Striking words from a colleague who is a Emergency Medicine Doctor in Thailand in relation to Emergency Medical Services (in Thailand)
Thailand is in crisis now
So what do they mean by this?
My colleague works at a leading private hospital (not to be confused with the UK model of a private hospital) and their ER is inundated with patients who present inappropriately.
In the course of our conversation recently, my colleague outlined the presentation of several patients who arrived at their hospital but should have either been taken by ambulance to the nearest hospital for immediate care, or to a specialist hospital for specific life saving treatment.
A son drive his parent over 1 hour to this particular hospital for treatment, based on the reputation of the hospital and on the basis that the government would pay for the treatment he perceived his parent would require. In itself, there is nothing wrong with this perhaps, except for the presenting condition:
Understandingly the parent was declared dead upon arrival.
The week before this, a family drove an elderly relative to the same hospital. The patient reportedly had suffered a stroke. Again, they chose this hospital as they perceived the level of care to be superior to that of the state one, and the treatment would be free.
The issue was that they lived in another province and the journey they undertook was 3 hours in duration. They also initially misled the attending ER doctor as to onset times, in order to try to get (free)treatment.
This patient was unable to be treated effectively, and would have been likely to have a better outcome had they been taken to their nearest hospital.
There is confusion with the public as to the ‘free treatment’ which is on offer.
Initially, the National Institute of Emergency Medical Services (NIEMS) said that:
the law will apply to only Red1 and stroke/ STEMI who attend to the nearest hospital
However just last week they changed their position on this and revised the ruling to the following:
No matter where the patient is if at the time the patient arrive at an ER as a Red1, Stroke or STEMI patient, they will pay
There is an acute lack of understanding of when to call 1669 (Medical Emergency Services Number). In Bangkok, it is reported that less than 30% of ER presentations have arrived by ambulance (in fact I would suggest that this number is probably more likely to be considerably less than 10%). The public either are unaware of 1669 (unlikely) or are more likely reluctant to use the service as they are not confident in the quality of the service they are likely to receive.
Thailand has a ‘unique’ pre-hospital emergency care system which as a Westerner (Farang in Thai!) it took me a considerable period of time to grasp the workings and politics of how it works (or in reality, is not working correctly).
I have posted a number of articles previously about staffing levels and quality of service, and I shall refer to several of these below to highlight some of the issues as they currently stand.
At a rough calculation, 84% of the ambulances and ambulance personnel in Thailand are volunteer. There are very few paramedics in Thailand. In a posting entitled ‘The future of EMSS in Thailand – my thoughts and views’ I referred to an academic presentation from 2015 by Dr Nathida Sumetchotimaytha where she reported that there were at the time of publication, only 65 registered Paramedics in Thailand.
She continued to suggest that ‘Resources are limited, time is money’
It was also reported that 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.
Volunteers are the backbone of pre hospital care in Thailand but they are lacking the level of training to be as effective as they could be. To set this in context, let us look at the qualification framework.
There are 4 qualification levels:
Emergency First Responder (EFR/EMR)
Emergency Medical Technician (EMT)
Advanced Emergency Medical Technician (AEMT)
EMR’s receive 40 hours training across 116 training centres, EMT’s receive 110hrs across 34 centres, AEMT’s need 2 years to qualify at one of only 2 approved centres(!) and Paramedics take 4 years at only 4 approved training centres. 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).
When looking at the 2015 count of trained personnel, there were 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!
The syllabus for the EFR is good, but it should be a stepping stone onto the EMT qualification and should not be the basis on which a nationwide service is supported.
So why is there a lack of confidence in how the service is delivered?
Several issues come to my mind:
Quality of training and recertification
There is no national set of clinical guidelines to which a volunteer/NGO ambulance provider is required to both adhere to and report against. Infection prevention & control is in the most, unheard of and in reality going to be nigh on impossible to implement for reasons mostly relating to vehicle construction and design, and the range of kit available for volunteers to use.
There are determined recertification periods for the qualifications, however there is a general perception that the EFR and EMT certification and subsequent recertification process is flawed with underlying issues in the quality of training and assessment against a framework which NIEMS and the Emergency Medical Institute of Thailand (EMIT) have developed.
Is this a fault of the volunteers? In no uncertain terms, NO it is not! They are dedicated volunteers who want to deliver a service to their community.
Do they have the right qualifications, clinical support and a development framework which allows them to do this? No, they do not and again, this is NO fault of the volunteers or their organising groups.
Volunteers are unable to progress beyond EMT. Is this right?
This brings me onto the ambulances and vehicles in use across the volunteer sector. There are some really good ones in use, but these are far and few between. A small number of the ‘big’ foundations have a substantial amount of money available to fund brand new ambulances, but the majority of organisations just don’t have access to this sort of capital funding and rely on used vehicles converted into an ambulance. These ‘serve a purpose’ but are they ‘fit for purpose’? On the whole, the answer to this is no, they are not fit and in a number of instances, they are outright unsafe and should not be on the road in any capacity.
This is a major reason, in my mind, why there is a lack of confidence of the volunteer sector by the public and a reluctance to use 1669.
Once you combine the training issues and vehicle issues, a pattern is starting to emerge.
Public awareness and training
Does your next door neighbour know how to do CPR? Do you know how to deal with a major bleed? What would you do if you came across someone who was unconscious?
In the UK, we all would have a pretty good idea as to what we needed to do but in Thailand, I would suggest that the answer to all three would be ‘no I have no idea’.
Would your Thai neighbour call 1669 if you were taken seriously ill? Or would you be taken in someone’s car to the nearest hospital?
School children need to be taught first aid and CPR in schools, they need to know how to use an AED. Adults need to be taught first aid and CPR, and how to use an AED.
EVERYONE needs to be taught these basic life saving skills.
1669 needs to be high in peoples minds. Call an ambulance, don’t take someone who is seriously ill in your car to hospital.
So is pre hospital care in crisis? Yes, it certainly is, but there is an opportunity to do something about it starting today.
What can and what will YOU DO?
(The information used was based on 2015 figures and the views represent those of the author)
(c) Chris Hall 2017