A man,39, was walking through a construction site when a nearby truck hit a large iron grating, knocking it on top of him. When paramedics arrived, the victim had no pulse and was not breathing, but he still had a chance at life. A paramedic had positioned himself between the iron bars to perform CPR. Fitzpatrick joined his colleague and tried to secure the man’s airway, but his mouth was full of blood and debris. Using a suction device to clear the mouth, Fitzpatrick tried to give him some air. With the help of a third paramedic, he then put a ventilation mask on the patient while his colleague operated the pump.
Meanwhile, other paramedics have brought an ultra-thin rigid stretcher known as a spinal board and carefully slid it under the patient. Once the patient was on the board, the grid was lifted from on top of him. The patient’s chest was still not moving, so Fitzpatrick inserted an endotracheal tube in his throat to help him breathe.
At the same time, the ambulance helicopter arrived with a doctor and an active compression device for CPR on board. The doctor managed to release air trapped in the patient’s lungs while Fitzpatrick, attempted to restart the heart, injected him with saline, adrenaline, and atropine. The patient did not respond, and the doctor pronounced him dead on the scene.
Fitzpatrick was unhappy that the man died, and not about the team’s efforts. “I think this guy was probably beyond our help, but with all the resources that were available I think he was given every chance.”
Cairo, Egypt: At 3:30am, November 23, 2008, night watchman Mansour Ali, 53, heard screams coming from across the street. Running to help, he found a man bleeding from a stabbed wound with his left leg twisted in an awkward position, which indicated his leg was broken. Ali rushed to the closest building and asked one of the residents to call an ambulance. After 30 minutes, the ambulance arrived at the Beirut Street address from the public Heliopolis Hospital, only three kilometers away.
The paramedics placed the wheel, collapsible stretcher two meters away from the injured man. First, they tried to move the patient to the stretcher by picking him up by his hands and legs. The man screamed from the pain in his broken limb, and the startled paramedics drop him on the ground. Ali then suggests they bring the trolley closer to the patient. The paramedics went back to the ambulance and brought a spinal board. Finally, the patient was transferred to the vehicle, and the ambulance departed to the hospital. Two days later, Ali received a call from the injured man, a plumber named Tamer, thanking him for saving his life.
Compare the performance of the Egyptian paramedics to the British paramedics, and it is not hard to conclude that Tamer’s life was saved in spite of, not because of the ambulance crews on the scene. The nation’s ambulance service is notorious for being late and inefficient. The Ministry of Health wanted to change that, and as of September 2008, Ambulance Egypt has been getting an overhaul.
In Dangerous Time, there is a real need for efficient and effective emergency response services in this country. An Information and Decision Support Center (IDSC) study reported that in 2006, Egypt had one of the highest death rates in car accidents in the world, with 156.3 deaths for every 100,000 vehicles. To compare, Switzerland had 8.7 deaths and the US 18.9 deaths. Egypt even beat India, which had 125.7 deaths per 100,000 vehicles. In 2007, 6,700 people died in car crashes in Egypt and more than 30,000 were injured.
According to the World Health Organization (WHO), cardiac problems are an even greater cause of sudden death. In 2004, 7.2 million people worldwide died of heart attacks and strokes. In 2002, nearly 392,000 Egyptians died from heart attacks and strokes and more than 400,000 Egyptians lost their lives in accidents and suicides. While more current data is available, WHO officials refused to release it, saying that the Ministry of Health had to release it first. As of press time, the Ministry of Health had not responded to a request for information.
Whether dealing with a car accident, heart attack or any type of emergency case, the rapid response and medical training of the ambulance crew helped to reduce fatalities radically. As part of the emergency response upgrade, modern, bright orange ambulances have been brought into service and dispatched in many areas across Cairo and the adjacent highways. The ambulance crews had replaced their jeans with a professional-looking green uniform. The new uniforms and barely dry orange paint, however, are just whitewash on the ambulance service’s failure to do what people expect: save lives.All New and Improved
All New and Improved
The Ministry of Health’s Emergency Care Unit (ECU) oversees ambulance services and the intensive care units in all of the nation’s hospitals, including public, private and teaching hospitals. The man overseeing the quality of the nation’s ambulances and their crews is Dr. Khaled ElKhatib, a 40-year-old cardiologist who joined the ECU three years ago as the evaluation and monitoring officer. ElKhatib stated that the overhaul of the ambulance service in Egypt started two years ago, with a budget of LE 2.5 billion of taxpayers’ money. The Ministry of Health bought 1,213 brand-new ambulances. Starting in September 2008, 200 of them had been put on the roads, with the remaining 1,013 to be deployed over the coming months.
“After the upgrade, we managed to achieve a response time of eight minutes. This could be achieved only using the new sophisticated ambulances,” ElKhatib explained. “I can tell you, some university professors can’t even operate some of the machines onboard those vehicles.”
Each new emergency vehicle is equipped with state-of-the-art lifesaving equipment, for a total vehicle cost of LE 500,000. ElKhatib stated that the ECU will soon receive six high-speed boats to serve areas in Luxor city and Qena governorate where the Nile is an easier way to transfer patients. There are also rumors that two ambulance helicopters will join Ambulance Egypt. The airlift service is currently only available for the army and senior government officials.
The upgrade plan does not include only hardware; new paramedics are needed to operate the new vehicles and equipment. The Ministry of Health has been hiring new staff with non-medical backgrounds and giving them the necessary medical training. The new paramedics are paid LE 1,200 monthly, more than double the old paramedics’ salary of about LE 500. The veteran paramedics, however, report that they have not received a raise as part of the overhaul.
“You can’t imagine the difference between the new paramedics and the old ones. The new ones are at a totally different level,” ElKhatib notes proudly. “They are university graduates. They know some English, and they respond to the training very well.” “A Black Comedy”
Dr. Yussef Tarek* is an Emergency Department specialist in a hospital in Sixth of October City. (*Names have been changed at the person’s request.) He recalls how on November 21, 2008, one of the new ambulances brought in a patient who had fallen from the second floor of a building. “While the patient was being brought out of the car, the paramedic accidently flipped the stretcher and dumped the patient on the floor. The patient screamed really loud, then went unconscious. It was a scene that happens only in black comedy movies,” Tarek stated cynically.
Tarek claimed that the patient was not properly strapped to the stretcher. The man was diagnosed with a brain hemorrhage, but it was not clear whether that was a result of his original accident or the paramedic’s actions. When Tarek confronted the paramedic, he told the doctor that it was only his second week of work.
On November 20, 2008, et followed the sirens of an orange ambulance in Heliopolis, arriving at a crowd of people surrounding a child,8, who had apparently been hit by a tram. Bleeding and crying on the pavement, the child was still conscious, though his right leg appeared partially severed at his knee.
The paramedics brought the spinal board and put the child on it without strapping him on. Scared of being put into the ambulance; the child tried to throw himself off the stretcher. Contrary to all regulations, none of the paramedics were wearing goggles to protect themselves from blood, and none of them was wearing proper medical gloves, only plastic grocery bags over their hands.
After leaving the accident site, the driver did not go to Egyptair Hospital, which was less than two kilometers away from the accident. Instead, he drove to the public Heliopolis Hospital — at least seven kilometers away with three sets of traffic lights in between. In the Emergency Department, the child was moved to surgery and his condition was stabilized.
Hani Moro, the head of the Emergency Department in Dar El Fouad private hospital and one of the nation’s leading specialists in emergency care, believed the paramedics’ response was poor. “The child should have been given neck support before moving him to the car, as he might have had a concussion,” he noted. “The bleeding should have been stopped inside the car.”
In October 2008, 45-year-old engineer Kamal Magdy* called an ambulance for his mother, who was vomiting blood. His mother lives in Manial, quite close to one of Egypt’s biggest public hospitals, Kasr El-Ainy. Magdy said that the ambulance arrived in 15 minutes and moved her quickly to the hospital, but the paramedics didn’t do anything to try to stop the elderly woman’s vomiting on the way to the hospital. “The ambulance in Egypt is not an ambulance like in Germany,” he noted. “It is a taxi with a stretcher and permission to use a siren.”
Greater Cairo is home to 14 to 17 million people at any given time, and according to 2006 figures from the Central Agency for Public Mobilization and Statistics (CAPMAS), some two million cars are cruising the streets of the capital city. Considering the congestion and the utter disregard for traffic regulations that Cairo drivers are notorious for, an ambulance driver’s job is far from easy. However, in Magdy’s case, with a major hospital just two blocks away, 15 minutes is a long time for a bleeding patient to wait for care.
When this reporter described the ambulance calls he had witnessed to ElKhatib, he looked surprised but offered no explanation.Cursory Training
A number of patients and physicians are skeptical of ElKhatib’s claim about the excellent abilities of the new paramedics. The truth is, Egypt’s paramedics undergo a very short training period compared to those in Europe or the United States. According to ElKhatib, the training course, which includes instruction on advanced life support measures and the use of the new ambulance equipment, is only four weeks long. It does not include clinical workshops inside hospitals. Egypt’s paramedics cannot perform complicated medical procedures, nor can they operate all the equipment in the new vehicle.
Ezzat Gomaa* ,44, is a paramedic who has been working the highways for more than 20 years. While demonstrating equipment in the new ambulance, he tried unsuccessfully to operate the new ventilator for nearly one minute. The device talks the user through the procedure with recorded spoken instructions in Arabic and repeatedly said that the oxygen cylinder must first be opened before the ventilator can be turned on. Gomaa never did open the canister, looking confused and finally turning to demonstrate another machine.
All the new ambulances are equipped with a portable defibrillator, a device used to restart a stopped heart with a powerful jolt of electricity. According to the Handbook of Cardiovascular Emergencies by Dr. James W. Hoekstra, defibrillation is the most critical action for treating cardiac arrest. A patient’s chances of surviving a heart attack decrease 7-10% for each minute he goes without defibrillation. If over 12 minutes have passed before defibrillation, the survival rate drops to 2-5%.
Mohamed Sameer,* a paramedic with an ambulance in Nasr City, claimed that the Ministry of Health rules make it impossible for him to use the device. “The defibrillator’s electrodes that should be attached to the patient’s chest cost LE 300 and can be used only once. At the Ministry of Health, they told us if we misuse them, we’ll pay the LE 300,” Sameer explained. “I can’t afford this amount of money. So, how can I use them?”
Ten different ambulance crews all confirmed the strict rules on using defibrillators. One paramedic said that he can only use it if he calls the ambulance central room and gets permission first. During those minutes wasted trying to obtain permission, the victim’s chances of survival are decreasing significantly.
ElKhatib stated that the Ministry of Health has not issued any such rule and denied that paramedics have to pay for “misused” electrodes. British paramedics, according to Fitzpatrick , receive extensive training. They can perform certain surgical procedures such as intubation (inserting a breathing tube into the throat), and are trained in advanced life support measures, such as defibrillation. They know how to administer intravenous fluids and medication.
In Egypt, paramedics are legally forbidden from giving any medicine to patients. For this reason, the new ambulances carry very few drugs, and they can only be used if a doctor is on board.
In the UK, paramedics are categorized into four levels, Fitzpatrick explained. Entry-level paramedics must first pass a theory course and a three-week driving course, then they go through four weeks placement on an ambulance crew under supervision, followed by six weeks of clinical management using scenario-based workshops to put learning into practice, and then another 150 hours under supervision in an ambulance. That’s nearly 20 weeks of training for the first level. The training requirements for a fourth-level paramedic are distributed over three years.
Dr. Mohamed Soultan, head of the ECU, felt that comparing Egyptian paramedics to their British counterparts is unrealistic. “Everything needs time. Do you think that the paramedics in Egypt are like the ones in London? Or a doctor in Egypt is like his peer in England? They are not the same, of course,” Soultan stated. The real reason our paramedics are so rushed through training is explained by a member of the Health Ministry committee that makes the list of equipment and drugs for new ambulances. He agreed to be interviewed on condition of anonymity because he is not supposed to reveal committee proceedings. “We were shocked [when we received the new ambulances] that we didn’t have enough paramedics, we didn’t know that. The new vehicles were coming, and we needed crews for those vehicles,” he explained. “The other option was to delay the [new] ambulances being put into service, but you can’t imagine the condition of the old vehicles.”
In Egypt, when a person needs an ambulance, they dial 123, the short code designated for emergency medical services. The call is forwarded to an operator at Xceed Call Center, a private company in Smart Village, on the outskirts of the city on the Cairo-Alexandria Desert Road. The Xceed operator logs the details: the caller’s name, address, phone number and a description of the accident. Sometimes, the operator will call the person back to make sure the report is not a hoax.
The Xceed operator then forwards the call to the ambulance dispatch center responsible for determining the caller’s location. The dispatcher asks the caller the same questions again, then consults an employee familiar with the area to determine which ambulance is nearest to the location. The dispatcher then contacts that vehicle via radio, gives the driver the details of the call and sends him to the scene. This cycle — from the initial call to actual dispatching the vehicle — takes three to four minutes, according to ElKhatib. In the United Kingdom, for example, the process takes only 90 seconds. Clearly, Egypt’s ‘enhanced’ ambulance response is still very slow. Add to those four minutes at least eight minutes for the vehicle to reach the accident, as ElKhatib claimed, and the shortest medical response time in an emergency is at least 12 minutes.
In the UK, 95% of the urgent cases find an ambulance at the door eight minutes after a caller dials 999. This is, in part, because there is no time wasted routing the call through an intermediary. London ambulances use a computer-aided automatic dispatch system. A 999 call goes directly to a dispatch center, which has two people handling each call. The operator receives the call, enters the details into a computer and sends a detailed request directly to the dispatcher’s computer. Using location-based technology, the position of all the ambulances in service is continuously monitored, and the computer software determines which vehicle is closest to the call. Directions to the accident site appear on an electronic map in the ambulance, not passed verbally over the radio, making it virtually impossible for drivers to get lost.
Ahmed Hani, 41, is a newly trained ambulance driver. Hani confesses that he once got lost on the way to the hospital and took a wrong turn. He found himself on Sixth of October Bridge and ended up taking 80 minutes to reach the hospital. He thanks God that his patient didn’t die. It is not really Hani’s mistake though. In many countries, ambulances, fire trucks, law enforcement vehicles and even taxis have for several years been using location-based computer system such as GPS to show addresses and the shortest route to reach them. For emergency responders, it is a critical feature.
“The use of automatic dispatching systems and electronic maps make sure that your ambulance will not end up in the middle of a field,” explains Jim Potter, the vice president of marketing for Zoll Data System, an US company that provides products and services for Emergency Medical Service (EMS) agencies and fire departments in North America. “[EMS] is a battle of geography. When a call comes from a certain location, you want an ambulance to go there as quickly as possible. The computer software will tell you which car is really the closest, so it will make it really accurate.” The Ministry of Health may have upgraded its ambulances and crews, but it hasn’t changed its traditional dispatching methods. Ambulances still use manual radio dispatching and rely on the drivers to memorize maps, ignoring all the benefits of technology.
The dispatching technology not only decreases response time, it analyzes the data it receives to help users determine the ideal number of ambulances and where they should be stationed. “Agencies that do not use EMS software tend to have more vehicles than they need,” Potter says. “It is like any computer program: If you use it, your data gets captured electronically and you go back and analyze that data. If everything is done on paper, because you have a difficult time measuring what you are doing, you can’t throw [proper] resources at the problem. It is really a matter of efficiency from a clinical and operational perspective.”
There is no shortage of paperwork in the ECU headquarters. In the administrative office, status reports are generated twice daily, morning and evening, and sheaves of papers cover the computer keyboards on the room’s six desks. One document tallies injuries from accidents broken down by route; another charts the number of available intensive-care beds with columns for each hospital. Still more reports are filed in a big blue folder labeled ‘Ambulance,’ and the office manager is preparing a file for Soultan’s signature. At 5pm, only two employees are still in the office, waiting for their boss to return. Soultan spends his day patrolling hospitals and ambulance crews, then comes back to his office to work until 8pm.
There’s plenty of data filling the filing cabinets, but the question is whether it’s actually used for anything. Egypt’s most dangerous road is the Cairo-Alexandria Agricultural Road: In 2006, 1,417 people died in traffic accidents along this poorly paved road, because it lacks safety measures such as designated pedestrian crossings or U-turn areas. But because there is no information at the Ministry of Health about the nature of the accidents on that route or any other place in Egypt, only how many accidents, ECU officials just deploy as many ambulances as possible.
On the first 43 kilometers of the road, between Shubra El-Kheima and Banha, 17 ambulances wait, almost unutilized. That’s an ambulance for every 2.5 kilometers, meaning fewer ambulances to deploy elsewhere in the country.
In a city like New York — with a population of about 8.2 million people — the automatic dispatching software may cost nearly the equivalent of LE 20 million, depending on many technical details. While Soultan has confirmed that there are still funds left in the Ambulance Egypt budget, the Ministry of Health has not yet committed to purchasing an automatic dispatch system and outfitting new vehicles with onboard computers.
“I went to London to watch a demonstration for the software,” Soultan says. “Don’t worry, it is in our renovation plan.” But when pressed about when the system would be installed, Soultan responds defensively, “Look, it is map-based software, and we don’t have those maps in Egypt. London is not like Egypt, it will take time.”
It is true that most of the nation’s cities do not have digital maps ready — only Cairo and Alexandria have them. However, these two cities have the largest populations in the country and the most complicated street systems. Should both cities be left without proper emergency response service until maps for the whole country are digitized? This may take years.
Bleeding will continue, in both lives and resources, as the Ministry of Health’s strategy for overhauling Ambulance Egypt focuses only on buying new vehicles. Spending hundreds of millions of pounds on cars, boats and even helicopters will not buy patients any time, because the protocols that manage those vehicles have proven to be flawed. “If I were a consultant, what I would suggest them to do is to take a look at what their need is: how many calls do they get, what is the nature of those calls and where those calls come from,” Potter says. “This is [their] demand for the past two years, for example. Then design a system around those calls.”
The ambulance service needs more than just new vehicles: It needs a complete system developed by experts in the field. The Ministry of Health, though, is trying to do it by itself.
Expert consulting is not a practice unknown to the government. Both the Ministry of Trade and Investment and the Ministry of Communications and Information Technology hired experts in their respective fields to evaluate their sectors and help develop plans to improve them. With money still in the budget, this is not a bad idea. Otherwise, all the Ministry of Health can offer us is an orange taxi service with sirens and pretty blue flashing lights. et