According to a data released by World Health Organisation (WHO) in 2004, cardiovascular diseases alone account of 10 per cent of the disability adjusted life years (DALY) lost in low and middle-income countries. In an article published in the American Journal of Public Health Mr King E mentioned that injury accounts for 16 per cent of global burden of diseases and about 90 per cent of the total burden of injury occurs in low and middle income countries. His finding reveals that with the same severity of injury, the probability of survival is six times worse in developing countries. WHO apprehends that death due to road trauma will exceed 2 million per year globally.

We know for sure that we can reverse this situation only if we refurbish our existing medical facilities. To do so we need to identify where we are lacking. My focus for identification are:

*Absence of extended umbrella of Emergency Medical Service (EMS)

*Poor doctor to patient ratio

*Inadequate specialised emergency care units/centers

*Lack of core hospital attention due to inadequate number of paramedics and first aiders

*Inadequate Ambulance car network

*Absence of a nationwide single telephone number dedicated to EMS

*Difficulties in identifying the municipal holding due to improper numbering and absence of simple road signs

*Road congestion

*Inadequate number of licenced paramedics. Even available paramedics are neither well trained to handle emergency cases nor are they equipped enough to treat such cases

*Hospitals are not designed to handle sudden rush of casualties

*Paramedics available are not volunteers and bulk of whom come from humble economic background. Therefore, they utilise their training mainly as a means of income generation and lacks spirit volunteerism

*Lack of clear policy to define whether the paramedic could use Cardiao Pulmonary Resuscitation (CPR) and life saving drugs, drugs for resuscitation or otherwise

*Absence of fund allocation for EMS

There are yet many more areas that warrant our attention. There are areas of technical and technological sensitivity that would require experts to handle.

Today we talk of HIV/AIDS, tuberculosis, malaria or arsenic poising as major health hazards. These diseases do not cause death or incapacitation in a matter of a minute. These are preventable diseases that would need prolonged treatment and hospitalisation while road trauma or cardiovascular diseases kill or incapacitate people almost immediately. Hence in my pleading for focusing on EMS.

There are countries in the world that have separate department for EMS under health ministry while some have independent establishment for EMS, yet some have this in the private sector. Many of the injury related disabilities and deaths would be readily amenable to low cost measures such as simple changes in training, better organisation and planning of services and availability of right skills and the right equipment at right places.

WHO has mapped its health promotion and diseases promotion strategies and has accorded high priority to Primary Care Development. EMS meets the primary needs of the patient and can prevent the social disruption of transfer out of their local community for secondary or tertiary care.

Since the conceptualisation of EMS is recent, exhaustive research should be undertaken to work out strategies and to choose the appropriate tools and practitioners to help save lives that did not warrant death that soon. Following could be thought for our country:

*EMS be treated as long neglected sector to give priority allocation.

*Should be treated as a separate establishment under Ministry of Health.

*Extended network of ambulance service.

*Greater number of people from middle to higher income group be persuaded to take paramedic courses. This training may be considered to be made compulsory for all doing post graduation.

*Issuance of licence to the paramedic be treated more seriously as they will be allowed to provide treatment including IV and resuscitation.

*Triage post be established at various points on the highways and places that are difficult going -- POL filling station could be thought to be used as Triage Post.

*A toll free single number telephone be introduced to make emergency calls.

*Calls that come from emergency call centers be received by hospitals in right earnest.

*Hospitals be instructed to receive the patients as soon as emergency call centers requisition their services.

*Municipal holdings be properly marked and streets be correctly sign posted to make identification easy.

*People at large be made aware to allow safe and priority passage of ambulance cars while on move.

*WHO be approached to help develop local EMS strategies and set priorities to address our local EMS needs.

*Map quality EMS goals and guidelines and set target year to achieve the goals.

*Use the World First Aid day to promote EMS to public.

*WHO and NOO be encouraged to invest more money in coordination with the govt.

*Since Red Cross and Red Crescent movement is already involved in Primary Health Care, they be encouraged and supported to add the task of saving human lives in health emergencies also in non-disaster situations.

*A clear guideline with regard to resorting to Cardio Pulmonary Resuscitation (CPR) should be given when to start resuscitation, when to withhold and when to stop resuscitation. These are the questions that the guideline should address to as CPR quality has emerged as a critical factor. The knowledge to improve the CPR is there but its impact on public health could be large.

There are many more ways to improve and implement quality EMS. Bench marking quality EMS is a gigantic task. With benchmarks in EMS, one can make objective determinations of how one can measure up not just at the service level but also down to the individual technician up to the highest body level involved in EMS. Life saving telemetry from ambulance to trauma center can improve the quality of EMS without much extra cost. Ambulance equipped with telemetry facility can transmit ECG to hospital emergency centre by radio to enable doctor to plan and prepare the treatment before the patient reaches the hospital. The development of paramedic units and mobile intensive care units can help rescue persons and can administer drugs, defibrulate patients and can perform other medical procedures in the field and en route to the hospital.

This is how many lives can be saved and many patients that would have been incapacitated would be brought back to normal life. This is why EMS is so important.

The writer is the former Chairman of Bangladesh Red Crescent Society.