Prehospital emergency care for trauma victims in Nepal: a mixed-methods study

Abstract

Background: The prehospital care system in Nepal is underdeveloped, with multiple providers, limited co-ordination of services and no national coverage. With no national ambulance service or emergency services phone number, people often call local hospitals during emergencies. Local hospital ambulances often only convey victims without providing care from trained Emergency Medical Technicians (EMT).

Objective: To explore the burden of trauma presenting to prehospital care providers and the experience of providing care to people with injuries in Nepal.

Methods: A mixed-methods study was conducted in collaboration with the Nepal Ambulance Service (the largest prehospital care provider in Nepal) in the Kathmandu Valley, Chitwan, Pokhara, and Butwal. The study involved the analysis of one year of de-identified callout data (May 2019 to May 2020) and semi-structured interviews with ambulance drivers, EMTs, dispatch officers and service managers. Interviews were transcribed, translated, and analysed using inductive thematic analysis.

Results: Of 1,408 trauma calls, 48.4% (n=682) received prehospital care, either at the scene, during transport, or both. Falls (35.8%) and road traffic crashes (19.1%) were the most common mechanisms of injury. The commonest types of injuries were fractures (33.1%) and suspected spinal injuries (10.1%). The cause of injury was not recorded in a third of records. The average time from call to arrival at hospital was 48 minutes (range: 20 minutes - 6 hours). Qualitative analysis identified factors facilitating effective prehospital care including adequate resources, systems and training. Heavy traffic, lack of prioritisation of emergency vehicles on the road and poor road quality often impeded arrival at the scene and delayed transport to hospital. At the scene, bystanders sometimes insisted on immediate hospital transfer without allowing EMTs to provided care and EMTs reported fear of legal repercussions if the patient died or had a poor outcome.

Conclusions: Trauma is a common reason for requesting prehospital care, which, on average, can be delivered in less than an hour. However, multiple factors hinder effective care delivery, requiring policy changes and professional development within the prehospital care system. Promulgation of a ‘Good Samaritan’ law could support prehospital care providers in offering on-site and en-route treatment.