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Paul Auerbach: The Nepal Ambulance Service

With the help of Rebecca Walker, a faculty member within the Division of Emergency Medicine at Stanford and a very active participant in Stanford Emergency Medicine International (SEMI), I am writing about the Nepal Ambulance Service (NAS), which has survived trial by fire in the aftermath of the Nepal earthquake.

A loyal and energized group of Nepali emergency medical responders in Kathmandu is still hard at work saving limbs and lives. NAS is the only functioning prehospital (ambulance) service in Nepal.

In 2008, the prehospital emergency medical services (EMS) situation in Nepal could be charitably described as at best ineffective, with no trained providers, no toll-free emergency telephone number or dispatch center, and only a few scattered, ill-equipped vehicles that hardly qualified as ambulances. Most patients were transported to the hospital by taxi. Nearly all patients requiring immediate resuscitation received no treatment prior to hospital arrival. I was made aware of this situation by an undergraduate student at Vanderbilt University, who introduced me to a determined group of Nepali physicians and business leaders with a track record of accomplishments, such as creation of a dialysis center in Kathmandu. Their vision was to create a functioning EMS system in Nepal. After a visit with them and assessment of the need, which was and remains profound, Stanford Emergency Medicine International signed on to create and deliver medical training.

Created in 2011 as a fledgling nonprofit, NAS has been thrust into the public eye this week with its amazing performance in response to the earthquake. Last week, when its call center was severely damaged, NAS teamed up with the police to perform rescues of buried earthquake victims and provide prompt medical attention to the victims. Small and austerely-equipped ambulances are providing the means for many victims who would otherwise not receive prompt medical attention to be treated and transported to a higher level of care.

Because the former call center building has been ruined, and the call volume has more than quadrupled, the ambulances and crews are being dispatched from a tent outside of the building. In addition to treating patients in the field, the emergency medical technicians (EMTs) are transporting patients from the airport to area hospitals as new patients are flown in by helicopter from remote villages. When the aircraft arrive at the airport, the patients are triaged and those deemed most critical are transported by NAS; the less critical patients are transported by private hospital ambulances.

NAS is Nepal’s first and only comprehensive professional EMS system and provides 24-hour services within the Kathmandu Valley, regardless of anyone’s ability to pay. The young men and women who studied to become EMTs for NAS are the first group of career professional medical “first responders” in Nepal. They took a chance on the success of NAS, a new and unproven nonprofit, during a time when Nepal was in a historic transition to achieve a new constitution. We were fortunate to be asked to assist, and through SEMI, trained Nepal’s first class of EMTs. The training was carried out by a team of Stanford emergency physicians side-by-side with many Nepali physicians. I will never forget attending the graduation of this class of EMTs. They were full of hope and poised for greatness, but the road has not been easy for them from a financial perspective.

Over the past 4 years prior to the earthquake, NAS EMTs have cared for more than 12,000 patients in the Kathmandu Valley, with an amazing average response time of 27 minutes from the moment of a call for help to arrival on-scene. However, before the earthquake, NAS had been stretched so thin (with only 5 or 6 vehicles operating within the Kathmandu Valley to serve a population of millions of people) that it was being very cautious about continuing public service announcements that encouraged the public to call the three-digit 102 emergency number. Indeed, prior to the earthquake, NAS had reached its capacity for responding and was unsure of its ability to respond were the number of calls to increase. This week, as NAS was challenged to profoundly stretch the limits of its system and endurance, their EMTs and staff have responded to the need and are more passionate than ever about the task at hand. When I was in Nepal this past week, I watched the EMTs and all who support them at work, and have never seen a more dedicated group of individuals. I watched them toil nonstop without taking time to eat or drink. They had to be forced to rest. Each EMT feels personally responsible for saving Kathmandu, and I write with conviction that NAS deserves all the support it can get.

In order to respond to the needs of Nepal, not only because of the earthquake, but for all the “normal” emergency medical situations (complicated childbirth, heart attacks, motor vehicle accidents, etc.), NAS will need to build an earthquake-safe call center, increase the number of ambulances and required personnel, extend its reach geographically and programmatically, and take its operations to the next level. It is an essential service of which the Nepal government and private sector should be exceedingly proud. While many international agencies are in Nepal attempting to help rescue earthquake victims and mitigate immediate risks, it is equally important to also think in the longer term, and rescue the emergency medical response system itself. As it was for the creation of NAS, the Board of Directors is dedicated to making this happen.

The financial situation for NAS has to improve. Many of the EMTs have at times endured working for months without pay while the NAS Board of Directors raised funds. If NAS is to survive, then a sustainable combination of government funding, private sector support (corporate or philanthropic), strategic partnerships with international healthcare and/or financial agencies, and personal donations will need to ramp up accordingly. Hopefully, this will be possible. Friends of Nepal Ambulance Service (friendsofnas.org) (“Friends of NAS”) is a reputable entity through which individuals can make monetary donations. Grant applications are being written and partnerships evaluated. NAS will hopefully become a model for success that can be replicated around the world wherever there exist opportunities to develop prehospital care systems that can provide both essential services and a window into the soul of health care delivery within communities with such obvious needs. We will learn from this earthquake crisis and continue to work toward a robust future for NAS and better days for the people of Nepal.

Paul Auerbach is a professor of Surgery, Emergency Medicine at Stanford University Medical Center.