NAEMSP: EMS in Low-Resource Environments

The COVID pandemic has stressed America’s emergency care systems with shortages of everything from manpower to PPE to ICU capacity. But if you want to be challenged a real bare-bones environment, try developing EMS in places like Ethiopia, Uganda, or Ghana.

Physicians Benjamin Abo and Torben Becker both have ample experience in such exotic locales, and that was the basis of their Jan. 16 presentation at the National Association of Emergency Physicians’ annual conference. Abo, DO, PMD, FAWM, is medical director for Gainesville Fire Rescue and other agencies in Florida, chair of the NAEMSP’s Wilderness EMS Committee, and well known from television appearances; Becker, MD, PhD, FAEMS, is chief of critical care medicine and director of prehospital research at the University of Florida and associate medical director for Alachua County Fire Rescue. They spoke on advancing prehospital care in low-resource environments.

There’s no cookie-cutter approach to it, said Abo, but lots of people have experienced failures and successes with different projects from which to learn. Abo’s experience includes teaching and starting an ambulance service in India; starting an ambulance service in Ethiopia; and other work in places like the Philippines, Uganda, and Guyana. Becker has worked on a variety of global health and international EMS projects, most recently in Ghana.

Question No. 1 in low-resource settings involves the finances of starting a program and making it work. There are a few approaches, Becker explained: Many smaller or educational projects are self-funded, though that can make them difficult to sustain. Department or agency funding can provide additional advantages such as a higher profile, academic components, and a greater level of collaboration. The most common approach, even in higher-resource countries, is funding through nongovernmental or nonprofit organizations. These often focus on specific causes—for example, maternal health—that can align with EMS concerns.

A potentially untapped but often effective avenue is research funding. The competition for such awards can be fierce, but private foundations as well as key federal agencies (e.g., the Department of Defense, USAID) can be overlooked sources of investment.

These projects can be limited in budget and duration and so come with an ethical imperative, Becker noted: Once the project’s over, don’t leave local populations without services they’ve become accustomed to and started using—have a plan for continuing those key elements.

The next key distinction is whether you’re creating something new or augmenting something existing. The first is typically a multiperson, multiyear effort requiring multiple levels of execution. The latter can be done on a much smaller scale—e.g., something as simple as a short-term education project—or be more complex, like transitioning a system from BLS to ALS or adding tiered response.

Either way, ensure objectives are clearly defined: What are the roles of you, those coming with you, and your local partners? Who’s responsible overall and for individual components? Do everyone’s timelines align? Develop a consensus beforehand, preferably in writing.

To craft these objectives requires a needs assessment. This can be done upon arrival or by a local partner in advance, but collaboratively is better. This is an essential step, and Becker provided an example from Haiti: You may arrive with great ideas to improve, for instance, emergency trauma care, but the public health ministry’s ambulance service mainly just provides interfacility transport. It does, however, contend with frequent oxygen shortages—knowledge that could inform a much more successful assistance project. “The needs assessment can help you really line up your goals with the goals of the service you want to support,” Becker said.

The next aspect to consider is oversight: Who can do what, and says whom? This involves both care-level tasks and bigger realms like medical direction and scope of practice, education, and progress toward overall goals. Hand-in-hand with that is credentialing: What will you need to work in the areas desired? Do you need a local medical license? Can you get hospital access? Do rounds? Treat patients?

Be clear about your intentions and always—this is Abo’s “prime directive”—keep local interests at the forefront. Local vetting can help get and keep it: Meet key stakeholders in advance and get to know each other. Explain who you are and what you want to do, and value their goals, perspectives, and input as well. Establish relationships at the local level (e.g., police, mayors, and religious and tribal leaders as well as clinicians and administrators) to build critical ownership, which contributes to sustainability.

Sustainability, Abo noted, is more than a few train-the-trainer courses—it has environmental, economic, human capital, psychosocial, and educational dimensions, and they all overlap. The best approach to it entails cultural sensitivity—knowing how things are done locally and why. Listen before you speak, and learn the language. “If you take cultural sensitivity into account,” Abo said, “you get the people involved, the politicians involved, the medical and religious leaders, and you really identify strong stakeholders so things can continue.”

John Erich is the senior editor of EMS World.