State of emergency/ Evolving EMS in Nigeria

The journey of EMS care in Nigeria has been a long and challenging one. Before 1995, ambulances in Nigeria were known for undertakers' services and not for carrying live patients.1 That year an oil company operating in the Niger Delta area of Nigeria kicked off a rudimentary ambulance system by engaging an ambulance for rescue and conveying of their emergency staff to the hospital. In the early 90s, Tokaro Emergency Medical Services, a division of an Israeli business group, introduced EMS in Lagos State. Due to low patronage and failed attempts to train some doctors in prehospital care, Tokaro EMS was disbanded a few years after its introduction and was subsequently bought by the newly emerging Emergency Response Services Group. In 2001 the Lagos State Government started its first attempt to implement EMS using the foreign firm. Shortly after this, in 2002, Rivers State Government started the second government owned EMS under the consultancy of Emergency Response Services Group. Subsequently, many other states began to make attempts to have EMS, including the states of Enugu, Ondo, Ogun, Delta, Akwa Ebom and the Federal Capital Territory. Other small private EMS agencies also started to emerge. Red cross rescue workers carry an unidentified body into a waiting ambulance after removing it from the rubble of collapsed building in Lagos, Nigeria. AP Photo/George Osodi EMS in Nigeria Today The current status of EMS in Nigeria reflects many attempts by both state governments and private organizations, all of which lacked EMTs, paramedics or any special prehospital training.2 Instead, doctors and nurses from hospital wards and consulting rooms were drafted into ambulances. Some states purchased a large fleet of ambulances, most of which lacked the necessary rescue or resuscitation equipment and were manned by roadside drivers. SPONSORED CONTENT BY MorTan ? Morgan Lens on Ocular Chemical Burns Ocular chemical burns are most often the result of accidents at home or work, although a growing number are from deliberately inflicted injuries. Automobile airbags are also increasingly cited as a source of alkali burns. Brought To You By EMS has become a political benchmark, rather than a health necessity. These politically motivated EMS organizations were launched with explosive fanfare and media coverage. To turn attention to EMS irrespective of the motive and quality is a positive step in the right direction in a society that hasn't recognized emergency medicine and emergency healthcare as crucial aspects of healthcare management.3 Apart from the absence of qualified personnel and relevant ambulance equipment, sustainability is an issue.4 Most government ambulance services started and then quickly collapsed when the government couldn't continue to inject funds into a system that generated no revenue. Health insurance in Nigeria is still rudimentary and doesn't have an adequate allowance for EMS.5 In light of this, even private attempts at EMS also met very serious challenges since costs could not be recovered from victims or their relations. There hasn't been a substantial effort to sensitize and mobilize the general public in EMS, resulting in public apathy to EMS throughout the country. A recent survey done in one of the cities with government-owned EMS showed that the majority of the public do not know the emergency number to call, what information to relay and actions they can take to sustain a patient's life while waiting for EMS to arrive.4 A victim is tended to by medics in an ambulance following a blast at a Catholic church near Nigeria's capital in Suleja. AP Photo/Dele Jones Due to the absence of Good Samaritan laws, bystanders aren't protected and worse still, as the study revealed, they receive harassment from the police whenever there is an attempt to assist victims. A bystander may lose his or her freedom if the victim eventually dies. To compound the issue, hospitals hold the bystander who takes the patient to the hospital liable for treatment costs. These challenges tend to pose limitations on the success of EMS programs in Nigeria.6 Because previous governments didn't have an interest in, or recognize the immeasurable benefits of an EMS system, programs have been starved of funds to a point of total collapse. When a government isn't interested in providing EMS, it's often at the verge of being scrapped until an interested government emerges.7 The invaluable need for effective EMS in Nigeria was brought to light when, in April 2016, six medical doctors travelling to a conference lost their lives in a bus accident. Federal Road Safety officers arrived at the accident to assist, but they weren't trained as first responders They packed the victims in a van and drove to a nearby hospital. Without training to provide adequate resuscitation and patient stabilization, more deaths occurred. 8 The victims who reached the government-owned hospital alive couldn't receive treatment because the hospital wasn't prepared for an emergency. One of the survivors stated that many of the victims wouldn't have died if emergency medical care was available.8 As a result of this incident and others, many state governments are now trying to institute EMS. One state was so eager to be identified among EMS operating states that they were set to kick off the program with only a few empty, dilapidated ambulances.9 Efforts to Improve EMS Because of the government's slow pace to initiate nationwide EMS in the country, the private sector has begun to fill the gap. Critical Rescue International (CRI) became the first formal private EMS after Tokaro Emergency Medical Services. CRI aims to adhere to international standards and ensures that their ambulance personnel are always updated at the Emergency Response Services training facilities. CRI employs the services of foreign experienced paramedics to teach Nigerians. International SOS, whose fleet primarily consists of trained and experienced doctors, initially concentrated on overseas medevac but has recently started some ambulance services in the country. Emergency Rescue and Resuscitation Services (ERRS) is the EMS division of the Emergency Response Services Group. ERRS operates primarily in the oil industry on a consultative basis, but steps are in place for services to be made available to the general public. Other EMS organizations include Flying Doctors International (who concentrate on medevac), First Assistance and others. Most of these groups provide ambulance services rather than EMS. Without any paramedics manning the ambulances, there's limited patient intervention during transportation, with focus being placed on BLS. The new emergence of paramedic schools in Nigeria will allow private EMS and ambulance services to train their staff and upgrade their services. The situation is also rapidly improving at the community, state and federal levels. Major health facilities are far away from the rural communities, the roads are bad and the population is sparse. A tailored approach to EMS seems to be the answer at this stage. A community in one of the eastern states has devised a unique system in which a two-wheeled motorcycle is used to convey victims to the nearest hospital. In Imo state, a model community EMS run by volunteers has emerged. The system is inexpensive, simple and effective. When fully evaluated, it may serve as a template for rural EMS in Nigeria. As the most populated city in West Africa, the Lagos government has recognized the need to protect the health of the teeming population and has invested more funding in their EMS than any other state in Nigeria. Lagos was the first state to introduce EMS and has continued to take the lead, with 15 ambulance points and recently acquired intensive care ambulances. There's now a fresh focus on training and retraining the rescue staff, who are largely nurses. Lagos has also established Marine Rescue, which aims at responding to the increase in instances of vehicles plunging into the lagoon. To address the public apathy in prehospital emergency care and stimulate public interest, the Lagos state government has embarked on an awareness campaign that includes free treatment for the first 24 hours of a stay, a dedicated and easy-to-remember phone number (123) and a standard communication network and call center.10 Despite the availability of programs such as International Trauma and Life Support (ITLS) and American Heart Association (AHA) programs (BLS, ACLS, PALS, etc.) in Nigeria, neither the Lagos state EMS crew nor the healthcare professionals in other state ambulance services have maintained current certification in these crucial programs. Doctors currently working in EMS have no training in ATLS or ITLS. To address this issue, formal EMT and paramedic training has begun in the country. States are now expected to send their personnel to certified professional training programs. As many states continue to implement EMS, the National Association of State EMS Directors has emerged. Most of the directors of the association are orthopedic surgeons with no prehospital training or background. For many years, there has been great pressure on the federal government for EMS in the country. In the private sector, the Emergency Response Services group has made several presentations to and held meetings with relevant officials of the federal government. With the heavy burden of trauma injury due to a high vehicle accident rate, insurgency, oil pipe explosions, floods, frequent building collapses and other incidents, the proposal for a federally funded, national EMS was initially made in 1970s. In the absence of federal funding, EMS development became stunted and states were forced to take up the initiative. In the later months of the previous administration, there was an upsurge in the interest for EMS, which led the federal government to set up a committee responsible for the development of a curriculum for the training of paramedics. In addition to this, the government has now approved two pilot institutions to start operations in line with the new curriculum. Moving EMS FORWARD Nigeria's current government came in with yet a greater zeal to realize effective and efficient EMS. In the last meeting of the National Council of Health few months ago, ambulance operation guidelines and call numbers were decided. Most importantly, a provision was made to the national budget to establish a regular source of funding for EMS operations in the country. Previously, there was no provision of emergency care in health bills and in the healthcare reforms. However, the new health bill has recognized the importance emergency care. Moving his passion for emergency care forward, Minister of Health Isaac Folorunso Adewole has given the directive that victims of trauma, gunshot wounds and accidents should be treated immediately by a health facility before asking for payment or a police report-a condition that's historically seen victims turned away from hospitals even when EMS or road safety has brought them.8 An EMS system must be available when needed, easily accessible, affordable and tailored to the society's socio-economic status. The federal Ministry of Health is working on these parameters to ensure it's a sustainable project. In 2012, in an attempt to implement EMS in Nigeria, the Federal Ministry of Health partnered with Israel to send doctors from some of the teaching hospitals in Nigeria Tel Aviv for two weeks of training. It became apparent that the two-week training period wasn't enough to produce prehospital professionals, neither was it capable of starting an EMS program in Nigeria.11 To ensure the quality of care and safety of the patients, the Federal Ministry of Health has recently directed the Emergency Response Services Group to ensure that all doctors and nurses working in the EDs of all federal health institutions be updated in resuscitation skills. This will enable the ED to smoothly and effectively take over from the prehospital professionals for continuation of care. In an effort to support the ongoing medical education of paramedics and ambulance personnel, ITLS was recently introduced into the country. The Australasian Registry of EMTs has also been opened in Nigeria especially for fast track-training programs for experienced nurses, doctors and health scientists. These are aimed at supporting existing personnel until the paramedics initiated by the federal government become available. It's comforting to know that the long-awaited Good Samaritan law is finally on the floor of the national assembly, though not captured by the recently released new Health Act of 2014.12 Conclusion It's hoped that the increase in government interest will reduce and ultimately eliminate previous practices, such as drafting nurses from the wards into the ambulance, relegating training and continued medical education, the use of untrained drivers and limited EMS funding will be a thing of the past and substandard, ineffective EMS in Nigeria will disappear. References 1. National Emergency Department Inventories. (n.d.) Emergency Medical Network. Retrieved May 3, 2017, from www.emnet-nedi.org. 2. Ogbebo W, Okeke V. (April 9, 2014). Nigeria commences paramedics technology in tertiary institutions. Leadership. Retrieved on May 3, 2017 from www.leadership.ng/blogposts/health-matters/364585/nigeria-commences-paramedics-technology-tertiary-institutions. 3. Solagberu B, Ofoegbu C, Abdur-Rahman L, et al. Pre-hospital care in Nigeria: A country without emergency medical services. Niger J Clin Pract. 2009;12(1):29-33. 4. Evaluation of emergency medical systems in 3 major Nigerian cities. (n.d.) Obala Foundation. Retrieved May 3, 2017 from www.obalafoundation.org/article_ems.html. 5. Onotai L. Nwankwo N. A review of the Nigerian health care funding system and how it compares to that of South Africa, Europe and America. Journal of Medicine and Medical Sciences. 2012;3(4):226-231. 6. Junaid A, Arthur L. Emergency medical care in developing countries: Is it worthwhile? Bulletin of the World Health Organization. 2002; 80(11):900-905. 7. Kobusingye O, Hyder A, Bishai D, et al. Emergency medical systems in low- and middle-income countries: recommendations for action. Bulletin of the World Health Organization. 2005;83(8):626-631. 8. Ojomoyela R, Ogundipe S, Obinna C. (April 26, 2016). How 6 Ekiti doctors died, survivor recounts. Vanguard News. Retrieved May 3, 2017, from www.vanguardngr.com/2016/04/ 6-ekiti-doctors-died-survivor-recounts/. 9. World bank applauds mimiko's health care system in Ondo. (March 26, 2016.) iReporterOnline. Retrieved May 3, 2017, from www.ireporteronline.com/world-bank-applauds- mimikos-health-care-system-in-ondo/. 10. Fadeyibi IO, Giwa SO, Shoga MO, et al. Ambulance services of Lagos State, Nigeria: A six-year (2001- 2006) audit. West Afr J Med. 2012;31(1):3-7. 11. Ojeme V. (February 28, 2012.) Nigeria, Israel partner on emergency medical Services. Vanguard. Retrieved May 3, 2017, from www.vanguardngr.com/2012/02/nigeria-israel-partner-on-emergency-medical-services. 12. Odufowokan D. (June 26, 2016.) House in move to protect the Good Samaritans youth. The Nation. Retrieved May 3, 2017, from