BEIRUT: When the Lebanese Army’s Independence Day preparations paralyzed traffic on the country’s main roads last month, a video of an ambulance stuck in the gridlock generated criticism from social media commentators lamenting the fate of the patient.
But according to several people working in the country’s emergency medical services system, Lebanon’s chronic congestion is the least of their worries in trying to provide reliable and swift care.
Inadequate infrastructure, inconsistent funding, lack of standardization of operations and problems with overall governance are all obstacles. As a result, the country’s first responders, however well-intentioned, are not always the most dependable, particularly in time-sensitive cases such as heart attacks.
While EMS systems vary worldwide, the majority of Lebanon’s first responders are volunteers with the Lebanese Red Cross. Other EMS agencies include the Civil Defense and private companies such as the Patient Transport Service.
Hospitals generally do not have their own fleet of ambulances to serve neighboring areas.
According to previous research conducted by Mazen al-Sayed, the director of emergency medical services and prehospital care at the American University of Beirut Medical Center, only 5 percent of patients suffering from cardiac arrest outside of the hospital’s care survive. Half of the survivors are left with severe brain damage as a result of the delayed aid.
This is partly due to the fact that the majority of the country is not equipped with automated external defibrillators. By comparison, in countries with more developed EMS systems, AEDs are commonly found in schools, offices, gyms and other populated spaces. Designed to be simple, users can operate an AED until paramedics arrive at the scene, increasing chances of survival.
Sayed’s findings are grim. The physician, who previously worked with Boston’s EMS, said the prehospital phase of treatment in these cases is the most important, and that a timely and proper response is essential to improve chances of survival.
“But this is not the fault of Lebanon’s EMS paramedics,” he said. “Ambulances are just one component of the system, but in Lebanon we don’t even have a functioning and reliable system to begin with.”
“There needs to be a standardized operating framework with national standards for prehospital training and certification to establish response times, and proper prehospital delivery care. This framework would study traffic patterns and would allow for proper coordination and communication between hospitals and EMS agencies.”
Sayed also noted that an organized emergency system would clearly define services and hospitals capacity. While one hospital might have a fully equipped emergency department, others may not, requiring ambulances to transfer patients upon arrival.
“Communication is key. Sometimes, we will get a call that someone is coming in with a particular condition. Other times, they will just show up without warning,” he said.
Other hospitals such as the Clemenceau Medical Center have one ambulance on site operated by the Patient Transport Service. Former patients of the center with the appropriate insurance can call directly, said Rola Hammoud, CMC’s chief quality officer. However, the ambulance is mainly reserved for transporting patients already in the hospital to other institutions.
Saint George Hospital University Medical Center in Ashrafieh operates a private neonatal ambulance, specialized for women in labor.
LRC Secretary-General Georges Kettaneh acknowledged the issues facing the organization’s first responders. At the moment, 3,500 trained volunteers work as EMS responders, with over 300 ambulances and 70 four-by-four vehicles.
Is it enough?
Not quite, Kettaneh admitted.
According to him, the LRC averages 12 minutes in its response time to 70 percent of calls, while the remaining 30 percent wait longer.
Comparatively, Sayed said that more developed systems have clearly adopted standards delivering an average response time of eight minutes for high priority cases.
The LRC had considered using motorbikes to arrive on the scene quicker while an ambulance is en route, but ultimately decided against it. According to Kettaneh, using motorbikes could be more dangerous in Beirut’s traffic.
“We need more [ambulances and paramedics],” Kettaneh said.
“It’s a financial problem. The Health Ministry provides us with about 30 percent of our budget, and the rest is fundraising.”
He said that Beirut currently has four ambulances that operate during the day. At night, however, the LRC is not on call and the nearest station outside Beirut is dispatched.
Ideally, Kettaneh estimated that the city should have about 10 to 12 ambulances with full-time staff around the clock.
Bilal Itani, a doctoral candidate in France’s NEOMA Business School, led a peer-reviewed study in October with co-authors Fouad Ben Abdel-Aziz and Hatem Masri, both doctors, recreating a map of the LRC’s ambulances in Beirut to optimize EMS response times.
“Knowing the limited resources, we focused on strategically relocating Beirut’s [LRC] ambulances according to areas receiving the highest number of calls. Additionally, outsourcing help from private agencies, we estimated that Beirut’s EMS service could ensure a 100 percent response rate with an average of nine minutes,” he said.
The additional use of private services would cost the LRC $25,852 monthly, the study estimated.
Taking out these added services, about 86 percent of calls could be covered within the same time span by implementing the ambulance relocation strategy.
“It is costly to have an effective EMS system,” Sayed said. Both Sayed and Kettaneh said that achieving a 100 percent response rate is near impossible. “The reason why it costs so much in other systems to call in an ambulance is because a fully equipped ambulance with trained professionals are available on site 24/7 even if no calls are coming in. If you don’t invest money into the system, then you can’t expect a high quality of service.”
According to Frederick Eid, who is strategy adviser to caretaker Health Minister Ghassan Hasbani, a standardized national plan is in the works.
“Our plan is divided into three phases, with some subphases. The goal is to automate operations and communications between EMS services, hospitals and patients themselves. The system is connected, and there has to be close coordination for maximum efficiency.”
In August, the ministry launched Phase 1A of the plan, in which hospitals in Beirut and Mount Lebanon will work to classify the services they offer.
“This way, EMS services can immediately know where the closest hospital with the most suitable services for the case to be treated is.” For instance, a severely burned patient could go straight to a hospital equipped with the relevant facilities, instead of just the nearest hospital.
Once the system is smoothed out in these regions, the ministry will roll out the plan throughout the rest of the country.
Phase 1A also establishes the most efficient traffic routes to get from point A to B, and develops stronger lines of communications between EMS paramedics and various medical institutions.
“We expect that this phase will be completed sometime in December,” Eid said.
A deadline for the entire plan to be completed, however, remains to be determined.
Sayed is skeptical. While he said that many meetings have been held with the ministry along with the Syndicate of Hospitals and EMS agencies, not much progress has been made.
“Such systems require clear long-term strategy, accountability, medical oversight and financing,” he said, “all of which are still missing in Lebanon.”