Experts endorse Mongolia to build its own sustainable model for better ambulance services

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Two disaster communications and health experts from Australia’s Griffith University, Hamish Mclean and Duncan McConnell, have come to Mongolia on a mission to develop the local emergency response and ambulance services.

Mclean is a senior lecturer in the School of Humanities, Languages and Social Science at Griffith University who has 30 years’ professional experience in crisis communication, reputation management and issues management. When he first came to Mongolia in 2016, he didn’t expect the local ambulatory service to be in such a dire state. But seeing potential for improvement and the enthusiasm of local experts for enhancing their skills and the services they provide, Mclean launched a program with local authorities called the Roadside to Nationwide EMS and Disaster Program for Mongolia.

As part of the program, he has been conducting workshops on disaster and crisis communications and brought on board Duncan McConnell, an academic staff at the School of Medicine of Griffith University, who is a highly experienced paramedic, flight paramedic, paramedic manager and trainer with significant international experience. As project leader and clinical director, Mclean and McConnell arrived in Ulaanbaatar on August 29 with some Canadian experts to assist in the development of local fire department and ambulance services.

The Ministry of Health, National Emergency Management Department (NEMA), Health Department of Selenge Province, Bayangol soum Hospital, Health Department of Nalaikh District, Mongolian Society of Emergency Medicine and Emergency Department of Darkhan-Uul Province are involved in the program. The UB Post sat down with Mclean and McConnell for interviews about the program and ambulatory services in Mongolia.

Hamish Mclean: Mongolia doctors are passionate and keen to polish their skills

How did you come to implement the project?

It all started with doctor Bayarmaa who was running the ambulance services in Mongolia coming to Griffith University for a Leadership Workshop for postgraduates from Asia. I was lecturing the workshop on crisis and disaster management and she came and sought me afterward. She said she was running the ambulance service in Mongolia and said they’ve got a lot of challenges. She was really keen on getting it better especially in terms of training and equipment and coordination between provinces and the capital. That was in 2016 and in 2017, I was in the UK and told Bayarmaa I could pop over to Ulaanbaatar to do a small seminar on disaster and crisis communications on my way back to Australia.  She said it would be great and the next thing, I was in Ulaanbaatar at a conference with around 200 people from all of the provinces talking two days about disaster communications.

Doctor Od from Selenge Province took me in -40 degrees Celsius right up into the area and explained the challenges the province faces with road accidents, especially on the highway between Ulaanbaatar and Russia. Very bad accidents happen because of the road conditions and the amount of traffic. He showed me the limited amount of equipment they had and I said that I’ll return to see if I can find someone with expertise in road accidents to provide some training and find some donations.

When I went back to the university, I met Duncan who is a paramedic and trainer very aware of different cultures and systems around the world. He agreed to come with me in September last year. We went to Selenge, ran a series of workshops, and handed over some equipment to the Ambulance of Sukhbaatar soum. We were overwhelmed by the professionalism of Mongolian doctors on the ambulance. A part of that is their high adaptability and abilities to deal with traumatic cases with very limited equipment and resources, particularly in the capital where there is a lot of traffic. Through workshops in Selenge and Ulaanbaatar, we sort of worked out that there really needs to be a new way of looking at ambulance services in Mongolia to meet public expectations and not to impose other countries’ system but create one that is for Mongolia and can develop on its own based on its resources and context.

Now we’re back for a national symposium, which will be held on September 6, to discuss all sorts of issues related to Emergency Medical Service (EMS). While we’re here, we will do workshops for NEMA in Darkhan-Uul Province, Bayangol soum, Nalaikh District and two more workshops in Ulaanbaatar. We also got very generous donations from companies in Australia. We’ve brought about 100 kilograms of basic good equipment – trauma kits, tourniquets, slings, bandaging, etc.

The whole aim of our project is to help one road at a time. There’s no way that we – a university – can provide a new service for Mongolia or donations for the whole country.  We’re looking piece by piece but also at the national system, which is the symposium addressing. Fortunately, we’re being joined by Chief of the Vancouver Fire and Rescue Service Darrell Reid who is one of Canada’s top rescuer officials and a senior officer from the British Columbia Ambulance Service Joe Acker who is assisting us with the training and so on on this trip. We’re going to ride with the Ulaanbaatar ambulance to see how it operates and provide some donations.

We want to help guide and provide whatever assistance we can to take this forward.

The project has been running for three years but it is widening its scope rapidly. How did you manage to bring in so many people and organizations into the project in such a short amount of time?

Mongolia is a country that needs assistance. It has got great capacity within its personnel – doctors are very dedicated and unbelievably keen to improve. We’re not the UN but we want to make a change by providing some real ability for lives to be saved. We want the ambulance that turns up for an accident on a highway to have some equipment to be able to save lives. Canadian experts recognize that this is a very good thing to help with.

We’ve received terrific support from the Mongolian Society for Emergency Medicine. They’ve been absolutely fantastic. We’ve received great assistance from a doctor from the WHO who has been guiding us and doctor Bayarmaa who is currently studying in Japan but has been constantly in touch with us for the past year to provide input. We’ve put together a messenger group with all of the doctors we’ve met and for the last 12 months, we’ve been discussing what their needs are and how we can help. We see ourselves as more of a support rather than saying, “This is what you need. We want to sell this great equipment”. That is not sustainable. You’ll be simply throwing money away. What you need to do is build your own system the way you need it and the way you can resource it with our help.

As you mentioned before, Mongolians doctors are skilled but what do they lack that it is preventing them from providing efficient pre-hospital care?

It’s not so much as to what they lack. They just don’t have the training to work outside the hospital. It’s a different work outside the hospital where you have all sorts of support. Local doctors are very good at providing care outside the hospital but what we’re trying to do is give them the extra skills to help them do it as best as they can. We’re also donating some equipment in provincial areas so that they have something to work with.

What would you recommend for improving local EMS?

We’re keen for agencies to work together and share resources and information. Everyone is talking about it in provincial areas and Ulaanbaatar but there needs to be a structure and training around that as well.

Would you like to add anything else?

Mongolian doctors are very passionate for change and passionate to help their patients. We’re accepted a lot more because we come from a university. We’ve not come from a company selling equipment. We just want to provide research advice, support, and workshops.

Duncan McConnell: Traffic and shortage of equipment are critical challenges for ambulances

What is your role within the program?

I’m the clinical director of the program. I’m working on some research at the moment that focuses around the comparison of ambulance models around the world. There are a few and I’m looking at what works best and where and whether it is still valid within developing or developed countries. What I’ve identified is that here in Mongolia, we need to come up with a sustainable model based on the needs and requirements of the country’s healthcare system so that when we implement changes or improvements or developments in a way, it’ll better service the Mongolian population and will continue to grow around the country.

We’re beginning to start at one location at a time and as we identify the challenges and the things that work and don’t work, the country can adapt to evolve a foundation of the structure, which can then be pushed out to another area and to another area. So, all of the provinces can eventually align and the whole country will sort of sing off from the same tune, so to speak. The Mongolian Society for Emergency Medicine spoke about the introduction of basic triage levels within a hospital environment and how that took a while to push out to other hospitals. We’re looking for a similar approach for ambulances – get it working in key areas and expand it with the help of the ministry, WHO and other organizations. We’re also trying to bring up the education standards of drivers so that instead of just driving the vehicle, they can be sort of be the extra pair of hands for the doctor. It’s not just about the drivers; we want to provide doctors who go in the ambulances some more understanding of how to apply their trade outside the hospital because at the moment, they are very hospital-focused since that’s what they’ve learned. I’m not talking about bamboozling them with lots and lots of books but giving some practical pre-hospital education that they can implement when working in an ambulance.

The approach to working outside the hospital is very different – it is uncontrolled, changes rapidly and it’s not a sterile environment. In a hospital, you got all of the nurses and doctors and everyone can sort of come together in one spot. These people are working in an ambulance away from a hospital and all of that support so we want to help develop their clinical reasoning and clinical care.

Some of the support we’re looking into with NEMA is the medical capacity of firefighters. If they get there before the ambulance, they can provide some of the basic care and basic life support to patients until the ambulance comes. By doing that, we’re trying to develop a continuum of care.

Yes, we are a university but we have expertise, understanding and an approach that is about collaboration and working with the Ministry of Health and other key stakeholders in the health system within Mongolia to help them build a sustainable model for them. Things that other countries do might not work here. By helping them develop a system based on their own needs, it becomes sustainable and a much more achievable project.

We don’t have lots of money. We’re not the UN or a place with a bucket load of money that can just bring in cartons and containers of equipment. We can source but again, we don’t have finances to bring lots of equipment. Nevertheless, we’ve got the expertise to help develop within.

Are you seeing any results or improvement?

Based on the feedback and the small amount of equipment we donated last time, it has shown some improvement in the areas we’ve touched already.

We noticed in a news video that doctors were treating patients correctly. I received the unedited, long version of the video and I saw the doctors we trained coming in with the equipment we supplied and allocating patients that were super sick in one place and sending someone to other patients that weren’t so sick. It was nice to see them operating in a similar way that we showed them in our training and using the equipment the way demonstrated We tried to get back to the basics (in the training) because we only had a short amount of time. We have had feedback saying that (participants) would love to continue the professional development because since medical school, they never really got the chance to go into a classroom and focus on new techniques and ways to better improve their patient care delivery. They were infectious for more training.

What do you teach at workshops?

Small things like how to stop bleeding with pelvic support belts and pelvic binder and how to put on cervical collars. These things will help change the approach to managing a trauma patient. If you don’t know the correct steps to treating a trauma patient, you could potentially harm the patient so by reinforcing the basics, doctors can modify their approach to treating patients they come across.

Can you share some of your observations in an ambulance here? How are local doctors operating in an ambulance and what are the challenges they face?

We made a video last time we were here. That video highlights two things straightaway. The first patient you see in the video is a seizure patient. The doctor knew exactly what he needed to do and how he can treat the patient. However, he didn’t have adequate airway adjuncts with him, he didn’t have a defibrillator in case the patient had a cardiac arrest and there was no cardiac monitor in the ambulance for monitoring the patient’s cardiac rhythm time. He did give some sedation medication for dealing with the seizures. In Australia, Canada or the UK, administering such medication requires cardiac monitoring and other certain measurements but none of that was available for him in the ambulance. Ironically, all of the equipment was sitting in my hotel room. I didn’t bring any of it with me that night because I thought ambulances would have that basic BLS to CLS level equipment in them, particlarly in the capital. I was surprised that we didn’t have them.

The doctor had a good collection of pharmaceutical agents to deal with pretty much everything he came across. He knew what to do but he had very limited equipment to provide the care that the patient needed. However, in saying that, the care he did provide – considering what he had – was excellent and we worked together to help him out in that capacity. I think that is the biggest challenge for Mongolian people and ambulances. The lack of equipment has reached to the point doctors hide the equipment they have so that no one steals it because they need it. If they leave it in the car, someone will take it and it might not come back.

It was sort of heartbreaking to watch these people working so hard, knowing what to do but being on the back foot the whole time trying to make solutions out of everything like the TV show MacGyver. In paramedicine, we’re sort of in the bridge between nurse and doctor. We’re independent practitioners, we think critically, we’re like a Swiss army knife, and we react and provide the most appropriate care depending on the situation presented to us. Sometimes we work in consultations with doctors, sometimes we work completely on our own, we can make our own decisions, administer drugs under our own authority, and provide the care required to suit the patient’s needs. The Mongolian doctor was doing all of that in the context but without equipment he really needed. He probably could have added maybe three or four things to that car such as a simple cardiac monitor, SPO2 which looks at the oxygen level in the blood and pulse rate, and airway adjuncts. This would have made the care of the patient a lot easier because on top of all of that, we then had to deal with the traffic at nighttime. The last 800 meters to drive to the hospital took us almost 15 minutes. It’s one thing not having the equipment to provide care but then, add the complexity of the traffic on top of that; it’s a long way before the patient can get the care he needs.

How can the Mongolian health sector improve?

A better establishment of primary care services. You have all of these hospitals sitting pretty much in the heart of Ulaanbaatar but the population is widespread. The ambulances have to go from an outlining area all the way into the center of bottleneck. That’s a significant delay in time response. Plus, they have to get back out of there. I think there needs to be an establishment of primary healthcare facilities around the town, which work similar to an emergency department and can handle a lot of the noncritical type patients. You just need to place a few in strategic locations and open a few more when able to. The beauty of that is non-urgent patients can go to these facilities – so not everyone is going to the hospital.

Also, the receiving of calls can be improved. This is a cultural thing left over from the Russian era. When people call for an ambulance, they could be asking about the most minor medical thing that doesn’t require a doctor or they could see a doctor in the morning. There needs to be reeducation within the community as well of what ambulances are used for. I think an education and understanding about ambulance and EMS is needed to the community. People need to understand what happens when an ambulance is tied up treating someone with a cut thumb or sore tooth versus someone in cardiac arrest and there’s no ambulance available to help them. Then there is an establishment of better flow of managing patients the ambulances go to because we can’t fix the traffic but we can extend the reach within the capital to enable a better flow of services for people. Another example that is being used for an ambulance response is dynamic deployment. It enables you to have (ambulances) start at a set location and go to particular areas so that it’s not just sitting around. This will allow ambulances to move out to certain areas quicker.

Dulguun Bayarsaikhan