The future of EMSS in Thailand – my thoughts and views.

According to an academic presentation in 2015 across the whole of Thailand there were only 1.34M patients transported by EMS to hospital. It has been projected that if the population used 1669 correctly that there should have been in the vicinity of 4M patients conveyed by ambulance. The figure however did however represent a 5% increase on the previous year (1.3M).

According to the same research presentation, in 2015 there were only 65 registered Paramedics in Thailand, 2,373 AEMT’s, 4,479 EMT’s & 66206 EFR’s. In addition to this, there where approximately 15,000 EMS vehicles (these range from First Responder vehicles up to MoPH Ambulances). EFR’s accounted for 71% of the personnel. Interestingly, Emergency Physicians accounted for about 1% of personnel – this is a drastically low figure!

EMR’s receive 40 hours training across 116 training centers, EMT’s receive 110hrs across 34 centers, AEMT’s need 2 years to qualify at only 2 approved centers(!) and Paramedics take 4 years at only 4 approved training centers. In the UK, a Paramedic can qualify in as little as 1 year (at a new program just launched – there are restrictive entry criteria) but in general, the training period is 3 years (a mixture of university and ambulance service placements).

A big issue is the apparent lack of career progression for a volunteer medic – they are seemingly blocked from progressing clinically beyond EMT and the only ‘next step’ is to a ‘call taker’ role within a 1669 center.

The report states that ‘Resources are limited, time is money’.

So what is the solution to some of the issues raised in this report?

Public Awareness: there needs to be a high profile campaign in order to raise awareness of 1669! A majority of admissions to the ER are what we would refer to as ‘self referrals’ (ie the patient arrives by other than an ambulance). In a high percentage of cases, the patient is arriving at an inappropriate hospital. By this I mean that they are most likely attending at their local ‘cottage’ hospital with a condition that requires a higher level of intervention and skill sets. This will only delay treatment and have a negative effect on the discharge result.

In cases of OHCA (out of hospital cardiac arrest) in a majority of cases, no by-stander CPR has been attempted for numerous reasons, and the ROSC (return of spontaneous circulation) percentage is very low. If and when an ambulance arrives, the ROSC rate is decreasing at 7-10% per minute since the patient went into cardiac arrest. (reference). It is worth noting that if by-stander CPR (and this can include compression only CPR) the decrease in survival rate per minute decreases to about 3-4%.

It does not take a genius to figure out that within 10 minutes of an OHCA with NO interventions (CPR, AED, ALS) there is little if no chance of survival.

So, as part of the public awareness program there is a clear and urgent need for community CPR training programs to be implemented. These should be run at secondary schools, university’s, technical colleges, within community groups and organisations (including the various youth groups), workplace training and open access public sessions! This needs to be followed up by investment in PADS (Public Accessible Defibrillator Scheme) ensuring that there are AED (Automatic External Defibrillators) available for anyone to use 24 hours a day, 7 days a week.

EMSS: Early in 2016 the NRSA (National Reform Steering Assembly) announced that there would be 4,000 more ambulances provided in order to boost the EMS sector (refer to article here). In their findings they stated that ‘…Thailand is in need of urgent reform of the reporting and reception of emergency medical cases, as well as emergency and first aid treatments (sic) before the patients arrive at any hospital.’ The aim of the report was to address the noted need for increased coverage across the country and increasing response times. The target is a 5km range and 5 minute response time to all 1669 calls.

I expressed my concerns at the time as to the feasibility of this and that with the current staff/volunteer resources, these would fall way short of providing the manpower to enable this project.

To date, there has been no further announcements regarding the additional ambulances and we can only speculate as to what has happened to this announcement.

This said however, EMSS DOES need urgent reform. The staffing levels are inadequate, the organisational relationship within a number of provinces is haphazard, there is intense rivalry between foundations in some parts of the country resulting from territorial disputes over who is going to respond to a call, lack of planned response management, hospitals turning away patients without adequate insurance (even though this has been made illegal for them to do so), a lack of 1669 coverage and provision in some areas of the country, nowhere enough suitably qualified staff and volunteers to deal with the categories of calls they are receiving and so the list goes on.

What do I mean by suitably qualified staff and volunteers? Lets refer back to the research presentation I started this post off with. In this presentation, the numbers/percentages of EMIT (Emergency Medical Institute of Thailand) registered personnel in 2015 where as follows:

Grade                   Number               Percentage

EMR                       66208                    71%

EMT                       4479                       5%

AMET                    2373                       3%

Paramedic           65                           <1%

The balance of the figures of staff are made up from hospital ER Nurses and Doctors who we will refer to in a later post.

It was also stated in the same report that there were c15,000 vehicles providing EMSS in one form or another. This means at a rough and approximate calculation, each vehicle as just under 5 staff/volunteers who will be using this vehicle on a daily basis, across a number of various shifts. This figure makes sense and actually correlates to figures we are using for our pilot project in Khonkaen (read here for an introduction).

So if we refer back to the 4000 ambulances the NRSA announced back earlier in 2016, there will need to be a minimum of 19,500 NEW staff and volunteers employed/recruited and trained up to the required standards. In order to obtain BLS standard on ALL the new ambulances, this will require that they are staffed with EMT personnel (full time or volunteer) and this will require investment into 2.1M hours of training!

OOOOPS! This is going to be a problem! This means each of the current EMT training centers is going to need to allocate 63,000+ hours of training and classroom time and each will need to accommodate an influx of almost 600 additional students, in addition to those already registered and undertaking training.

Result? Chaos! There is not enough capacity within the training system to accommodate this influx.  Even if capacity could be conjured out of a magicians hat, it would take at least 2 years to get the staff trained, assessed and prepared to be competent to be operational! This does not take into account the time required in order to actually recruit and vet the applicants.

Herein arises another issue, which was alluded to earlier: organisational capacity and structure. The current EMSS infrastructure is NOT ready to accommodate this influx in both EMS personnel and the resultant increase in admissions into the emergency departments across the country.

Why? The numerous Foundations NEED, in order to survive and work within a modernised and reformed EMSS, to abandon the inter-service rivalry and start to work on a regional and provincial cooperative basis. This will not be sufficient however and there would need to be a number of issues addressed, including:

    standardisation of training and reassessment criteria
    mutual aid and funding
    clinical governance
    introduction of clinical KPI’s (key performance indicators) measuring survival outcomes
    uniformity of equipment
    safety standards of existing ambulances and EFR vehicles with a funded replacement program over 5 years to ensure patient and crew safety is maintained
    sustainability of service

Once these and numerous other points have been introduced into the equation, you can see that we have a serious problem in provision of anything approaching a ‘semi professional’ ambulance service. The key to success would be Foundations merging or entering into collaborative/cooperative working arrangements.

This brings me to the next issue, the quality of training! It varies across the country and can range from extremely good to lacking and needing attention. The quality of EMR training will vary from one training center to another. The basic curriculum is standardised, however the quality of delivery can vary considerably!

Once qualified as an EMR, a volunteer can then undertake the 110 hours training to become an EMT. However as I mentioned earlier, the ‘career’ potential is limited from here onwards and this needs to be addressed! There is no reason why a volunteer EMT cannot progress to complete the AEMT training in theory. Well actually there is a huge reason – they would need to give up their ‘day job’ (the one which provides them with the financial stability in order to volunteer!) and go back to school for 2 years in order to complete the required training. This is not feasible in most instances – volunteers are just that! They generally have a career, a mortgage to pay, a family to support…they cannot afford the time away from work in order to qualify as an AEMT and then, the salary scale is going to be generally lower than that they were previously earning before qualifying.

So how can this be addressed? EMIT has come under academic criticism as to ‘how’ it has administered the entire EMSS provision since its inception. However it has done a lot of good work and my personal view is that it has been tied up with the multi layered bureaucracy of government and civil service administrations!

The way forward is to change the training methodology. Instead of their only being 2 AEMT training centers, allow private sector training providers, who have met a determined suitability criteria, deliver the training in a modular form. Recognise that the volunteers coming onto the course have a broad depth of knowledge which can be APEL’d (Accreditation of Prior Education and Learning). Instead of 2 years of classroom and practical delivery of skills, deliver the course in modules which are all interrelated and provide a broad framework of knowledge and skills. Utilise e-learning as a core delivery method with face to face assessments and seminars as and when needed, allowing a volunteer to set the pace of their own learning to suit their needs and free time.

Consider an intermediate grade between EMT and AEMT which would introduce additional clinical and diagnosis skills.

More importantly however, recognise that the volunteer has a lot to offer and that they are the backbone of over 70% of ambulance operations in Thailand! Without the volunteers, the entire infrastructure would collapse overnight.

In a future article I will delve in greater detail into how the ‘mutual aid’ and collaborative/cooperative working between Foundations could be attained. I will also discuss the options available regarding training and ongoing development of both staff and volunteers.

Khamnakorn EMS & Rescue has in its planning, taken into account all the issues raised above, and we have already undertaken research as to how we can adopt many of the issues into our development and organisational structure. We would be more than willing to discuss collaborative/cooperative working relationships with other Foundations across the province in order to develop the provision of pre-hospital emergency care and raise the standards.

Please note: This article is an analysis review and represents the views of the author.
(c) Chris Hall 2016


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