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Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Towards a National Ambulance Service in Nepal

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Many of us have had the good fortune to visit Nepal, to climb, trek, tour and otherwise enjoy the wonderful adventure and recreational opportunities afforded by the varied geography and wonderful people. The country has had its fair share of political unrest and economic difficulties, but in the main, it is a land known for its beauty, opportunities, and hospitality. Like many countries in its part of the world, the medical establishment needs support and improvement, particularly in the realm of emergency medicine and pre-hospital care.

I'm pleased to report that there is excellent progress being made on establishing a National Ambulance Service in Kathmandu, Nepal. Working groups of International Medicine Fellows and faculty members from the Division of Emergency Medicine have collaborated with a large working group in Nepal, a highly motivated young man, David Amselam from Vanderbilt University, and many others to craft a project plan that will hopefully lead to a series of approvals and sufficient funding to allow the program to get off the ground.

As stated in the working project plan, the Nepal Ambulance Service (NAS) is a nonprofit initiative dedicated to the establishment of an emergency medical response system to provide high-quality medical care for sick and injured people. Along with services such as police departments and fire personnel, an adequate emergency medical system is an essential public good, critical to providing life-saving interventions. Although the NAS has long term objectives of expanding its service to all of Nepal, its immediate focus is to improve the quality and accessibility of emergency medical care within the greater Kathmandu and Patan municipalities. The NAS project plan aims to coordinate emergency medical training, communication with area hospitals, and rapid transport and treatment for individual patients, regardless of their ability to pay. A precedent for the implementation of such a system within a developing country has recently been executed successfully in India, Nepal’s neighbor to the south. Lessons learned from this accomplishment will be used to guide the novel system of pre-hospital care in Nepal.

Nepal currently has a population of 27 million people with an average life expectancy of 62 years, ranking it 132nd out of 179 countries. Infant mortality and maternal mortality are high and compare even less favorably to other counties (142nd out of 177). There is approximately one doctor for every 18,000 people, and only 15 hospitals in the entire country have an accident and emergency (A&E) department. These A&E departments are commonly under-staffed, with minimal resources, and suffer from overcrowding.

Pre-hospital emergency care, a critical component of the patient safety net, disaster response, and healthcare accessibility, is virtually non-existent. There is no toll-free emergency telephone number, no centralized emergency medical services dispatch center, only a few scattered, ill-equipped ambulances, and no formally trained pre-hospital personnel. The adverse health consequences of this are extensive and contribute to Nepal’s high mortality rates for common medical emergencies, poor ability to respond to disasters, and reduced access for the majority of the population to adequate healthcare.

Currently, victims of trauma, obstetric, or medical emergencies in Kathmandu are transported to the hospital by a taxi or private vehicle, with no medical care in transport. The people of Kathmandu do not have a recognized phone number to call for emergencies, and many patients are not transported in time for meaningful intervention.

Private ambulance services in the area consist of a haphazard system that is unreliable for its indigent population. The outcome of traumatic emergencies is impaired further by the lack of rapid transport to hospitals with capabilities to care for the patient.

NAS was created by a group of volunteers who identified the need for pre-hospital healthcare delivery in Nepal in order to decrease the morbidity and mortality of emergency conditions. The organization seeks a sustainable solution directed by local professionals, the cooperation from the Nepali government, secure funding, and well-trained providers and educators. NAS is established in collaboration with local experts, including Mahesh Nakarmi of Healthcare Foundation of Nepal (HECAF) and Dr. Rajesh Gongol, medical director and surgeon at Patan Hospital. Stanford emergency medicine physicians joined the project in 2008 to serve as partners in developing an educational program, as well as consultants to the overall project.

Success of the project depends on the collaboration of local hospitals, law enforcement, physicians, the private sector and certain agencies, including the military, within the Nepali government, all of which have offered their support. The creators of NAS hope the center can serve as a working example to influence the development of prehospital care and emergency medicine in underserved countries.

The NAS will also play an important role in responding to large-scale emergencies, such as earthquakes and other natural disasters. The NAS will help coordinate an area-wide response, with highly skilled emergency medical technicians (EMTs) contributing to the management, triage, and transport of patients during mass casualty incidents (MCIs). NAS plans an emergency medical response with the capacity of radio communications to offer a first-line response in the event of such a disaster, even if telephone lines and mobile phone networks are not functioning. This planning is especially important in light of the fact that Kathmandu is currently lacking in disaster management preparation - despite the widely held professional opinion that the region is “overdue” for a major earthquake.

NAS will provide organizational structure to the development of an emergency medical response system (EMS) for Nepal, beginning in the Kathmandu Valley. A central dispatch center will provide detailed instructions for trained ambulance personnel, and communicate with hospitals to direct ambulance patients, depending on patient needs and specialty availability. Training of medical personnel for patient transport will also be coordinated through NAS. NAS, with the assistance of local hospitals, will provide emergency medical transportation to any person who needs care within the Kathmandu Valley.

Continuing education and training will be provided in collaboration with medical professionals currently practicing in Nepal and Emergency Medicine physicians from Stanford University School of Medicine. The Kathmandu Police Department will provide necessary space for ambulance parking, and the Nepali Department of Health will support the efforts of NAS as an endeavor to improve the lives of the Nepali people because of their increased timely access to healthcare.

NAS will employ emergency medical technicians (EMTs) to perform life-saving treatment at the scene of an emergency as well as en route to the hospital. NAS employees will be trained to effectively communicate with emergency departments during patient transfer. Limited medications will be carried on NAS ambulances. In order to maintain their skills, graduates of NAS training will participate in continuing medical education taught by medical providers as well as by experienced EMTs.

It is anticipated that NAS will start with a small fleet of ambulances as well as a number of first responder motorcycles with operations based in Thamel. Given the narrow, congested streets of this city, first responder motorcycles would likely be the first on scene. The EMT, serving as the first responder, could provide immediate first aid, communicate with police to assist with crowd control, and update the incoming ambulance of the situation. The ambulances would be equipped for Basic Life Support (BLS) services to patients. This would include administration of oxygen and other non-invasive techniques, such as splinting broken bones, administering glucose for hypoglycemia, basic wound management, and stabilization of trauma patients with a cervical collar and backboard.

• NAS will have no difficulty in finding beneficiaries, as more than 90% of emergency cases currently arrive by taxi or private vehicle.

• NAS will prove its worth with the lives and limbs saved from timely interventions on behalf of victims who have suffered trauma and medical emergencies.

• NAS has supportive interest from the Nepali government, multiple organizations within Kathmandu, and international experts invested in the success of NAS.

A public education campaign on medical emergencies will be conducted to inform the target population of the importance of prompt medical care, including the fact that delays of even minutes can lead to permanent disability or death. Through a multi-faceted communications and public awareness campaign, NAS will promote the 3-digit emergency phone number and inform residents of the Kathmandu Valley of the importance of promptly transporting gravely sick and injured individuals to hospitals as quickly as possible.

My last visit to Nepal was excellent, in large part due to excellent suggestions and guidance from all concerned. We were able to meet with the U..S Embassy team, which arranged a meeting with the head physician for the Nepal military, who introduced us to a number of individuals and arranged a tour of the military hospital. Other persons with whom we met included physicians responsible for emergency departments at various hospitals (from which will be required agreements for receiving patients), the police chief for Kathmandu, the Chief Medical Officer of the military hospital, an assembly of business leaders, the Health Care Foundation of Nepal team, a member of USAID, and others. We also visited the Ambassador to Nepal from India and the Dean from one of the medical schools, who wants to not only support EMS, but upgrade emergency medicine in general in his country. We had to do a bit of "divide and conquer," so I did not attend a meeting with my colleagues with a representative of the World Health Organization. There was a morning conference at Patan Hospital, in which the medical community at large was introduced to the concept. It was well attended, and no opposition was voiced.

The consensus was that there is a clear need for an EMS system, and everyone pledged support in terms of philosophical support, space, call center support, medical community buy-in, military buy-in, etc. There are certainly issues of timing, governance, and financial support that need to be discussed, negotiated, and finalized. My impression is that this is a much needed and doable project, and so we will continue to actively support the effort to create the service. The next step for us in the U.S. is creation of a nonprofit 501(c)3 corporation into which philanthropic donations and grant monies can be directed. Because of the economic situation in Nepal, the Nepal Ambulance Service will depend upon financial resources derived from other sources, either in-kind contributions or cash donations. Funding will depend greatly on private sector support, innovative fund raising schemes from the general public, and the wider philanthropic community. It is hoped that the international donor community will also be of financial assistance.

"White coat diplomacy" is a concept whose time has more-than-come. The opportunity to assist other countries in improving their innate medical capabilities, and to help structure systems of locally trained individuals in such a manner that what is created becomes self-sustaining is an important concept for our country. While it is certainly important for volunteers to provide direct medical care to individuals and populations in time of need, it is equally important to create situations where countries can meet their own needs on a regular basis. The Nepal Ambulance Center will hopefully serve as a model of what can be accomplished when countries come together to solve problems and "put something back" for those who have regularly given so much.

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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