Abstract
We describe the evolution of the nonprofit Nepal Ambulance Service (NAS) in a narrative of its 10-y history, presenting geographical, social, cultural, and financial considerations that permeated the development of NAS. We gathered narrative information from the NAS leadership and partners to detail key organizational considerations regarding the implementation and maintenance of the prehospital system in Nepal. We describe the response of NAS to the 2015 earthquake and summarize transport data for 6 mo before and 6 mo after the event. The data collected included the date and time of calls received, time to ambulance dispatch, on-scene time, time to arrival at the hospital, time until the ambulance crew was back in service, patient age and sex, chief complaints, and work shift time of the ambulance crew. To characterize the time to response and transport after the 2015 earthquake, we present the means and standard deviations of the time intervals. There was an overall increase in calls and, specifically, trauma-related calls after the 2015 earthquake. The time from a call placed to dispatch was stable, approximately 2 min, throughout the period, whereas the time from dispatch to the scene and arrival at the scene varied widely. We discuss the response to coronavirus disease 2019 (COVID-19). The NAS provided care to 1230 patients with COVID-19. The descriptive data show how well NAS responded to a major national disaster and the recent pandemic.
Introduction
The 10th anniversary of the Nepal Ambulance Service (NAS) provides an opportunity to tell the story of a sustainable out-of-hospital operation and detail some of the organizational elements that may be useful in other countries. The NAS currently operates 10 ambulances in 4 locations in Nepal and is working with the Ministry of Health and Population, Nepal, to provide training to prehospital providers in each Nepali province. With >60,000 calls and 57 safe obstetric deliveries to its credit, NAS has proven that it has a role in responding to the emergency medical needs of Nepal. In the spirit of continuous quality improvement and offering context to other similar efforts, we reviewed the history and progress of NAS. Even with successful launch of a project, it is important to take stock, adjust, and improve if possible. 1 By detailing creative solutions to financial and cultural challenges, educational program designs, and response to crisis, we describe one example of successful development of a nonprofit health system that could be helpful for other groups that may face similar organizational challenges.
Nepal covers 147,000 km2, similar in size to the US state of Georgia, and is home to 8 of the 14 highest mountains in the world. Since the first successful Mount Everest summit via the Nepali route (South Col) in 1953, a steady stream of mountaineers, photographers, and trekkers has led to an increasing number of visitors in Nepal. The need for medical care for locals and visitors led to the establishment of networks such as the Himalayan Rescue Association and NAS, which aim to provide emergency care and link trained health workforces in Nepal. However, Nepal’s geography presents a profound barrier to emergency care. Much of the population lives outside of the Kathmandu Valley and has limited transportation options,2,3 some in areas accessible only by foot, pack animals, or helicopters. In comparison, 9% of Nepal’s population resides in the Kathmandu Valley, which covers 336 km2 and includes 3 major cities: Kathmandu, Lalitpur, and Bhaktapur. There are more than a dozen hospitals in the Kathmandu Valley. Despite the relative availability of clinical sites and trained physicians in the Kathmandu Valley compared with those in rural Nepal, until recently, medical care was still greatly hindered by lack of prehospital emergency care. 4 In 2009, the majority of patients (53%) in Kathmandu arrived at hospitals by taxis, and only 14% of the category with the highest severity triage arrived by ambulances. 5 Only 10% of patients came by ambulances, which were ill equipped and had no trained health workers. 5 Public emergency telephone numbers and certified ambulances were nonexistent. At the launch of NAS in 2011, the initial goal was to cover densely populated areas near the Kathmandu Ring Road 6 and later expand.
Development of NAS
In April 2011, the nonprofit organization NAS was launched with the mission to provide rapid ambulance transport to hospitals along with lifesaving medical care by trained emergency medical technicians (EMTs) for sick and injured people regardless of their ability to pay. The key founding members included Nepali leaders in entrepreneurship and philanthropy, disaster preparedness experts, Patan Academy of Health Sciences faculty, and several volunteer international students and fellows. After 2 y of collaborative work among NAS, Nepal Telecom, and the Ministry of Information and Communications, a 3-digit toll-free emergency number (102) was established. 7
The NAS began operations with 2 ambulances and by 2012, was operating 5 ambulances. Currently, NAS operates 10 ambulances: 6 in Kathmandu, 2 in Pokhara, 1 in Chitwan, and 1 in Butwal. Pokhara and Chitwan are major international travel destinations, and Butwal provides access to key transportation routes. Each vehicle is equipped with basic life support equipment. Today, NAS employs 27 EMTs, 20 ambulance drivers, 6 dispatchers, and 5 administrative support personnel. Each ambulance is staffed by an EMT and emergency first responder (EFR).
EFR training is more basic than EMT training but is crucial to both scene safety and patient transport. The ambulances and dispatch center are staffed 24 h/d, 7 d/wk. Crews work 48 h/wk in 12-h shifts from 0700 to 1900, with 2 dispatchers per 12-h shift. The NAS operates with assistance from Nepali police services, which allow ambulances and EMTs to stage on their properties. Radio communication was banned during the launch in 2011 because of government security concerns, forcing parties to communicate over unreliable mobile phone networks. In April 2020, this prohibition was finally lifted. The NAS installed a walkie-talkie repeater to use very-high-frequency communication.
Financial Aspects
The NAS provides care to patients regardless of their ability to pay. For those who can pay, NAS initially charged 20 rupees ($0.17 US dollar [USD]) per kilometer one way plus the cost of medication and disposable medical equipment. The charge has since increased to 25 rupees ($0.21 USD) per kilometer. The average total cost to patients is approximately 600 rupees ($5 USD) per encounter, with funding supplemented through several means. The NAS continues to operate at a deficit of approximately $500 USD/mo. Fundraising for the initial launch of NAS was achieved through private philanthropic and corporate donations. The initial 5 ambulances, each costing approximately $25,000 USD, were donated by local donors. Medical equipment, such as cervical spine collars, backboards, and splints, was produced locally. For most operations, the Nepali government did not contribute to costs. Beginning in 2019, financial support was provided by the Kathmandu metropolitan city council to cover ongoing operational deficits. Local Nepali businesses and donors from within Nepal and abroad contributed to the operational costs of overhead, equipment, and ambulances. Education and training materials continue to be provided through an academic partnership with the Stanford Department of Emergency Medicine and through several nonprofit organizations committed to the success of NAS. The ongoing operational support for NAS from academic and nonprofit organizations includes mentoring of Nepali EMTs and international students completing electives to create data-driven reports for NAS to use in grant writing. Additional international support was granted to NAS after the 2015 earthquake, increasing the number of ambulances and expanding the system. Unfortunately, because income continues to lag, it is unlikely for NAS to become financially independent in 2022.
Education
The Essential Out of Hospital Care course was developed in partnership with faculty from Stanford medical school and Patan Academy of Health Sciences. The course was used to train the first class of EMTs in 2010, with students selected from medicine-adjunct fields that included health assistant, assistant nurse midwife, and community medical assistant. The learning tools included classroom lectures, skills workshops, and written assignments. As an example of the training tools, we presented the training material for respiratory assessment in Table 1. To date, 3 courses have been organized, training approximately 140 EMTs. The third course was conducted entirely by Nepali trainers. A Nepali medical director and Nepali physicians also lead quality improvement and continuing education while promoting awareness of and gathering support from the local community. Education for the local community by NAS takes place in schools (teaching young people how and when to call for help in an emergency) and community venues (to highlight the importance of recognizing the urgency of common issues, such as chest pain or stroke, in older populations). By including the community in education and awareness efforts, NAS hopes to improve the quality of care provided in a timely manner.
Nepal Ambulance Service training material for respiratory assessment
RR, respiratory rate; SpO2, saturation reading; COPD, chronic obstructive pulmonary disease.
During the initial training course for each class of EMTs, key EMT and external defibrillator first-responder skills are organized into the following categories: IV placement and fluid resuscitation, basic life support, emergency childbirth and obstetric skills, trauma management, triage and disaster response, leadership, medical management, ambulance operations and transport, and communication. The level of care is above what is normally provided by a basic US EMT but below that provided by a US paramedic. Following this course, EMTs receive training twice a year to refresh basic concepts such as airway management, shock, cardiovascular emergencies, cardiopulmonary resuscitation, automated external defibrillator use, cardiac monitoring, respiratory emergencies, neonatal resuscitation, trauma resuscitation, pharmacology, and obstetrical emergencies. The refresher training sessions are from 3 to 5 d and run in partnership with foreign volunteer instructors and nonprofit financial support for training equipment. In addition, senior international paramedics provide mentorship with established NAS crews on dispatched calls to ensure smooth transition from in-classroom skills to active duty.
Recently, Nepal’s Ministry of Health and Population established a new collaboration between the national dispatch center and NAS. The directive also gave NAS responsibility for training EMTs and EMDs in each of the 7 provinces, which required the development of 1 dispatch center in each province. The NAS will manage the national dispatch center and provide technical support to each provincial dispatch center. The emergency number 102 will be designated as a national toll-free number. The ultimate goal of NAS is to operate a nonprofit national ambulance service with funding and operational support from the Nepali government.
Overcoming Cultural Barriers
The organization Friends of NAS has used local advocacy and social media promotion to raise awareness of ambulance availability. Currently, after a decade of operation, dispatch remains underutilized, with approximately 15 to 20 calls/d, meaning that many sick patients choose to arrive at hospitals by taxis or other means. An increase in calls during a crisis in Nepal can make adequate staffing difficult, a challenge seen in other countries as well because of limited numbers of trained providers. When Kathmandu nears complete shutdown because of political rallies, the calls increase to 70 to 100/d, indicating that people are aware of the dispatch system but tend to take alternative transportation. The causes of this phenomenon are likely to be multifactorial, including a fear of billing and poor cultural understanding of out-of-hospital care. Unlike countries that have long-standing ambulance services, readily available cardiopulmonary resuscitation courses, and Stop the Bleed campaigns, Nepali citizens are not routinely trained to recognize critical illness. Since 2017, Friends of NAS has worked with EMTs to arrange first aid classes in local schools and public places to highlight the importance of out-of-hospital care.
NAS Involvement in Rescue After the 2015 Earthquake
The 2015 earthquake had catastrophic consequences for Nepal. On April 25 at 1156 Nepal Standard Time, an earthquake centered in the Gorkha region struck Nepal and its neighboring countries. The initial quake had a magnitude of 7.8. Aftershocks began immediately, with over 400 aftershocks recorded by the beginning of 2016. Two aftershocks occurred, one with Mw=6.7 on April 26 and one with Mw=7.3 on May 12. 8 Avalanches and landslides started within minutes of the initial earthquake. 8 -10 In Nepal alone, the toll from the earthquake was >8000 deaths caused by the initial earthquake and approximately 700 additional deaths caused by aftershocks and landslides. More than 22,000 people were injured. Nearly 500,000 buildings were destroyed, and >250,000 were partially damaged, leaving 3.5 million people homeless. An ice avalanche on Pumori, a mountain 8 km away from the Everest Base Camp, killed 24 people and injured >60. The Everest Base Camp avalanche resulted in the deadliest single day on the mountain. 9
There were severe impacts on hospitals and the prehospital medical system in Kathmandu. Damage to major thoroughfares and disruption of sewage structures hindered transportation and care. Tribhuvan International Airport was initially closed but reopened late in the day exclusively for relief flights. A postdisaster needs assessment conducted by the Nepali government and published by the World Bank found that >1000 public and private health facilities were completely destroyed or damaged. The earthquake affected over one third of health facilities in Nepal and caused 6.33 billion rupees ($53 million USD) in damage to healthcare structures. 10
By noon, just 4 min after the initial earthquake, the NAS headquarters sustained enough damage to be nonoperational. The phone number 102 and most telephone lines were out of order. Although no calls were recorded by dispatch on April 25, the ambulance crews drove with army and police personnel into areas of fallen buildings and transferred victims to local hospitals. By April 26, NAS was able to create a Facebook post announcing that ambulances were still available despite damage to the headquarters and call lines. That day, an ambulance was called to a home for the blind in Bhaktapur, 13 km east of Kathmandu. The NAS EMTs extricated and resuscitated victims found in the rubble. In the following days, NAS arranged to use the police emergency number 100 and stationed ambulances at the main police station in Ratna Park, Kathmandu. By April 27, NAS began working with the Federation of Nepali Chamber of Commerce & Industries on a relief operation utilizing ambulances for disaster rescue. For 10 d, ambulances continued to be dispatched in collaboration with the army and police. For weeks thereafter, NAS transported people rescued locally in the Kathmandu Valley and patients flown from rural areas of Nepal who arrived at Tribhuvan International Airport. Because the number of victims soon outpaced capacity, only critically injured patients were transported by ambulances. Unfortunately, because of damage to the call center, we lack official records of ambulance runs from handwritten records. Seven hundred sixteen victims were transferred by NAS during the aftermath of the earthquake.
Transport Data
The NAS provided the transport log with deidentified data collected by ambulance dispatchers and recorded on monthly spreadsheets from October 2014 to October 2015. The data were collected for quality improvement as part of standard operations. No training was provided on data collection. After the 2015 earthquake, NAS was able to provide operational ambulance services (except for April 25, 2015), although the damage to the headquarters and communications systems impaired data collection. No calls were recorded from April 25, 2015, to May 1, 2015.
The data collected included the date and time of calls received, time to ambulance dispatch, on-scene time, time to arrival at hospital, time until the ambulance was back in service, patient age and sex, chief complaints, and interventions. Patients were stratified as adult and pediatric (age <18 y), and the mean ages were calculated. All data used for the analysis were deidentified, ie, the data did not contain protected health information. The study was exempted from human subjects’ research by the Stanford medical school institutional review board, protocol number 63658. NAS leadership provided data and permission to analyze and report transport data. The data are presented as mean±standard deviation (range).
From October 2014 to October 2015, a total of 2585 patients were transported: 2407 adults and 178 children. The monthly proportion of calls related to male patients (52%) was similar to that of calls related to female patients (48%).
The data on the time of calls were collected only from April 2015 to October 2015. During this period, a greater number of calls were placed during the day (0700–1859) than at night (1900–0659), with the overall calls during the day accounting for 58% of calls.
The chief complaints that initiated the dispatched calls were grouped into categories based on the frequency of recorded calls. The complaints were categorized as breathing problems, chest pain, altitude-related illness, gastrointestinal, genitourinary, fever/infection, neurological, obstetrics/gynecological, endocrine, toxicology, psychiatric, trauma, hypertension, and unconsciousness. Overall, 21% of patients were trauma victims. There was an increase in trauma cases following the earthquake, from 16% before the earthquake to 27% in May and 28% in June. Among the transported patients, 19% presented with breathing problems. For these patients, oxygen administration was the most frequently used intervention by emergency medical service (EMS) providers.
The time from the initial call to placing an ambulance back in service was divided into intervals and summarized by month. The time in minutes from a call placed to dispatch appeared to be stable throughout the period observed: 2.0±0.1 (1.9–2.2) min. The time from dispatch to arrival at the scene varied widely, with the greatest values observed in April and May 2015: 17.5±5.1 (12–25) min. The time at the scene also showed wide variability: 11.2±3.0 (6–15) min. Compared with the time needed to arrive at the scene, the time from dispatch from the scene to arrival at the hospital varied less: 21.4±2.9 (16–22) min. Mean total time in April and May was 73 ±9.4 (46–77) min.
Limitations
Because the 2015 earthquake significantly damaged Kathmandu’s infrastructure, few data are available for the week following the earthquake. We had to make assumptions based on our observations. Communication for the NAS system was routinely maintained through cellular phones; however, their function was compromised because of network outages immediately after the earthquake. Although the cellular network was re-established within hours after the first earthquake, there continued to be sporadic disruptions. The software system was built uniquely for the system described above, without a backup system. We also have much less data on staffing immediately after the event, adequacy, and applicability of training in disaster response and skills for assessing scene safety.
Our ability to assess whether the NAS EMS system was built adequately to respond to a disaster was impaired by lack of data collection from April 25, 2015, to May 1, 2015. However, as opposed to solely using observations by individuals, objective data provide some context.
NAS in COVID-19 Pandemic Response
In 2020, when the SARS CoV-2 pandemic began, NAS was tasked with transferring patients COVID-19 in the Kathmandu Valley to the COVID-19 crisis management center, a government body. Nepal was the first country in South Asia to report a confirmed case of the virus on January 23, and cases rose slowly until May. 11 The increase was slow, in part because the government initiated a strict lockdown on March 24 that included closing land borders to neighboring India and China, canceling all arriving international flights, and closing schools. However, with easing of travel restrictions on June 1, 2020, thousands of workers arrived home from India and China, resulting in a 10-fold rise in cases. Phased reopening began on June 15, with the lockdown ending on July 21, 2020. As of November 2021, the Ministry of Health and Population had confirmed 821,000 cases and over 11,500 deaths.
Before the 2020 lockdown, there were approximately 23 ambulance runs daily. From late March until July, the calls increased to approximately 130/d. The NAS responded by doubling on-duty dispatchers, serving approximately 11,700 patients during the lockdown, 1230 with suspected or confirmed COVID-19. Decontamination of ambulances and acquisition of personal protective equipment proved to be challenges. Also, there were limited treatment options. International academic and nonprofit partners helped with the provision of materials as well as training sessions to teach evolving COVID-19 best practices and the use of inexpensive locally available materials such as dilute bleach and homemade alcohol-based sanitizing fluids. Several initiatives resulted in funding and in-kind donations for face masks, thermometers, and gowns. NAS ground ambulances continue to be staged at the Kathmandu airport to receive helicopter evacuations from regions unreachable by ground ambulances but requiring medical transport (major trauma, COVID-19, or severe illness).
Discussion
The success of this nonprofit organization was based on several factors. The first was the collaboration with medical institutions in Nepal and higher-income countries, 4 especially with Stanford medical school, which helped to ensure quality standards for the developing EMS system. This collaboration was essential for training of EMS personnel and establishing a system of education for continued operation. The train-the-trainer model enabled the third EMT course to be conducted without the help of the outside educators, demonstrating the ability of NAS to create a sustainable workforce and staffing model. The second cornerstone of success was the ability of NAS to address financial and cultural barriers. Public awareness campaigns increased the ability of NAS to respond to the community’s concerns and build trust. Although currently, NAS still operates under a financial deficit, the deficit is only 2%. Funding has been sustained by cooperative efforts among institutions, local government, and the local business community. There is continued involvement from foreign communities, which facilitates sustained integration of global technical expertise and fundraising.
The analysis of the NAS response to the natural disaster of the 2015 earthquake and the COVID-19 pandemic showed that NAS can continue providing services during mass casualty incidents. Since the launch of NAS in 2011, the Nepali government has increased its commitment to NAS by increasing financial support and granting NAS oversight of the national dispatch center and EMT education. Nepalis increase their calls to NAS during crises, suggesting growing confidence in the dependability of NAS and recognition of NAS by Nepali communities. NAS also demonstrated its ability to rise to unforeseen challenges of the COVID-19 crisis by organizing training with new techniques for care of patients, protection of providers, and partnering to fundraise for these purposes.
Future Development
In the future, NAS plans to improve operations by building redundancy into the tracking system. If another natural disaster were to damage infrastructure, data collection and ambulance function would not be hindered to as great a degree as during the 2015 earthquake. In addition, NAS aims to expand operations by training EMTs from all 7 provinces. The NAS is well prepared for its ongoing responsibilities bestowed by the government and looks forward to continuing its pivotal role in the continuing development of a national EMS system in Nepal.
Footnotes
Acknowledgments
This update on the NAS initiative was spearheaded by Dr Paul Auerbach, an accomplished wilderness medicine researcher, frequently called the Father of Wilderness Medicine. Dr Auerbach continued mentoring the authors working on this manuscript until his death. The Nepali founders of NAS include the entrepreneur and philanthropist Om Rajbhandary, Dean Emeritus of Patan Academy, general surgeon Rajesh Gongal, and disaster expert and nonprofit leader Mahesh Nakarmi. Several international nonprofit organizations also contributed to the success of NAS through fundraising efforts and education, including Friends of NAS (United Kingdom), Reggio (Switzerland), and the International Medical Corps (United States). The academic contributions included teaching by >40 volunteer faculty and fellows from Stanford University.
Author Contributions: Data analysis and interpretation (NJP, DI, RG); drafting of the manuscript (AMW); critical revision of the manuscript for important intellectual content (RW, DI); approval of final manuscript (AMW, NJP, RG, DI, RW).
Financial/Material Support: None.
Disclosures: None.