Emergency response units are very crucial to the survival of many patients in

emergency scenarios like road accidents, child birth, heart attack and other medical
emergencies. It may not be sufficient to fully treat the present condition, but it
includes rapid assessment of the proper intervention and may help to enhance their
survival, control morbidity, and prevent disability. One of the many emergency
cases is childbirth. According to data from the Indonesian Demographic and Health
Survey, hemorrhaging and eclampsia were responsible for 52% of the deaths of
women in childbirth in 2008. These medical conditions are both preventable,
provided that the mother is assisted by a trained childbirth assistant in a childbirth
facility that has adequate equipment and medical supplies, as well as the capacity
to provide or refer to critical care and emergency services. This was reaffirmed in a
study conducted by the Women Research Institute (WRI) in six poor districts and
one city, which indicated that childbirths that took place at home and were
attended by a dukun often encountered difficulties, such as the lack of clean water,
electricity for lighting, sterile space and equipment, and necessary medicines, which
carry risks for the health and safety of the baby and mother (Noerdin, 2011). Death
due to child birth complications are also a major problem in Nepal, and it is
estimated that every 10 minutes of every day a woman dies in Nepal due to
pregnancy and child birth. In fact, Nepal is one of the highest in the world when it
comes to maternal mortality rate. According to Human Development Report 2001,
maternal mortality rate in Nepal is 540/1,000,000 whereas it is 410 in India, 440 in
Bangladesh, 340 in Pakistan, 60 in Sri Lanka, 55 in China, 170 in the Philippines, 7 in
UK and 8 each in Japan and USA (CBS, 2002). It is believed that maternal mortality
rate is significantly higher in the rural than in the urban areas due to the
remoteness of their location. This reflects the importance of transportation and
access to medical services in the survival of these patients (Paudel 2002). In India,
about 69% of the population lived in rural areas in 2011. According to the national
census of 2011, the number of rural villages in India is 540,867. Out of these, only
22% of the rural population lives within 5 kilometers from the nearest town; 28%
are in a range of 5 to 10 kilometers from a town; and the majority of 50% are
located 10 kilometers from the nearest town (Census 2011). This is why an efficient
mode of transportation is very important not just in rural areas but also in urban
areas.
Ambulances are very crucial in emergency cases. However, there are many
issues when it comes to its management. Financial viability is one of the problems
encountered by ambulance services. This is due to the fact that most ambulances
are free of charge and are only funded by the government. Because of the low
funding, emergency personnel are also forced to find better paying jobs which leads
to shortage of trained personnel (Paudel 2002).
Components of emergency medical systems
An emergency medical system must be appreciated as a system of care with
linked and interdependent components: pre-hospital care (including transportation)

and care at the hospital. All components must work together to make a lasting
impact on the health of a population. The organization and operation of pre-hospital
care will vary from country to country but should be linked to health facilities. When
pre-hospital transportation is poor or absent, deaths that could have been
prevented even by inexpensive procedures occur (Mock et al, 1998). The
majority of obstetric deaths may fall into this category. When the quality of care at
hospitals is poor and leads to death, communities may be discouraged from
promptly taking patients to such facilities even when the capacity exists to
transport patients there (Leigh et al, 1995).
A. Pre-hospital care
Pre-hospital care is the care provided in the community (at home, school, work
or recreation area) until the patient arrives at a formal health-care facility capable of
providing definitive care. Pre-hospital care should comprise basic strategies with
proven effectiveness, such as accessible and rapid transportation and the
deployment of personnel with basic life-support skills. The majority of the world's
population does not have access to formal pre-hospital care (Liberman et al 2003).
Since resource availability varies greatly between and within countries, different
tiers of care exist. Where no formal pre-hospital system exists, the first tier of care
may consist of laypeople in the community who have been taught basic first-aid
techniques (known as first responders). Recruiting and training particularly
motivated citizens who are more likely to confront emergency situations (such as
public transportation drivers) to function as pre-hospital care providers can add to
this resource (Mock et al, 1998). The second tier comprises paramedical personnel
using dedicated ambulances and equipment. The implementation of a second tier
may not always be feasible in low-income countries, where trained personnel are
few and where high running costs make round-the-clock coverage difficult. Although
providing universal access to paramedical personnel and ambulances may be
beneficial, adopting this policy would be premature for populations lacking more
basic interventions, such as laypeople to act as first responders and accessible
transportation (Hauswald et al, 1997).
B. Personnel
There is little published literature on the impact of first responders. One study
in northern Iraq and Cambodia evaluated a programme designed to train a core
group of paramedics; these paramedics then trained thousands of laypeople to act
as first responders. The study demonstrated a significant reduction in mortality from
injury among populations with a high prevalence of injury (Husum et al, 2003).
There are no studies comparing the effectiveness of lay responders with that of
trained paramedics. In Ghana, it was demonstrated that commercial taxi and
minibus drivers trained in first aid could provide effective pre-hospital care (Mock et
al, 1998).

In most of sub-Saharan Africa and Asia, paramedical personnel (and

ambulances) are used only to transfer patients between health facilities and not
from the scenes of injury or from their homes (Joshipura et al, 2003). The level of
training of paramedical personnel should be appropriate to the provider. Some
evidence has shown that training paramedics in basic life-saving skills improves
patients' outcomes (Ali et al, 1998).
The recommended ratio of 1 team to 50 000 people suggested by McSwain
results in response times as low as 46 minutes (McSwain NE, 1991). Traffic
congestion, poor maps, poor road signs and limited road access may all increase
response times in cities with poor infrastructure. (Response time is measured from
the time a call activates the emergency medical system until the team arrives on
the scene.) In Monterrey, Mexico, an area with a ratio of 1 team per 100 000 people,
the average response time was 10 minutes, while in Hanoi, Viet Nam, five teams
dispatched from one station that are expected to serve 3 million people (1 team per
600 000 people) have recorded an average response time of 30 minutes (Mock et
al, 1998).
C. Equipment and communication
Nowhere is the demand for efficient communication and rapid transportation
more critical than in emergency medical systems. The best teams equipped with
state-of-the-art technology and supplies will be wasted if they cannot reach patients
quickly or if they have no contact with the hospitals where their patients are to be
taken. The majority of the world's population lives in areas with weak
telecommunications infrastructure. Innovations are needed to provide efficient
emergency communication in such settings in order to enable these populations to
gain access to the emergency care interventions that already exist. Equipping
traditional birth attendants and remote health units with radio receiver sets linked
to local hospitals is one method that has been used to shorten response times and
thus reduce maternal deaths (Samai et al, 1997).
D. Transportation
Transporting a patient from the location of an acute event to a hospital is a
critical element of pre-hospital care, since a lack of transportation is often the major
barrier preventing patients from accessing emergency care (Macintyre et al, 1999).
In devising a pre-hospital transportation system, locally available resources and the
range of viable alternative means of transportation should be considered. For
example, seriously ill and injured patients may be brought to medical facilities by
commercial vehicles, the police or relatives using private motorized or nonmotorized transportation (Kobusingye et al, 2002). Emergency transportation should
be accessible at short notice; a vehicle with a stretcher is ideal but almost any
mode of transportation that gets a patient to a facility where definitive care can be
obtained is acceptable. A bicycle ambulance in Malawi that was set up to improve

emergency obstetric care was actually used more often for patients who had been
injured and for medical emergencies (Lungu et al, 2001).
E. Health facilities
The capabilities of formal health facilities vary immensely between and within
countries. In some low-income countries, emergency medical care may be
effectively delivered at a health centre staffed by non-doctor clinicians. However,
such a facility will be grossly inadequate for the management of a severe multiple
injuries or obstructed labor. Similarly, using a tertiary facility to provide basic
services will create inefficiencies in the emergency medical system and in the
health system overall. Time and lives are lost because patients are taken to facilities
where the desired definitive care is not available. Chronic problems resulting from
inappropriate triage underscore the need to emphasize the "systems" aspect of
emergency medical care. Putting the emphasis on the systems ensures that proper
communication is given to first responders so they know where and when to refer
patients and can receive feedback about cases that they have managed well or
poorly. The WHO Guidelines for essential trauma care lists comprehensively the
most appropriate resources for various levels of health-care facilities (Mock et al,
2004).