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Establishing Pre-hospital Emergency Medical System in Sri Lanka

First D.D.M.Lakruwan
Last Dassanayake
Name your project or intiative Establishment of Pre-Hospital  Emergency Medical System in North Central Sri Lanka: Gaining some thing from nothing in a resource poor setting

1st country of focus

Sri Lanka

Relevant to the conference theme

Summary By the year 2009 there wasn’t a pre-hospital Emergency Medical System in Anuradhapura. This project was designed fulfill that requirement. There were no local institutions providing training on developing, management and monitoring Pre-hospital EMS. The knowledge was gained through a training program arranged by JICA at Osaka. Establishment of pre-hospital EMS was achieved by fulfilling a set of objectives. Operations of pre-hospital EMS were monitored during first 6 months to understand the technical, logistic and legal issues. During initial 6 months they provided emergency health care to 213 patients and trained 650 population in suburbs on basic life support
What challenges does your project address and why is it of importance? Trauma has become a leading course of hospital admissions in Sri Lanka. Annually average 600,000 admitted to government sector hospitals following trauma. The contribution of the private sector is unknown. During the last 3 decades road traffic accidents have increased by 249%. Therefore an effective pre hospital EMS is essential to reduce morbidity, mortality and secondary injuries.

Rapid urbanization had disrupted the organic solidarity in many cities of Sri Lanka with in few decades, that prevailed for centuries giving minimal or no time to flourish a reasonable mechanical solidarity to compensate. Furthermore increased life expectancy and demographic transition had increased the proportion of the elderly in community who are with more non communicable chronic disorders and emergencies related to them in urban societies
In suburbs it was found on a survey the knowledge and practice of proper and safe initial care and transport of a trauma victim is less than 10% which would lead to secondary injuries even though there volunteerism is high. Furthermore on direct observation it was seen vehicles like three wheelers and motorcycles are used more and more in transporting trauma victims to hospital with little or no care regarding secondary injuries
How have you addressed these challenges? Do you see a solution? Establishment of the emergency ambulance service in the municipality of Anuradhapura

An initial survey was carried out by direct communication and site visits with the potential pre hospital care providers of the municipality of Anuradhapura. The possible institutions with the capability of generating the human resource and the infrastructure were
1. Teaching Hospital Anuradhapura
2. Municipal fire and rescue team
3. Red cross Anuradhapura
All these three institutions had the some extent of infrastructure that can be used in the pre-hospital emergency services and the man power that can be trained for that purpose. Yet the institutions were not engaged in the pre hospital emergency medical services due following reasons
1. Not adequate knowledge in pre-hospital EMS system:
2. Inadequate resources
3. No proper training
4. Different motives and working objectives
5. No interest
There were no academic institutions in Sri Lanka as per 2009 providing a formal education on Pre-hospital EMS, developing, management and monitoring Pre-hospital EMS. Required knowledge was gained by attending a relevant group training program in Pacific Resource center, Osaka, Japan and studying the EMS of Senri emergency and critical care center and the pre-hospital EMS of Osaka fire department.
Establishment of the pre-hospital emergency medical system was achieved by fulfilling a set of fine objectives which included community mobilization communication, developing community and institutional pressure groups, Public private partnership to obtain training and equipments, telecommunication, identification and strategic collaboration with the key partner institutions ( Police, Teaching Hospital Anuradhapura, Australian Sri Lanka Charitable Health fund, Medical Teams International (MTI), human resource development, infrastructure development, acquisition of equipments, formulations of standard operations plans, establishment of codes of practice and designing the EMT documentation formats, studying the possible legal implications and preventive methods through brain storming sessions with relevant expert panels.
Community training on Basic life support
This was designed under the umbrella of the pre hospital EMS of Anuradhapura to increase the chances of survival of the rural population until they are transported to the hospitals from their remote locations following medical or surgical emergencies considering the fact the high level of volunteerism of the village community and low skill levels. This program was developed to run as a collaborative program with the national blood service of Sri Lanka. The stake holders are usually the blood donors of the village community who usually having the higher tendency in volunteering in such emergencies
How do you know whether you have made a difference? During the first six months (01/06/2010 to 30/11/2010) the Pre-hospital EMS had dispatched 211 victims followed by medical and surgical emergencies. It had conducted 14 basic life support skill development programs targeting the rural communities with a participation 645 villagers. In additions it had provided emergency medical care in 4 mass population gatherings during that period

Considering the cohort of victims there was a gradual rise in the number of victims with the advancing age until the third decade of the life. There was a relative reduction in fourth and fifth decades and rise again in the sixth decade attributing to the retiring age. After that the number gradually reduces
Medical emergencies (52.5%) were slightly out numbering surgical emergencies (44.13%). Obstetric cases represented only 2.3% . Two cases were obviously dead according to the working criteria when approaching the scene which account for 0.9% of the cases. Two patients were in cardiac arrest when team reaching the incident (Acute collapse had been witnessed by the bystanders). They were brought to hospital while continuing cardiopulmonary resuscitation. One was confirmed death at the out patient department and the other admitted to Emergency treating unit and diagnosed as an acute myocardial infarction and survived in the acute phase
The majority of the surgical emergencies were road traffic accidents (32) that accounted for 34% of the total surgical emergencies. There had been significant bleeding in 32 cases representing 15% of the total victims which necessitated vigorous active measures to arrest the bleeding. Spinal stabilization was done in 54 cases representing 24.8% of the total number of victims
Considering the medical emergencies the main cause for dispatch was chest pain and difficulty in breathing (34) the key words leading to urgent cardiac or respiratory emergencies. This accounted for 30.4% of all the medical emergencies.
In three instances the advice of the doctor was requested over the phone by the EMTs in the field which is 1.5% of the total cases. Since the multiple casualties were hypothesized doctors of the unit in person attended to mass population gathering during “Pichchmal pooja” and “poson” religious ceremonies held in the municipality and directly involved in managing 16 critical cases which represent 7.5% of the cases
30 % of the cases were attended in less than 5 minutes form the call and 69.7% of the cases were attended with in 10 minutes from the call
Have you or the project mobilized others and if so, who, why and how? A strong community mobilization, formulation of a pressure group with in the institution and the community and obtaining the support of the local and the regional health administrators and the other collaborative bodies were prime objectives of this project.

Convincing the necessity of the pre-hospital EMS to municipality of Anuradhapura to the local and the regional health authorities was the key to the successful commencement and the continuity of the project. Evidence based data, national level annual data of the Ministry of health regarding the current trauma admissions and the trauma management and the health benefits in line with the health master plans that could be expected form the pre hospital EMS considering the effectiveness of the Pre- hospital EMS of the Osaka prefecture were used as the solid information. Multiple levels of health management were invited (local, regional, national) for the initial discussions to obtain the liaison and come in a collective decision in order to prevent the complexities. The initial discussions were conducted in a non directive manner as round table discussions and lectures. Director Teaching Hospital Anuradhapura, Regional Director Health Services, Anuradhapura, National Coordinator, Disaster Preparedness and Response Unit, Ministry of Healthcare and Nutrition Sri Lanka, Governor of North central Province, Mayer of Municipality of Anuradhapura were the invited participants for the initial discussions. In the discussions it was agreed that the pre-Hospital EMS is an important element missing in our health system. It was agreed Pre-Hospital EMS need to be established to cover the entire district of Anuradhapura and as a pilot project to proceed with a service to cover the municipality with a population with 70000 or an area of 5km radius from the town center.
A separate series of lectures were arranged to the hospital workers regarding the EMS in Osaka convincing them this is another area of healthcare and it can increase the chances of the survival of victims. This communication was extended to the community leaders (politicians, influential clergy), professional groups (lawyers, General Medical Officer’s association), and Business community of the municipality. It was expected to develop a pressure group for this project by this communication which ensures the continuation of the program.
When your donor funding runs out how will your idea continue to live? Since the Teaching hospital Anuradhapura was the largest health care institution of the municipality with a large human resource out numbering other small institutions it was selected as the host institution to establish the Pre-Hospital EMS. Municipality and the Fire and rescue were also evaluated as the potential hosts. Yet due to lack of man power, difficulty in establishing the monitoring methods in those two institutions and more importantly the less success in the Fire department based pre-hospital EMS in Colombo lead to select Teaching Hospital Anuradhapura as the host organization. And a separate unit was established in the hospital to carry out this function as Disaster Preparedness and Response Unit which later developed to Disaster Preparedness and Triage Unit. Nurses are working as the EMTs and the EMT level two raining was provided to them by collaboration of Medical Teams International. During that training 5 doctors in the hospital were trained as trainers who could carry out this trading in the hospital for more nurses if necessary with out external support. The Ambulance to the Unit was donated by the Australian Sri Lankan charitable health fund and it was incorporated to the regular ambulance fleet of the hospital and through that it was deployed to the unit so it is maintained as a regular ambulance in the hospital.

Even though at the beginning the project needed assistance from the donor agencies it was designed as such it can be maintained by Teaching Hospital Anuradhapura with out much external support to ensure the sustainability

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