S. D. South1, M. Boeck2, J. E. Foianini1, M. Swaroop1 1Northwestern University,Surgery,Chicago, IL, USA 2Cornell University,General Surgery,Ithaca, NY, USA
Introduction: Ninety percent of injury-associated deaths occur in low-and middle-income countries (LMICs), most in the pre-hospital setting. We sought to describe obstacles to, and propose novel solutions for, developing a pre-hospital system in Santa Cruz de la Sierra, Bolivia, which lacks a formal emergency medical response system.
Methods: From August to December 2016, needs-based assessments were performed with local stakeholders, including policy makers, physicians, and firefighters via interviews and focus groups. Questions focused on a review of available resources, previous attempts to establish pre-hospital system elements, and current medical-legal culture.
Results: In Santa Cruz de la Sierra there are two classes of ambulances: private and public. Private ambulance services respond to unique eight-digit telephone numbers. There is no emergency number for public ambulances or for communicating with authorities during a medical emergency. Law enforcement plays no formal role in providing or coordinating emergency medical care. Ambulances are not regulated and operate with varying levels of medical equipment and training. The Bolivian system of referencia y contrareferencia (the inter-hospital patient transfer system) is the sole user of public ambulances, and does not respond to public requests for emergency services. The call center for coordinating inter-hospital transfers is housed within the operational center that responds to large-scale disasters and possesses the necessary resources to serve as a potential dispatch center. There are no governmentally recognized or accredited pre-hospital personnel training standards, resulting in a paucity of medical care during transport. Policy makers consider the absence of trained personnel as the most cumbersome barrier to legislation supporting effective pre-hospital care. There is a large pool of unemployed and underemployed physicians in the region. Within this group there is a desire to work as public volunteers in exchange for additional training and field experience, which stakeholders recognize as an untapped resource.
Conclusion: Critical pre-hospital system deficits, and the recognition of underutilized resources, prompted our group to propose a strategy to merge unmet needs with untapped reserves in Santa Cruz de la Sierra. Specifically, this translated into a service-learning program that will provide didactic courses and field training to unemployed and under-employed physicians in exchange for ambulance staffing. In response to this proposal, the department of health invited our group to write legislation to support a pre-hospital system, including mandates that establish a single medical emergency response number, regulatory services for ambulance dispatch, and policy supporting pre-hospital training programs. This study demonstrates how collaborative assessment can be used to derive novel solutions to, and drive legislative policy support for, trauma systems in LMIC’s.