TSCNewsletter:Thailand's Emergency Services

Getting from the Crash in Time
Developing countries start to look at improvements in ambulance services as a way to cut traffic-related injuries and deaths

During his nine years as a physician treating crash victims at a rehabilitation center in Thailand, Ted Brown didn't give much thought to the kind of care his patients had received en route to the emergency room, or the traffic safety factors that might have contributed to the crashes that caused their injuries.

His perspective changed after he returned to the U.S. and took a course in injury and public health taught by UC Berkeley Traffic Safety Center Director David Ragland. Brown, who was enrolled in the interdisciplinary Masters of Public Health program, began to understand the scope of Thailand's traffic safety problems and the need to improve what is known as "pre-hospital care."

"I had never thought about injury as something you could study, the same way you study the epidemiology of a disease," Brown says. "The course was a real eye-opener."

Uniquely Vulnerable

Like many developing countries, where two-wheeled vehicles are widely used for personal transport, Thailand has a high share of vulnerable road users. Some 72 percent of crash victims were either riding on or driving motorcycles. That's more than 10 times the U.S. rate. Brown observed mothers take two, three, even four children to school on the backs of motorcycles, and the children he saw were almost always riding bareheaded. Overall, about half the riders wore helmets, he observed. "Maybe the owner of a motorcycle has a helmet, but then he says to his college friends, 'Let's go get some fast food,' and they all get on the motorcycle," Brown explained. He also observed pickup trucks often being used as "school buses," with kids riding unbelted in the back.

Inspired by Ragland's class, Brown returned to Thailand this summer, not to work as a physician, but to engage in a month-long study of emergency medical services in Bangkok and in Chiang Mai, a province in northern Thailand with a population of about 1.5 million.

Bangkok, Brown says, has a fairly sophisticated dispatch system and provides training to emergency medical services staff, but in Chiang Mai it's a different story. There, meagerly-funded private foundations have traditionally been the only providers of emergency medical services. The foundations' emergency medical workers are underpaid and overworked, typically putting in 75-hour weeks, with little formal training and, often, no access to proper emergency medical equipment. With no dispatch coordination, several different emergency medical units might rush to the same crash site after hearing of the accident over a police scanner. The first unit on the scene transports crash victims to one of the city's hospitals, which may or may not be a trauma center. The "ambulance" is usually a pickup truck with a stretcher in back. The foundations provide this service at no charge to the patient and receive no formal support from the hospitals or the public health department. They rely on donations of funds and equipment.

When Brown arrived in Chiang Mai to study how these EMS providers operate, he expected to see few bright spots. "I thought it was still this Wild West, take your chances [operation]."

Putting Together an EMS 'Blueprint'

But a new system, begun last fall by the local health department, is slowly taking hold. Through interviews with doctors, nurses and officials from the health, fire, and police departments, including the Chief of EMS planning for Thailand, Brown found what he termed a "good blueprint" for pre-hospital care in Chiang Mai.

Operating on a slim budget, the health department has developed a plan to expand emergency medical services and organize them. In addition to the independent emergency rescue foundations already in operation, the health department has asked nine area hospitals to establish their own emergency medical service units. So far, three have agreed. Under the plan, each unit, whether hospital-based or independent, is designated to cover a specific territory. A dispatch center coordinates the activities of units: first dispatching EMS workers to a location and then assigning patients to a hospital. The plan also includes training for emergency medical workers.

With a skeletal system in place for training EMS staff and coordinating the activities of EMS units, pre-hospital care in Chiang Mai seems to be headed in the right direction. However, funding is extremely limited, and adherence to the organizational structure is spotty.

"Rescue workers still want to call their own shots," he says. Units will still rush to a scene even if the crash is outside their territory. And some rescue workers still insist on transporting victims to hospitals with which they have a relationship, rather than following the direction of the dispatch center.

"They get such a low salary," Brown says. "They're kind of looking for any side salary they can make." That should be addressed by a new payment system in the works, Brown says, in which EMS providers will receive $15-$25 per patient from the national health insurance system, versus the old informal payment method direct from hospitals. One drawback to the new system is that the EMS providers won’t receive compensation for months after submitting paperwork.

There has been reluctance on the physicians' end of things, too. While some doctors have volunteered to help train rescue workers, most of them, Brown says, seem oblivious to the project. "My impression is that most physicians don't know about it. They think of pre-hospital care as being a separate entity. It's not really medicine in their eyes."

Chiang Mai's plan to improve pre-hospital care is one of many springing up in cities across Thailand, Brown says. Thailand intends to have a national system of pre-hospital care fully established by 2006. However, there is little funding from the central government, and local and provincial authorities are being left to solve their EMS problems largely independently, which could slow progress.

Thailand's experiences are similar to those of many developing countries. With high percentages of vulnerable road users and inadequate pre-hospital care systems, traffic-related injury and death are major public health concerns in these countries. Currently 90 percent of the disability adjusted life years (a useful measure of the societal cost of injuries) lost to traffic collisions occur in developing countries. On an international level, traffic collisions are ninth on the list of causes of the global burden of disease, and they are expected to rise to third by 2020.

Brown, who is now a Multiple Sclerosis Clinical Fellow at the University of Washington, hopes to raise awareness about Thailand's EMS problems and its burgeoning pre-hospital care program through upcoming journal publications. His Master's thesis in Public Health was devoted to his observations and research in Thailand. Download it here.