Article Info
Year: 2009
Month: October
Issue: 4
Pages: 24-25,29
Reference: Al-Shaiban H., Choudhry A., .Saudi Epidemiology Bulletin. 2009;16(4):24-25,29.
Provision of health care to sick hajjis is entrusted to the Ministry of health, while the Saudi Red Crescent Society (SRCS) shares the responsibility of transportation of these patients and provision of first aid and emergency care. However, the role of the SRCS in health provision, especially in relation to patient transportation to MOH health facilities, has not been studied adequately.
A descriptive cross-sectional self-administered questionnaire-based study was conducted in Makkah and Mina centers during Hajj 1429 Hijra to assess the workload and practices of the medical teams of the SRCS regarding referral and transportation of emergency cases to health facilities; and to assess the coordination and communication mechanism between SRCS and MOH teams regarding referral and transportation of emergency cases. Of the 22 SRCS centers in Makkah and the 35 SRCS centers in Mina, 11 centers in Makkah and 16 centers in Mina were selected randomly; while all 111 teams posted at these centers were included in the study (55 teams from Makkah centers and 56 teams from Mina centers).
One hundred and one (91.0%) team leaders were Saudis, with mean age of 30 years (SD ± 6); 10 (9.0%) leaders were paramedics, 92 (82.9%) were Advanced Emergency Medical Technicians (EMT) and eight (8.1%) were Basic EMT. Regarding their training, 106 (95.5%) had one or more certificate in life support, and 83 (74.8%) had attended at least one training course during the past year. The team leaders had an average experience of 7 years (SD ± 6); 92 (82.9%) had previously participated in Hajj duty under 5 times, 33 (29.7%) were participating for the first time, and only 19 (17.1%) had participated over 5 times. The study showed that 17 (16.3%) team leaders had performed 100 and more Cardiopulmonary Resuscitations (CPR) during their entire career, 87 (78.4%) had done less than 100 CPRs and 7 (6.3%) had not. Endotracheal intubation (ETT) had been performed over 25 timesby 9 (8.1%), 1 – 25 times by 73 (66.0%), and 29 (26.0%) had not done any ETT during their whole career.
Information about patients was available for 109 teams. These teams had received 1,381 emergency calls in the last duty shift, with a mean of 13 calls (SD ± 5) for each team (range 5 – 22). Out of these emergency calls, 208 had been cancelled for different reasons and 156 of the emergency cases had been shifted to hospitals by others before the teams could reach the scene.
The total number of cases attended by the 109 teams was 1,342 cases (mean = 12 cases, SD ± 5) during the last duty shift. Emergency care was provided for 1,154 hajjis (mean = 11, SD ± 4) for each team. However, 172 cases were not given emergency care by the teams for different reasons: as 107 were not emergency cases, 50 cases refused medication, 12 cases were found dead, and 5 cases could not be found. One hundred seventy nine cases were given care and referred, or advised to go to hospitals or PHCC by themselves without transportation as they were mild cases; while 813 cases were transported to hospitals (mean 8, SD ± 3, for each team) in the last shift.
Teams managed a total of 987 cases, whose disease distribution is given in Table 1. CPR was performed for 40 cases by 24 teams (21.6%), and 87 teams (78.4%) did not perform any CPR in the last duty shift. Automated External Defibrillator (AED) had been used for 15 cases by 8 teams only (7.0%) in the last duty shift, while 103 teams (93.0%) had not used it.
Response time for teams ranged from 1 to 90 minutes (mean 12, SD ± 12). Transfer time of the emergency cases from the scene to the nearest hospital ranged from 2 to 45 minutes (mean 15, SD ± 9).
One hundred and three team leaders (96.3%) of 107 reported some delay in transporting cases to hospitals. The most common reasons indicated were overcrowding of streets (82.0%), delay during locating the emergency case inside the camp or the scene (43.2%) and delay due to poor support from traffic/security staff (39.6%).
Only 41.1% of team leaders reported coordination and communication with the hospitals before transportation of cases.
Editorial note:
Organizing emergency care and transportation services during hajj is an immense task and, apparently, SRCS management is performing this job efficiently.
Regarding suitability of the assigned persons for the job, this was the first time of participation in hajj for 29.7% of the team leaders. Since Hajj is a unique emergency situation, it is preferable if team leaders had some previous experience of hajj duty. The study showed that a small percentage of team leaders (6.3%) had never performed any CPR, and about a quarter had never done an endotracheal intubation during their entire careers, which could create a serious handicap should the need arise.
The common diagnoses of the handled cases included non-specific fatiguability, malaise, and muscular pains, followed by fever, hypertension and acute abdomen. Pattern of diseases observed in this study appears different than the Dhaffar’s study, which investigated patients transferred by SRCS ambulances to the emergency of a hospital during the month of Ramadan, which is similar to Hajj in terms of over crowdedness. The study demonstrated that the highest proportion of diagnoses was contusions, lacerations, abrasions and cut wounds mainly due to car accidents.1 One of the reason for this difference may be that in Hajj the period is longer than Umrah in Ramadan and that Hajjis have to perform many religious rituals in a very limited time period. For example, hajjis have to walk very long distances which make them prone to fatigue, malaise, and muscular pain more often than those performing Umrah during the month of RamadanAn
Another justification is that quiet a few cases handled by the SRCS teams were assessed as mild illnesses and were not transported to the health facilities, but were included in the listing of diagnosis of cases; whereas Dhaffar’s study described only the cases received at the hospital emergency room, who are, in fact, the more severe cases than those observed in the field.
Although crowdedness in Mina was extreme during the time this study was conducted, the response time revealed in this study is remarkable. As compared to Al-Ghamdi’s study on emergency medical service rescue times in Riyadh, which reported an average rescue time of 35.8 (± 6.4) minutes, the response time in this study was 10.23 (± 5.6) minutes.2 However, this could have been achieved because of the close locations of the centers to the Hajjis camps, particularly in the Mina area, allowing faster accessibility to the nearby camps; in addition to the small size of Mina, as compared to Riyadh city.
This study showed that there was very poor communication and coordination between the SRCS staff and MOH staff before transporting cases to ER. This poor communication and coordination may lead to delay in accepting cases in ER or arranging for beds if they require admission, which may be life threatening and may prevent the EMT team from responding to other emergency calls.
References:
1.Dhaffar KO, Sindy AF, Gazzaz ZJ, Shabaz J. Evaluation of an emergency service attempted by the Saudi Red Crescent Society. Saudi Med J 2005; 26(2): 357-359.
2.Al-Ghamdi AS. Emergency medical service rescue times in Riyadh. Accid Anal Prev. 2002 Jul; 34(4):499-505.
Table 1: Type of cases attended and managed by medical teams of Makkah and Mina SRCS centers during Hajj season 1429 H .
|
Problem
|
Total
|
95 % C.I
|
|
|
No.
|
%
|
||
|
Non-specified
|
158
|
16.00
|
13.82-18.40
|
|
Fever
|
143
|
14.49
|
12.40-16.79
|
|
Hypertension
|
129
|
13.10
|
11.07-15.28
|
|
Acute abdomen
|
126
|
12.80
|
10.79-14.96
|
|
Bronchial asthma
|
75
|
7.60
|
6.07-9.38
|
|
Syncope
|
58
|
5.90
|
4.53-7.48
|
|
Hyperglycemic coma
|
52
|
5.30
|
4.00-6.80
|
|
Hypoglycemic coma
|
52
|
5.30
|
4.00-6.80
|
|
Gastroenteritis
|
41
|
4.20
|
3.04-5.54
|
|
Seizures
|
26
|
2.63
|
1.76-3.78
|
|
Angina
|
22
|
2.22
|
1.44-3.30
|
|
Trauma without coma
|
16
|
1.62
|
0.96-2.56
|
|
Electrocution
|
16
|
1.62
|
0.96-2.56
|
|
Myocardial Infarction
|
15
|
1.51
|
0.89-2.44
|
|
Trauma with coma
|
13
|
1.32
|
0.73-2.19
|
|
Burns
|
13
|
1.32
|
0.96-2.56
|
|
Chronic Heart Disease
|
8
|
0.81
|
0.38-1.53
|
|
Vaginal bleeding
|
7
|
0.71
|
0.31-1.40
|
|
Road Traffic Accidents
|
5
|
0.51
|
0.19-1.12
|
|
Labour
|
5
|
0.5
|
0.19-1.12
|
|
Bleeding
|
3
|
0.30
|
0.08-0.82
|
|
Fracture
|
2
|
0.20
|
0.03-0.67
|
|
Cerebrovascular Accidents
|
1
|
0.10
|
<0.00-0.50
|
|
Choking
|
1
|
0.1
|
<0.00-0.50
|
|
Heat stroke
|
1
|
0.1
|
<0.00-0.50
|
|
TOTAL
|
987
|
100%
|
|