Pre-Hospital Care Dilemma

The ambulance agenda in Malaysia has been postponed for too many years and I am glad that major steps have been taken to finally rectify it. But a few questions still remain unanswered. From my observations, the previous attention brought forth by the local print media on the ambulance issues did not bring much change. However each time there will be a new catch word, Improve Ambulance Service, Trauma Care, “Stay and Play” or “Scoop and Run”, Healthcare Quality, Empty Ambulance and the latest catch word is “Pre-Hospital Care”

I have learned that, one of the main reasons this issue was not able to take off, is the lack of key people in the industry. *The Emergency Physician*. The Head of Traumatology in Malaysian was a General without soldiers; there were practically no emergency physician in the country back then. The Accident and Emergency departments were headed by physicians from other discipline such as Orthopedics, Anesthetics and even Medical Officers. Today this scenario is changing; I salute all who were involved in producing our own Emergency Physicians. The “Accident and Emergency Departments” which used to be “No Mans Land” have been given a new name “Department of Emergency” (Jabatan Kecemasan) and are currently being headed dedicated emergency physicians.

Another issue involves the supporting allied health personal. These can be divided into two categories. Emergency Nurses and Medical Assistant fall under the Trained, Certified and Licensed to practice category, where as the First Aiders, First Responder and EMS Enthusiast who fall in the Trained & Certified but unlicensed category. The emergency nurses and Medical Assistants are very highly trained but unfortunately their trainings are focused on in-hospital care. When it comes to practicing out of hospital, in the fields, very few of them are able to perform as well as they do in the hospital.

For many first aiders and first responders in Malaysia who are mostly volunteers, the trainings are not a straight forward issue. Anyone who has interest in the paramedical field would have started with Basic First Aid and progressed to Advance First Aid which was the highest levels of training offered by the St Johns Ambulance and the Red Crescent Society. Thanks to Sukom 1998, the First Responder Life Support course was introduced in Malaysia by MASTEM and is on going. HUKM in 2001, collaborating with St Johns Ambulance and the Rotary Club initiated the Emergency Medical Technician – Basic course, which is the first level of three level EMT – Intermediate and EMT- Paramedic in the American Paramedic Syllabus. Some 50 odd EMS enthusiasts who were mostly volunteers, graduated from this course before it was temporarily discontinued after 2002.

There were also short term certificate courses such as, Basic Life Support, Advance Life Support, Advance Cardiac Life Support, Aquatic Rescue, and Malaysian Trauma Life Support conducted for small groups. Unfortunately there were no clear academic pathway for Pre-Hospital Care training in Malaysia, unlike in developed countries with clear academic pathways, an EMS enthusiast could earn a PHD in paramedical sciences or management. These volunteers represent the largest number of ambulance crew in Malaysia, which for the past one month have been described as “Inadequately Trained Ambulance Crew”. Are they to be blamed for their lack of knowledge?



EMS hardware, the ambulances and pre-hospital care equipments is another orphan issue that has no clear guideline. In Malaysia the definition of an ambulance starts with a marked van with beacon lights, siren system, a stretcher and first aid kits box, to purpose build emergency vehicles with paramedical ergonomic design, equipped to handle high dependency patients.

But its very sad the better ambulances are totally not affordable, ambulance builders and importer in Malaysia are taking advantage on the lack of governance in ambulance specification, standard and pricing to practically reap the industry of the little budget they have, to survive and operate. Even with tax exemption, medical equipments for EMS are extremely costly. Most organisation wanting to start an ambulance service are taken in to purchase what they don’t need at a high cost. At times, to cut cost, ambulance vendors compromise vital safety features in the ambulance vehicle by removing ABS breaking system, airbags or auxiliary batteries.

Testing and Commissioning, product familiarization training are not done, hence the dilemma of ambulances breaking down due to improper use, highlighted by our health minister. Pre-Hospital Care vendors, should be identified and regulated. Unethical vendors should be investigated and
publicized to disallow them from cheating the industry, especially now as pre-hospital care vehicles and equipments are in demand inline with the governments move to improve services.

In summary, the Malaysian Pre-Hospital Care Dilemma, needs a collective effort if we want to see any improvement in the near future. No single entity will be able to provide a complete solution. The Ministry of Health, Ministry of Education, the current pre-hospital care providers such
as the St Johns Ambulance, Malaysian Red Crescent Society, the Fire and Rescue Department, JPA3 and most importantly, the Malaysian community need to be involved. *Pre-Hospital care is not a business; it’s a service to humanity.*