Individuals at risk of anaphylaxis are often prescribed adrenaline (epinephrine) autoinjectors such as EpiPens. A recent review published in Clinical & Experimental Allergy finds that these autoinjectors, which people use to self-administer adrenaline into the muscle, can deliver high doses of adrenaline into the blood, but these levels are short-lived and may not be sufficient to save lives in cases of fatal anaphylaxis.
Anaphylaxis is an acute systemic hypersensitivity reaction to an allergen or trigger, typically associated with skin reactions, nausea/vomiting, difficulty breathing, and shock.
Investigators noted that data from animal and human studies suggest that intravenous adrenaline infusions delivered directly into the blood can prevent fatal anaphylaxis, but adrenaline autoinjectors may have little impact in such deadly cases.
“For effective management of the most severe allergic reactions, adrenaline given by continuous intravenous infusion, with appropriate fluid resuscitation, is likely to be required—how this is safely achieved in the pre-hospital setting remains to be determined,” the authors wrote. This challenge stems from the fact that fatal anaphylaxis is unpredictable and fast. Fortunately, fatality is rare, with a population incidence of 0.03–0.51 per million per year.
Findings suggest significant increase in emergency department utilisation for hypertensive disorders of pregnancy over 14 year span
Photo by Camilo Jimenez on Unsplash
Hypertensive disorders of pregnancy, the second leading cause of maternal deaths worldwide, may be sending a significantly higher number of pregnant people to the emergency department. Between 2006 and 2020, researchers found a surge in emergency visits and admissions for the condition that causes serious maternal and neonatal complications and accounts for 6.3% of all pregnancy-related deaths in the United States.
The study, which appears in JAMA Network Open, also suggests greater emergency utilisation for the disease among underrepresented racial and ethnic groups.
“Hypertensive disorders of pregnancy often develop suddenly, even in healthy women, and symptoms may appear without warning and progress rapidly,” said senior author Erica Marsh, MD, professor of obstetrics and gynaecology at the University of Michigan Medical School and chief of the division of reproductive endocrinology and infertility at U-M Health Von Voigtlander Women’s Hospital, of Michigan Medicine.
“Ideally, this risk would be detected during prenatal care and lead to early intervention. Our study indicates more people turning to the emergency department, which may reflect a higher prevalence of the condition or an increased awareness for prompt assessment and treatment.”
Hypertensive disorders of pregnancy, which could include preeclampsia, gestational hypertension, and eclampsia, are serious complications that involve elevated blood pressure.
The American College of Obstetricians and Gynecologists recommends management of severe blood pressure in pregnancy within 30 to 60 minutes of diagnosis to prevent complications such as stroke, myocardial ischaemia, seizure, placental abruption, and maternal and neonatal mortality.
Disparities in ED reliance, disease severity
Researchers analysed nationally representative data, finding a 76% increase in emergency encounters related to the condition over the 14-year span, up from 31 623 to 55 893, and nearly 1.5 times as many ED admissions – up from 17 338 to 43 563.
Concerns about costs, time constraints, misconceptions about the necessity of early care or barriers to accessing prenatal care may be possible factors for the increase, authors say.
“The disparities in reliance on emergency rooms for this disease may imply limited access to timely outpatient care or other health system barriers,” said lead author Courtney Townsel, MD, MSc, who was at Michigan Medicine at the time of the study and is now at the University of Maryland.
Black, Hispanic, and Asian or Pacific Islander groups were also more likely to both utilise emergency care and be admitted to the hospital for hypertensive disorders of pregnancy.
“The disproportionate rate of admissions among certain racial and ethnic groups suggests worse disease severity by the time people seek care,” Townsel said.
“Racial differences in emergency care utilisation for hypertensive disorders of pregnancy underscore the ongoing racial disparities in US maternal morbidity and mortality and highlight a critical need for accessible, culturally competent community-level interventions for all.”
Joshua Lupton, MD, has no memory of his own cardiac arrest in 2016. He only knows that first responders resuscitated his heart with a shock from a defibrillator, ultimately leading to his complete recovery and putting him among fewer than one in 10 people nationwide who survive cardiac arrest outside of a hospital.
He attributes his survival to the rapid defibrillation he received from first responders – but not everybody is so fortunate.
Now, as lead author on an observational study published in JAMA Network Open, he and co-authors from Oregon Health & Science University say the study suggests the position in which responders initially place the two defibrillator pads on the body may make a significant difference in returning spontaneous blood circulation after shock from a defibrillator.
Researchers used data from the Portland Cardiac Arrest Epidemiologic Registry, which comprehensively recorded the placement position of defibrillation pads from July 1, 2019, through June 30, 2023. For purposes of the study, researchers reviewed 255 cases treated by Tualatin Valley Fire & Rescue, where the two pads were placed either at the front and side or front and back.
They found placing the pads in front and back had 2.64-fold greater odds of returning spontaneous blood circulation, compared with placing the pads on the person’s front and side.
The current common knowledge among health care professionals is that pad placement – whether front and side, or front and back – is equally beneficial in cardiac arrest. The researchers cautioned that their new study is only observational and not a definitive clinical trial. Yet, given the crucial importance of reviving the heartbeat as quickly as possible, the results do suggest a benefit from placing the pads on the front and back rather than the front and side.
“The key is, you want energy that goes from one pad to the other through the heart,” said senior author Mohamud Daya, MD, professor of emergency medicine in the OHSU School of Medicine.
Placing the pads in the front and back may effectively “sandwich” the heart, raising the possibility that the electrical current will be delivered more comprehensively to the organ.
However, that’s not readily possible in many cases. For example, the patient may be overweight or positioned in such a way that they can’t be easily moved.
“It can be hard to roll people,” said Daya, who also serves as medical director for Tualatin Valley Fire & Rescue. “Emergency medical responders can often do it, but the lay public may not be able to move a person. It’s also important to deliver the electrical current as quickly as possible.”
In that respect, pad placement is only one factor among many in successfully treating cardiac arrest.
Lupton survived his cardiac arrest and went on to complete medical school at the very hospital where he spent several days recovering in the intensive care unit – Johns Hopkins University in Baltimore. The episode led him to alter the focus of his research so that he could examine ways to optimise early care for cardiac arrest patients.
The results of the new study surprised him.
“I didn’t expect to see such a big difference,” he said. “The fact that we did may light a fire in the medical community to fund some additional research to learn more.”
Research by West Virginia University has demonstrated that American Heart Association and American Stroke Association guidelines are effective at speeding up hospitals’ response times for stroke treatment and can be mastered even by members of ‘ad hoc‘ medical teams that assemble rapidly on the fly.
When a stroke patient arrives at an emergency room, specialists from across hospital departments – emergency medical services, neurologists, pharmacists, physicians, nurses, radiologists and technicians – rush to coordinate a team response. AHA and ASA guidelines put specific limits on how much time can optimally elapse between the onset of ischaemic stroke, in which blood flow to the brain is blocked, and subsequent events like arrival at the hospital and delivery of an infusion.
But experts have questioned whether the communication of those best practices helps medical teams that assemble temporarily and whose members don’t typically collaborate. In a Journal of Operations Management article, WVU associate professor Bernardo Quiroga and coauthors answer that question using data about more than 8000 patients who received stroke care at a large hospital between 2009 and 2017.
“‘Time is brain’ for stroke victims,” Quiroga explained. “Blocked blood flow to the brain kills almost two million neurons a minute, so your life or ability to walk or talk hinges on how quickly multiple professionals coordinate to restore blood flow. If you’re lucky, you’re treated within the first hour of symptom onset. Better yet, you receive a shot of Tissue Plasminogen Activator, which dissolves clots. TPA works better the earlier it’s given and usually isn’t effective after 4.5 hours.”
In 2010, the AHA and ASA launched Target: Stroke, a program that identifies stroke care best practices and standardises each step in the process. Participating hospitals reduced median treatment times from 79 minutes in 2009 to 51 minutes in 2017, but it wasn’t clear if that improvement was driven by adherence to best practices or by clinicians learning through repetition as they handled more stroke cases.
To figure that out, the researchers investigated whether repeated ‘learning by doing’ decreased the hospital’s stroke care time. Then, they evaluated whether deliberate, ‘induced’ learning and implementation of AHA/ASA best practices decreased the time further.
Learning through repetition worked. The more strokes the hospital treated, the faster it responded. For each doubling of cumulative stroke alerts, ‘door-to-needle time’ – the time to get patients from the hospital door to a TPA infusion – decreased by 10.2%.
Best practices also worked. Specifically, the researchers examined two best practices: the Helsinki Model protocol, which directs that EMS staff keep stroke patients on the stretcher for transport to the CT room rather than transferring them to ER beds; and the Rapid Administration of TPA protocol, which requires the pharmacist to be in the CT room with TPA before completion of the CT scan. Those protocols significantly reduced the hospital’s door-to-needle time beyond improvements from repetition-based learning.
According to Quiroga’s coauthor and former PhD student Brandon Lee, that matters because it demonstrates the efficacy of best practices and shows ad hoc teams learning guidelines and implementing them long-term.
However, Lee emphasised the importance of the presence of the hospital’s stroke advisory committee, which set targets, evaluated stroke teams’ performances and gave feedback.
Without similar “countermeasures to organisational forgetting,” Quiroga acknowledged that best practices aren’t always sustainable, especially on ad hoc teams.
“In the case of the best practice indicated by the Helsinki Model, compliance is difficult because the hospital needs to coordinate with multiple independent EMS systems. Some EMS providers may be reluctant to commit resources to extended time in the CT room, and EMS staff turnover may lead to forgetting,” Quiroga said.
Lee added, “Overall, because ad hoc teams are fluid, information sharing is harder. And when a group of people don’t know each other well, group learning slows. But although ad hoc teams learn more slowly, we determined they still learn.”
The research also assessed whether neurologists’ abilities to meet time goals were affected by their recent experiences treating prior stroke patients.
“As team leaders, neurologists can have an outsized influence on performance,” Quiroga said. “Because other members of the ad hoc team aren’t familiar with each other, they lean on their leader.”
But data showed stroke teams improving response times regardless of how many stroke cases the neurologist had treated individually or what the neurologist’s recent success rate was. Quiroga said that’s good news.
“The implication is that learning and sustaining best practices ensures an even quality of care for patients, regardless of individual neurologists’ experience levels.”
In the event of an accident or an attack, members of the public can save lives by performing first aid measures until the arrival of emergency medical services. But those people willing and able to serve as first responders will also need access to first aid equipment.
“There must also be certain equipment available to manage major bleeding. The question then is where this equipment should be placed, so that people who want to help can quickly access bleeding control kits,” says Carl-Oscar Jonson, adjunct senior associate professor at the Department of Biomedical and Clinical Sciences at Linköping University and head of research at the Center for Disaster Medicine and Traumatology in Linköping.
The first recommendations
Until now, there have been no guidelines for where such bleeding control kits should be located to ensure maximal utility. The current study, published in the journal Disaster Medicine and Public Health Preparedness, now contributes research-based recommendations.
“We found that the largest number of lives saved correlated with bleeding control kits being placed in two or more locations on the premises, but most importantly they shouldn’t be placed at entrances. We also concluded that the equipment must be accessible within 90 seconds’ walking distance,” says Anna-Maria Grönbäck, doctoral student at the Department of Science and Technology at Linköping University, who was involved in developing the simulation.
This means that bleeding control kits should not be placed at entrances, which is often the case with automated external defibrillators (AEDs). The reason for this is that they may be difficult to reach in a situation where many people have to be evacuated at once, such as in the case of attack or major accident. According to attack statistics, roughly 20 injured people will need first aid including a bleeding control kit each. It may be helpful to locate bleeding control kits in the same places as clearly marked AEDs, as long as not located at the entrances.
Bomb consequences simulated
The recommendations are based on conclusions reached by the research team by developing a computer-based simulation of an explosion in a large shopping centre with thousands of simultaneous visitors. In their simulation, the researchers have looked at what happens right after an explosion. The majority of the simulated people try to get out of the premises and move towards the exits. Simulated people close to the blast suffer varying degrees of injury and start bleeding.
In the simulation, some individuals help those injured by applying direct pressure to reduce bleeding, or by trying to find equipment. It is a race against time. Depending on how long it takes to get the equipment, the simulated casualty may die from blood loss.
To find the best strategy for the placement of bleeding control kits, the researchers tested four different scenarios in their simulation. They weighed together the outcomes of the many simulated courses of events for each scenario and compared them to understand which placement of equipment saved the largest number of lives.
Researchers at Karolinska Institutet have evaluated dispatching drones equipped with automated external defibrillators (AED) to patients with suspected cardiac arrest. In more than half of the cases, the drones were ahead of the ambulance by an average of three minutes. The drone-delivered defibrillator was used in a majority of the cases which proved to be cardiac arrests. The results have been published in The Lancet Digital Health.
“The use of an AED is the single most important factor in saving lives. We have been deploying drones equipped with AED since the summer of 2020 and show in this follow-up study that drones can arrive at the scene before an ambulance by several minutes. This lead time has meant that the AED could be used by people at the scene in several cases,” says Andreas Claesson, Associate Professor at the Center for Cardiac Arrest Research at the Department of Clinical Research and Education, Södersjukhuset, Karolinska Institutet, and principal investigator of the study.
Every year, around 6000 people in Sweden suffer a sudden cardiac arrest, but only a tenth of those affected survive. Although an early shock with a AED can dramatically increase the chance of survival and there are tens of thousands of AED in the community, they are not available in people’s homes where most cardiac arrests occur.
Since 2020, in an effort to cut the time to defibrillation with an AED, Karolinska Institutet, together with Region Västra Götaland, SOS Alarm and the drone operator Everdrone, have tested the possibility of dispatched an AED-carrying drone at the same time as an ambulance is alerted. The project covered an area of approximately 200 000 people in western Sweden. An initial study conducted in the summer of 2020 in Gothenburg and Kungälv showed that the idea was feasible and safe.
“This more comprehensive and follow-up study now shows in a larger material that the methodology works throughout the year, summer and winter, in daylight and darkness. Drones can be alerted, arrive, deliver AED, and people on site have time to use the AED before the ambulance arrives,” says Sofia Schierbeck, PhD student at the same department and first author of the study.
In the study, drones delivered a AED in 55 cases of suspected cardiac arrest. In 37 of these cases, the delivery took place before an ambulance, corresponding to 67%, with a median lead of 3 minutes and 14 seconds. In the 18 cases of actual cardiac arrest, the caller managed to use the AED in six cases, representing 33%. A shock was recommended by the device in two cases and in one case the patient survived.
“Our study now shows once and for all that it is possible to deliver AED with drones and that this can be done several minutes before the arrival of the ambulance in connection with acute cardiac arrest,” says Andreas Claesson. “This time saving meant that the healthcare emergency centre could instruct the person who called the ambulance to retrieve and use the AED in several cases before the ambulance arrived.”
The research was mainly funded by the Swedish Heart-Lung Foundation.
Scientists in the Netherlands have developed a special EEG cap which can diagnose stroke in the ambulance, allowing the patient to receive appropriate treatment faster. The research is published in the journal Neurology.
Every year, millions of people worldwide suffer an ischaemic stroke, the most common type of stroke, when a blood clot blocks a blood vessel of the brain, causing a part of the brain to receive no or insufficient blood. Prompt treatment is crucial to prevent permanent disability or death.
Neurologist Jonathan Coutinho, Technical Physician Wouter Potters and professor of Radiology Henk Marquering, all from Amsterdam UMC, invented the brain-wave cap, which allows an EEG to be carried out in the back of an ambulance. This shows whether there is an ischaemic stroke and whether the blocked cerebral blood vessel is large or small.
This distinction determines the treatment: in case of a small ischaemic stroke, the patient receives a blood thinner, and in case of a large ischaemic stroke, the blood clot must be removed mechanically in a specialised hospital. “When it comes to stroke, time is literally brain. The sooner we start the right treatment, the better the outcome. If the diagnosis is already clear in the ambulance, the patient can be routed directly to the right hospital, which saves valuable time,” says Coutinho.
Jonathan Coutinho said: “Our research shows that the brain-wave cap can recognise patients with large ischaemic stroke with great accuracy. This is very good news, because the cap can ultimately save lives by routing these patients directly to the right hospital.”
Between 2018 and 2022, the smart brain-wave cap was tested in twelve Dutch ambulances, with data collected from almost 400 patients. The study shows that the brain-wave cap can recognise patients with a large ischaemic stroke with great accuracy. “This study shows that the brain-wave cap performs well in an ambulance setting. For example, with the measurements of the cap, we can distinguish between a large or small ischaemic stroke,” adds Coutinho.
In order to develop the brain-wave cap into a product and bring it to the market, TrianecT, an Amsterdam UMC, spin-off company was founded in 2022. In addition, a follow-up study (AI-STROKE) is currently ongoing in which even more measurements are collected in order to develop an algorithm for improved recognition of a large ischaemic stroke in the ambulance. The Dutch Heart Foundation has also recognised the importance of this research and has made 4 million euros available for large-scale research into faster treatment of ischaemic stroke.
The Law Society of South Africa (LSSA) has urged members of the public and civic associations to formally object to proposed amendments to the Road Accident Fund Act which, if approved, will have “dire consequences” for all South African road users.
The draft amendment bill was gazetted earlier this month by the transport minister. It proposes major changes to how the fund operates and how it will pay claims.
According to the LSSA, it proposes significant changes to the existing law, including removing the rights of drivers, passengers and pedestrians to claim compensation for injuries they have suffered. Instead, it proposes that the fund will only provide significantly reduced “social benefits”.
And, says the LSSA, an innocent injured party would still be denied the common law claim against the guilty party for the balance of his or her loss.
Yet all road users contribute directly or indirectly to the fund through the fuel levy, estimated to be about R45-billion a year.
“The poor and disempowered, who make up the vast majority of claimants and who are compelled to use public transport, will bear the brunt of the consequences of these amendments. They will be forced into the public health system, as the prescribed tariffs will not cover the actual costs incurred at a private hospital. Under the present system, many receive treatment at dedicated private healthcare facilities,” the LSSA says in its statement.
Claimants will also not receive any lump sum payments and, if they are not able to produce a payslip, it was unlikely that they would receive compensation for loss of earnings.
The LSSA said those who can afford it will be compelled to take out private accident cover for medical and other expenses as well as accident benefits.
“This is likely to be very costly, as there will be no reimbursement of expenses covered from the fund. Medical aids will more than likely exclude cover or the cost thereof will have to materially increase to preserve the funds in the pool for all members.”
The LSSA said road accident victims will be uniquely discriminated against by the proposed legislation.
“Their rights to be compensated for harm suffered by the fault of another will be taken away. Persons who suffer harm from medical negligence or are injured in train or plane or boat accidents or in shopping centres, hotels, construction sites, holiday resorts, private homes or by electrocution or pollution and by a host of other causes, have unfettered rights to seek compensation from the person or entity who caused them harm.
“Innocent motor vehicle accident victims, alone, do not have this right, despite the fact that they pay premiums to the fund.”
At present, injuries sustained in a motor car accident anywhere in South Africa by any person are covered by the Fund.
The Bill now excludes injuries suffered in motor vehicle accidents in parking areas, sports fields, farm roads, driveways, private estates, game reserves or any other private road.
People who are not citizens or permanent residents are also not covered.
Persons crossing a highway are not covered. Persons injured in a hit and run are not covered. Pedestrians, drivers and cyclist who may test over the legal limit for alcohol and their dependents are not covered.
The Bill also proposes doing away with payments for pain and suffering, loss of amenities of life, disability, disfigurement or shock.
It also does away with lump sum payments for loss of earnings or support, replacing them with monthly payments, and giving the fund the right to continually reassess its liability to continue to pay.
While at present all medical and other expenses reasonably incurred that arise directly from the accident are covered, these will now be subject to a prescribed tariff. Any future medical expenses have to be pre-authorised.
The LSSA said the Bill also largely ousts the role of the courts in determining contested claims, establishing instead alternative dispute resolution procedures followed by referral to be a yet-to-be established Road Accident Fund Adjudicator.
Co-chair of the KZN Personal Injury Lawyers Association Anthony De Sousa said the biggest issues around the Bill was what was not known, such as what “social benefits” were and what the treatment tariffs would be.
“We don’t know what we are signing up for”.
“What also worries me is the people it excludes, such as pedestrians crossing highways. They don’t do that for fun. They do it because they have no choice and are trying to get to work or home.
“They are poor people and if they are knocked down, they really need help. To exclude them is just weird.”
He said while there may be a case not to cover motorists who don’t have licences, or who are over the legal alcohol limit, the Bill also proposed that their dependents are not covered, such as a child who is injured.
“The kids are not at fault, but suddenly they have no claim.”
He said the approach seemed to be: “Let’s try and save some money”.
“We pay a lot of money to the fund in terms of the levy. If you were to take that money and take up an insurance policy, you would probably get better cover and better value for money.
“I don’t think, no matter how they change it, it won’t work until they sort out the dysfunctionality, the administrative inefficiencies in the fund. You can change it to whatever system. They cannot properly administer it and run it.
“If they did their jobs properly, the fund would be saving itself a bucket load of money.”
De Sousa said the association was presently putting together its formal response to the proposals.
Collen Msibi, spokesperson for the Department of Transport said, “The bill is out for comments. The department will welcome all views and suggestions for its consideration.”
Survivors of out-of-hospital cardiac arrest (OHCA) who received initial bystander defibrillation with a nearby automated external defibrillator (AED) reported better outcomes at 12 months after arrest compared with those initially defibrillated by paramedics, according to a new study from Monash University which appears in Heart.
The retrospective study recruited adult non-traumatic OHCA with initial shockable rhythms between 2010 and 2019. Survivors at 12 months after arrest were invited to participate in structured telephone interviews. Outcomes were identified using the Glasgow Outcome Scale-Extended (GOS-E), EuroQol-5 Dimension (EQ-5D), 12-Item Short Form Health Survey and living and work status-related questions.
Of 6050 patients, 3211 (53.1%) had a pulse on hospital arrival, while 1879 (31.1%) were discharged alive. Survival rates were highest with bystander defibrillation (52.8%), followed by dispatched first responders (36.7%) and paramedics (27.9%). Of the survivors, 1802 (29.8%) survived to 12-month post-arrest; of these 1520 (84.4%) were interviewed. 1088 (71.6%) were initially shocked by paramedics, 271 (17.8%) by first responders and 161 (10.6%) by bystanders. Bystander-shocked survivors reported higher rates of living at home without care (87.5%), upper good recovery (GOS-E=8) (41.7%) and EQ-5D visual analogue scale (VAS) ≥ 80 (64.9%) compared with first responder and paramedics, respectively. After adjustment, initial bystander defibrillation was associated with higher odds of EQ-5D VAS ≥ 80 (adjusted OR (AOR) 1.56), good functional recovery (GOS-E ≥ 7) (AOR 1.53), living at home without care (AOR 1.77) and returning to work (AOR 1.72) compared with paramedic defibrillation.
In October last year, Eastern Cape Health MEC Nomakhosazana Meth announced a three-phase plan to address key challenges with the province’s emergency medical services. PHOTO: Black Star/Spotlight
By Siyabonga Kamnqa for Spotlight
Gogo Nothembile Fanti (76) says she suffers from a heart condition and every time her grandchildren call an ambulance, they are told to wait, but it never arrives. She is one of about 40 patients – mostly older persons – sleeping on the floor and in chairs at All Saints Hospital in Ngcobo in the Eastern Cape during Spotlight’s visit on 30 January. They are all waiting for an ambulance to take them to referral hospitals such as Nelson Mandela Academic Hospital and Bedford Hospital about 60 kilometres away in Mthatha. They come from various villages around Ngcobo.
Fanti, like many other patients, says they are forced to sleep there overnight as the free transport provided by the hospital leaves at the crack of dawn.
“I had to call my neighbour to [bring] me here, otherwise I could have died waiting for the ambulance. They told me that I have to be taken to Mthatha to see a specialist, but having to sleep under these conditions at my age is a terrible experience,” she says.
An old problem
The challenges with patient transport, specifically emergency medical transport in the Eastern Cape, are not new. Spotlight has previously reported on the issue here, here, and here.
In October last year, Eastern Cape Health MEC Nomakosazana Meth in a response to a written question in the provincial legislature by DA MPL Jane Cowley said that there are 84 Emergency Medical Services (EMS) bases in the Eastern Cape – 16 of those are in the Chris Hani District where All Saints Hospital is situated.
Based on the numbers Meth provided, the district also has the highest vacancy rate – 65%. This means of the 796 posts available, there were 518 vacancies for EMS staff at the time of her response in October. Overall, for the whole province, the total posts were 3 269, but 1 202 were vacant at the time.
The province needs 671 ambulances based on its population but has 447 ambulances of which only 200 were rostered, meaning they were in service at the time. In Chris Hani District, they need at least 72 ambulances but only have 62 of which just 38 were rostered and on the road to provide a service.
Staff shortages and ambulances undergoing maintenance are among the reasons why there are not enough ambulances rostered in the province. Not one of the 84 EMS bases in the province complied with the national EMS regulations for personnel numbers.
According to the DA’s provincial health spokesperson, Jane Cowley, there are 150 ambulances at any given time in for repairs. “The average turnaround time for repairs is a shocking 100 days – this is because they use the Government Fleet Management Services, who are owed in excess of R300 million by the [provincial health department] so they really don’t prioritise ambulance repairs.” She says the DA has been calling for the decentralisation of ambulance repairs and the development of public-private partnerships, which the party believes would speed up repair turnaround times dramatically.
Shouldering the burden
Providing some perspective on the impact this has on services and patient lives, a doctor says there are some districts where, at times, there is only one paramedic on duty per shift (the doctor spoke to Spotlight on condition of anonymity given the risks of reprisals from the health department). “When there is a serious call from opposite ends of the district, then you have to wait for the paramedic to deal with the one case, then come to the second. Patients in hospitals are deemed ‘less serious’ than if they are on the roadside. So, patients can wait for hours in a district hospital before being referred to a tertiary hospital. We recently had an elderly man with wet gangrene on his foot who waited in a casualty for two days. Then he died,” the doctor says.
The doctor says they often have a full casualty unit on Saturday nights. At times there may be four patients waiting for a referral. They may have gunshot wounds, been stabbed in the neck, and assaulted with a head injury. The casualty fills up as time passes and the number of patients waiting for referrals now grew by three, while the other four are still waiting in casualty. The three may be all orthopaedic patients. The doctor will ask the nurse about the patients and is told EMS said “no ambulances available”. “Maybe you have the energy to paste this update on the EMS WhatsApp group. Maybe you try to phone someone yourself to escalate this issue. Maybe someone is able to contact the provincial office and request a private ambulance to assist. But by morning, there are still six patients waiting… then one dies. The oncoming team will now have to re-discuss these patients with the new team at the referral centre. The same thing happens day after day… patients miss appointments, have to be re-discussed, get a new date due to the perseverance of the doctors, then maybe miss another date due to EMS not being available… It is extremely exhausting for all concerned,” the doctor says.
According to two paramedics (who also spoke on condition of anonymity), they struggle with inadequate equipment in EMS vehicles. This, coupled with poor road infrastructure, often puts them under enormous pressure, they say. “Cellphone network also disappears during loadshedding and this makes it impossible for patients to reach our services,” says one of the paramedics. “When we eventually arrive at the accident scene or at a sick patient, we are often met with insults from frustrated patients who said they’ve been trying to get hold of an ambulance for hours. Often, they forget about the challenges we face in trying to get to them on time,” he said.
Three-phased plan – yet to be financed
Meth in her parliamentary response last year said, “The[se] frequent transfers of patients put a heavy burden on the emergency medical services as there are no ambulances to do inter-facility transfers and therefore the emergency ambulances are used to transfer patients from hospitals to other hospitals over long distances with no ambulances left for emergency response at community level.” She said this is why there are often poor ambulance response times or no response at all.
In an attempt to address this, the provincial health department is working on a three-phased EMS plan targeting 28 hospitals across districts – among them All Saints.
This plan, however, will need funding to get off the ground.
Explaining the department’s three-phased plan, provincial health spokesperson Yonela Dekeda last week said the department plans to recruit additional personnel as funding becomes available and so did not provide timeframes. She says phase one is aimed at providing a dedicated inter-hospital transfer ambulance on a day-shift basis at the 28 priority hospitals. They aim to appoint 120 new staff members for this.
In phase two, the department wants to appoint an additional 120 personnel to make the day service a twenty-four-hour service and phase three is to extend this to other hospitals and provide them with the personnel needed.
But, says Dekeda, the department will need R27 million and they expect funding only to be made available in the 2023/24 financial year.
Working to address EMS challenges
Meanwhile, she says, the department has been working to address the many challenges facing EMS in the province and there are some improvements. “These include the response rate to priority 1 calls (life-threatening calls). Over the past three quarters – ending December 2022 – the department has been meeting its targets for priority 1 calls by responding within 30 minutes (urban areas) and 60 minutes (rural areas).” She didn’t however specify what percentage of calls met these targets.
According to her, the department has taken a developmental approach to achieve compliance with the national EMS regulations. She says over the next three years there will be continued investments in infrastructure, equipment, staffing, and vehicles to promote compliance with the ideal promulgated in the regulations.
“We have purchased an additional 50 ECG monitors at a cost of R19 million to supplement the equipment in our ambulances as required by the regulations. About R15 million has been allocated to improving the infrastructure at selected EMS stations around the province and an additional allocation is expected in the next financial year to support the strategy,” she says.
In the current financial year, she says, the Engcobo Local Service Area where All Saints Hospital is located was allocated two intermediate life support practitioners.
Dekeda says the department’s priority remains emergency patient care, so the majority of the current resources are still allocated to this.
“We are using our staff interchangeably between planned patient transport and the emergency transport service. One will understand that the planned patient transport works on weekdays (Monday to Friday) while emergency ambulance services are a 7-day operation, 24 hours a day. We are committed to increasing the number of staff on the emergency transport and then developing a separate staff complement for the planned patient transport service.”
Dekeda also says recruiting more staff is coupled with interventions to have the district hospitals offer the appropriate package of services, which will reduce the number of trips transferring patients. She says by employing dedicated teams to manage transfers of patients at the 28 priority hospitals as part of the three-phased plan, the hope is to improve the overall responsiveness of the ambulance fleet.
“We will continue with this recruitment in the next financial year and also focus on the operational staff to assist with the transfers of critical patients. All Saints is one of the district hospitals that will benefit,” she stresses.
“A total mess”
But some Eastern Cape residents remain sceptical.
Responding to the new plans, activist and community leader from Xhora Mouth, Phumzile Msaro says they are tired of empty promises. “This EMS problem is going to be with us for a long time as long as there are still unreliable people at the top. Every day we are faced with challenges as rural dwellers. Just yesterday (09 February), I called an ambulance for an elderly villager from Xhora Mouth who had fits. The assistants at the call centre lied and said the ambulance was on its way but we waited all day, only for the ambulance to arrive at 7 pm after a number of frantic calls throughout the day. The elderly person only managed to arrive and get assistance at Madwaleni Hospital at 9 pm. We keep hearing about all these so-called plans but nothing gets implemented on the ground. It’s a total mess,” he says.
Cowley echoes these sentiments. She says due to ambulance shortages and the severe shortage of EMS personnel, especially advanced life support paramedics, ambulance turnaround times are very slow, particularly in rural areas. “People can wait up to a day for an ambulance and sometimes that is too late. They have many plans but cannot seem to implement them as there is no political will to do so. It’s just a talk shop. In all my extensive oversight visits, the constant and main complaint is the lack of or slow ambulance service.”
