Emergency medical services in South Africa

Paramedics tend and load a patient into an air ambulance after a train crash in Pretoria

Emergency medical services in South Africa are a public/private system aimed at the provision of emergency ambulance service, including emergency care and transportation to hospital.

Organisation

Land Ambulance

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South African Medics at work

Emergency ambulance service is provided by each South African province. The system of government operated ambulances is generally referred to as 'Metro'. In addition to the paid responders, the government system is supplemented in many areas by unpaid volunteers. In cases where volunteers are used, the standards for operation are set by the provincial Health Department, which also provides vehicles, equipment, and operating expenses. Operations are normally administered at the local level through the Emergency Management Service , which oversees police and fire protection, as well. The co-location of ambulances with fire apparatus is common in South Africa, although they are two independent services. The national emergency number for ambulances in South Africa is 10 177.

These publicly operated services are supplemented by two private-for-profit ambulance companies, NetCare 911 and ER24, both of which operate nationally, and by a variety of local private services, such as AmbuStat. The statutory services and private companies are further supplemented by voluntary ambulance services, including the South African Red Cross, and St. John Ambulance. All are required to meet the same standards as the public services with respect to staff qualifications. These services are self-dispatching, and do not participate in the national emergency number scheme.

Air Ambulance

Public air ambulance service is provided by the Red Cross Air Mercy Service from bases throughout the country. The system operates both helicopters and fixed wing aircraft, and both turboprop and jet aircraft as well. Emergency air ambulance service is also provided by Netcare 911, operating nationally with both Fixed Wing (Jet aircraft) and Rotary Wing (Helicopters) Aircraft. Private air ambulance charters are also available from a number of aircraft charter companies throughout the country. Global JetCare Based out of West coast of Florida in the United States. We are owner/operator with our own 135 certificate and two Lear Jets 36xr dedicated solely for world wide Medical Transports.

Rescue

Technical Rescue services is for the most part provided by the local Fire Service of each municipality. However, due to the reduction in service, much of this has been taken over by volunteer based organisations. Nationally, mountain rescue (Berg) is carried out by the Mountain Club of South Africa (MCSA) who work along side the South African Air Force as the high altitude dictates the use of military specification helicopters. In the Western Cape, technical rescue mostly confined to the Cape Metro is carried out by Wilderness Search and Rescue who work in conjunction with Cape Metro Ambulance and Red Cross Air Mercy Service. In Kwa Zulu Natal, Rescuetech carries out the technical rescue needs in the province in conjunction with the South African Police Service Search and Rescue Division. Rescuetech also has access to its own fleet of aircraft, both fixed and rotary wing for use in aerial searches and the transport of rescue crews to remote locations.

Standards

Training

In South Africa there are currently 3 different levels of proficiency in Short course training:

• BAA or Basic Ambulance Assistant – This is a Basic Life Support (BLS) certification, and approximately the equivalent of the US EMT-B. This is the minimum qualification to be a crew member of an ambulance in South Africa. Training includes a 160-hour course consisting of lectures and practical simulations. The lectures cover basic anatomy and physiology, basic life support (including both CPR and first aid), emergency care, the use of ambulance equipment, including Automated External Defibrillators (AED), and various medico-legal issues.

• AEA or Ambulance Emergency Assistant – This is an Intermediate Life Support (ILS) certification, and generally close to the same scope of the US EMT-Iin most skills but the South African countparts have much more training in comparison, but with some added skills. To apply for this training, candidates must have a minimum of 1,000 hours of practical experience as a BAA and they must pass an entrance exam to be eligible for the course. As an alternative route to certification, those completing the more advanced tertiary qualifications may challenge the examination and be certified as an AEA after successfully completing their first or second year of training. Training at this level consists of a 470-hour course, consisting of 240 hours of lectures and practical simulations, and 230 hours of experiential learning. AEA's are qualified to practice various invasive techniques such as IV therapy, needle Cricothyroidotomy and needle Thoracocentesis, as well as Electrocardiogram interpretation, manual external defibrillation, and are allowed to administer various drugs.

• CCA or Critical Care Assistant and the "National Diploma" – These are Advanced Life Support (ALS) Candidates must complete a 1,200-hour course to qualify as a CCA in addition to prior BAA and AEA qualifications, this level usually takes more than 4 years to complete. the ND is three-year full-time study at college. CCA / ND are both registered as a Paramedic with the Health Professions Council South Africa and they can continue to do an additional 1 yr post Graduate study is available to obtain the Btech degree.

Below are two new university qualifications;

• ECT or Emergency Care Technician -This mid-level course is of two years duration, and exits on a level just above what many know as Intermediate Life Support (ILS), but below Advanced Life Support (ALS). This course is covered at 5 different training colleges in South Africa. Students who pass this course are eligible to apply to the HPCSA to be registered in the category of Emergency Care Technician (ECT). Lebone College of Emergency Care is situated in Pretoria.

• BTech/BEMC or The Bachelor Degree Technology or Bachelor Degree in Emergency Medicical Care, is a four-year professional degree and students who achieve this degree are eligible to be registered with the HPCSA in the register for Emergency Care Practitioner (ECP) which has an additional scope of practice over the Critical Care Assistant and the National Diploma qualifications. The two additions in stand-alone capabilities are Thrombolysis and Rapid sequence induction. ECP's are also trained in the rescue disciplines offered by their institutions, normally up to the level of Advanced Rescue Practitioner. Example: High Angle II-, Motor Vehicle-, Fire Search and Rescue-, Aviation-, Confined Space-, Structural Collapse-, Industrial and Agricultural-, Trench-, Aquatic Rescue, etc. The advantage of the Btech qualification is that it is a university qualification that is consistent with the international industry trend.

Further opportunities for educational advancement exist for the ECP, as they are able to articulate into various Masters (M.EMC)(Mphil.EM)(MSc.EM) and Doctorate (DEMC)(PhD) programmes.

All EMS personnel in South Africa are required to meet the standards of the governing body, the Health Professions Council of South Africa. A formal Register is maintained for each type of EMS certification. All health practitioners in The Republic of South Africa are regulated by the Health Professions Council of South Africa (HPCSA) in terms of legislation set out in the Health Professions ACT. To confirm a practitioner's qualification and license you can check the I register

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South African EMS rescue scenes

Future training

Recently, the Health Professions Council of South Africa (HPCSA), has begun steps to change the system of education in the Emergency Services and they hope to change the EMS training system by 2010. These steps would involve limiting short course ( BAA ) and only having a 2-year nCert (Intermediatte level qualification) and B-Tech (ALS level qualification). Given the economics of the system and its current reliance on volunteers in some communities and locales, it remains unclear whether it will be either possible or practical to eliminate the BAA certification for anyone other than paid staff in the near future.

The mid-level course is 2 years in duration, and exits on a level slightly above Ambulance Emergency Assistant (AEA), but below Advanced Life Support (ALS). They are placed on the Emergency Care Technician (ECT) register. The clinician qualification is a four-year professional degree in Emergency Medical Care (Bachelor Emergency Medical Care), and is placed on the Emergency Care Practitioner (ECP) register. The only four institutions in the country currently presenting the ECP qualification are the:

• University of Johannesburg
• Central University of Technology
• Durban University of Technology
• Cape Peninsula University of Technology

Medical oversight

Under the old system, all levels of EMS personnel essentially functioned as an extension of their Medical Director's license to practice medicine. However, under the new system both Emergency Care Technicians and Emergency Care Practitioners are permitted considerable latitude with respect to independent practice. Standing orders or protocols do exist, and consultation with a physician (particularly for the ECT) is an option, but for the most part the ECP and CCA functions as a fully independent practitioner, similar to the Paramedic Practitioners in the UK.

Staffing

Currently, ambulances are staffed by the BLS and ILS practitioners, usually working paired together (BAA & AEA). In many volunteer services however, at least some of the time a crew of two BAAs is not uncommon. The ALS providers (CCA) normally work on rapid response vehicles to improve response times. CCAs are required to be dispatched in support of the ambulance crew to all Priority 1 (Code Red) patients (those with high-acuity conditions or injuries). The national objective is to have one staffed emergency ambulance for every 10,000 population by 2010, however, in some parts of the country this ratio is currently approximately 1 ambulance for every 30,000.

Vehicles

The vehicles used by EMS in South Africa can vary greatly across a broad range. They may be large or small, new or quite old, often driven by local economics. There is no specific current standard for ambulance design in South Africa. Some vehicles comply with either the European standard CEN 1789 or the US standard, KKK-1822, but many meet neither standard. There are even examples of motorcycles with stretcher-carrying sidecars. There is currently a major initiative underway by the government of South Africa to replace much of the ageing existing fleet with brand new, high standard emergency ambulances. Current plans call for the replacement of approximately 450 ambulances by 2010.

Dispatch

In the past, EMS dispatch has occurred from a variety of sources, and in many cases, involved self-dispatch, as the currently operating private companies still do. The evolution of EMS is seen in South Africa as a national priority, and the government has created a National Emergency Medical Service Strategic Framework, complete with both goals and timelines. The current objective calls for centralised dispatch to be available from at least two call centres, located in major centres, in each South African province by 2010. A national emergency telephone number for EMS has been established. This number is 10–177.

Response times

There are currently no official "response time" standards in the South African system. However, response times of fifteen minutes for high-acuity calls in urban areas are considered acceptable, and in rural areas, response times of up to forty minutes for similar calls are not uncommon.

See also

• Health in South Africa

Further reading

• "International EMS systems in South Africa: past, present, and future", C . MacFarlane et al., Resuscitation, Volume 64, Issue 2, Pages 145–148.