Advanced Pre-Hospital Care and Ambulance Services in Malaysia

Introduction and Definition of Pre-Hospital Care

• Presenter Profile: Lt.(PA) Nurhan Norris Ma W.C. (MAB Reg No.$8913$, DMHS, AEMTC, BSc (Hons) Emergency Med, MDRM, PhD©). The presenter serves as the ProCHEs Academic Program Chair and Lecturer for the Faculty of Health Sciences at the Higher Colleges of Technology, Sharjah, UAE.
• Definition of Pre-Hospital Care (PHC): According to the World Health Organization (WHO, $2015$), PHC is defined as the phase of care necessary to get a patient from the point of injury to the place of definitive treatment.
• The Scope of PHC Services: It is considered an extension of medical care services beyond the physical walls of the Emergency Department (ED). It encompasses a wide array of activities including:
  • Ambulance services spanning ground, air, and water transport.
  • Emergency Medical Dispatch and the provision of Pre-Arrival Instructions.
  • Specialized practices such as battlefield medicine.
  • Medicine for mass gatherings and medical standby operations.
  • Disaster relief efforts.
  • First responder initiatives and basic first aid.

Learning Outcomes and Objectives

• Core Learning Outcomes:
  • Describe the basic principles inherent in Pre-Hospital Care.
  • Describe specific patient assessments required in pre-hospital emergency settings.
  • Discuss the emergency management of patients presenting with medical problems.
  • Discuss necessary emergency investigations and subsequent actions to be taken.
• Scientific Objectives:
  • Discuss the basic concepts underpinning PHC.
  • Describe the specific architecture of the Malaysia PHC system.
  • Explain the concepts of the Emergency Medical Service (EMS) system.
  • Discuss the roles and responsibilities of the First Responder (FR).

Factors Driving the Need for Pre-Hospital Care and Ambulance Services (PHCAS)

• Population Dynamics:
  • Rapid urbanization and overall population growth.
  • The emergence of a higher income and more mobile population.
  • Expansion of roadways (more and longer routes) and the implementation of mass rapid transportation.
  • Specific "migratory" travel patterns where the workforce dweels at a significant distance from the place of work.
  • Demographic shifts including an increasingly ageing population and a broader age group within the economically productive workforce.
  • Continued industrialization and longer life expectancy.
• Medical Practice Trends:
  • Decentralization of primary care services coupled with the regionalization (centralization) of highly specialized medical services.
  • Hospital specialization in areas such as trauma, cardiac care, neurosurgery/medicine, respiratory, intensive care, child and women's health, infectious disease, transplant, and day-care services.
  • Increasing specialization in acute care management for trauma, myocardial infarction, and stroke.
  • Structural challenges such as hospital bed shortages and the trend toward shorter hospital stays.
  • Advancement of community-based treatment strategies and an increase in out-of-hospital care.
  • Growth in patient autonomy and preference for affordable, high-quality medical care.

The Continuum of Care and Historical Origins

• The Continuum of Care Flow (Sikka & Morgolis, $2005$): The process follows a specific sequence:
  1. Bystander care.
  2. Notification, dispatch, and response.
  3. Prehospital care.
  4. Transportation.
  5. Emergency care.
  6. Definitive care.
  7. Rehabilitation.
• Historical Development:
  • Ancient Documentation: PHC roots are found in the Battles of Uhud and Hunain in the Arabian Peninsula over $14$ centuries ago.
  • Key Historical Figures: Florence Nightingale ($1820$–$1910$) and Sir Robert Jones who worked on the Manchester-Liverpool canal, UK in ($1888$).
  • Modern Systems: More organized systems emerged in the US and Ireland during the ($1960s$).
  • Founders and Regional Models:
    • JF Pantridge (Ireland) is known as "The Father of PHC" for establishing the Coronary Care Ambulance Unit.
    • United Kingdom: BASIC (British Association for Immediate Care).
    • United States: EMS developed via the Department of Transportation (DOT) in the ($1960s$).
    • Germany: Notrazt model.
    • France: SAMU model.
  • Current Professional Bodies: Faculty of Pre-Hospital Care, RCS (Edinburgh), which offers the Diploma and Fellowship in Immediate Medical Care.

Models of Pre-Hospital Care Systems

According to Van Rooyen et al. ($1999$), pre-hospital systems are categorized into five types:

1. Hospital-based systems: Services directly linked to hospital facilities.
2. Jurisdiction-directed systems: Managed by specific local or regional government authorities.
3. Private systems: For-profit or commercial entities.
4. Volunteer systems: Non-profit or community-led services.
5. Complex systems: Integrated or hybrid models combining multiple approaches.

The Malaysian Pre-Hospital Care System (PHCAS)

• Universal Access: In July $2007$, the government introduced "One nation, one number," establishing the universal emergency number "$999$".
• MERS 999: Malaysia Emergency Response Services acts as the central hub.
• Response Infrastructure: There are three primary Response Centres located in Kuala Lumpur, Melaka, and Kuching.
• Medical Coordination: The Medical Emergency Coordinating Centre (MECC) oversees the dispatch and medical management.
• Core Structure Components (S-P-S-O):
  • Structure of PHCAS in Malaysia.
  • Process of care.
  • System integration.
  • Outcomes of clinical care.
• Operational Pillars: Clinical care, Transportation, and Command, Control, and Coordination.

Next Generation Emergency Services (NG999)

NG999 is a strategic integrated digital system designed to enhance resource sharing and data exchange between emergency call centers and central agencies.

• Technical Enhancements:
  • Integrated web-based digital maps and caller ID.
  • Geolocation services and Artificial Intelligence (AI).
  • Smart mobile applications for incident handling.
  • TM has introduced a new NG999 app for registered users allowing the use of text, photos, and video to enhance communication speed and quality.
• Workflow Comparison (MERS 999 vs. NG999):
  • MERS 999 Process: Caller -> $999$ RC (at TM) using Voice/Data -> MECC (at Hospital) -> Responder in Ambulance. A major drawback noted is that callers remain on the line for long durations between $999$ RC and MECC, often answering queries twice.
  • NG999 Process: Caller -> $999$ RC-MECC (Integrated Voice and Data) -> Responder in Ambulance. This is intended to be more efficient by reducing redundancies.
• Specialized Apps: Includes SaveME$999$ versions specifically for the DEAF and the BLIND.

Philosophies of Care and Stakeholders

• Operational Philosophies:
  • "Scoop and Run": The American EMS Model, focusing on rapid transport to the hospital.
  • "Stay and Play": The Franco-German Model, focusing on stabilizing the patient at the scene.
  • The Middle Ground: "Appropriate intervention at the appropriate time," aiming to bring advanced medical care to the roadside while exercising judgment on when not to intervene.
• Personnel Involved:
  • Doctors: General Physicians, Emergency Physicians (EPs), Surgeons, and Anesthetists.
  • Paramedics: Medical Assistants (MAs) and Staff Registered Nurses (SRN).
  • Uniformed Agencies: BOMBA, APM (Civil Defence), Police, Army, EMTs, and EMRS.
  • NGOs: PBSM (Red Crescent), St John Ambulance, Mercy Malaysia, and others.
  • Volunteers: Individuals who have undergone basic training and participants in Flying Doctor Services.

System Components and Medical Oversight

• Organizational Structure: Includes lead agencies, main players, supporting agencies, and public involvement.
• Service System: Covers integrated services, primary and secondary responses, inter-facility transfers, medical direction, communication, and Disaster Management ($Mx$).
• Human Resources: Focuses on training, certification, accreditation, privileging, personnel pools, and career development/research.
• Equipment: Spans call centers, land/air/water vehicles, life support equipment, and pharmaceuticals.
• Medical Direction (Medical Oversight): Defined by Holroyd et al. (JAMA $1986$) as a physician-directed quality assurance system. It is essential for professional and public accountability.
  • On-line (Direct): Immediate voice communication with a physician during patient care.
  • Off-line (Indirect): System-level input occurring before or after care, including protocols, audits, and education/training.

Ambulance Grading and Legal Considerations

• Land Ambulance Categories in Malaysia:
  • Grade A1: Full Grade A equipment plus specialized machines (e.g., neonatal incubator, mobile intensive care facilities).
  • Grade A: Full Grade B equipment plus transport ventilator, defibrillator, and cardiac monitor.
  • Grade B: Basic immobilization and splints, trauma kit (cervical collar), triage cards, and scoop stretcher.
  • Others: Basic Patient Transport Service Van (PTSV), four-wheel drive (4WD) vehicles.
• Key Issues and Legal Challenges:
  • Documentation: The necessity of good record-keeping and independent reviews.
  • Legal/Ethical: Issues regarding consent, treatment without consent, and negligence.
  • Forensics: PHC personnel may pronounce death, but they do not certify death.
  • Authority: Limitations on physical restraint and legal implications of breaking and entering for rescue.
• Referenced Guidelines:
  • Jabatan Kesihatan Negeri Selangor: "Garis Panduan dan Polisi Perkhidmatan Rawatan Pra Hospital & Ambulance Edisi $2$".
  • Ministry of Health Malaysia ($2019$): "Policy on Safety of Land Ambulances" (MOH/P/PAK/$426.19(8P)$).
  • WHO: "Prehospital Trauma Care Systems".