Nepal Ambulance Service/Stanford Win International Award
On December 1, 2018, the Nepal Ambulance Service, with assistance from Stanford Emergency Medicine International (SEMI) and other supporters, was selected from a host of projects in eight countries to receive the Quality Improvement and Patient Safety Award from British Medical Journal for “Scalable quality improvement activities that have led to measurable improvements in health outcomes.”
The effort started more than ten years ago, when a Vanderbilt University student connected with Paul Auerbach, MD to discuss the lack of pre-hospital care in Nepal. At the time, the country had ambulances, but as they lacked trained prehospital care providers, they were essentially glorified taxis.
Creating a system of pre-hospital care in Nepal presented unique challenges: helicopters are often more appropriate transport in mountainous terrain, emergency medicine is not yet formally recognized as a specialty, and the last monarch was overthrown just ten years ago.
Yet Auerbach, who had visited Nepal several times for wilderness medicine and research, recognized there was a need. “It seemed like a tremendous opportunity to help the people and the country that have given so many of us so much,” he noted. Auerbach traveled to Nepal with fellow SEMI team members S.V. Mahadevan, MD and Rebecca Walker, MD to pursue several key goals:
1) Identify local funding and leadership for the project
2) Develop partnerships with hospitals
3) Assess infrastructure and government support
4) Evaluate existing medical training
Initially, the Nepalese government was not involved as they were focused on crafting and stabilizing a system of governance.* Instead, support and oversight came from a group of local business leaders who, in partnership with SEMI, drafted a mission statement and created a board for the newly-formed Nepal Ambulance Service (NAS).
Auerbach, Mahadevan, and Walker provided strategic guidance based on experiences in other countries. SEMI members also accompanied the NAS founders on meetings with CEOs of area hospitals to establish partnerships and draft Memoranda of Understanding that included fair treatment for all patients, regardless of personal financial situation.
Crafting a Curriculum
In developing an Essential Pre-hospital Care course, SEMI was mindful of the types of presenting cases unique to Nepal, and providers' clinical skills. The course focused on basic emergency care as advanced paramedic skills were beyond the scope of the initial training program.
According to Walker, “The more we studied pre-hospital care, the more we realized that basic interventions like airway management, safe transport, hemorrhage control, providing oxygen, and automated defibrillation can have the biggest impact on outcomes, especially when applied systematically and consistently.”
Mahadevan added that insuring that the course was contextualized was also important. "We focused more on cultural and geographic differences, and presenting diseases and conditions, like snakebites and poisoning." Some curriculum choices were based on data culled from hospital records; childbirth and maternal health were identified as very important.
The First Class
In 2010, the first group of EMT students began pre-hospital care training, with instruction from SEMI physicians and providers experienced in teaching EMS internationally. The curriculum also included simulations and hospital rotations focused on obstetrics, pediatrics, surgery, orthopedics, and emergency medicine. That November, 50 students graduated with their EMT certification; many of them joined NAS.
In 2015, a 7.8 magnitude earthquake struck Nepal, killing more than 9,000 people. Casualties might have been higher, but the highest acuity victims were sent for treatment by NAS, the only internal organization to offer prehospital care with trained ambulance personnel. “In a terrible way, out of that tragedy came a lot of growth for NAS,” noted Mahadevan. “The government may not have been aware of the effort prior to the earthquake, but after, NAS was treating the sick and injured that included their own loved ones.”
Strengthening the System
Building the new system, it turned out, was just half of the equation. Of equal importance was strengthening and expanding. NAS collected data on patient care, including the frequency and patterns of different conditions. SEMI used the data in an epidemiological assessment of how to adjust and strengthen pre-hospital care training.
In December 2016, SEMI led a second training class for another 50 EMTs. The class graduated in late 2017. Auerbach, Walker and Mahadevan serve on the NAS advisory board, which also includes a diverse group of Nepalis exploring ways to grow the system. One outgrowth has come via technology.
In early 2018, SEMI team member Peter Acker, MD launched an app in Nepal designed to make prehospital care protocols available to EMTs in real time. Acker collaborated with Nepalese partners to develop scenario algorithms that would prompt EMTs on key interventions such as administering oxygen or medication, establishing an IV, and monitoring blood sugar. Due to lack of funding, it has been challenging to conduct additional EMT training programs, so the app has served to remind EMTs of protocols and procedures.
Currently, NAS operates in four major metropolitan areas, but looking ahead, SEMI aims to help NAS achieve a presence in every district in Nepal. This will require a host of services – ambulances, hospitals, rescue helicopters, etc. – to build a comprehensive network of support. In July 2018, for the first time, many of those entities came together at a conference to discuss next steps.
"The ultimate goal is to ensure that every Nepali has access to emergency pre-hospital care," notes Mahadevan.
* After the monarchy was abolished in 2008, several coalition governments cycled through until 2015 when a new constitution was announced, creating a federal democratic republic.