Smooth flow of well-equipped Ambulance Service on roads can save many precious lives

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 Smooth flow of well-equipped Ambulance
Service on roads can save many precious lives

Dr. Saba Tariq, MBBS, MPhil,
University of Health Sciences, Lahore

The sirens and lights of the ambulance is not a good sign to see. It shows that some one’s life is in danger and someone’s beloved requires an emergency treatment. No one can realize the pain and sorrow of the person’s relative who is going through this phase.

I have my self-gone through this agony. My father got a sudden heart attack.  Within seconds he became unconscious and we immediately arranged an ambulance and put him in. The ambulance with all its flashing lights and siren started running towards the Hospital. I was in the ambulance fearing and praying for my father’s life. There was too much traffic and congestion on the roads. People were least bothered about the siren of the ambulance. No one was aware of the situation that it’s some one’s matter of life’s and death. I was both in a state of anger and shock. Many questions were floating in my mind. Why this person is not giving way to the ambulance? Is he not hearing the siren? Why he is not removing his car from the front of the ambulance? Will he do the same if this ambulance has his beloved one?  With various questions in my mind, I kept on praying for my father’s life. I also realized that the one who want to give way to the ambulance are feeling difficulty in giving way as they don’t know how they can facilitate the ambulance towards its way to the Hospital. I realized that with traffic surge on the roads, ambulances have a difficult task of transporting patients to hospitals on time. After a few minutes of drive finally we reached a nearby hospital. We went straight into emergency. The emergency team of the hospital tried to defibrillate my father, but all in vain. We were late. I could not save my father. The most important person in my life had gone and I was standing there helpless cursing the system in agony and pain. My father was everything to me: my parent and teacher, he did everything for me. He cared about me when others didn't. Now I am left alone to grieve his passing. His life was important for me and for my family as he was the guiding force for all of us. It was devastating.

 Delay in Emergency Care

After few months of my father’s death when the life started becoming normal I did reflection of the entire event. I asked myself where the problem lies. What went wrong? What can we do to overcome this problem of overcrowding on roads and people’s ignorance towards the ambulance siren and lights? I read many articles and it was quite amusing to me that the problem lies not on one side, but there is another side of the story. There were factors related to delay in emergency care from ambulance as its own and there were factors related to delay in providing treatment because of heavy traffic and ignorance of the people to give way to the ambulance.

 Golden Hour Theory

In accordance with the "Golden Hour" theory, in order to increase the survival of a road traffic accident victim or a heart disease patient, he must be taken to the health care facility within an hour of the incident, which enhances his chances of recovery by 70 to 80 per cent. "Golden Hour" theory of the World Health Organization (World Health Organization) is followed all over the world.

It was very disheartening to see that there were very few data available in Pakistan that can tell us about how many people lost their lives due to delay in ambulance reaching the Hospital. One of the largest private networks of ambulance in Pakistan is provided by the Edhi Welfare Organization. On interviewing few drivers of this network it became known that if there is no traffic in front of the ambulance, it reaches its destination 20 km away within 10 to 15 minutes, but due to heavy traffic on the road this distance is covered in more than an hour.  They were also of the opinion that if the city traffic is simplified and there is an increasing sense of awareness among people about traffic rules and regulations, it will reduce deaths due to delays in a patient’s access to hospital tremendously.

There is a quasi-experimental study conducted by young scientists, focusing on the objective of determining the campaign’s effectiveness to increase the percentage of vehicles that make way for ambulances. An information campaign was organized on a mass level to raise public awareness on the importance of providing a way to ambulances. This study was conducted in Karachi, Pakistan and in this study, three observational surveys were carried by trained observers in different parts of the city. The experts recorded the results of before, during and after surveys on a checklist, taken at three different times of day for two days on each road. The main reasons that came out from 245 analyzed observations were overcrowding of the traffic and carelessness or resistance on the part of the drivers who were driving before the ambulances. Traffic block caused by sudden brakes of small buses and active VIP movements was few of the other reasons causing hindrance on passage of ambulances. The survey concluded that changing the negligent behavior of people by organizing mass media campaigns and giving compassionate, humane messages in the media like “giving way to ambulances can save lives”, is the solution of this problem.1  

 In another study, researchers were keen to determine ways for better transportation to improve maternal, newborn and child health in Pakistan. The conclusion was made that better access to health facilities by effective referral linkages and improving the transport facilities can ameliorate maternal and child health in Pakistan. A system of integrated vouchers with community services can improve the use of services.2  

Similarly, in another study published in emergency medicine journal the scientist conducted a survey through Pakistan National Emergency Departments Surveillance (Pak-NEDS).  An active pilot surveillance was administered in seven tertiary-care emergency departments of six main cities of Pakistan between November 2010 and March 2011. Out of 274,436 enrolled patients, the way they approached the Emergency departments (EDs) was recorded for 94.9%, of which 4.1% approached EDs through ambulances. The significant difference between the mean ages of ambulance and the non - ambulance group was seen (38 ± 18.4 years versus 32.8 ± 14.9 years, p value < 0.001). The patients of ambulance group came with the main complaint of head injury (12%) while the fever was the main presenting complaint of non-ambulance group (12%). Patients of all age groups were less likely to use an ambulance compared to those >45 years of age (p-value < 0.001). The odds of ambulance use by patients with injuries were 3.5 times more as compared to non-injured patients (p-value < 0.001). 

Patients brought to the ED by ambulance were 7.2 times more likely to die in the ED than non-ambulance patients. They concluded in their research that the use of ambulances in Pakistan is very limited. Ambulances were commonly used for elderly or injured patients and there is a greater mortality of these patients in the ED who were brought by ambulances.3

Standard Ambulance Service

This research throws a big question that why patients coming in ambulance are more likely to die in the emergency department? The dilemma in Pakistan is that the government has failed to provide ambulance service according to international standards. The emergency treatment that can be provided in the ambulance is not easy as these ambulances lack the equipment to do so and therefore they are merely playing a role as to provide the mode of transport. In another study, the researchers wanted to look into the quality and accessibility of pre-hospital Care on Pakistani civic roads. The study was undertaken on a 592-km-long National highway in Sindh, a province of Pakistan. The deficiencies noted during the study were more time span to reach a tertiary care hospital, that is, around 31 to 70 minutes, no triaging (86%), informing hospitals (64%), or recording response times (57%). The facility of the stretcher was there in all ambulances (n=12), but only a few had oxygen cylinders (58%). The median schooling of ambulance staff (n=13) was 8 years (IQR=3-10), and the median paramedic training was three days (IQR=2-3). These deficiencies can be overcome by making lasting public-private partnerships whose aim should be to train health care providers, provision of necessary medical supplies, and connect ambulance stations with designated healthcare facilities for appropriate road traffic incident triage.4 It was quite shocking to see that only 58% of the ambulances had the oxygen cylinder, whereas none of them had portable defibrillators. Just by providing defibrillator in the ambulances we can save hundreds of ischemic heart disease patients dying from ventricular arrhythmias. This also reminds me of the ambulance in which my father was taken into hospital as it has no facility of oxygen cylinder and the portable defibrillator was also missing.

These factors can be overcome mainly if the government provides sufficient fund to the hospitals and installed these lifesaving equipment in the ambulances. The important question here is that what we  can do on our part in order to save the lives of the patients in the ambulances and to prevent the delay of ambulances in reaching the hospitals. The government by law has given some special rights to the emergency vehicle so that unnecessary delay can be prevented and lives of the patients can be saved.  Fortunately, there is an act in law by the name of “Right of way to emergency rescue vehicles and ambulances”. According to this law, every person who is driving any vehicle on the road should make every effort to provide untroubled and smooth passage to an ambulance with active sirens or warning lights and to any rescuer who is acting under this act.5

All these laws and measures have been taken in order to prevent delay in ambulance reaching the hospital. In a study conducted in India special traffic volume surveys were conducted to identify the existing situation and the problems faced by the users. Furthermore, this survey was also useful for analyzing the parameters like peak hour, pedestrian behavior type and number of peak hour ambulances. In the next step they designed the network. In network designing two steps were involved. The first step was the identification of origin (hospital) and destination (accident spot). In the next step they identified various intermediate points and different routes to reach the destinations. This was done with the help of Google maps. Further, travel time on these routes was founded by persons travelling on these routes simultaneously at the same time period. Same process was repeated while returning to the origin (hospital). The survey was conducted by considering auto-rickshaw (three wheeler) in the place of ambulances as a mode of travel. This new technique avoids the usage of real time ambulances in the study. Speed and Delay studies were conducted on these routes. In this interesting study, they found various reasons for delay in carrying the patient to the hospital. According to them at most of the road parking were not available. Vehicles were parked asymmetrically on the road. Sometimes they covered almost 80% of the road while leaving a very narrow passage for the cars and other vehicles that can pass which results in a massive traffic jam. This chaos and congestion due to decrease in width of the road results in delaying emergency treatment of the patient. Sometimes the congestion is so much that it covered the entire road and even main entrances of the hospital. This further causes unnecessary delay in the patient’s care. Speed and delay studies may provide us with the present traffic conditions, which may put a check on our hospital’s over-reliance on the driver’s experience and provide us with a dynamic traffic data that can be put to use to enhance the efficiency of the system. In conclusion the study told us that space for the proper parking should be allocated. One way to avoid the delay is to find the shortest path to reach the required destination. The most important thing is to educate people in general.6 

In a study scientist concluded that the most important thing is to bring awareness among the public on proper use of ambulance facility. They started a campaign to educate people about the proper use of ambulance and they found that educating people will reduce ambulance calls. By decreasing the non-serious conditions, the same ambulance will be available for serious conditions, in this way preventing unnecessary death.7

In another study, the researchers suggested that the ambulance facility should be charged to avoid unnecessary delays and to avoid calls from not so critical patients, but it should not be applied in critical cases. Provision of alternate transportation services for not so critical patients who actually do not need an ambulance service may also reduce unnecessary use of an ambulance.8, 9 It is very important to educate the public on how they can facilitate the ambulance. In general, it is important for the bikers to have their back mirror intact and whenever they hear the ambulance siren, they must slow down, being careful is really important, because some people can have a moment of panic and slam on the brakes. It is also proposed that you should move your vehicle to the left (move to the left so an ambulance could pass down). If you can't move left safely, stay where you are and let the emergency vehicle overtake you. It is also important that you avoid driving in your path and if you have to take any turn don’t take turn suddenly. These steps are important to save the lives of the patients.   

Another thing which can be done to bring awareness to the public is that we can arrange mock drills. These drills can educate people on the sensitivity of the issue. In these drills the one who gives way to ambulance can be encouraged by giving some reward. Such mock drills have been done in other countries as well. In India a mock drill was organized in which they found 135 individuals who gave way to the emergency vehicles and then subsequently were awarded to reward and were labelled as Lifesavers.10

In Pakistan, it is a dilemma where people do not observe day to day traffics rules and regulations. To make them understand about the importance of giving way to the ambulance and to save someone’s life is a difficult task. However it is not impossible. A project Raasta Dou, has been initiated by City Lights Productions in collaboration with the International Committee of the Red Cross (ICRC) to create awareness for citizens to yield right of way for emergency vehicles in jam-packed traffic (11). 

Recalling another incident the ambulance driver told that how a little girl with the split head injury lost her life because one car was not giving way and continuously making it difficult for an ambulance to pass. Although the child had a head injury but didn’t lose her consciousness. If she could be managed to get timely in the hospital her blood can be contained and her life can be saved. The main objective of the Raasta Dou project was to create awareness that a rushing ambulance means that’s someone’s life is in danger and a motorist can help save that life by giving way to the ambulance. It is an important part of the campaign to reduce the response time in order to save the life of the patient.

The key point is that put yourself in their shoes. Imagine you had a family member or beloved one in that ambulance you would want them to have the medical care as soon as possible without having any delay in the traffic. The darkness, sorrow and depths of grief that some ones' faces after losing his or her beloved one cannot be described in words. In a country like Pakistan where majority even those who are educated violate the traffic rules is so common. People even think that these rules are useless. Many youngsters are dying in road traffic accidents as they don’t follow the traffic rules and there is no strict checking. In this case the implementation of the law is the key. As rules are rules and everyone has to follow them. We should all realize our responsibility and it is also our moral obligation to do as much as we can to save lives as the world’s most precious thing is life. We should not become responsible for someone’s death. There are certain situations in medicine where a fraction of a second delay can result in somebody’s death.  Always remember that the ambulance siren signals that someone’s life is in danger and that person in the ambulance could be our father, mother or relative too. However, even if not, our concern should be no less for other people too. In the end I would like to quote this message “Give way to the ambulance. It could be the only difference between life and death. Today, it may be a stranger. Tomorrow, it could be someone yours”

REFERENCES

  1. Shaikh S, Baig LA, Polkowski M. Effectiveness of media awareness campaigns on the proportion of vehicles that give space to ambulances on roads: An observational study. Pak J Med Sci 2017 ;33(1):221.
  2. Uddin Mian N, Malik MZ, Iqbal S, Alvi MA, Memon Z, Chaudhry MA, et al. Determining the potential scalability of transport interventions for improving maternal, child, and newborn health in Pakistan. Health Research Policy and Systems. 2015 Nov 26;13(1):S57.
  3. Zia N, Shahzad H, Baqir SM, Shaukat S, Ahmad H, Robinson C et al. Ambulance use in Pakistan: an analysis of surveillance data from emergency departments in Pakistan. BMC emergency medicine. 2015 Dec 11;15(2):S9.
  4. Bhatti JA, Waseem H, Razzak JA. Availability and quality of pre-hospital care on Pakistani inter urban roads. Annals of Advances in Automotive Medicine. 2013 ;57:257.
  5. The Punjab Emergency Service act 2006 (Act IV of 2006).
  6. Singh S, Thakur P, Agarwal C. Analysis of traffic conditions in highly urbanized areas: a case of Christian Medical College, Vellore. International Journal of Application or Innovation in Engineering & Management. 2015 4:2 
  7. Ohshige K. Reduction in ambulance transports during a public awareness campaign for appropriate ambulance use. Academic Emergency Medicine. 2008;15(3):28993.
  8. Ohshige K, Kawakami C, Kubota K, Tochikubo O. A contingent valuation study of the appropriate user price for ambulance service. Academic Emergency Medicine. 2005;12(10):932-40.
  9. Anthony IV JB, Moscati R, Janicke D, Lerner EB, Seymour J, Olsson D. A multisite survey of factors contributing to medically unnecessary ambulance transports. Academic Emergency Medicine. 1996;3(11):1046-50.
  10. http://timesofindia.indiatimes.com/city/jaipur/Life-savers-awarded-for-giving-way-toambulance/articleshow/56161667.cms
  11. www.icrc.org/pk
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