International Medics visit Ministry of Health Ambulance Depot

See Paramedics in Gaza for original post

Yesterday we visited the Ministry of Health’s ambulance depot in Gaza City. The government’s ambulance service runs alongside that of the Red Crescent, the Civil Defence, Military Medical services and some some small NGOs. The day-to-day emergency calls are predominantly responded to by the Red Crescent, but the Ministry of Health vehicles have the capacity to assist at busy periods and especially during conflicts.

They also run many community first aid trainings, health professional refresher trainings and have recently participated in some Majax (major incident) drills with other services. During quieter periods the MoH ambulances mainly run patient transfers, including taking dialysis patients to appointments, transferring between hospitals and taking patients to the Rafah and Erez border crossings for treatment abroad. They have about 30 intensive care ambulances and 67 first response vehicles, with 23 EMT-Is/nurses and 142 first responder (EMT-B) drivers. At present they are short of some nurses who have been recalled to hospital Emergency Departments due to staff shortages.

We had a long talk (and coffee) with a few different managers, who were all formerly on the road and will still get back into uniform in times of crisis. Then we had a look round some of the ambulances in the depot, talked to some of the crews and tried to get our heads round the huge issues facing the ambulance service here. In many ways, the ambulance service is a microcosm of Gaza in general. The complex problems facing it as a service are also the problems facing the wider population. There’s the huge issue of the Israeli blockade, now compounded by the political situation in Egypt. Then there’s the border closures, which leaves intubated patients waiting at the Erez crossing into Israel for hours while the medical team keeping them alive watch the oxygen and equipment batteries run down.

There’s the resulting scarcity of resources that means that the MoH ambulance have no non-rebreather masks (something that we use routinely and offhandedly back home) among many, many other items.  There’s the crippled economy, a government that can’t pay its workers on time and the resulting poverty and 50% unemployment rate. Then there’s the dependence on international aid, the lack of training opportunities and inadequate infrastructure. And of course there is constant tension and violence, with occasional vast and devastating military aggression.  In short, these broader issues combine in the health service to make the provision of even a basic standard of care exceptionally difficult.

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Looking around the depot, nearly every ambulance is a different make and model… The service is basically dependent on international aid and foreign donations – the ambulances have been sent by many different countries at different times. The result is a total lack of standardisation. The challenge of keeping all of these ambulances on the road is pretty overwhelming, with each vehicle needing different maintenance and parts. Any parts that need to be sent into Gaza from abroad are at the mercy of the tightly controlled border crossings – at present there are two ambulance that have been in the garage for more than three months awaiting parts.  That’s before you get inside the ambulance, where the fittings and medical equipment are different for literally every vehicle. Many of the vehicle interiors are not up to international safety standards with inadequate ventilation in the back, fittings that cannot be deep cleaned and limited safety features for crews. Learning how to use a defibrillator is hard enough – the crews here have to learn how to use at least 5 different models. Then there’s all the different ventilators, the various stretchers, the changing layouts. It’s ten times the work just to get the basics.

Lifepak 15 defibrillator used in the UK

Much of the equipment has been donated for a reason – its old and no longer used in the donor country. It’s better than nothing, of course, but it was shocking to see some of the equipment in use. One ambulance had a defibrillator the size of a briefcase with no screen. So you can defibrillate someone, sure. But you don’t know what cardiac rhythm you’re defibrillating – you’re basically having a go and hoping for the best. It’s hard for me to comprehend when I’m so used to a nice flashy Lifepak 15 which does everything short of fold the blankets. In a

Defibrillator used in Gaza

cardiac arrest it gives me the cardiac rhythm (or lack of) in my patients, it can time and pace my CPR, it can note down the drugs I’ve given, monitor my patient’s oxygen, CO2 levels and blood pressure, and verify my intubation. If I give any shocks it prints me out a nice little record afterwards of the heart rhythm before and after each shock, as well as a summary of the entire job. By comparison, the machine we saw yesterday sends a shock when you press a button. That’s it.

This is the result when a political crisis, failing economy and conflict without end converge. Reliance on piecemeal donations means standardisation is impossible, let alone service improvement. International aid works until the day that you are no longer a priority. The crisis in Syria has resulted in a huge withdrawal of aid from the ambulance service here as money and support migrates to a more intense crisis. For example, until 2013 the International Committee of the Red Cross were paying to maintain 62 MoH vehicles, then it was 5 and now its none. They used to pay for uniforms, now they don’t. You can’t argue with the simple economics – the Red Cross have finite funds and the situation in Syria is desperate. But it underlines the huge instability of an ambulance service (and broader health system) relying on aid to function.

We had a good look around a few ambulance and chatted with a few crews. As with the Red Crescent, it’s great to find the common ground between ambulance workers around the world. This time the managers were asking us how our systems manage Emergency Department handover times and triage. They looked disappointed when we told them that neither the UK or New Zealand seem to have cracked it yet. They were also pretty astonished to hear how much of our work in the UK is alcohol related (it is prohibited here, which gave me the strange experience last night of a load of completely sober football fans in the street below after El Clasico last night). In Gaza there isn’t drunken chaos on a Saturday night but there are alot of motorbike crashes as young lads ride smuggled motorbikes with no licence or helmet and two friends on the back. We plan to write alot more about the working conditions for ambulance crews here, hopefully with some interviews so the EMTs can speak for themselves. We’re also heading back to the MoH soon to discuss things in more depth, visit some other ambulance stations and discuss trainings.

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