EMS Development in Low- and MiddleIncome Countries: Considerations for Improving Education Internationally

By Mel Ebeling, Ellen Schenk, PhD, MPH, and Nee-Kofi Mould-Millman, MD, PhD, MSCS, on behalf of the SAEM Global Emergency Medicine Academy

In the United States, a call to 911 for a medical emergency normally results in an ambulance promptly arriving at the scene. This ambulance is usually stocked with equipment for a variety of chief complaints and, perhaps most importantly, staffed with at least one trained emergency medical technician (EMT) or paramedic with the skills to stabilize the patient. In several areas of the country, a fire truck and/or police officer, depending on the nature of the call, may also have been dispatched and available at the scene to provide additional support to the emergency response.

While the emergency medical services (EMS) systems across the U.S. have their own challenges and inadequacies, reports consistently indicate that many EMS systems in low- and middle-income countries (LMICs) are underdeveloped to adequately respond to out-of-hospital medical emergencies.

Implementing basic EMS is a highly cost-effective health system intervention capable of averting over 50% of mortality in LMICs. Personnel constitute a critical backbone of any EMS system; thus, training EMS personnel in basic and life-saving medical interventions is a productive approach to strengthening frontline care and bolstering fragile health systems, according to experts

There are several analyses on the state of EMS systems in LMICs that address the critical need for formal, standardized education of EMS personnel. Lack of skilled personnel has specifically been documented as a barrier to out-ofhospital emergency care in 61% of studies included in a review of prehospital care in LMICs. In Nepal, there was no formal education for EMS personnel until a partnership between the new Nepal Ambulance Service and a U.S. university enabled the provision of EMT training, graduating the first class in 2010. Armenia relies on on-the-job training with no standardized education for EMS personnel. Similarly, no formal system exists to train EMTs in Sri Lanka. In LMICs where formal EMS training programs exist, like India, lack of governmental regulation has resulted in programs with differing academic standards.

The EMS and broader health care system configuration should influence the breadth and depth of education required of its providers. In high-income countries, the Anglo-American model and the Franco-German model are the two predominant EMS system models. The former favors a “load and go” approach, emphasizing the need for immediate transport of the patient to a higher level of care, usually emergency departments. The latter champions a “stay and play” strategy, focusing on bringing the higher level of care often through specialisttrained physicians to the patient at the scene. There is no evidence to suggest superiority of one model over the continued on Page 32 other. Conceptually, though, formal standardized EMS curricula should be tailored to the local health care system, while considering a multitude of factors: desired scope of practice of EMS personnel, regulatory environment, and the local burden of disease.

Cost is another significant factor that must be considered when trying to advance EMS personnel education in LMICs. While existing courses, like Advanced Cardiovascular Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Prehospital Trauma Life Support (PHTLS) could be adopted to readily provide EMS education in LMICs, such courses are often too costly to be implemented or scaled as-is. More cost-effective and locally appropriate training alternatives have been developed to help communicate the same concepts while considering local cultural context and factors. For example, the TEAM course has been well received in Haiti in place of ATLS, which can require an abundance of resources. Additionally, the STEPS course for trauma care has been offered in Egypt as a viable alternative to ATLS, albeit for physician training rather than EMS personnel. Importantly, this course recognized cultural concerns regarding the use of human cadavers, and instead implemented a veterinary cadaver lab. Other resources being actively used to aid the development of EMS curricula and provider training include Free Open-Access Medicine (FOAMed) and low-cost simulations.

Ultimately, instituting formal education for EMS providers is a universal and continual necessity to achieve effective EMS systems globally. Strengthening EMS education in different parts of the world, though, must consider the unique needs, population, health system configuration, and resources of that particular country or locale. No one country’s standards are entirely sufficient, nor appropriate, for another’s. What works well in one country may not meet the health system and population needs in another. Thus, two tenets hold true: first, that formal education of EMS personnel is important to advancing EMS systems globally, and second, that EMS education must be locally and contextually appropriate to help develop knowledgeable and skillful cadres of EMS professionals whom citizens can rely on in times of need.

Mel Ebeling is a secondyear medical student at the University of Alabama at Birmingham Heersink School of Medicine and an EMT/ HAZMAT Specialist in the fire service. Mebeling@uab.edu

Dr. Schenk is currently a second-year medical student at Dartmouth’s Geisel School of Medicine. Her background is in global emergency care system strengthening, and she holds a PhD in International Health Systems from Johns Hopkins and a Master’s Public Health in global health from Emory University. Ellen.Schenk.MED@dartmouth.edu

Dr. Mould-Millman is an emergency medicine physician-investigator with expertise in global health, trauma, and prehospital care. He is an associate professor of emergency medicine at the University of Colorado Denver and serves as principal investigator of the C3 Global Trauma Research Network. Nee-Kofi.Mould-Millman@cuanschutz.edu