Prehospital emergency healthcare is a vital component of the emergency medical services system in terms of timely and appropriate intervention for sick or wounded patients (Bahadori and Ravangard, 2013). Prehospital care enables the management of emergency interventions based on circumstances and environment and is adapted to the person in need of emergency treatment.
The provision of prehospital emergency health services varies greatly around the world. While doctors are the team leader in ambulances in some countries, paramedics have this responsibility in others, such as in the United States. Others assign either a doctor or a paramedic as the team leader (Page et al, 2013; Wilson et al, 2015).
In the UK, emergency medical services are provided by the NHS and are free of charge to residents and visitors. Emergency calls can be classified as A, B and C using Advanced Medical Priority Dispatch System (AMPDS) software. They are classified as category A if the condition is immediately life threatening, category B if the condition is serious but not immediately life threatening and category C if the condition is not immediately life threatening nor serious.
For category A and B/C calls, an emergency response can initially be a rapid response vehicle other than an ambulance, crewed by a paramedic or ambulance technician equipped to provide treatment at the scene of the incident, or an approved first responder dispatched by and accountable to the ambulance service (Black and Davies, 2005).
Prehospital emergency medical service delivery in Qatar is similar to that in the UK from a staffing, dispatching and equipment/technological point of view. This will be of interest to paramedics contemplating a career move to Qatar, especially in the context of the upcoming FIFA 2022 World Cup being hosted there.
This article presents observations from a visit by a paramedic and an emergency nurse educator to Qatar's Hamad Medical Corporation Ambulance Service (HMCAS) between the 26 January and 1 February 2020 as well as information from the literature, and compares prehospital emergency health practices with those in Turkey.
Qatar
Qatar is located on a 160 km-long peninsula on the west coast of the Persian Gulf. Islands included, it occupies 11 493 km2 of land (Bener and Mazroei, 2010). While the country's economy was based on fishing and pearl gathering for years, oil and natural gas became its main sources of income after their discovery in the country in 1939 (Carter, 2005; Djella et al, 2019).
In line with the airline, navigation, trade and construction sectors, the country's infrastructure and economy developed quickly in the 21st century. This has made Qatar a rapidly developing country in terms of infrastructure and population, despite its hot and dry desert climate (Wilson et al, 2017).
As of 2022, the population of Qatar is 2 826 286 (2 043 351 men and 782 935 women) (Planning and Statistics Authority, 2022; World Population Review, 2022). Rapid developments in Qatar have led to an influx of immigrant workers to help with the construction of infrastructure (Al-Harahsheh et al, 2019); immigrant workers constitute 88.4% of Qatar's population (Planning and Statistics Authority, 2022).
The official language in Qatar is Arabic while English is the second language and used by many people. However, a significant proportion of the population speak neither languages, which can be a problem in the prehospital setting (Graham, 2017).
Prehospital emergency services
Hamad Medical Corporation (HMC) is the biggest health service provider in Qatar. As a government organisation, it provides free health services to the rapidly growing population, the majority of whom are immigrants and their families (Goodman, 2015; Coleman et al, 2016; Coleman and Wiggins, 2017; Al-Badr, 2018).
Alongside the Primary Health Care Corporation, HMC has been improving constantly to respond to and meet the needs of the country's growing population. Striving for ongoing improvements, it recently surveyed its staff and patients who reported overall they thought HMCAS provided a good service to the population of Qatar across a number of domains (Carolus et al, 2022a; 2022b).
HMCAS is part of HMC and provides prehospital care services nationally (Munk et al, 2009; Wilson et al, 2017). It provides prehospital emergency care using land, air and bicycle ambulances within Qatar's borders and sometimes beyond (Pathan et al, 2017; Wilson et al, 2017). In addition, HMCAS provides patient transport, local and international patient transfer services and medical cover for special events such as sporting competitions, including the upcoming FIFA 2022 World Cup (Alinier et al, 2022).
Land medical emergency response vehicles
HMCAS land vehicles are staffed solely by degree-qualified ambulance paramedics and critical care paramedics (CCPs), and are referred to as Alpha, Delta, Charlie and Oscar units (Fares, 2014; Kamel et al, 2016).
The majority of ambulance paramedics are from Tunisia, India, the Philippines, Jordan, Morocco and Egypt, while the CCPs are most often from South Africa, the United States and Australia (Gangaram et al, 2017; Graham, 2017). They all undergo an onboarding and training programme, which enables them to work in line with local standards and culture, and to qualify for their practitioner licence from the Ministry of Public Health, which they need to maintain by completing a minimum number of continuing professional development courses each year.
Alpha unit
An ambulance is referred to as an Alpha unit and is crewed by two ambulance paramedics (Fares, 2014; Wilson et al, 2017; Hamad Ambulance Service (HAS), 2022a).
They are the most prevalent resource across the country since they are dispatched to all emergency calls (Fares, 2014; Campbell et al, 2016).
Once on scene, the ambulance paramedics assess and stabilise the patient, and may decide to call for additional support if further interventions outside of their scope of practice are required, before initiating transport to hospital. After the initial assessment and treatment, if the patient agrees, they are transported to hospital (Graham, 2017). Sometimes, cases assigned an Alpha unit are also assigned a Delta vehicle.
Delta unit
These 4x4 response cars are manned by a single supervisor paramedic (Wilson et al, 2017; HAS, 2022b). They are primarily a non-clinical supervising unit that is used to manage resources and the scene and for communicating with the various emergency services potentially involved in the case (Fares, 2014).
Delta paramedics can provide a global point of view of cases they respond to. Their main focus is safety from a 360° case perspective, team leadership and communication (Kamel et al, 2016).
Paramedics assigned to Delta units generally speak Arabic, have the same clinical qualifications and licence to practise as a paramedic working in an Alpha unit and have worked for at least 5 years in Qatar.
Charlie unit
Charlie units are also 4x4 response vehicles with one critical care paramedic (CCP) and one ambulance paramedic, referred to as a critical care assistant (Wilson et al, 2017; HAS, 2022c).
CCPs have the highest scope of practice in the prehospital care setting in Qatar, with the authority to use a broader range of drugs and equipment, and advanced clinical skills (Howard et al, 2018; Al-Thani et al, 2019). They are dispatched alongside an Alpha unit to the most critical cases as determined by the dispatcher in the National Command Center (NCC) (Al-Badr, 2018; Campbell et al, 2016).
Oscar unit
There are four types of Oscar units.
The Oscar Access (Oscar Alpha) is like a Delta manager unit while the Oscar Effectiveness (Oscar Charlie) has a more clinical oversight and is manned by a CCP manager. Both units are self-dispatching to the cases practitioners feel they need to attend.
Then there are Oscar Quality and Oscar Production, staffed by managers credentialed at paramedic level. These are dispatched only to mass casualty incidents (MCIs) (Figure 1).
Air ambulances
Helicopter emergency medical services (HEMS) have been used for patient transportation for decades and have become a standard component of prehospital emergency care systems, including in Qatar (Al-Thani et al, 2017).
The helicopter ambulances in Qatar are called LifeFlight units. While they belong to the army, among the crew are an ambulance paramedic and a CCP from HMCAS.
They are continuously operational and can be dispatched to remote areas to respond to emergency cases or, sometimes, to transfer patients in a critical condition (Pathan et al, 2017). The patient can be transferred directly to the hospital by the helicopter ambulance team by landing on the helipad on top of a newly extended hospital emergency department and trauma centre in Doha (Fares, 2014; Howard et al, 2018) (Figure 2).
Call system
The dispatch of emergency vehicles (ambulance, civil defence/fire department and various types of police services) is coordinated by the NCC, which uses a single emergency number (999) (Wilson et al, 2017).
Emergency calls are first triaged by a call taker from the Ministry of Interior to determine whether the call is related to fire, health or police. The first information (such as the caller's number and location) is saved in the computer-aided dispatch system (this is called ‘Najem’—an Arabic abbreviation for ‘unified geographic system’).
Medical emergencies are transferred to an emergency medical dispatcher (EMD) from HMCAS, located at the NCC, who determines the main complaint and resources required through a telephone triage process (ProQA) (Wilson et al, 2017).
If a high-priority response is needed, the EMD immediately dispatches an Alpha unit while still collecting information about the case. This information is immediately relayed to the dispatched unit(s) through radio and a mobile data terminal.
If additional units or higher clinical skill levels are required as determined by the ProQA system, the EMD dispatches further units with the same ‘call for service’ reference number.
The EMD remains on the line to give first aid instructions until the ambulance arrives. This may include instructions related to blood loss control, burns and management of basic life support for unconscious patients (Al-Thani et al, 2019). Meanwhile, the EMD also communicates with the dispatched units to give further information about the case through radio. All radio communications are recorded.
The responding unit(s) is directed to the address of the emergency using the mobile data terminal with its built-in global positioning system (GPS) (Wilson et al, 2017).
Under Qatar's National Health Strategy Intervention goals, 75% of patients with life-threatening conditions living in urban and rural areas should be attended to by an ambulance within 10 minutes and 15 minutes respectively (Al-Thani et al, 2019).
Four dispatch codes are used by HMCAS: priority 1/Zulu code; priority 1/Yankee code; priority 2/X-ray code; and Transport (priority 3).
Priority 1/Zulu code is issued for immediate life-threatening situations and is equivalent to category A in the UK. Priority 1/Yankee code is assigned to serious cases and is equivalent to category A in the UK. Sirens and lights are used for all priority 1 calls but not during priority 2/X-ray cases, which are equivalent to category B or C in the UK (Wilson et al, 2017).
Ambulance stations
Prehospital emergency healthcare services in Qatar use a hub and spoke model (Fares, 2014; Wilson et al, 2017). While the hub is the centre of a specific area, the spokes branch off and are used to minimise the prehospital emergency health response time in specific geographical regions (Graham, 2017).
Hubs are more developed facilities than spoke stations as they have more space for the HMCAS staff and vehicles. They include an office and desks for supervisors, supplies, stand-by equipment and spare ambulances (Fares, 2014).
In-vehicle technology
The road vehicles are equipped with a wide range of technology including an automatic traffic light control system for many intersections in Doha. This application, managed by the Public Works Authority, enables a faster and safer crossing of several key intersections by emergency vehicles when their lights and sirens are activated, as they automatically control the traffic lights based on their direction of movement (Wilson et al, 2017).
The vehicles and main assets such as stretchers, portable patient monitors and response bags are also equipped with radio frequency identification technology allowing for quick inventory taking across the whole fleet (Hutton and Alinier, 2013). The technology indicates the date each piece of equipment was serviced and can send a reminder when planned maintenance is required. The system alerts the crew if a tagged piece of equipment is missing from the vehicle as they are about to leave the scene.
As the temperature in Qatar is very high, doing effective manual chest compression is difficult for prehospital workers. Therefore, all HMCAS emergency vehicles are equipped with external mechanical chest compression devices (Meyer et al, 2016).
Logistics and equipment of HMCAS ambulances
Managing the operations and logistics of a large, modern ambulance service is complex. HMCAS has several large warehouses that contain equipment to meet the country's needs for daily operations as well as extraordinary cases.
HMCAS uses a prepack system for all of its disposable supplies, which are stored in response bags and ambulances (Hutton and Alinier, 2013). Items are grouped according to type of clinical intervention; for instance, everything required to establish vascular access is in the same package. This minimises the number of items the crew need to check in the ambulance before starting a shift.
After responding to a case, unused materials in the prepack are brought back to the hub, then transferred to the store, sorted and prepared for future use in a new prepack. Paramedics on light duty work alongside other ambulance attendants in the store to package items.
Prehospital emergency health services in Turkey
Turkey is a vast country, with an area of 779 452 km2 (Çağatay, 2012; BBC, 2022) and a population of 84 680 680 at the end of 2021, which is relatively homogeneous (Turkey Statistical Institute, 2022).
Both the Franko-German and Anglo-American model are used in the prehospital emergency health services in Turkey (Paksoy, 2016; Şimşek et al, 2019). Ambulance and emergency medical services are provided for free (Ekşi, 2016). Doctors, paramedics, emergency medical technicians and nurses take charge in emergency call centres and ambulances, and doctors and paramedics are team managers in emergency ambulances (Paksoy, 2016; Ekşi, 2017; Şimşek et al, 2019). In the most serious cases, teams with doctors, which are limited in number, are dispatched.
After the first intervention has been made by paramedic teams and teams with doctors, patients are transferred to hospital as per the Anglo-American model (Ekşi, 2017).
As in Qatar, the command and control centre is equipped with highly developed technologies, which enable staff to see on the monitor where all the teams are and direct the closest team to the case (Paksoy, 2016).
In Turkey, stations are classified into three categories according to the type of service they provide.
Type A stations
These stations provide 24-hour ambulance cover and more than one team/ambulance may be based at them. Those with doctors on the staff are type A1 stations and those that do not have doctors in the team are type A2.
Type B stations
These stations provide 24-hour ambulance and emergency services integrated with primary, secondary and tertiary health organisations.
Those integrated with the hospital emergency service are called type B1 stations and those integrated with primary health institutions are called type B2 stations (Yaman, 2015).
Type C stations
These are emergency health stations affiliated with the prehospital emergency health services management in terms of administrative and personal rights, and provide ambulance services based on need only at certain hours of the day (Resmî Gazete, 2000), and generally operate on weekdays and for 12 hours only. They are established depending on the population density of an area.
Ambulances are classified as land, air and sea ambulances. Land ambulances are classified as patient transfer ambulances, intensive care ambulances and specially equipped ambulances.
Emergency aid ambulance teams include at least one doctor or paramedic or an emergency medical technician who has completed training as determined by the Ministry of Health, another health professional and a driver. In emergency aid ambulances without a doctor, at least one of the crew members is a paramedic who is clinically qualified to treat the patient.
To work in emergency aid ambulances without a doctor or paramedic, an emergency medical technician must first complete the basic module, which covers trauma resuscitation and advanced life support in children and adults, and hold a certificate.
Doctors and health professionals who work in intensive care ambulances must first complete and hold certificates for the basic module, as well as adult advanced life support and trauma resuscitation courses approved by the Ministry of Health.
Doctors and health professionals who work in the neonatal patient transport ambulance must first complete the basic module and advanced life support in children and/or neonatal resuscitation programme approved by the Ministry of Health and hold a certificate (Resmî Gazete, 2006; 2012).
Air ambulance services in Turkey started to operate in 2008 and were established to provide rapid emergency responses over long distances. Helicopters and fixed-wing aeroplane ambulances are used by the air ambulance services in the country (Şimşek et al, 2019).
Conclusion
Prehospital emergency health services in Qatar are highly standardised, developed and very well resourced with a modern fleet of vehicles. The country's strong economy has enabled it to acquire advanced technology and adopt a model well suited to its geographical and population size. It relies strongly on standardisation of its resources, processes, manpower and integration to the wider healthcare system. In line with this, patient safety is given a high priority with a constant focus on improvement. In contrast with Turkey, the main challenge Qatar faces is to serve a very culturally diverse population, to an even greater extent to that in the UK. JPP