EMS in Oaxaca: An Approach to the Differences

in Emergency Medicine 



Introduction

For my independent project, I am studying the differences in EMS between Vermont (United States) and Oaxaca (Mexico). I am researching this to find the differences in patient care and available funding; which ultimately defines patient care. One factor that I suspect, is there is less funding here than in Vermont. Funding is a huge part of pre-hospital care as it shapes the level of care that a patient is able to receive. I would like to know how EMS in Oaxaca manages with minimal funding for EMS. I am curious to see how they may work around this issue and still be able to maintain adequate patient health care. 

Background Information

I have worked in emergency medicine in the United States for nearly 3 years now. I work on an ambulance department in Northfield, Vermont as an advanced EMT and I have worked in 2 different emergency departments in the state of Vermont. With this experience, I know exactly what I am comparing the care here to. This saves the step of me needing to research EMS care in Vermont. However, there exists a new and potentially different form of EMS care in Oaxaca. This is what I will be comparing my knowledge of EMS in Vermont to. In order to make sure I understand these differences to the extent that I would like, I needed to find an ambulance department to volunteer at. So, my first step was to briefly interview people in Oaxaca to find out which ambulance department would best suit me. I started by interviewing a doctor in Capulaplam. He told me that the ambulance departments there are only for extreme emergencies which only happen 2-3 times each year. Knowing this, I decided to move my attention away from the pueblos and to the city of Oaxaca. I interviewed a fire fighter who also works on an ambulance department, and he told me that I would need to ask the Red Cross located on Bustamante if I could volunteer there. He suggested the Red Cross to me because they handle the majority of emergency calls and that also it would be the best reflection of pre-hospital care in Mexico, as the Red Cross is essentially the same in all of the cities in Mexico.

The Red Cross here is part of the World organized Red Cross, however it differs from the U.S. Most cities and towns in the United States have municipality-run ambulance departments that are a part of the individual town or county. The Red Cross in the United States is known mainly for its contribution of blood donning and help with food and water during emergencies. The Red Cross in Oaxaca is also known to help in emergencies, but its role here is much more defined by its presence as a permanent city ambulance department. 

According to "Municipality of Oaxaca, Guelaguetza (in Spanish). Oaxaca. 8 September 2009", the municipality of Oaxaca has a population of 265,006 in an area of 45.48 km squared. Of these people, 97.14% live in the central city, which means that approximately 257,427 residents are subjected to emergencies that may require an ambulance. I should state, however, that the Red Cross is not the only ambulance department operating in the city. There is the Red Cross, and also a fire departments that has two stations and ambulance departments, along with private ambulances that run out of clinics and hospitals. Obviously, there are more people concentrated here than in Vermont, but it is the quality of care that I am interested in, not the quantity of patients or call volume.

The entire state of Oaxaca has the same ambulance                                        The orange in this map represents the Red Cross primary coverage area.

departments ran through the Red Cross, along with                                        There are also some exceptions when help is needed in nearby areas in

various private ambulances and hospitals.                                                       in which case the Red Cross will respond.

According to "AAOS, Care and Transportation of the Sick and Injured", in any given emergency that requires immediate medical attention, care must be initiated and completed within what is known as the "golden hour". This hour is broken down into the following: 10 minutes for EMS to be called and arrive at the scene, no more than 20 minutes at the scene initiating care and preparing the patient for transport, and no more than 30 minutes transporting the patient to an appropriate medical facility. If this time of caring for a patient exceeds one hour, the chances of permanent injury and death increase drastically. This is something that I am going to keep in mind as I interact with Red Cross members and patients here in Oaxaca city.

Information from  http://en.wikipedia.org/wiki/Oaxaca#Health states that emergency medicine in the state of Oaxaca, Mexico serves a population of roughly 3.5 million people.  Of this population, roughly 95 percent receive health care from at least one government agency. Oaxaca consists of 1,020 primary health care medical facilities and 28 hospitals which are staffed by 3,337 doctors, 5,400 paramedics, and 6,887 other health care providers. A primary health care medical facility in Mexico has the capabilities to provide quality care just as in the United States. And although they do not have as much money as the United States, their protocols are nonetheless mandated by the World Health Organization just as in the United States (http://en.wikipedia.org/wiki/Primary_health_care). Oaxaca is, however, one of the poorest states in Mexico, and because of this they may lack some of the medical care that other wealthier states may be able to afford. For instance, the state of Nuevo León has about the same population, but has about twice as many hospital beds than Oaxaca.  It is also estimated that 44% of women here receive pre-natal care from people who are not medically certified. In the state of Oaxaca, there are 95.1 maternal deaths per 100,000 which is over the national average of 63.3 (http://en.wikipedia.org/wiki/Oaxaca#Health). Although the city of Oaxaca has more modern equipment, a lot of the rural pueblos do not, as I discovered from my interview with one of the doctors at the clinic in Capulaplam (http://paramedictv.ems1.com/Media/1702-Mexico-EMS-getting-local-fire-engine-ambulance/) In most of the rural parts of the state such as Capulaplam and Santa Anna de Valle, there exists a clinic which has some equipment to care for day to day problems such as the flu. These clinics are usually staffed by 2 – 3 medics who have received two years of training in a medical program.

Research Plan

I had an interview for a job with the Red Cross on Bustamante on Thursday, March 1st. The interview was conducted just like a regular job interview would be. I presented my certifications to prove that I am legally able to care for patients, I told them my goals as I have stated above, and they had a brief conference with the two directors and assistant chief and told me that I could start working immediately if I would like to.

For the first two weeks I had to study medical terminology in Spanish. This had to be done before interacting with patients and fellow EMS (TUMS, as they call it here) members in the field. The next two weeks were to be an explanation and evaluation of the equipment used in their ambulances. This was all overseen by a training officer, and I have passed this provisionary period, which means that I am permitted to go on ambulance calls by Tuesday, April 3rd.

The equipment used here was surprisingly similar to what I use in Vermont. Some of the equipment is even manufactured by the same brand, meaning that it is literally the exact same piece of equipment I would use in the states. Below are some pictures of the equipment used here. I will also give a description of some of the differences I have found so far:

Shown in the left picture is a BVM. This is used for ventilating patients. This particular instrument is important in my study because although it is the same, this one looks a little bit old, as one can tell from the picture. The reason is because it is old; about 10 months old, in fact. In my ambulance department in Vermont, once a BVM or any piece of equipment is used, it gets properly discarded. Here, there is not enough funding for a new one every time. They do, however, have a special way that they clean and sanitize them for continued use, which is cheaper for the department and the cleaning is more-or-less sufficient. These are the types of differences that I expect to encounter more often than actual differences in patient care. The reason I say this is because again, the World Health Organization mandates all EMS care. This means that it is relatively constant throughout most developed/developing places. There are obviously places in the world that do not even have ambulances and people die more frequently, and there are also places that do not follow the protocols mandated by the WHO. However, this does not seem to be the case in my experience here. The main difference here is simply a lack of funding to have modern equipment and to be able to replace equipment after every use. There is an especially important piece of equipment which all ambulances should have, but no ambulance at the Red Cross can afford. This machine is the AED and Zoll monitor. This piece of equipment is vital in every ambulance in the United States and is simply too costly to afford in the ambulances here, although they are present in the hospitals. This 20,000 dollar machine analyzes heart rhythms, takes automatic blood pressures, measures how much oxygen a patient is receiving, and can also shock a patient in cardiac arrest; its most important function. During a period of cardiac arrest, this machine is one of the most important an ambulance crew can have. According to AAOS, access to an AED during cardiac arrest is the most important factor in determining a positive patient outcome. Without AEDs in the ambulances here, there best option is to arrive at a hospital as quickly as possible.

Interviews:

Capulaplam:

Here, while waiting for our massages, I was able to speak with one of three medics who work at the health clinic in Capulaplam. The medic had been working at this health clinic for about 3 years, as soon as he completed his two year medical program, which he had to take in Oaxaca city. The majority of the visits and checkups there are not severe. The health clinic usually sees minor health concerns such as the flu and scorpion stings. In the facility they had no reception, only people waiting to be seen by a medic who was working alone at the time. Serving a population of about 2,000, this clinic is very similar to the clinics in most other small pueblos. The clinic had some modern equipment such as electronic blood pressure monitors, but still lacked much of the equipment found at a hospital. The one thing that separates this clinic from the Red Cross is that they had 1 AED machine which is used for cardiac arrest. My attention, however, is towards the ambulance. I looked in the back of the small ambulance they had, which is only used for serious emergencies, such as a heart attack or car accidents. The ambulance had some equipment such as a small selection of IV equipment, a back board, and some breathing apparatuses. Because the clinic is so small, most equipment is kept in the clinic and used there, as they could not afford to purchase separate equipment for the ambulance and clinic. In emergencies, the doctors come to the clinic together, bring the necessary equipment from the clinic with them in the ambulance, and proceed from there. The clinics are interesting because they provide a small level of care in comparison to big cities, however the call volume for the ambulance is about 2-3 emergencies each year. And the clinic usually only sees a few people a day with general health concerns. The pueblo clinics are not suited to my needs because there would probably not be an ambulance call while I was there, however they are very interesting and necessary because a lot of Oaxaca is concentrated in rural pueblos such as Capulaplam which means that a high number of Oaxacans receive medical care in this fashion. The medic told me that if people needed long-term care, or more advanced care, that they would need to go to the nearest hospital located about 30 minutes east of Capulaplam.

Red Cross:

Each member at the Red Cross has undergone the same training, with the exception of the directors. Each member has a certification in TUMS (or Emergency Medicine as it is called in the United States). With this certification, which takes 1 year to obtain, members can operate the ambulance and provide patient care which includes many of the things that I do in the United States, such as IVs, patient assessments, Oxygen, and the administration of medications. Each working member at this Red Cross is paid, however, they do have a volunteer program but it is not required to take the 1 year course if only a volunteer. The director of the ambulance department and clinic is a licensed medical doctor who has worked in parts of the United States like Texas. There is a director of just the ambulance department, Ami, and she has worked for the Red Cross for almost 11 years now. She has the equivalent of a paramedic license. This is the person who assumed responsibility for me while I work there, and she needed to be present when I ran ambulance calls.

Ami - chief of department:

I met with Ami briefly to find out if their were any things that she would change about the department if it were possible. She mentioned three important things: 1) new equipment. The equipment they use is often old or of bad quality. One can tell that Ami is dedicated as she would want better patient care over a higher salary. Ami mentioned that there is a cross between having new equipment and being able to operate 24/7. Obviously they have chose to operate 24/7 and chose to lack better equipment. 2) Uniforms that are purchased by the department or funded through an agency. 3) More members to even the work load of the members that the Red Cross employs now (which remember is 6).

Some logistics of the department:

This ambulance department and building has been located on Bustamante for 83 years; operated by the Red Cross for all of them. Here there are 2 big ambulances that can fit two patients each (the ambulances most commonly seen in the United States), 6 van ambulances which are smaller but contain the same equipment, 1 first responder truck, and 1 search and rescue vehicle. During an emergency, each ambulance is staffed by two EMT's and 1 driver. The ambulance department itself only has 6 permanent members who are paid, as well as 2 or 3 volunteers who work when they have time. In times of serious emergencies, members from the Red Cross clinic help run ambulance calls. There are 10 people who work there including the director, who sometimes need to offer their assistance to the ambulance department when needed. Because there are only 6 working members at the ambulance department, their shifts and work schedules are long-lasting and intense. The shifts are from 7am - 9pm each day, and each member works 6 days per week. Their schedules are set as each member works the same 84 hour shift per week.



The salary of the members is very low. The rate is 200 pesos per day, or 1200 pesos per week, or 60,000 pesos per year and includes no benefits or retirement plans. The department receives a salary at the beginning of each year which is made to last the entire year. The money comes exclusively from donations from a wide range of people and companies. Nothing here is funded through the government. Also, the ambulances do not charge patients for the health care services. Each person in Oaxaca has the same access to free health care. The members here have to buy their own uniforms which cost 1,000 pesos and include 1 pair of pants, 1 shirt, 1 pair of boots, and 1 vest. They are also required to purchase their own helmets which they use when they are on the roadways. These helmets cost 2,500 pesos each. Along with the uniforms, the members are required to purchase their own medical kits and supplies when they need to be replaced. The money that comes from the donations is just enough to cover ambulance repairs and building maintenance. The rest of the costs are covered by the dedicated members that work here. 

     $12,500 for these 5 helmets, all paid for with the member's own money. 

This is proof that it takes dedication, and most of one's time to work at this ambulance department. Though there are difficulties with money, these are the ways that the EMT's work around those issues: by dedicating most of their time, using a lot of their money to buy supplies and uniforms, and having a true passion for the job because otherwise, it might not be worth all the hard work.

Reflection and Discovery:

I have reached a fairly good understanding of the issues the Red Cross faces here; the issues that affect patient care. Patient care is enhanced drastically when there is access to sufficient funding, as in the United States. Patient care here is lessened due to the lower funding that this department receives. Although the same equipment is used over again, the members do what they can to make sure their equipment is as sanitized as it can be, and that when equipment breaks or malfunctions, the EMT's purchase replacement equipment with their own money. Although we have seen the struggles and difficulties in the department, they nonetheless change their ways in order to ensure that there is medical care for the public each day of the year at no cost.

The knowledge that I have gained here is immense. Not only did I get a chance to learn medical terminology in Spanish, I also had the opportunity to continue my EMS career here with almost no break in between. Going back to work again in the United States will be another new opportunity for me. There I will truly be able to reflect on the differences in patient care as a result of the funding available.

Self Assessment:

I have learned much about how EMS operates in Oaxaca, which is also an accurate reflection for most of Mexico's cities. I learned that there are not many differences in the level of patient care people receive. If anything, the Cruz Roja has a higher level of care than ambulances in the United States because they also employ doctors and nurses who have a bigger scope of practice and more medical knowledge than EMT's. Through my research here and the ambulance call that I went on, I was able to understand much about the processes of emergency medicine here. I am grateful for the opportunity here at the Red Cross and hopefully can return in the future in hopes of making a positive impact here, even if only on a small scale.

Work cited:

1 - http://www.nationsencyclopedia.com/economies/Americas/Mexico-POVERTY-AND-WEALTH.html

2 - http://www.emtlife.com/archive/index.php/t-17865.html

3 - http://en.wikipedia.org/wiki/Oaxaca#Health

4 - http://en.wikipedia.org/wiki/Primary_health_care

5 -  http://en.wikipedia.org/wiki/Oaxaca#Health

6 – http://paramedictv.ems1.com/Media/1702-Mexico-EMS-getting-local-fire-engine-ambulance/

7 – Interview with a medic in Capulaplam – Friday, February 10, 2012 @5 pm

8 – Interview with Red Cross member – Friday, February 24, 2012 @4:30 pm

9 - http://www.ifrc.org/en/what-we-do/where-we-work/americas/mexican-red-cross/

10 - http://www.ifrc.org/en/what-we-do/health/

11 - http://www.ifrc.org/en/what-we-do/health/ifrc-health-in-numbers/

12 - http://bomberos-de-oaxaca.es.tl/Visi%F3n.htm

13 - http://www.youtube.com/watch?v=yKFiwhWM50o

14 - "Care and Transportation of the Sick and Injured". AAOS. 2012 Jones and Barlett Learning LLC.