiac monitors, two defibrillators, andat least one functioning ventilator.

In February 1994, the Nicaraguan Ministry of Healthestablished a collaborative relationship with the Society forInternational Advancement of Emergency Medical Care,Incorporated. (SIAEMC). SIAEMC is a United States–based,nonprofit organization whose mission is to help improvethe emergency care provided to populations throughout theworld through information exchange and developmentprograms. Since that time, the organization has acted as anunpaid consultant, has donated medical and teaching equip-ment, and has organized provider and instructor trainingprograms for physicians, nurses, and paramedics. SIAEMChas also sponsored observer rotations in the United Statesfor Nicaraguan physicians and recently initiated a pilotpediatric injury-surveillance project in Managua.

Despite the Ministry of Health’s support of emergencymedicine, continued budget cuts and the push towardprivatization of health care have severely constrained thegovernment’s financial support. With this in mind, a neworganization, Asociacion Nicaraguense de Cuidados deEmergencia y Trauma, or ANCET (Nicaraguan Associationfor Emergency Care and Trauma), was formed in 1995 toprovide a local organizing body, independent of governmentsupport, that works for EMS development and advocatesfor emergency physicians.

In the past 2 years, ANCET has initiated several projectsto improve prehospital care in Managua. In March 1996,Nicaraguan physicians from ANCET and US members ofSIAEMC jointly taught the first prehospital trauma coursefor Managua’s fire department and Red Cross ambulancepersonnel. Since that time, ANCET has held monthly teach-ing conferences for these fledgling paramedics. Further,ANCET has submitted a proposal to the Ministry of Healthto improve prehospital care in the capital. This proposalincludes the creation of a central communications centerwith a single emergency phone number and a plan to for-mally coordinate and geographically partition the servicesprovided by the three prehospital agencies. If the plan isapproved, ANCET would write care protocols, provide on-going medical control, and implement a system of paramedictraining. Additionally, the proposal calls on the governmentto work to obtain an adequate quantity of vehicles andequipment, including the estimated 30 ambulances needed

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to adequately serve Managua’s 1.5 million people. This pro-posal is currently being considered by the newly electedgovernment.

In summary, the development of emergency medical ser-vices in Nicaragua is an important and cost-effective publichealth intervention and is a high priority. In the past fewyears, government and nongovernment agencies haveworked together on many programs, which have alreadyhad a dramatic impact on the quality of emergency careprovided to the population. Although much work remains,Nicaraguan emergency medicine has grown out of its infancyand is expected to continue to develop rapidly in the future.

R E F E R E N C E S1. World Population Prospects: The 1994 Revision. New York: United Nations, 1994.

2. Nicaraguan Economic Data. Managua, Nicaragua: American Embassy, June 1996.

3. Social Panorama in Latin America: 1994 Preliminary Overview of the Economy of Latin Americaand the Caribbean. Santiago, Chile: Latin American and Caribbean Economic Commission, 1994.

4. 1994 Vital Statistics. Managua, Nicaragua: Ministry of Public Health, 1994.

5. Health Statistics of the Americas: 1992 Edition. Washington DC: Panamerican Health Organization,publication no 537.

6. Health Statistics of the Americas: 1993-1994 Edition. Washington DC: Panamerican HealthOrganization, publication no 542.

7. Principal Causes of Morbidity and Mortality, 1995-1996: Hospital Antonio Lenin Fonseca Martinez.Managua, Nicaragua: Ministry of Public Health, 1996.

Reprint no. 47/1/87869Address for reprints:

Gary B Green, MD, MPH

Department of Emergency Medicine

Johns Hopkins Hospital

Marburg B189

600 N Wolfe Street

Baltimore, MD 21287-2080