Forum Home

Abysmal Emergency Medical Services

PROF RASHID E MAHBUB finds our emergency medical services essentially crippled at both public and private hospitals.

Shawkat Jamil

Medical emergency is an acute health problem which needs immediate attention for comfort and safety of life. It is a pre-hospital arrangement for patient care. It needs immediate transportation to an emergency room of a hospital for definite care. It will not be an exaggeration to say that the overall condition of a country's medical services is best reflected in its emergency service facilities. In Bangladesh, unfortunately though, we have virtually no emergency facilities system, a fact which accounts for thousands of deaths every year.

The common causes of medical emergency in Bangladesh are acute diseases, trauma and accident, violence, drowning, snake bites, suicidal attempts and burn. In delivering medical services, our public hospitals are obligated to provide emergency services to patients, especially to the poor. But facilities required to provide services are so poor that patients often receive delayed and inadequate treatment at public hospitals. Lack of skilled manpower and ill-planning compound the situation, failing to provide services at the time of a patient's need. Some small hospitals provide only first aid.

Condition at the private hospitals is good and bad at the same time. On one hand, they have better equipments and comparatively skilled manpower but affording those services are too expensive for the poor and lower income groups. So when an emergency patient needing immediate treatment is taken to a private hospital, s/he is left unattended until the hefty bills are paid.

Specialised public hospitals have their own emergency services. They receive the patient on arrival, provide the required services. But these hospitals are overcrowded, and lack of beds and other facilities make the services uncomfortable and unsatisfactory. They also lack logistics and manpower. In district hospitals the facilities are a lot poorer and more inadequate than divisional hospitals. They provide emergency medical care of sorts for the district town and its surroundings. But problems arise when there is big accident or disaster. Upazila hospitals also have some provisions for emergency medical service but their conditions are even worse. They in fact give service as a first service provider and transfer the patients in the nearby emergency department of the medical college hospitals or district hospitals. Here the transportation is done by the ambulance if there is any or with the hired vehicle with some logistic supply and medical attendant. Thanks to lack of coordination, there are often incidents of unexpected deaths on the way because in many instances this transferring takes so much time that the patient succumbs to his/her injuries.

Emergency service provider physicians are to keep medical record and inform the police if there is any unusual finding of medico-legal importance. A physician is also legally bound to attend the court of justice as an expert witness. It does not only take away a lot of their time but also put them in embarrassing situations. This is one of the reasons why private hospitals are less interested to attend the call on emergency medical care. This law related aspect of emergency medical facility should be taken seriously and addressed immediately. Many patients are not even admitted in private hospitals for these complicated legal problems. Although everyone is admitted in public hospitals, due to legal impediments it often takes doctors or para-medics more than usual to attend patients. A patient who attempted suicide cannot be attended until certain legal matters are settled but such complications often take a heavy toll on patients. Therefore, these legal matters must be amended immediately.

There are different types of hospitals and clinics both in private and public sectors. Each of them is to be graded according to their emergency medical service capacity. No clinic and hospital can refuse treatment for the patient's inability to pay. If necessary, laws should be formulated to this end.

	Photo Courtesy

Bangladesh is a small land with a vast population and poverty. It is making significant strides in social and economic transformation. Per capita income is increasing, poverty is reducing. Literacy rate is also increasing while women are becoming more empowered.

Social sensibility on emergency medical services is rising. Mobility of the people have increased manifold. Life expectancy has improved. This makes a big demand on emergency medical services.

Hence a national planning is the demand of the day for the emergency medical services. It should be economically affordable as well as accessible to all. In south East Asia, Srilanka has a national Emergency Medical Services. In our National Health Policy, 2011 emergency medical services are included as a basic right of the people. A national planning on emergency medical services is inevitable and should incorporate public and private healthcare providers, professionals, economists and other stake holders. The government is to be in the driving seat. The plan should be done prioritising certain matters: accessibility, affordability and last but not least, improvement of technologies and other facilities. In order to come up with an effective and people-friendly emergency service providing system, the following things need attention.

Human resources
Physicians and nurses are the traditional providers of emergency medical services. There is a need for a group of skilled volunteers. The trainees are to be taken from the public, pharmacists and paramedics. They will be trained first aid and some other basic life supports. They can work as early detectors and early reporters on emergency medical services. There will be a group of paramedics to work with the ambulance for advanced life support. They are to be trained to perform life saving techniques like CPR and cannulation and others. Medical assistants and nurses are to be trained on advance life support so that they can work as emergency practitioners at pre-hospital medical care and in transport vehicles. Pre-hospital medical care is very important for the treatment of emergency patients. In case of trauma, the patient is best served in an operation room. All physicians working in emergency medical services are to be trained on advanced life support skills.

Transportation plan
Like the US, there should be a national telephone number so that anyone in need of emergency services can call for help and transportation.

Ambulance services
There should be ambulance services, different types with different facilities. This will be in addition to the ambulance services of individual hospitals, clinics, charities, municipalities, agencies and industries. The ambulance may have facilities for CPR and First Aid. In high grade ambulance, ICU (Intensive care facility) facilities and other logistics may be added. The cost of transportation is to be reasonable or free for those who may not be able to pay.

Emergency room
Basic Life Support is to be made available in the emergency room. Periodical exercise is to be planned for big emergencies. Patients in the emergency medical services are to be classified in groups according to their needs of attention. First group needs reassurance and first aid. Second group needs some investigation and observation. Third group (serious group) needs immediate intervention to save life either by operation, intensive care or cardiac care. In public hospitals, lack of beds makes the problem worse. Some beds are to be marked for emergency medical services. In big hospitals, all sorts of specialist services are to be kept ready for the emergency hospital services.

Legal impediments
The present health service system is less interested to provide services to emergency care patients, particularly of road traffic accidents and violence that relate to various medico-legal cases. The law is to be changed according to the present need. Violence occurs in cases of negligence of treatment. This can be minimised by definite treatment protocol.

Prof Rashid E Mahbub is UGC Professor and Former President, Bangladesh Medical Association.