Out-of-hospital Emergency System in South Africa
Craig and Minh recently did a great podcast discussing many of the above points: listen to it here on the PHARM
South Africa has a unique out-of-hospital healthcare system, it is by far one of the more developed when compared to neighbouring countries and many standards meet that of first world norms however we are by all means still a developing country and still have many steps to go. We rely on a two-tiered system of government and private medical facilities; this counts for both in and out of hospital systems. The large private organisations provide services are often comparable to first world standards whereas our government system, which is under far greater burden, excels in certain fields but also suffers from the excessive strain.
- Paramedics predominantly provide services out of hospital. Doctors and nurses working in the out-of-hospital environment are the exception.
- Paramedics are trained at different levels
- Basic Life Support (BLS): 5 week course equipping the provider in basic life sustaining measures (basic ventilation, CPR, how to recognise varying conditions and limited treatment (glucose, activated charcoal, oxygen, nitrous oxide). They are registered by the Health Professions Council of South Africa (HPCSA) in the supervised practice category and thus usually have an ILS or ALS practitioner working with them
- Intermediate Life Support (ILS): This is a 6 month course (requires BLS and practical experience prior). The provider is equipped to manage any patient requiring basic life support, in addition they can place IV lines for fluid therapy as well as administer certain medications as indicated (aspirin, beta2 stimulants, ipratroprium bromide, dextrose, and BLS medications). They are registered as independent practitioners and can treat and make decisions at their own discretion.
- Advanced Life Support (ALS): this can be done through continuation from the ILS qualification or via a program at a tertiary institution. In South Africa ALS practitioners are referred to as paramedics. All can give varying levels of Advanced Life Support medications and perform procedures however each is limited by a specific protocol. As an example an ECP is capable of RSI & fibrinolysis while the other qualifications are restricted in this field.
- Critical Care Assistant (CCA): Course method consists of +- 11months as well as practical experience (in addition to having previous ILS qualification).
- Emergency Care Technician in Emergency Medical Care (ECT) – 2 year full time at a University (this includes practical rotation during the course)
- National Diploma in Emergency Medical Care (NDip) – 3 year full time at a University (this includes practical rotation during the course)
- Bachelors in Emergency Medical Care (B.Tech/B.EMC) also known as ECP – 4 years full time at a University (this includes practical rotation during the course)
Methods of transport
- Road ambulance transport is the most common means of transport. While the standard of equipment on ambulances varies, the national department of health is making an effort to standardise minimum requirements for ambulances. In general ambulances are regular transport vehicles that are converted to accommodate a stretcher. Most ambulances have space for two patients on stretchers. In certain areas with a heavy burden of patients its is not uncommon for multiple patients to be transported simultaneously to a health care facility.
- Aeromedical transport has a presence but is often heavily burdened and reserved primarily for transportation when distances are excessive for road transport. While there are cases where ambulances travel over 800km (Springbok to Cape Town) with patients, the aeromedical services reduce the incidence of these type of cases. The aeromedical services also provide a rescue service in the form of rotor-wing retrieval. Fixed wing services are also available in certain areas.
- Fire service: they have predominantly ILS trained practitioners at each station and roaming ALS practitioners. They do not transport patients however they often provide assistance at motor vehicle collisions as well as giving temporary care in medical rooms based at the fire station. They play a major role in rescue operations throughout the country.
- Rescue services: these are a linked to the state ambulance service in the Western Cape, they provide support for motor vehicle extrication, structural collapses, wilderness rescues as well as others incidents which require specialised equipment and resources.
- Volunteer organisations provide an important resource that supplements the full time services. These include organisations such as Wilderness Search and Rescue, Sea Rescue, volunteer ambulance services as well as others.
Where the gaps hide
While we have a system that overall provides an essential service that is accessible to most, some of the biggest challenges include:
- Interprovincial variation on equipment, personnel resources and standards
- Response times to primary emergency calls can take over an hour till the 1st resources arrive on scene in rural regions
- Inter-hospital transfers to a higher level of care can take hours to be processed even in urban areas (this includes critical patients)
- Densely populated urban areas with good resources and under-resourced rural areas
- Poor socioeconomic circumstances (lack of transportation, formal employment) putting additional strain on the road ambulance services (many individuals utilise ambulance transport for primary healthcare needs – not a problem unique to the developing world)
These restraints lead to a burdened service however provides an environment which encourages practitioners to work hard, find simple cost effective solutions for everyday problems.
Links to the various scope of practice policies
ALS protocol (primarily for NDip and CCA. Bachelors degree paramedics/ECPs have the added scope of RSI medications as well as thrombolytic drugs)