- Email: [email protected]
Emergency medical services in Zimbabwe
Resuscitation 65 (2005) 15–19
Emergency medical services in Zimbabwe Neil Thomson a,b,c a c
City of Harare Fire Brigade and Ambulance Services, Harare, Zimbabwe b London Ambulance Service NHS Trust, UK Accident and Emergency Department, Charing Cross Hospital, London, UK Received 10 January 2005; accepted 10 January 2005
Abstract Emergency medical services in Zimbabwe are of a very variable standard, and exist in many forms: • Reasonably well-developed urban emergency medical services systems mixed with very poorly resourced and under-developed rural services. • Very high patient workloads, with severely ill medical patients and a large proportion of major trauma and multiple-casualty situations (public safety is given a low priority, and public transport is poorly regulated). • Long emergency response times and patient transport distances. • Somewhat under resourced and under developed emergency departments, with large numbers of critically ill acute patients, as well as many non-emergency/chronic patients who have no other access to appropriate health care. This paper provides a description of the development of ambulance services and acute health care in Zimbabwe, and outline the current demands on the system. Particular reference is made to the City of Harare Ambulance Service, which is considered to be the most developed of the local authority services. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Emergency; Ambulance service; Welfare
1. Background
2. Health and welfare
Zimbabwe is a landlocked country in Southern Africa, bordered by South Africa, Botswana, Mozambique and Zambia. The country has an estimated population of 12.9 million, of which approximately 50% live in urban or suburban areas. Harare, the capital city, is located in the northeastern quarter of the country, and has a population of about 1.8 million. Zimbabwe is a country rich in natural and mineral resources, and much of the country’s income comes from the export of tobacco, cotton, agricultural products and gold. Another major source of income is from tourism.
The World Health Organisation estimates the life expectancy at birth at 37.9 years; the child mortality rate (probability of dying under 5 years of age, per 1000) is 111. The very high prevalence of HIV is the most likely cause of this. In 2002, UNAIDS estimated that approximately 33% of the adult population of Zimbabwe was HIV positive. In reality, the figure is likely to be much higher, especially in the urban areas. Clinicians have estimated that in the region of 70% of persons attending healthcare facilities do so with HIV-related conditions. The rate of unemployment in Zimbabwe continues to increase, and with the economy having deteriorated dramatically over the past few years, many large corporations have been forced to close and redeploy staff. Recent changes in the agricultural sector have contributed to rural-to-urban mi-
E-mail address: [email protected]. 0300-9572/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2005.01.008
16
N. Thomson / Resuscitation 65 (2005) 15–19
gration and unemployment. Inflation is currently estimated to be in the region of 600%. Total expenditure on health in 2001 was 6.2% of GDP. Healthcare in Zimbabwe, once considered to be very good, has been in a steady decline, with deteriorating facilities, increasing demand on resources and the high cost of disposable and capital equipment contributing to this. Despite national policies of ‘health for all by the year 2000’ in the 1980s (which was changed to ‘health services for all by the year 2000’ when it became clear that HIV was a major problem), health care for the general public has become substandard and unaffordable. Arguably one of the greatest problems at the moment is the high rate of staff attrition, with people leaving both the public and private sectors for other countries. They cite financial reasons and frustration with failing systems as the main reasons for emigration.
3. Pre-hospital care Until recently, there was no statutory requirement for either the state or local authorities to provide any sort of emergency medical service. This said, there are essentially four models of ambulance services in Zimbabwe: 1. 2. 3. 4.
Local authority services. Government, hospital or clinic based services. Private services operated by mines, large estates, etc. Private/for profit services.
Until relatively recently, the public perception of an ambulance service has been that of a means of getting people to hospital. Over the past 10–15 years there has been a shift in this perception in the urban areas, where there is now recognition that care starts in the pre-hospital phase. To the detriment of the development of the profession, the “means of transport” view is unfortunately shared by many health care professionals and policy makers at all levels (this is starting to change for the better, primarily because many of the more developed ambulance services are quite vocal and the public have seen increasing standards of care and levels of training). 3.1. Local authority services Legislation allows the operation of an ambulance service by a local authority, such as a city, town or rural council. Services offered by the larger local authorities and cities vary from relatively basic (i.e. similar to the Government Hospital model) to very advanced, such as the City of Harare, which offers a tiered response system with advanced life support capabilities and purpose built and well-equipped vehicles. It is safe to say that the better a service is, the more of everyone else’s work it either has, or is ethically obliged, to undertake. The City of Harare is expected to respond, by road, to incidents over 100 miles out of the city, on a weekly basis, and is
also involved in moving patients between intensive care units in the teaching hospitals. These ambulances are funded by local ratepayers, and operate on a not-for-profit basis. Many of the local authority ambulance services are part of the fire brigade. 3.2. Government hospital ambulances These are essentially a steel canopy on four wheels with a bed. They are staffed by a driver, with little or no training in ambulance aid, and patients are accompanied by a nurse, nurse-aid or student nurse, who invariably sits in the front of the vehicle on long trips. Many of the staff working for these facilities have undergone professional ambulance training, often at their own expense—they have been urging the system to change but without success. Their mandate is to move patients between one hospital or clinic and another. They are also required to attend to emergencies (such as road accidents) out of the areas served by local authority ambulances, but they invariably do not do this work, as they are not immediately available. Where the ambulance is driven by a trained member of staff, he (or she) will often not want to attend a serious incident other than in a supporting role to the local authority services, as he is aware of the shortfalls of his vehicle and equipment, and does not want to be put in a compromising position. Mission hospitals may have slightly better vehicles obtained by donation, but their equipment, skill level and operating systems are no better. The Government ambulances are funded by the taxpayer. Of startling note is that in the past few months the Government has received a fleet of ox-drawn ambulances for use in the rural areas. These, funded by a UN grant, will be staffed by an ‘attendant’ who will look after the oxen. They will mostly be used to take pregnant women to the local clinic for delivery. 3.3. Private services operated by mines/agricultural estates These are run by company owners as part of in-house occupational health care system. They are generally substandard in design and equipment, and staffed by a trained or un-trained driver, and either a nurse or clinic orderly. Because of the relative collapse of large industry and agriculture, the numbers and quality of these ambulances are falling. 3.4. Private/for profit ambulance services This is a rapidly developing area at present, with many individuals or small consortiums trying to use this as a moneymaking service. The concept is centered on the belief that anything operated by the state or local authorities is of a poor standard, and that anything offered by a private company is better. The reality is that this is not always the case. While the
N. Thomson / Resuscitation 65 (2005) 15–19
regulations to govern these operations are designed to encourage development of the state and not-for-profit services, they are also designed to regulate practices deemed unsafe and unethical. The largest and oldest private company – Medical Air Rescue Service (MARS) operates a fleet of ground vehicles in the major urban areas, and has access to fixed wing aircraft for long-distance retrievals – the standard of equipment and training is high, as is the cost. All private services are obliged to provide support for the local services in the event of a major incident and all have done so on numerous occasions.
17
of either Ambulance Technician, Emergency Medical Technician, or Paramedic, based on their training and experience under a ‘grandparenting’ arrangement. Personnel may challenge a registration examination to move from a lower level. Uptake of the registration process has in general been very good, especially amongst staff in more developed services who see the need for protection of the profession and understand that in time to come, registration is the pathway to development. At the time of writing there are in excess of 400 registered personnel in Zimbabwe, the vast majority being Ambulance Technicians. Table 1 summarises the training levels and the skills used by each level.
4. Regulation A national registration system for ambulance personnel was provided for in the revision of the Health Professions Act in 2001. Under this scheme, personnel could register with the Allied Health Practitioners Council of Zimbabwe. In the past, there was no legislation covering grades of training and protecting titles. This was used to great advantage by private services, which publicised that they employed ‘paramedics’. A three-tier system was developed, based largely upon the South African system. Subsequent legislation provides for the registration of ambulance services and training facilities, and a revision of the civil protection act will require local authorities to provide an ambulance service that conforms to these regulations. There is presently a period of grace for services to comply with these regulations, and in view of the current poor state of the economy, it is likely that this period of grace will be extended. Existing ambulance personnel who apply for registration with the Council are assigned to one of the three levels
5. Access to emergency medical services A national emergency number (‘999’) has been in operation since the 1970s. This is free from fixed telephones and in urban areas is answered either in the regional telephone exchange by untrained operators, who transfer the call through to the appropriate services (police, fire or local authority ambulance). In rural areas the call goes through to the nearest police station; the police then have the responsibility of passing the call through to other services or coordinating a response to any incident. Cellular (mobile) telephone regulations require that network operators provide a toll-free number for emergency access. In areas where there is network coverage, 112 generally works but where it is answered is network dependant. Private ambulance services have tried to link their control rooms to cellular networks, with the aim of capturing more calls than they would ordinarily receive. This has had the detrimental effect of delaying response to major accidents and incidents by
Table 1 Level
Duration of training
Key skills
Drugs
Ambulance technician
4–5 Weeks (excludes induction and driving training—these are service-specific)
Basic life support; AED’s trauma care; paediatric, obstetric and neonatal care major incidents, rescue and hazardous Materials
Oxygen Entonox; activated charcoal oral glucose gel
12 Weeks (including 5 weeks supervised clinical practice)
IV fluids, intubation and LMA’s, manual defibrillation, needle thoracostomy and needle cricothyroidotomy
Salbutamol adrenalin (severe asthma; anaphylaxis) atropine, organophosphate poisoning) aspirin, GTN, naloxone IV, glucose, IV fluids,
Approximate equivalent South Africa
Emergency medical technician
Paramedic
25–30 Weeks (50% supervised clinical practice)
Sedation to facilitate intubation, surgical airways chest drains
Tramadol, nalbuphine, etomidate midazolam, suxamethonium, diazepam, lignocaine/amiodarone
Basic ambulance crewperson/ basic ambulance attendant
United Kingdom
Ambulance emergency assistant
Ambulance technician
Critical care attendant/paramedic
Paramedic
18
N. Thomson / Resuscitation 65 (2005) 15–19
the responsible authorities, particularly in Harare, where an effective local authority ambulance service exists.
6. Dispatcher training and call prioritisation This is very variable. In places where there are very few resources, there are no dispatchers. In busier and more developed services, dispatchers are trained in-house. Brand-name systems such as Advanced Medical Priority Dispatch System (AMPDS) are too expensive to use fully in Zimbabwe, so services develop their own priorities and pre-arrival instructions (if any). This is clearly an area that needs to be developed and improved in the future.
7. Response times There are no national targets for response to emergency calls—services generally set their own. The City of Harare Ambulance Service requires that an ambulance (if available) is dispatched within 2 min of the receipt of an emergency call. Ambulances often have to travel long distances – The City of Harare has four stations covering a population of approximately 2 million people, but calls outside the City Limits are very common – it is not unusual for ambulances to respond to calls within a 100 miles radius of the city, and incidents as far as 200 miles away have been attended. The service has only an ethical obligation to respond to incidents outside its jurisdiction, and obviously the further away the incident the more serious that incident has to be to justify a response. Helicopters are almost never available for this type of response. Inappropriate use of ambulance services is a worldwide problem. There can be very few communities where demand for service is less than supply. The difference lies in what is considered to be appropriate – a person fallen out of bed and requiring an ‘assist only response’ to be picked up is common in the United Kingdom – such a call is almost unheard of in Zimbabwe, and would have to be a very special circumstance to elicit any sort of response. The law in Zimbabwe does not require an ambulance response where one is not justified.
8. Common problems facing ambulance personnel 8.1. Clinical There are a great many clinical problems that ambulance personnel in Zimbabwe have to face that would be considered extreme in any ‘developed’ country. Ambulance crews in the advanced services – such as The City of Harare and MARS, and to a lesser extent in the other local authority services – are trained and equipped and have the necessary experience to handle these specific problems. These include:
8.1.1. Distance Because of the relatively sparse population and small numbers of hospitals, crews may have long distances to travel before arriving at the scene—in many cases, the condition of certain time-critical patients will be very bad. Whilst in urban areas, ‘8-min’ response times are feasible, there is inadequate funding to allow for the number of ambulances to cover the peri-urban areas to this extent, and less so in the rural areas. Driving long distances on poorly constructed roads and with a driving public that have no respect for emergency vehicles is not easy. Pedestrians and animals and broken-down, unmarked vehicles in dark roads contribute further to a very stressful driving situation. The low number of fatal ambulance accidents in the regulated services (two in the last 16 years known to the author, and neither the fault of the crew) speaks volumes for the crews’ capabilities. Distance also comes into play once the patient is on board—crews have to be trained and confident to manage patients for long periods. 8.1.2. Severity of illness/injury There are high levels of serious trauma in Zimbabwe, the majority being the result of road accidents. There are several explanations for this: i. Vehicles fall into two categories—those that are new, overpowered and very fast, and those that are old and far from roadworthy (yet still very fast). ii. Roads are generally in a poor state, with inadequate engineered safety features such as crash barriers, pedestrian overpasses and fences to keep animals off the road. iii. Road signs and traffic lights are often vandalised, or more recently stolen and the aluminium sold off as scrap (and reportedly used to make coffin handles for the vibrant funeral industry). iv. Alcohol use is common, and although drink-driving regulations exist, they are hard to enforce (the legal limit is also higher than that in other countries—0.80, compared to 0.35 in England). Alcohol use by public transport operators has frequently been identified as the sole or major factor in major accidents, and efforts have been made to increase the penalties for this. Legislation is only as effective as the police who enforce it, and corruption within the law enforcement services has been reported frequently as a problem. v. Blunt and superficial penetrating (e.g. bottle-wounds) trauma from violent assault has always been common in Zimbabwe, but alarmingly, the severity of penetrating injury appears to be on the increase—shootings and stabbings, once rare, are now commonplace. This could be attributed to an increase in lawlessness, but is also a symptom of deteriorating socio-economic conditions, where starvation leads to a greater need to resort to crime for survival. In general, ‘medical’, ‘paediatric’ and ‘obstetric’ patients present late into the system, with severe illness and injury
N. Thomson / Resuscitation 65 (2005) 15–19
patterns—ambulances intended for use for less serious calls often are involved in the management of serious or critical patients. Suicide and attempted suicide are also very common, with organophosphate-based poisons and chloroquin tablet overdose being common. 8.1.3. Multiple casualty incidents These are very common, and crews are generally well experienced in this type of incident—public transport accidents with 20 patients occur almost daily in Harare, with 50+ patient calls happening about once every 6 weeks. There are two types of public transport in Zimbabwe—the sixteen-seater minibus (which usually carries more than 20 people) and the 76-seater bus (often loaded with more than 100 passengers.) Most of these vehicles are driven by young and inexperienced drivers lured by the prospect of a few extra dollars for a few extra passengers and extra trips during their shift.
9. Hospital services Rural, district and small urban hospitals have no dedicated accident and emergency department—patients are seen in either the wards or the outpatients clinic when they arrive, and are more often than not treated and either discharged or admitted by nursing staff. It is rare for one of these centres to have more than one doctor available around the clock, and in many instances, patients will only be seen by a doctor the following day. Seriously ill or injured patients will be discharged as soon as possible. Zimbabwean nurses are generally well trained, and have a great deal of experience in managing ill patients and making decisions, which is why they are being recruited all over the world, the United Kingdom being a choice destination for many of them. The larger provincial and central hospitals do have accident and emergency facilities, as do some of the private hospitals. As emergency medicine is not recognised as a speciality in its own right, these departments are staffed by people who are, by and large, not interested in emergency medicine, but are doing locum work, or waiting for a training post in one of the other specialties of medicine. In theory, these major hospitals have all specialties available on site at all times. In practice, the level of care is very variable, with seriously ill or injured patients being seen by an inexperienced doctor with no training in emergency medicine, and then being referred to a specialty, where
19
even the sickest of patients will be seen only by an intern. Senior staff are on call from home, but attendance is very variable. Over the past 3 years, there has been frequent industrial action in one or more key areas of the health service almost all of the time—action by any one group of nurses, junior doctors, senior doctors, laboratory staff, radiographers or cleaners effectively brings the hospital emergency department to a standstill. While hospital management often advise the media that emergencies will still be seen, in practice, ambulance services often have to take patients elsewhere, or leave them at the scene. This places a tremendous strain on ambulance crews both physically and emotionally. In Harare, both of the state-run teaching hospitals have CT scanning facilities on site. However, access to these after normal office hours is almost impossible, and during working hours patients (other than the under-fives) are expected pay cash for any imaging. This sometimes delays treatment to the extent that what might have been surgically correctable in the acute phase might be deemed inoperable in the post-imaging phase.
10. The future Despite the rather dismal picture described above, the majority of people in the ambulance services—state, local authority and private are eager to see the profession develop, with a unified sense of purpose and a desire to meet acceptable international standards. However, in a collapsing economy, this is not always easy—availability of basic resources such as fuel have to be redressed before issues of equipment and drugs and disposables can be dealt with. There has been a great deal of talk in recent years about developing emergency medicine as a speciality—however, to do this requires training and equipment and these, in turn, require funding.
Further reading [1] United Nations Core Health Indicators 2002 http://www3.who. int/whosis/country/indicators.cfm%3Fcountry=ZWE%26language= english. [2] http://www.unaids.org/nationalresponse, Zimbawe. [3] http://news.bbc.co.uk/1/hi/world/africa/3889219.stm ‘Zimbabwe Returning to Stone Age’ BBC World.
Emergency medical services in Zimbabwe Neil Thomson a,b,c a c
City of Harare Fire Brigade and Ambulance Services, Harare, Zimbabwe b London Ambulance Service NHS Trust, UK Accident and Emergency Department, Charing Cross Hospital, London, UK Received 10 January 2005; accepted 10 January 2005
Abstract Emergency medical services in Zimbabwe are of a very variable standard, and exist in many forms: • Reasonably well-developed urban emergency medical services systems mixed with very poorly resourced and under-developed rural services. • Very high patient workloads, with severely ill medical patients and a large proportion of major trauma and multiple-casualty situations (public safety is given a low priority, and public transport is poorly regulated). • Long emergency response times and patient transport distances. • Somewhat under resourced and under developed emergency departments, with large numbers of critically ill acute patients, as well as many non-emergency/chronic patients who have no other access to appropriate health care. This paper provides a description of the development of ambulance services and acute health care in Zimbabwe, and outline the current demands on the system. Particular reference is made to the City of Harare Ambulance Service, which is considered to be the most developed of the local authority services. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Emergency; Ambulance service; Welfare
1. Background
2. Health and welfare
Zimbabwe is a landlocked country in Southern Africa, bordered by South Africa, Botswana, Mozambique and Zambia. The country has an estimated population of 12.9 million, of which approximately 50% live in urban or suburban areas. Harare, the capital city, is located in the northeastern quarter of the country, and has a population of about 1.8 million. Zimbabwe is a country rich in natural and mineral resources, and much of the country’s income comes from the export of tobacco, cotton, agricultural products and gold. Another major source of income is from tourism.
The World Health Organisation estimates the life expectancy at birth at 37.9 years; the child mortality rate (probability of dying under 5 years of age, per 1000) is 111. The very high prevalence of HIV is the most likely cause of this. In 2002, UNAIDS estimated that approximately 33% of the adult population of Zimbabwe was HIV positive. In reality, the figure is likely to be much higher, especially in the urban areas. Clinicians have estimated that in the region of 70% of persons attending healthcare facilities do so with HIV-related conditions. The rate of unemployment in Zimbabwe continues to increase, and with the economy having deteriorated dramatically over the past few years, many large corporations have been forced to close and redeploy staff. Recent changes in the agricultural sector have contributed to rural-to-urban mi-
E-mail address: [email protected]. 0300-9572/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2005.01.008
16
N. Thomson / Resuscitation 65 (2005) 15–19
gration and unemployment. Inflation is currently estimated to be in the region of 600%. Total expenditure on health in 2001 was 6.2% of GDP. Healthcare in Zimbabwe, once considered to be very good, has been in a steady decline, with deteriorating facilities, increasing demand on resources and the high cost of disposable and capital equipment contributing to this. Despite national policies of ‘health for all by the year 2000’ in the 1980s (which was changed to ‘health services for all by the year 2000’ when it became clear that HIV was a major problem), health care for the general public has become substandard and unaffordable. Arguably one of the greatest problems at the moment is the high rate of staff attrition, with people leaving both the public and private sectors for other countries. They cite financial reasons and frustration with failing systems as the main reasons for emigration.
3. Pre-hospital care Until recently, there was no statutory requirement for either the state or local authorities to provide any sort of emergency medical service. This said, there are essentially four models of ambulance services in Zimbabwe: 1. 2. 3. 4.
Local authority services. Government, hospital or clinic based services. Private services operated by mines, large estates, etc. Private/for profit services.
Until relatively recently, the public perception of an ambulance service has been that of a means of getting people to hospital. Over the past 10–15 years there has been a shift in this perception in the urban areas, where there is now recognition that care starts in the pre-hospital phase. To the detriment of the development of the profession, the “means of transport” view is unfortunately shared by many health care professionals and policy makers at all levels (this is starting to change for the better, primarily because many of the more developed ambulance services are quite vocal and the public have seen increasing standards of care and levels of training). 3.1. Local authority services Legislation allows the operation of an ambulance service by a local authority, such as a city, town or rural council. Services offered by the larger local authorities and cities vary from relatively basic (i.e. similar to the Government Hospital model) to very advanced, such as the City of Harare, which offers a tiered response system with advanced life support capabilities and purpose built and well-equipped vehicles. It is safe to say that the better a service is, the more of everyone else’s work it either has, or is ethically obliged, to undertake. The City of Harare is expected to respond, by road, to incidents over 100 miles out of the city, on a weekly basis, and is
also involved in moving patients between intensive care units in the teaching hospitals. These ambulances are funded by local ratepayers, and operate on a not-for-profit basis. Many of the local authority ambulance services are part of the fire brigade. 3.2. Government hospital ambulances These are essentially a steel canopy on four wheels with a bed. They are staffed by a driver, with little or no training in ambulance aid, and patients are accompanied by a nurse, nurse-aid or student nurse, who invariably sits in the front of the vehicle on long trips. Many of the staff working for these facilities have undergone professional ambulance training, often at their own expense—they have been urging the system to change but without success. Their mandate is to move patients between one hospital or clinic and another. They are also required to attend to emergencies (such as road accidents) out of the areas served by local authority ambulances, but they invariably do not do this work, as they are not immediately available. Where the ambulance is driven by a trained member of staff, he (or she) will often not want to attend a serious incident other than in a supporting role to the local authority services, as he is aware of the shortfalls of his vehicle and equipment, and does not want to be put in a compromising position. Mission hospitals may have slightly better vehicles obtained by donation, but their equipment, skill level and operating systems are no better. The Government ambulances are funded by the taxpayer. Of startling note is that in the past few months the Government has received a fleet of ox-drawn ambulances for use in the rural areas. These, funded by a UN grant, will be staffed by an ‘attendant’ who will look after the oxen. They will mostly be used to take pregnant women to the local clinic for delivery. 3.3. Private services operated by mines/agricultural estates These are run by company owners as part of in-house occupational health care system. They are generally substandard in design and equipment, and staffed by a trained or un-trained driver, and either a nurse or clinic orderly. Because of the relative collapse of large industry and agriculture, the numbers and quality of these ambulances are falling. 3.4. Private/for profit ambulance services This is a rapidly developing area at present, with many individuals or small consortiums trying to use this as a moneymaking service. The concept is centered on the belief that anything operated by the state or local authorities is of a poor standard, and that anything offered by a private company is better. The reality is that this is not always the case. While the
N. Thomson / Resuscitation 65 (2005) 15–19
regulations to govern these operations are designed to encourage development of the state and not-for-profit services, they are also designed to regulate practices deemed unsafe and unethical. The largest and oldest private company – Medical Air Rescue Service (MARS) operates a fleet of ground vehicles in the major urban areas, and has access to fixed wing aircraft for long-distance retrievals – the standard of equipment and training is high, as is the cost. All private services are obliged to provide support for the local services in the event of a major incident and all have done so on numerous occasions.
17
of either Ambulance Technician, Emergency Medical Technician, or Paramedic, based on their training and experience under a ‘grandparenting’ arrangement. Personnel may challenge a registration examination to move from a lower level. Uptake of the registration process has in general been very good, especially amongst staff in more developed services who see the need for protection of the profession and understand that in time to come, registration is the pathway to development. At the time of writing there are in excess of 400 registered personnel in Zimbabwe, the vast majority being Ambulance Technicians. Table 1 summarises the training levels and the skills used by each level.
4. Regulation A national registration system for ambulance personnel was provided for in the revision of the Health Professions Act in 2001. Under this scheme, personnel could register with the Allied Health Practitioners Council of Zimbabwe. In the past, there was no legislation covering grades of training and protecting titles. This was used to great advantage by private services, which publicised that they employed ‘paramedics’. A three-tier system was developed, based largely upon the South African system. Subsequent legislation provides for the registration of ambulance services and training facilities, and a revision of the civil protection act will require local authorities to provide an ambulance service that conforms to these regulations. There is presently a period of grace for services to comply with these regulations, and in view of the current poor state of the economy, it is likely that this period of grace will be extended. Existing ambulance personnel who apply for registration with the Council are assigned to one of the three levels
5. Access to emergency medical services A national emergency number (‘999’) has been in operation since the 1970s. This is free from fixed telephones and in urban areas is answered either in the regional telephone exchange by untrained operators, who transfer the call through to the appropriate services (police, fire or local authority ambulance). In rural areas the call goes through to the nearest police station; the police then have the responsibility of passing the call through to other services or coordinating a response to any incident. Cellular (mobile) telephone regulations require that network operators provide a toll-free number for emergency access. In areas where there is network coverage, 112 generally works but where it is answered is network dependant. Private ambulance services have tried to link their control rooms to cellular networks, with the aim of capturing more calls than they would ordinarily receive. This has had the detrimental effect of delaying response to major accidents and incidents by
Table 1 Level
Duration of training
Key skills
Drugs
Ambulance technician
4–5 Weeks (excludes induction and driving training—these are service-specific)
Basic life support; AED’s trauma care; paediatric, obstetric and neonatal care major incidents, rescue and hazardous Materials
Oxygen Entonox; activated charcoal oral glucose gel
12 Weeks (including 5 weeks supervised clinical practice)
IV fluids, intubation and LMA’s, manual defibrillation, needle thoracostomy and needle cricothyroidotomy
Salbutamol adrenalin (severe asthma; anaphylaxis) atropine, organophosphate poisoning) aspirin, GTN, naloxone IV, glucose, IV fluids,
Approximate equivalent South Africa
Emergency medical technician
Paramedic
25–30 Weeks (50% supervised clinical practice)
Sedation to facilitate intubation, surgical airways chest drains
Tramadol, nalbuphine, etomidate midazolam, suxamethonium, diazepam, lignocaine/amiodarone
Basic ambulance crewperson/ basic ambulance attendant
United Kingdom
Ambulance emergency assistant
Ambulance technician
Critical care attendant/paramedic
Paramedic
18
N. Thomson / Resuscitation 65 (2005) 15–19
the responsible authorities, particularly in Harare, where an effective local authority ambulance service exists.
6. Dispatcher training and call prioritisation This is very variable. In places where there are very few resources, there are no dispatchers. In busier and more developed services, dispatchers are trained in-house. Brand-name systems such as Advanced Medical Priority Dispatch System (AMPDS) are too expensive to use fully in Zimbabwe, so services develop their own priorities and pre-arrival instructions (if any). This is clearly an area that needs to be developed and improved in the future.
7. Response times There are no national targets for response to emergency calls—services generally set their own. The City of Harare Ambulance Service requires that an ambulance (if available) is dispatched within 2 min of the receipt of an emergency call. Ambulances often have to travel long distances – The City of Harare has four stations covering a population of approximately 2 million people, but calls outside the City Limits are very common – it is not unusual for ambulances to respond to calls within a 100 miles radius of the city, and incidents as far as 200 miles away have been attended. The service has only an ethical obligation to respond to incidents outside its jurisdiction, and obviously the further away the incident the more serious that incident has to be to justify a response. Helicopters are almost never available for this type of response. Inappropriate use of ambulance services is a worldwide problem. There can be very few communities where demand for service is less than supply. The difference lies in what is considered to be appropriate – a person fallen out of bed and requiring an ‘assist only response’ to be picked up is common in the United Kingdom – such a call is almost unheard of in Zimbabwe, and would have to be a very special circumstance to elicit any sort of response. The law in Zimbabwe does not require an ambulance response where one is not justified.
8. Common problems facing ambulance personnel 8.1. Clinical There are a great many clinical problems that ambulance personnel in Zimbabwe have to face that would be considered extreme in any ‘developed’ country. Ambulance crews in the advanced services – such as The City of Harare and MARS, and to a lesser extent in the other local authority services – are trained and equipped and have the necessary experience to handle these specific problems. These include:
8.1.1. Distance Because of the relatively sparse population and small numbers of hospitals, crews may have long distances to travel before arriving at the scene—in many cases, the condition of certain time-critical patients will be very bad. Whilst in urban areas, ‘8-min’ response times are feasible, there is inadequate funding to allow for the number of ambulances to cover the peri-urban areas to this extent, and less so in the rural areas. Driving long distances on poorly constructed roads and with a driving public that have no respect for emergency vehicles is not easy. Pedestrians and animals and broken-down, unmarked vehicles in dark roads contribute further to a very stressful driving situation. The low number of fatal ambulance accidents in the regulated services (two in the last 16 years known to the author, and neither the fault of the crew) speaks volumes for the crews’ capabilities. Distance also comes into play once the patient is on board—crews have to be trained and confident to manage patients for long periods. 8.1.2. Severity of illness/injury There are high levels of serious trauma in Zimbabwe, the majority being the result of road accidents. There are several explanations for this: i. Vehicles fall into two categories—those that are new, overpowered and very fast, and those that are old and far from roadworthy (yet still very fast). ii. Roads are generally in a poor state, with inadequate engineered safety features such as crash barriers, pedestrian overpasses and fences to keep animals off the road. iii. Road signs and traffic lights are often vandalised, or more recently stolen and the aluminium sold off as scrap (and reportedly used to make coffin handles for the vibrant funeral industry). iv. Alcohol use is common, and although drink-driving regulations exist, they are hard to enforce (the legal limit is also higher than that in other countries—0.80, compared to 0.35 in England). Alcohol use by public transport operators has frequently been identified as the sole or major factor in major accidents, and efforts have been made to increase the penalties for this. Legislation is only as effective as the police who enforce it, and corruption within the law enforcement services has been reported frequently as a problem. v. Blunt and superficial penetrating (e.g. bottle-wounds) trauma from violent assault has always been common in Zimbabwe, but alarmingly, the severity of penetrating injury appears to be on the increase—shootings and stabbings, once rare, are now commonplace. This could be attributed to an increase in lawlessness, but is also a symptom of deteriorating socio-economic conditions, where starvation leads to a greater need to resort to crime for survival. In general, ‘medical’, ‘paediatric’ and ‘obstetric’ patients present late into the system, with severe illness and injury
N. Thomson / Resuscitation 65 (2005) 15–19
patterns—ambulances intended for use for less serious calls often are involved in the management of serious or critical patients. Suicide and attempted suicide are also very common, with organophosphate-based poisons and chloroquin tablet overdose being common. 8.1.3. Multiple casualty incidents These are very common, and crews are generally well experienced in this type of incident—public transport accidents with 20 patients occur almost daily in Harare, with 50+ patient calls happening about once every 6 weeks. There are two types of public transport in Zimbabwe—the sixteen-seater minibus (which usually carries more than 20 people) and the 76-seater bus (often loaded with more than 100 passengers.) Most of these vehicles are driven by young and inexperienced drivers lured by the prospect of a few extra dollars for a few extra passengers and extra trips during their shift.
9. Hospital services Rural, district and small urban hospitals have no dedicated accident and emergency department—patients are seen in either the wards or the outpatients clinic when they arrive, and are more often than not treated and either discharged or admitted by nursing staff. It is rare for one of these centres to have more than one doctor available around the clock, and in many instances, patients will only be seen by a doctor the following day. Seriously ill or injured patients will be discharged as soon as possible. Zimbabwean nurses are generally well trained, and have a great deal of experience in managing ill patients and making decisions, which is why they are being recruited all over the world, the United Kingdom being a choice destination for many of them. The larger provincial and central hospitals do have accident and emergency facilities, as do some of the private hospitals. As emergency medicine is not recognised as a speciality in its own right, these departments are staffed by people who are, by and large, not interested in emergency medicine, but are doing locum work, or waiting for a training post in one of the other specialties of medicine. In theory, these major hospitals have all specialties available on site at all times. In practice, the level of care is very variable, with seriously ill or injured patients being seen by an inexperienced doctor with no training in emergency medicine, and then being referred to a specialty, where
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even the sickest of patients will be seen only by an intern. Senior staff are on call from home, but attendance is very variable. Over the past 3 years, there has been frequent industrial action in one or more key areas of the health service almost all of the time—action by any one group of nurses, junior doctors, senior doctors, laboratory staff, radiographers or cleaners effectively brings the hospital emergency department to a standstill. While hospital management often advise the media that emergencies will still be seen, in practice, ambulance services often have to take patients elsewhere, or leave them at the scene. This places a tremendous strain on ambulance crews both physically and emotionally. In Harare, both of the state-run teaching hospitals have CT scanning facilities on site. However, access to these after normal office hours is almost impossible, and during working hours patients (other than the under-fives) are expected pay cash for any imaging. This sometimes delays treatment to the extent that what might have been surgically correctable in the acute phase might be deemed inoperable in the post-imaging phase.
10. The future Despite the rather dismal picture described above, the majority of people in the ambulance services—state, local authority and private are eager to see the profession develop, with a unified sense of purpose and a desire to meet acceptable international standards. However, in a collapsing economy, this is not always easy—availability of basic resources such as fuel have to be redressed before issues of equipment and drugs and disposables can be dealt with. There has been a great deal of talk in recent years about developing emergency medicine as a speciality—however, to do this requires training and equipment and these, in turn, require funding.
Further reading [1] United Nations Core Health Indicators 2002 http://www3.who. int/whosis/country/indicators.cfm%3Fcountry=ZWE%26language= english. [2] http://www.unaids.org/nationalresponse, Zimbawe. [3] http://news.bbc.co.uk/1/hi/world/africa/3889219.stm ‘Zimbabwe Returning to Stone Age’ BBC World.