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Home Extras An "objective" look at the emergency ambulance services (Part II)

An "objective" look at the emergency ambulance services (Part II)

by Dr. Teo Aik Howe

{Part II}

So, what have we determined so far?

That emergency ambulances are a special kind of animal, dedicated to saving lives, reducing further injury, improving outcomes and providing help when it is most needed. It is the SLK of the Mercs, XKs of the Jags, 7-series of the Beemers ... [you get the picture].

But it is not about hype, it is about performance. It is about getting all that life-saving capability to the patient in good time. Or else, it will just be a wannabe; a hyped-up balloon of hot air, waiting to be deflated and dishonoured.

Can we get that live-saving capability on our ambulances ? YESSSS, can be done, have done it. All it requires is WILL and the self-belief that it is the right thing to do.

On the other hand, can we arrive in 10 minutes ?? So that we can make a difference ? Hmmmmm this is much more difficult to attain, and much more complex to manage.

But before we get into the difficulties, let me put my point straight out, to the point. In order to achieve this 10 minute response time, we will need to DECENTRALIZE the emergency ambulance services. If we want to reach a dying man in 10 minutes, so that we can save his life, our ambulance must be close by, and ready to act. We must be near his home, or his workplace. We must be in his community. That is the only way.

The Malaysian Health Services in fact is a success story in decentralization. After all, we built more than 200 hospitals all over the country; more than 2000 healthcare clinics scattered almost everywhere. Our Ministry of Health proudly states its capabilities and achievements in decentralization ie. more than 90 % of our population live within 10 km of a healthcare facility; more than 80% live within 5 km of a healthcare facility. These are statistics to be rightly proud of. But somehow, that's as far as we got. We failed to realize that in today's urban cities, that 5 km may translate to 30 minutes traveling time. This is, by far, too long for an emergency ambulance to take to reach a patient to provide any meaningful help. So, placing ambulances only in hospitals is inadequate especially in our cities [where half our total population live anyway]. Decentralization of ambulances into the communities in the only way to achieve that elusive 10 minute response time!

The problem is this; there are tens of thousands of communities in Malaysia. It will surely not be feasible to place an ambulance in each one of them. Who will pay for it ? After all, running an emergency ambulance is NOT CHEAP. Will the government pay ? Hmmmm, honestly I think not. If the central government decided to pay for decentralized ambulance stations, you can almost bet your last dollar that the first stations will be somewhere in PutraJaya or Bukit Tunku or near where the mighty and powerful spend their time.

So then how ? I think it we should act on this. That's right, WE. WE in the community. We, the users. We, after all, will gain the most by having an emergency ambulance parked in our community. We should act on this. We should raise the money, we should pay for the maintenance and functioning of the emergency ambulance stations; and we should define what we want from the emergency ambulance. We act, we become the boss laaa.

Can this be done ? SURE ! After all, St John Ambulance already has a good many years of experience managing decentralized emergency ambulance stations both in Kuala Lumpur, Klang and in Penang. MRCS has also similar experience at this. Both St John Ambulance and MRCS provide good emergency ambulance services; capable, cost-effective and progressive. They just need the funds.

So, let's help them help us. Start up a community effort; actively engage with your local St John Ambulance or MRCS services. Work actively with them toward creating a decentralized emergency ambulance service for your community. It will not be easy; but it will be worth it. Ask the people whose lives were saved by the early life-saving care provided by these ambulances. And hope that, one day, if we ourselves were to need the assistance of these ambulances, we would have succeeded by then to have placed one nearby.

Well, we have kind-of determined that emergency ambulances are important if we want to save lives. These ambulances must be well-equipped, their staff well-trained and they must be decentralized to community in order to respond rapidly.

If all this somehow comes true, we will have super-duper ambulances everywhere! The problem is, most of the time, they will be called to respond to non-emergencies or where their role is merely to transport the patient to the nearest hospital. Won't that be a waste of money and resources, apart from being a morale-sapping, demoralizing and demeaning job for the highly trained paramedic?

That's exactly what's happening in other more-advanced-than-we-are countries. In those countries, ambulances are widely decentralized, very well equipped and staffed with well trained paramedics who are very highly paid. The emergency ambulance services are EXPENSIVE ! The government pumps in millions every year, gets the insurance sectors and the employers to chip in as well, build-in tax breaks for subscribing to ambulance services etc etc ...... and it is still NOT enough. All that money is still not enough to maintain the services as they want it. They sometimes refer to it as "that big black hole"!

Despite that, calls are still coming in for non-emergencies. People who wake up in the morning and feel too ill to go to the hospital, call the ambulance. People with headache from too much beer the night before, call the ambulance. People with sick children call the ambulance; despite the three cars that they have in the driveway. Elderly people who live alone often call the ambulance to help them back into their beds after they have fallen off; or call in the middle of the night, just to have a chat with someone nice. When there's a small fender-bender on the roads, 5 - 10 people call the ambulance.

The numbers of true emergencies (the bang-bang-shish-kebab-kebang type of incidents) are actually few and getting fewer; but they really do very well for these true emergencies, though. Quite a few ambulances will come, supervisors cars, and maybe even a heli hovering about above. Press guys pushing to interview the paramedics. Every patient strapped up to the spinal board, lateral immobilizers and straps everywhere. Sweat, gore and blood. And lots of "Go, Go, GO!" in true US Marine style. True Hollywood style stuff.

But I'm not sure that's the way we want to go.

I'm not sure it is best for our Government to create a system like that. Firstly, it will cost a bomb. A big expensive, big-black hole of a bomb. You know our Malaysians laaa. Government give the money and the service, we USE it laaa. After a while, we figure out a way to ABUSE it laaa. Then we sulk and cry when we are told that we cannot abuse the system. We call up our service centers, and they make a hoo-haa and everything dies down after a while. The abuse of the ambulance services continues. After a longer while, our trained and motivated paramedics will just decide to lay-back and take it easy. Why go to all that trouble ? It'll not be urgent anyways. And after that, decentralized ambulances will no longer be at the community stations, but somewhere under the tree, near the Roti Canai or Rojak station. Cendol and Teh Tarik becomes the order of the day.

So, how to create a system where a service is provided for free, but not abused ? Here, we should learn from the Americans. Build in the capitalist 'let-the-market-forces decide". Charge for emergency ambulance services !!!

Now, before you dismiss me as crazy, hear me out..... then you are perfectly welcome to still call me crazy.
Charge for the emergency ambulance services. Charge RM 10 per ambulance call. Cheaper than taxi, more expensive than free. Slightly more expensive that the ride in your own car. Most importantly, it is affordable. For those who cannot afford it, or those fellas who are unconscious, or alone, waive the charge ! For those fellas who really really abuse the ambulance service, send them a bill for RM 250 (which is about what Singapore charges those non-emergencies who insist on calling the emergency ambulance services).

Let's be realistic. That RM 10 does NOT cover costs of managing the emergency ambulance services. It doesn't even cover 10 % of total costs. Emergency ambulances are EXPENSIVE, even in Malaysia. So, how to be viable ? How to build many many decentralized ambulance stations if each and every one of them is losing money ?

Here, the government needs to play its part. After all, what are the taxes that we pay for ? The government must spend more on developing the ambulance services. Today in Malaysia, we can fairly say that it is much much more likely to have a heart attack or a stroke or a road traffic accident, than a fire incident or a search and rescue incident. You are much more likely to see ambulances on the road than the fire engine. Yet, BOMBA has a well-developed network throughout the country; millions of RM yearly; and lots of 'toys' to play with; whilst the ambulance services are still down in the dumps. This is NOT correct. And NOT what is demanded by our fellow Malaysians. We need to develop the ambulance services to be on-par with the BOMBA services.

The government needs to spend much much more money on developing the ambulance services. Period.
But remember my "big, black hole" quote earlier ? Here is where we need to be careful. We cannot afford to throw money into that big black hole like the Westerners have done, and are now regretful about. We should instead look at developing the field in phases. Man-man-lai !

The government should offer to PARTIALLY SUBSIDIZE the setting up of decentralized emergency ambulance stations by St John Ambulance, MRCS, Volunteer Fire Rescue Squads and probably throw in the JPA-3 fellows as well. Pay part of the costs of building a station, and its equipped ambulances, and ask the community in that area to chip in as well. Then the community will get their own ambulance station. The government should also pay for every ambulance call that is taken up by the ambulances. This will go toward subsidizing the costs of maintaining the services [and at the same time, ambulance services that do not show enough workload, will automatically find it hard to survive, and close down or restructure automatically]. For all that money that the government is spending, they should now have the right to put conditions. Like, standards to be achieved, KPIs to be met, Clinical Audits to be done, rules to be adhered to, outcomes to be reported, documentation to be done, supervisory levels, feedback mechanisms etc etc etc. Ambulance service providers now get to do what they had always wanted to do in the first place; provide emergency ambulance services that matter. The money and support would continue as long as they continued to do that job well. And the community finally gets a say in what they want. They take part of the financial responsibility for the service; they actively participate and they play their part in educating their own community about the emergency ambulance services.

That sounds to me like a viable solution. Government pays, and sets demands list. Community chips in and sets wish list (but more than that, this active participation in the ambulance service inherently reduces abuse). Ambulance service providers are happy because they get some money, and they get the opportunity to do good work and be appreciated by their own community. Hospitals are most happy because they finally have some help with this work. Patients should be most happy, because for that little bit extra that they pay, there are more ambulances available, which respond faster and better, helping save their lives. #

The author, an emergency physician, always strive for a better emergency ambulance service in the country, share his thought in his famous blog at WebNotes in Emergency Medicine, emergencywebnotes.blogspot.com

 

CorResponder: Gan Hoo Kok

 

 

Last Updated on Friday, 07 August 2009 05:34  

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