Integrated Clinical Clerkship in Emergency Medicine AY 2021- 2022

Early recognition, appropriate interventions, and prompt transfer remain the cornerstone of pre-hospital care. The provision of emergency services results to better clinical outcomes as lifesaving and life-prolonging measures can be given to patients with acute life-threatening conditions before they receive definitive treatment in the hospitals. Especially in far flung and geographically isolated areas where people and patients need to go down the mountain or ride a boat for hours just to get to the nearest hospital or clinic, pre-hospital care is as important as definitive treatment as it drastically improves patients’ survival. Without pre-hospital care, patients are left to suffer on their own along their way to the facility and be in mercy of time. In the documentary “Ambulansiyang-de-paa”, it is evident that pre-hospital care plays a critical role in the management of emergency situations. The difficulties and barriers to health care brought about by the geography of the area, unavailability and inaccessibility of quality medical services and trained medical personnel, and lack of education worsened the way how emergency cases are handled in such scenarios. Not only the pre-hospital care suffers in these situations, but also the entirety of health care including disease prevention, health promotion, and education. Although the documentary was made 5 years ago, it is still near to our present reality. It revealed how difficult our kababayans work just to live on a daily basis. Thus we must continue to push, not only for the improvement of prehospital care, but also for the development of the other areas of our health care system.

Emergencies are inevitable and acute life-threatening conditions may happen to anyone, anywhere. Pre-hospital care is an essential part of emergency response which focuses on caring for seriously ill or injured patients before they reach a hospital, and during emergency transfer to hospital or between hospitals. This will serve as the initial point-of-contact by the first responders or emergency medical technicians. At this level of intervention, even a basic assessment of the patient is crucial and will affect the outcomes of the patient. A lot of factors play a role in pre-hospital care such as a functional protocol, trained medical responders, fully-equipped transport vehicles, and many more. All of these factors matter as time is very essential in responding to life-threatening situations.

But in the iWitness documentary, Ambulansyang de-paa, all of the barriers not just in pre-hospital care, but also in our health system, were revealed.  To this day, geographically isolated areas lack access to basic health care. It remains a challenge for them to get treatment for preventable diseases. Health centers are located far from them and residents had to make a hammock to transport non-ambulatory patients from the mountains down to the health center in order to get treatment. Burn patients do not get proper treatment and suffer the consequences. Just imagine if a functioning pre-hospital care is in place in these areas, we could prevent a lot of these cases from occurring or progressing.

Pre-hospital care is very important, especially in improving the outcome of patients with acute life-threatening conditions, because any treatment that can be given or interventions that can be done on-site or during transportation can be life-saving. If a patient can be immediately secured and stabilized even before reaching the hospital for more definitive care, their prognosis can also be significantly improved. Needless to say, it is essential that quality healthcare, both pre-hospital and hospital-based, be accessible to everyone because emergencies do not just happen in cities or major provinces where resources are relatively more abundant and easily accessible. With this, it is important that quality pre-hospital care be established and reinforced in rural areas as well so that patients and accident victims with time-sensitive conditions can receive the timely and appropriate care that they need.

Pre-hospital care is an essential part of a responsive and well-functioning emergency care system. According to the WHO Emergency Care System Framework, facility or hospital care is just one part of emergency care; the function of a responsive system starts at the scene, which involves the bystander response, dispatch, and provider response. This is where the system is activated, and the time to dispatch and time to scene are crucial so that proper onsite care may be given. The next function is transport, which involves patient transport to the facility and transport care. This usually involves an ambulance where the destination triage and transport care may be performed. Faster transport time and time to provider are also crucial to achieve in an emergency care system. However, as seen in the documentary Ambulansyang de Paa, the reality of pre-hospital care in the secluded areas of our country cannot be any more different. Because of multiple compounding factors, including but not limited to lack of proper road access and scarcity of healthcare facilities, people in these geographically disadvantaged areas are forced to utilize unconventional means to transport those in need of medical care. Due to the lack of roads, dispatching providers to the scene is simply not possible, and thus patient transport becomes the first step of the system. Relying on willing people from their community, patients are transported on foot in hammocks through a 3-4 hour hike along precarious terrain just to get them seen by a doctor in town. But even if they get them to the closest facility, the municipal health center is only equipped to handle basic cases, and may still need to transfer to a bigger hospital if they will not be able to manage the patient adequately. This current system is definitely inadequate and unsustainable, and will inevitably collapse when a bigger emergency occurs. However, the solution is not solely on the part of the healthcare system, but the burden must also be put on other agencies. Health truly is multifactorial, and needs the cooperation of all sectors of the country to ensure that health for all, especially emergency care, is achieved, even for those in the most hidden places of our country. 

Pre-hospital care includes the initial triage and treatment of the patient at the scene followed by the transport to the available health center and handover to the emergency department. When an ambulance is called, this is performed by emergency medical services (EMS) responders. It allows patients to be safely and speedily transported to centers which can aid in the management of acute life-threatening conditions, as well as establishes temporizing measures that could stabilize the patient so that they can survive for longer and have improved prognosis.

However, pre-hospital care is dependent on several factors, such as personal, socioeconomic, and environmental. It is useless to have adequate and reliable pre-hospital care like ambulances when the patients and their families are not aware of what constitutes emergencies. Education plays an important role in pre-hospital care so that the patients can identify true emergencies, call the appropriate numbers, and be transported to the health center or hospital in a short amount of time. Furthermore, education of the family and community would also play a role since the use of CPR is one of the most effective measures of improving outcomes and giving the patient more time to be saved in an emergency. For communities which have never been trained in basic CPR, patients may have already passed away by the time that the ambulance arrives. This is especially true in the Philippines, where the traffic can delay arrival at the hospital. In Ambulansyang-de-Paa, the socioeconomic and environmental factors affecting pre-hospital care are evident. For far-flung and rural communities, there is no easy way to gain access to a hospital setting. Their so-called “pre-hospital care” is dependent on the goodwill of the community and kindness of their neighbors and rural doctors who attend to their needs and walk or carry them for several hours to their destination. The brand-new health facilities that were shown in the documentary are useless when those communities that are supposed to use them cannot even access them. Even though ambulances and emergency vehicles are available, the road infrastructure is inadequate, and the communities are too isolated. It is clear that the rural community in the documentary relies solely on their lone physician. It’s a tragedy to see patients that could have been saved if only they had been brought to healthcare centers earlier.

Pre-hospital care must be improved in the country. It must be made a priority of the government to be able to adequately address the gaps in healthcare, be it in the number of healthcare workers, the access to facilities, the available equipment, the education programs, or the methods of safe and speedy transportation. Trying to address only one factor is a band-aid measure that will eventually fail as long as the other factors are still impeding patient access to healthcare.

Pre-hospital care is often an individual’s entry point into the health care system, and it plays a vital role in acute life-threatening conditions which require timely, coordinated, and comprehensive care. Often, these injuries and illnesses demand immediate assessment and administration of life-saving interventions, and pre-hospital care buys time for these patients before receiving definitive treatment in a more advanced care setting, usually in hospitals and advanced specialty centers. In identifying, prioritizing, and addressing problems first outside of the hospital, pre-hospital care therefore becomes a course-altering factor in the trajectory of these patients by preventing further morbidity and improving prognosis and survival outcomes.

As we acknowledge the indispensable role of pre-hospital care as a door into the health care system, we also identify many diverse social, economic, and political factors that hinder the development of appropriate, responsive pre-hospital care. As highlighted in the documentary Ambulansyang de Paa, we saw how poverty, devolution of health care, geographical isolation, lack of health care personnel, and government neglect of building stronger health systems using the primary health care approach all contributed to the problems of the sitios in Bansud, Oriental Mindoro. These glaring inequalities that all undermine pre-hospital care inevitably create a tall barrier to free, comprehensive health care, and chances of improving health outcomes for everyone all the more becomes nil.

Therefore, it is only just and necessary to call for a whole-of-society approach in improving not only pre-hospital care in the country but the entire health care system as well. After all, we are not only concerned with admitting the patient into our care settings—it is imperative that as the patient navigates through the various levels of care, our referral systems are able to accommodate and respond to their needs while anchoring on the concepts of accessibility, continuity, justice, and quality comprehensive care.

Prehospital care systems are crucial to a patient’s overall survival, as they are often the first responders to medical emergencies. Without a doubt, this is one of the fields our country desperately needs to improve on, especially in rural communities, as these far-flung locations often fall victim to the lack of physicians, empty facilities, and improperly allocated resources in provinces. Many Filipinos have to travel all the way to the capital, despite the distance and increased cost, simply because rural areas are unable to provide this. Although their diseases are curable, they do not have the means to avail of this treatment, thus eventually leading to their demise. It is disheartening to know that many Filipinos may expire without ever stepping foot in

a health center due to the lack of funds, adequate transportation, and access to information. This truly highlights how broken our healthcare system.

The documentary showed the disheartening reality of the consequences of the lack of access to pre-hospital and hospital care in the Philippines. There are certainly a lot of factors at play on why pre-hospital care improves outcomes of patients, especially those with acute life-threatening conditions. First, pre-hospital care enables provision of standardized health care protocols administered by well-trained personnel. This is in contrast to what the documentary film portrays. In the documentary, the medications administered to the patient with tuberculosis are not the proper medications, thus possibly even worsening the patient’s conditions. Second, time is of the essence in diseases and accidents, especially in emergencies. What could have been saved, improved, or ameliorated could possibly worsen if there are delays. In the documentary, it takes approximately 3 to 4 hours for people from the mountain to descend to the municipal health center to seek medical advice and treatment. This shows an integral factor that should be considered in discussions regarding the improvement of pre-hospital care and the overall access to healthcare: the geographically isolated and disadvantaged areas (GIDA) in the Philippines. GIDAs consist of marginalized populations that are physically and socioeconomically deprived of goods and services. Service provision in this population is difficult because it is geographically hard to gain access to them. Thus, more skilled healthcare providers should be distributed to GIDAs to eliminate possible delays and lack of access to quality health care. In the documentary, it was also mentioned that whenever someone was sick, first aid was given by the people. While bayanihan is something good and encouraged, patients in need of immediate medical attention may not be afforded the right treatment because people in GIDAs may not be adequately trained and well-equipped. It was also mentioned in the documentary that patients were only transported to the municipal health center when their conditions were already severe. This highlights the importance of timely quality health care, which, according to numerous studies, improves patient outcomes. Moreover, it was also mentioned that, sometimes, after walking for 4 hours, doctors were not present because of a conference. Even if geographical barriers are transcended, lack of well-trained personnel is still a grave issue that needs to be addressed. This has got me asking myself why there is no sufficient healthcare personnel in GIDAs. I believe that most, if not all, medical students have the heart to serve the Filipinos. However, individual love and passion for service are sadly sometimes not enough to address the needs of people in GIDAs. The entire healthcare system should also provide an enabling environment in which passionate medical professionals can best serve. The system should provide subsidized and even free medical training and education, provide sufficient equipment to enable provision of quality healthcare to all people, increase funding, partner with communities and GIDAs to know what the communities need and to help them empower themselves to live healthy lifestyles and observe proper sanitation and good hygiene, and to increase the benefits and pay of healthcare workers. 

Despite the difficult life, lack of well-trained and well-equipped healthcare professionals, lack of access to basic healthcare, and lack of pre-hospital care, I have to agree with the documentary that there is still hope especially if the aforementioned proposed solutions are implemented. After all, health is a right.

What is the importance of pre-hospital care in improving outcomes for patients especially for those with acute life-threatening conditions and in improving access to health care?

It is unfortunate, but nonetheless the reality, that a vast majority of Filipinos lack access to adequate healthcare. This is a result of many factors present in our country. Among these is the geography of the country, which is primarily archipelagic causing much of the population to be divided by seas into thousands of islands. Next is the volcanic nature of our archipelago, which in turn produces a high density of difficult to traverse mountain ranges, valleys, and rivers. Finally, you have the societal distribution of the Philippine population, which tends to have a large concentration of resources, people, and consequently medical personnel in a handful of large urban centers with a huge but spread-out rural population. This causes a mismatch in the distribution of medical facilities and trained medical service providers requiring patients or doctors to travel great distances over difficult terrain with a lack of infrastructure in order to access treatment or to reach underserved areas. This was demonstrated in the documentary we watched. This problem is even more acutely felt in emergency cases that cannot afford the wait or the travel time necessary to reach appropriate medical care. While the simplest answer is to make specialized services more available to the underserved, we are met with the equally unfortunate reality that resources in our country are finite. As much as it would be ideal to make to have tertiary centers within easy access to all Filipinos, we simply do not have the resources to accomplish this due to our position as a developing country and the previously mentioned limitations of geography. However, this does not mean that there is nothing we can do. We can reduce mortality and morbidity in these underserved areas by improving pre-hospital care and access to pre-hospital care in the form of more rural/local health units, more training for the personnel manning these, and better policies regarding the provision of initial treatment and stabilization before patients in emergencies are brought to larger hospitals. This requires relatively fewer resources than building more specialized hospitals for all underserved rural areas and is likely a more feasible compromise in improving outcomes for otherwise inaccessible areas. Although the ideal scenario would be to accomplish both better pre-hospital care and more even distributed tertiary hospitals, in the uniquely Philippine context of complicated geography and widespread poverty, improving pre-hospital care is an efficient way to maximize limited resources.

What is the importance of pre-hospital care in improving outcomes for patients especially for those with acute life-threatening conditions and in improving access to health care?”

Pre-hospital care involves everything that happens to the patient prior to their arrival to the hospital for medical treatment. This can involve the resting and waiting at home that the patient normally does first before finally going to the clinic, as well as all the interventions done for the patient during this time, such as the proper or improper nutrition being given, the proper or improper medications given, etc. Even the process of bringing the patient to the clinic and everything involved with that are elements of pre-hospital care, and it shows that pre-hospital care is influenced by, not only the health sector, but many different sectors of society. One demonstration of this is how the accessibility to health care is influenced by the infrastructure that is in place in the form of (or the lack of) roads, vehicles, and hospitals to reach the right health care required, and these should ideally be provided by the local government unit.

Pre-hospital care here is most clearly seen as well in the form of the clinic that one of the patients with tuberculosis was brought to. Because there was at least some access to a clinic nearby, the patient was able to receive the right treatment for his tuberculosis without having to go to the hospital. The presence of this clinic allowed the patients to receive health care and to make it more accessible to them, though there was still much difficulty to get there given the lack of infrastructure mentioned earlier.

In acute life-threatening situations, the lack of roads and vehicles leads to less access to proper health care, and these could lead to an increase in morbidity and mortality because they are unable to get the right health care in time. The clinic in the video was a pre-hospital care facility that allowed patients to receive some kind of health care before being brought to the hospital. This kind of intervention had probably allowed better outcomes for the patient, and this shows how vital pre-hospital care facilities are to the improvement of health care access and to treat patients with acute life-threatening conditions.

What is the importance of pre-hospital care in improving outcomes for patients especially for those with acute life-threatening conditions and in improving access to health care?

Good access to healthcare meant people receiving the care they need whenever they need it. Without good prehospital care, it would be difficult to transfer and provide care for those who are injured on site and those who have illnesses in far flung places. If prehospital care is well-integrated with hospital and primary care, there will be less friction in the referral system, there will be better access and healthcare response, and there will be prompt healthcare provision. Early detection, first aid and prompt interventions will mean that care is given when people need it the most and prevent the deterioration of patients with life-threatening conditions.

Provision of appropriate pre-hospital care can indeed significantly improve patients’ health outcomes especially in the face of healthcare inaccessibility imposed by various societal factors. As seen in the documentary, the inaccessibility to healthcare services in the various localities of our country particularly those in far-flung areas is still very apparent. Our health centers are not equipped enough to cater to the various health needs of the community. They are supposedly the standard bearers for primary care in the communities but given the absence of adequate support they end up being helpless institutions. The community’s sick then suffers as a result. As such, the empowerment of our primary care providers is long overdue. By ensuring they receive enough financial support, appropriate healthcare equipment & supplies as dictated by the community’s needs, and proper training for their healthcare workers, we can ensure accessible, timely, and proper healthcare service delivery may it be in emergent pre-hospital care to health education of the community.

Pre-hospital care plays a major role in improving outcomes for patients as it involves the first line in giving appropriate treatment or management to medical emergencies. This is especially true with acute life-threatening conditions such as trauma which require quick intervention to improve prognosis. In the provided documentary, there were several obstacles encountered while trying to provide patients the proper medical care from far-flung barangays from lack of sustainable and accessible transportation system to poorly-equipped health centers. These barriers added to the feeling of helplessness of the community members and made them develop poor health-seeking behaviors. 

Thus, a well-equipped health center with appropriately trained staff can be the difference between life and death for such patients. Additionally, an effective system (i.e. ambulance availability, active communication among healthcare institutions/providers, trained allies to healthcare) should also be established so that the proper management be given to the patient, from initial assessment to transport to handover and initial management of patient in the appropriate setting (i.e. hospital equipped to address the situation) and in the least time possible. This way, the patient will have an easier access to the care he/she deserves or needs to survive his/her condition.  

In the Philippines, the Bayanihan spirit is one of communal unity, helping others without expecting rewards, to achieve a certain goal. Moreover, Filipinos are well-known for their resiliency in the face of adversity, trauma, tragedy, threats, and other significant sources of stress. Pre-hospital care refers to emergency medical services rendered to an emergency patient prior to and during transportation to health care facilities. As shown in the documentary, we can see the inadequacy of many factors that have caused negative effects on the lives of our fellow Filipinos in far-flung areas. Providing a timely assessment and intervention may prevent or decrease mortalities. Moreover, the importance of early intervention on outcomes of emergencies should be emphasized. There are so many factors contributing to the lack of access to high-quality healthcare. Lack of human resources, such as doctors, was shown. It was mentioned that about 142 municipalities still don’t have doctors within their community. In addition, lack of pharmacies, developed roads, ambulances, medicines, and health centers also pose a negative impact on the lives of the Filipinos. Lack of access to factual information was also limited in rural areas. This was shown when the people in Sitio Dyandang did not know that TB is treatable. Furthermore, different sectors of the government need to be more involved in establishing high-quality pre-hospital care in far-flung areas. We are taught to adapt and endure, but we must learn that we need to demand more to receive the services that we, Filipinos, deserve. 

We might think of the hospital as the first facilitator of healthcare in a community, but the reality is that these are often the last line of care a patient will interact with in seeking treatment. Everything from the community where they reside to the roads they use to reach the town proper have their place in affecting how one accesses care. As we saw in the documentary, treatment was already being started in their village even without a doctor or a place nearby to get medicine. Despite their efforts, the community could only care for their sick so much, but without access to basic goods like medicines and sufficient meat, regaining full health would be very difficult. By the time they make the rough journey to the barangay health office 4 hours away, the condition of the patient has seriously deteriorated. The consequences would be even more pronounced in emergency situations when you cannot afford 4 hours of travel to get help. This is why a true universal healthcare approach would focus not only on strengthening tertiary care hospitals, but improving the environments of the communities themselves and making healthcare more readily available to the those in the farthest reaches of our country.

Prehospital care is definitely important in improving outcomes for patients with life-threatening conditions because in instances of acute life-threatening conditions, every second matters. The difference between a good outcome or a negative outcome such as morbidity or mortality could only be a few seconds. Therefore, it is definitely important that before arriving to the ED where hospital care can already be administered, pre-hospital care should be given because those acts and processes will help either prevent the patient from desaturating or could provide the initial care that is vital for survival. For example, a simple pre-hospital procedure like CPR could help preserve the oxygenation of the brain of an unconscious patient while waiting to arrive to the ED. Another example is when is comes to massive bleeding because by doing simple maneuvers like applying pressure or packing a wound, we can prevent a massive hemorrhage that could be devastating to the patient.

In other words, pre-hospital care is the important first step in treatment when it comes to acute life-threatening conditions. It is a s if it is an extension of hospital care and can give the patient better chances. On the aspect of improving access to health care, as seen in the documentary, pre-hospital care would have guided the residents living in the mountains as to what could be the best first step or initial treatment for these patients. Also, in instances of life-threatening conditions in the mountains, having a system with pre-hospital care can help improve the access to health care because these residents do not have to travel for hours just before they can reach for help. In addition, pre-hospital services can also help in triaging patients in these remote areas whether they really have to travel far to reach a hospital or if first aid and simple medical management can be done. Overall, pre-hospital services improves access to health care, specifically hospital care, by acting as an extension of the hospital in places that couldn’t be reached or accessed by health care.

Pre-hospital care refers to medical services that are provided by first-line responders at the time and site of emergency, even before the patient reaches a health facility. These are essential to survival in acute life-threatening cases, because instituting initial management and the smooth transfer of patients helps mitigate delays and prevent fatal complications. Good pre-hospital care involves the presence of knowledgeable responders, means for transport, ample equipment, and communication with the health institution – which the communities introduced in Ambulansiyang de Paa did not have.

In the documentary, many members of the community were impoverished, suffering from conditions such as malnutrition and otherwise treatable infectious diseases. Finances and location posed significant limitations. The need to traverse dangerous terrain for at least 4 hours (with only a hammock as a makeshift ambulance) kept them from seeking care and receiving treatment early into the course of their diseases. Hence, they were often forced to resort to alternative remedies that were inappropriate for their conditions, and be transported only when their lives were already on the line. In worst case scenarios, patients would die midway, or they arrive at the facility only to find out that there is no doctor on call.

The fact that a significant number of our countrymen still live in such conditions is devastating. So many lives can be saved if communities were equipped to recognize their medical conditions, and if their living conditions allowed them basic necessities such as water, electricity, food, and sanitation. It is also evident that local governments need resources to ensure that their facilities are well-stocked and well-manned, that roads safe and passable especially during emergencies, and that social support can be made available in times of need. This strengthens the fact that we need good governance and adequate investment for the improvement of our healthcare system, so that timely pre-hospital care can be provided – even before conditions become a matter of life and death. Filipinos deserve nothing less.

In the Ambulansyang de Paa documentary, we witnessed the impact of living in a geographically isolated community with no access to healthcare services. No matter how urgent the care was needed, everyone in the community had to go through the wearisome journey of travelling for 3-4 hours by foot along the mountains of their community. Even manageable conditions like tuberculosis or usually uncomplicated processes like childbirth turn into more complicated cases just because of the delayed care that they receive. Some even die in transit just because of the long duration of transportation and the lack of effective prehospital care. Due to this, families unfortunately bear the burden of treating their conditions with very little knowledge of what should be done.

If planned and coordinated properly, prehospital care can save lives and prevent lifelong disabilities. These are the emergency medical services rendered to a patient to stabilize, resuscitate, and prevent further injury before and during transportation to more equipped health care facilities. The interventions serve as temporizing measures to delay the events that can lead to death, disability or more complications. Another component of prehospital care that should not be compromised is proper patient handling and having a safe a well-equipped means of transportation. This is important especially in injuries that require proper positioning and stabilization to minimize complications (e.g., spinal cord injuries). In the documentary, they only use a duyan to transport the patient. This is quite unsafe especially for trauma patients because it has the risk of making the injury worse.  This further highlights the fact that timely and appropriate prehospital care plays a vital role in ensuring that patients, especially those who suffer from acute life-threatening conditions, get their best chance of surviving from their respective diseases and injuries.  

Providing medical emergency care to patients reduces morbidity and mortality in the transition from crisis to definitive care. In the Philippines where most hospitals are situated in metropolitan areas, patients in GIDA are able to receive proper medical attention through prehospital care. In settings wherein appropriate definitive care is inaccessible, pre-hospital emergency care then becomes the end-of-spectrum intervention to improve health outcome. Be it the preliminary, transitory, or definitive care that is given to patients, pre-hospital care indeed plays a part in making health care accessible to even the farthest communities.

In the documentary, we saw many patients in Bansud, Oriental Mindoro who are in need of urgent medical care. They had to travel by foot for hours just to go to the nearest doctor. While we did see an improvement in their condition afterwards, it gives me the impression that this kind of system is unsustainable. The issue of lack of funds and accessibility is still a major obstacle.

Looking at pre-hospital care at its conventional definition of emergency medical service already provides some benefit; however, it may be more significant to expand its definition to all health service that occurs in the "pre-hospital" continuum of care.

The documentary of Kara David, “Ambulansyang-de-Paa”, made me remember what we learned in LU3 about “Doctors to the Barrio” and the lack of medical facilities in the provinces. The short film shows the lack of knowledge the filipinos in the provinces have with regards on how to handle medical conditions, and how important it is to act on them as soon as possible to avoid complications. However, their lack of doctors, more so those who specialize in emergency medicine, prevents them from getting access to quality health care.

In the film, two children suffering with tuberculosis, intestinal hernia, malnutrition, among others that are yet to be determined, have worsened because of neglect. Furthermore, the time spent on travel on foot is not accompanied by any doctor or medical equipment who/that can perform pre-hospital care, unlike here in Metro Manila where ambulances actually exist.

Pre-hospital care is very important as it improves patient outcomes, most especially those with acute-life threatening conditions such as a heart attack or other time-sensitive illnesses. This is usually done by doctors specializing in emergency medicine, who are the health providers at the scene of a disaster. It is because of them that life is prolonged and death is avoided before it is too late. 

It is heartbreaking that aside from the absence of doctors, the citizens of the province itself lack knowledge on how to do pre-hospital care. In the video, they showed Kara David multivitamins and a sachet of coffee as treatment for tuberculosis! In addition, the father of John Lloyd preferred to go back home instead of admitting his son in the hospital when he is already there. 

Comparing what is happening in the film to what we have in Metro Manila, we really get to see what we have here and what they lack there—that is, how fortunate we are to have shining hospitals full of expensive machines and ambulances that will only take us minutes to get to the hospital. We get to see how healthier we all are here, compared to those living in the mountains where most children have intestinal hernia or suffering from malnutrition. I can only imagine how a person dying because of bleeding or how a person who is having a heart attack will survive if it takes 4 hours to get to the hospital, only to find out there is no doctor in site due to a seminar. So what is the importance of pre-hospital care? I am pretty sure that without it, there will be an increase in the number of deaths per day, souls that could have been saved, and cries from family members who only wished they could have done something if only they knew more.

Acute life-threatening conditions narrow the gap between life and death, and signs and symptoms telling of such conditions should be recognized immediately. This allows us to provide appropriate and timely interventions done for pre-hospital care in the hopes of preventing untimely deaths. Pre-hospital care allows us to address serious and time-dependent conditions that could lead to life-threatening complications and outcomes, and in doing so, we are preventing or delaying the patient’s deterioration so that a definitive management may be eventually provided. Since access to healthcare, especially in our local setting, is inconsistent to many population groups, pre-hospital care provides the acute management that any patient needs from the time the life-threatening condition starts until the patient is observed by a physician or any healthcare worker in a hospital. This inconsistency in access to healthcare is evidently seen in the documentary, as patients were not provided the appropriate pre-hospital care during their travel to the local health center or hospital. It was not even provided even before their travel, while at their homes. Given that there are many factors that may hinder access to healthcare, pre-hospital care is one of the things within our control that may play a role in bridging the patients to their healthcare providers as their conditions are addressed while they are seeking care.

Prehospital care, which is provided by emergency medical providers (EMS), is important in minimizing the consequences of serious injury, including both morbidity and mortality. The major benefits of this are realized in the second phase of trauma, wherein deaths occur within several hours of the event. Most causes of death during this time occur due to airway compromise, respiratory failure or uncontrolled hemorrhage, all of which can be treated using basic first aid measures. Timely provision of care halts the cascade of events that quickly lead to death or lifelong disability.  

Prehospital care can also benefit patients by preventing delayed deaths which is the third phase of trauma. Deaths during this phase occur days or weeks after the initial injury and are the result of infection, multisystem failure or other late complications of trauma. Measures used to prevent mortality during this phase include proper wound and burn care, adequate mobilization of fracture and oxygen and blood pressure support during the first hours of traumatic brain injury amongst others. 

Even in countries with limited resources, prehospital care may be given by recruiting motivated volunteers and non-medical professionals in the community and giving them specialized training and basic supplies and equipment. Each community should identify the best method of transporting patients to the local health facility. Once there, a healthcare provider who has received more formal training can assess and treat the patient. This has a lot of benefits and improves access to healthcare in far flung communities as it provides citizens with the knowledge and skills needed to provide first aid to people with injuries, creates community capacity to render assistance to injured victim at the scene and enhances a community’s capacity to handle mass casualty events such as earthquakes and floods which are common in the Philippines. 

Reference: World Health Organization. (2005). Prehospital trauma care systems. https://www.who.int/violence_injury_prevention/publications/services/39162_oms_new.pdf 

Pre-hospital care plays a major role in improving outcomes for patients coming in with Emergency conditions. They play a role in bridging the patient’s home and hospital care. A number of life-threatening conditions are time sensitive and are dependent on immediate interventions for favorable outcomes.  Pre-hospital care may immediately address life-threatening conditions and start life-saving interventions even before arriving in the hospitals. How a patient is handled in the time between the inciting event and arrival at the ER is critical for some patients.

From the documentary, it was shown how access to healthcare was hindered by different factors outside of the hospital. The struggles to seek healthcare is disheartening to see when these are infrastructures, services, and care that should be available for all.

Pre-hospital care is the part of emergency care that is in charge of the initial treatment of patients in a pre-hospital setting, and it has the potential to enhance the health outcomes of patients with time-sensitive diseases. It can minimize morbidity and mortality in individuals with life-threatening diseases if delivered adequately and on time. Its potential to assist more patients is critical in decongesting our country's overcrowded healthcare system.

Considering that emergency situations/conditions are time-dependent, the quality and accessibility of pre-hospital care greatly matters in improving patient outcomes. Ambulansyang de Paa emphasized on the impact of the accessibility of pre-hospital care to these outcomes. As demonstrated in the documentary, the prolongation and the delays in access to healthcare increases the detriments of health conditions/problems until these detriments become emergent and life-threatening. Appropriate health workforce distribution, financial capability and sustainability, and appropriate infrastructures are some ways to help provide accessible healthcare. Ultimately, multi-sectoral collaboration with all stakeholders, most especially members of the community, must be done in order to comprehensively address the obstacles in quality pre-hospital care.

Pre-hospital care comprises treatment given to patients before the arrive at the hospital, including evaluation and care. The documentary highlighted the difficulties in terms of pre-hospital care in some areas of the country and the struggle some patients go through because of this. The lack of access to proper pre-hospital care puts the patients at risk for complications, infection and increases the risk of mortality. The key problems seen in the video include inaccessible health centers and hospitals, unavailable ambulance, unfinished roads, lack of medical personnel and medical supplies among others.

Without the access to health personnel, patients in some areas of the country are forced to consult their neighbors and barangay officials, oftentimes resulting to incorrect medical advice. As seen in the documentary, the locals use random alternatives for medications due to the lack of supplies and the inaccessibility of healthcare facilities.

Prehospital care is a critical component of the health systems, and it is necessary to improve the outcomes of injury and other time-sensitive illnesses. Injuries and other time-sensitive illnesses such as cardiac arrest, stroke, sepsis and other emergencies are significant contributor to premature mortality and disability. These emergencies need timely attention and in some areas of the country as seen in the documentary, it is not possible unfortunately. Without the availability of a fast transport system and ambulance, medical emergencies are not attended to. This lack of pre-hospital care negatively affects the outcomes of medical, obstetric, and pediatric emergencies.

Acute life-threatening illnesses and accidents can happen anytime, anywhere, and to anyone. Most of the time, these conditions are time-dependent and require immediate life-saving interventions and pre-hospital care given by trained personnel such as the primary survey which can be done to secure a patent airway, stabilize the cervical spine, ensure breathing, control bleeding and ultimately, decrease the probability of morbidity and mortality. Patients should then promptly be transported with continued care preferably by an ambulance to the nearest capable healthcare facility. However, many places in the Philippines, such as several villages in Bansud, Oriental Mindoro, are geographically isolated, and as such, there are no trained healthcare providers that are part of the community. Instead, they have to transport patients by foot in a make-shift hammock attached to a bamboo pole, termed “ambulansiyang-de-paa” then walk for at least 4 hours through a muddy, slippery, and dangerous path. These hours and even days of delay before patients can reach the nearest healthcare provider and/or hospital leave most patients with deformities, disabilities, and worse, death. Many die without seeing a doctor as they do not even attempt to make the travel since they do not have the money to pay for formal care services.

The local government of Bansud acknowledges that there is an alarming health problem in their Mangyan communities. However, I was disappointed to see that their solution to increasing health care access was to build a hospital. This wrongly allocates the already scarce resources as it does not solve the root problem of why it is hard for the Mangyans to access healthcare facilities and services: the distance and dangerous trek to get to local healthcare facilities/providers, and the inability to pay for healthcare services. Theoretically, building primary healthcare facilities with trained personnel, free services, and basic equipment and supplies that are near and accessible to these communities will be better at improving health outcomes than building another solitary, large but inaccessible hospital. 

Health is multifactorial. As such, I have come to realize that pre-hospital care is more than just a paramedic and an ambulance. For places that have no formal prehospital system, improving healthcare outcomes relies heavily on the care provided by the community from the scene of disease or accident until the patient reaches a healthcare facility. And it is possible for this community-based prehospital care to be inexpensive but sustainable.  Basic strategies can include recruiting, training, and equipping willing members of the community to perform basic first aid techniques, giving culturally-appropriate and acceptable public health lectures to the community to educate them about common illnesses and correct any misconceptions or harmful community health practices, partnering with NGOs and institutions to provide periodic healthcare assessments, preventive strategies, free medicine, and supplies to the community, improving transportation to healthcare facilities by creating safer and shorter designated pathways to the nearest healthcare facilities, and creating direct and two-way communication channels between the Mangyan communities and healthcare providers. These can be possible with strong initiative and support from the government and sustainable coordination with the communities, and private partners.

In the video “Ambulansyang-de-paa”, one problem that can be noted is this nation’s non-functioning pre-hospital care especially in the rural, far-reaching areas. First and foremost, the people of Bayan ng Banson and Villa Pag-asa have poor public health knowledge about diseases such as tuberculosis and cannot identify emergent and urgent cases that need a hospital visit and confinement such as severe malnutrition and dehydration. Another problem would be the roads to the nearest health center and hospital were hours away and only accessible by foot for those who live in Banson. It was commendable that the community resort to bayanihan by transporting an ill member via duyan, but it was mentioned that several members have died while traveling because it would take at least 4 hours with dump truck road travel to get to the nearest health center; 8 hours by foot if they weren’t able to reach the dump truck cut off time. It was also a problem that only one doctor is assigned to the health center who cannot be at the post 24 hours a day, 7 days a week.

Literature suggests that a well-functioning pre-hospital care system--- such as improved bystander response, dispatch, provider response, patient transport, and transport care--- has significantly reduced preventable trauma deaths from serious injuries, reduced mortality and morbidity,  and reduced injury severity. There were also several studies which reported that it was cost-effective to have a system of trained laypersons (such as the barangay health worker in the video) and paramedics to avert mortality. Pre-hospital care should include evidence-based strategies, prioritized and tailored to each community. It should  institute basic and inexpensive strategies and interventions that can minimize the probability of death or disability, and  should be simple, sustainable, and efficient.

References

Bashiri, A., Savareh, B. A., & Ghazisaeedi, M. (2019). Promotion of prehospital emergency care through clinical decision support systems: opportunities and challenges. Clinical and experimental emergency medicine, 6(4), 288.

Husum, H., Gilbert, M., Wisborg, T., Van Heng, Y., & Murad, M. (2003). Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia. Journal of Trauma and Acute Care Surgery, 54(6), 1188-1196.

Thind, A., Hsia, R., Mabweijano, J., Hicks, E. R., Zakariah, A., & Mock, C. N. (2015). Prehospital and emergency care. Essential surgery: disease control priorities. 3rd edn. Washington DC: World Bank, 245-62.

Pre-hospital care allows patients, particularly those with acute life-threatening conditions, to be given immediate and appropriate care to prevent aggravation of their case, provide initial intervention, and to conduct life-saving resuscitation if needed. This also ensures safe and timely transportation of the patient to the nearest hospital or medical facility capable of providing the necessary management.

In Ambulansyang de Paa, it can be seen how the lack of adequate pre-hospital care gives rise to certain difficulties in patient care. For one, the transportation of the patient from his home to the health center proved to be challenging. The lack of ambulance capable of reaching their location made him and his family reluctant to have him follow-up with his doctor. His TB then was not adequately resolved, and his overall state worsened. Similarly, the baby who had severe dehydration and marasmus took hours and multiple stops before he was given appropriate management (IV resuscitation), which could have been done even prior to admission, ensuring that the baby is stable while on transport. Establishing pre-hospital care, along with addressing other socioeconomic factors (e.g., lack of infrastructures, unequal dissemination of HCWs), should improve these said situations, allowing patients better access to healthcare.

Another application of pre-hospital care that is currently rising is teleconsultation. If properly implemented, especially in the remote areas, this would allow patients to see a doctor without having to worry about transportation or possible exposure to diseases like COVID-19. They could receive medical advice in the comfort of their homes. Teleconsultation may also pave way for patients and their families to know if their case needs to be urgently seen. Interallied communication (e.g., between the consultant and emergency personnel) may also be improved, allowing resources to more quickly reach the patient.

In the documentary, access to health care was blocked by the absence of pre-hospital care services. It was evident that access to health care was blocked not only by the absence of ambulance and healthcare workers but also by the absence of concrete roads and bridges. It highlights the concept that health is multifactorial. Providing pre-hospital care is not just about having two ambulances on standby in the local hospital. It is also about improving transportation and the general financial capacity of the community. Improving access to pre-hospital care is important in improving outcomes for patients especially for those with acute life-threatening conditions. Primary survey and resuscitation can be done by trained healthcare workers in pre-hospital care to prevent mortality and morbidity. With proper materials available, bleeding can be stopped, the cervical spine can be stabilized to avoid further injury, and needle thoracostomy can be performed for pneumothorax, for example, providing much-needed help in the care in the emergency room.

Proper pre-hospital care is very important in improving outcomes for patients because patients could easily deteriorate or worsen on the way to the hospital. This is especially true for patients with acute life-threatening conditions - these patients need immediate care, and delaying basic interventions in favor of waiting for them to reach the hospital may lead to their demise. Access to proper health care is not synonymous with access to hospitals - it includes everything else, such as proper access to primary health care clinics, nutrition, sanitation, and yes, proper pre-hospital care. As shown in the documentary Ambulansyang-de-Paa, because of limitations in infrastructure there is difficulty in bringing patients to see health professionals. While the resilience of the communities shown in the documentary is praiseworthy, this is not ideal at all. Many complications can happen in the 3-4 hour trek down to the municipal health center, and that time delay will still increase while they are being transported to the hospital, at which time patients would already be in a much worse state than they had began with. It doesn't help that those volunteering to help bring the ill down to the healthcare centers do not know how to manage these conditions. Proper pre-hospital care would thus be able to prevent these complications, but this would also entail fixing many other related socioeconomic issues such as the rampant poverty, lack of proper governance, lack of funding, lack of medicines, lack of electricity and proper infrastructure, lack of doctors and other HCWs, etc.

Pre-hospital care is crucial in improving outcomes for acute conditions because interventions at the scene and during transport are time-based and can be lifesaving or prevent significant disability. Furthermore, efficient pre-hospital care also facilitates timely access to further medical care that patients need. These were evidently lacking in Ambulansyang de Paa wherein they did not have a reliable means of communication with the local health facility, and their mode of travel was inefficient and hazardous for both patients and caregivers. Aside from having enough equipment, vehicles, and personnel, their journey also highlighted the importance of infrastructure like safe roads and bridges to facilitate more timely provision of services and to minimize the risks and hazards for the patient during transport. It was a reminder that providing holistic healthcare for the people also includes pre-hospital care, not just establishing more health facilities.

Pre-hospital care allows patients with acutely life-threatening conditions to have immediate access to essential medical services to stabilize their conditions. It avoids unnecessary downtime contributing to deterioration before being seen and given definitive management in health centers or hospitals. Lack of or inadequate pre-hospital care puts patients at increased risk of morbidity and mortality. As seen in the documentary, some patients have died along the way, died even without seeing a healthcare personnel, or had worse conditions before seeing a healthcare personnel. Having advanced and integrated pre-hospital care in place is as vital as having health centers and hospitals. A multi-factorial and multi-sectoral approach are needed so that effective pre-hospital care is established and accessible to all Filipinos.

The documentary Ambulansyang de Paa exposes the gaps in the Philippine healthcare system, and how such deficiencies ultimately translate to poor health and outcomes for real people, with the understanding that resolution of an issue first requires knowledge of its existence. 

Not all conditions require management at a hospital but, without adequate community-level care, these conditions may progress and eventually require in-hospital treatment. Even in situations that necessitate hospital-based care at the outset—such as for acute, life-threatening conditions—certain life-saving steps may be performed for a patient before they are brought to a hospital, especially considering the time it takes for them to reach a hospital vis-à-vis the narrow window of time that their condition affords.

Access to healthcare must be improved, certainly, but it should be remembered that hospitals are not the only source of care, and it is equally vital to establish adequate and accessible pre-hospital care for every Filipino.

Acute life-threatening conditions are typically very time-sensitive, in which timely interventions may mean life or death for patients with these conditions. Without adequate pre-hospital care, specifically transport (as shown in the documentary), patients may not make it to the proper healthcare facilities in time. In fact, they may not even make it there at all without the necessary infrastructure to allow easy access to them. Thus, the various aspects of pre-hospital care are shown to be highly necessary if we went to improve outcomes and quality of life for the general public, especially for those in far-flung areas.

Pre-hospital care ideally already begins the management of the patient even before they reach the hospital, thus improving chances for survival especially for those with life threatening conditions. For these people, their life ticks in seconds. Not in the minutes or in the hours. However, in our current system, ideal and complete pre-hospital care seems almost next to impossible. From my experience, people within well-populate areas already have much difficulty acquiring transport, much less an actual ambulance capably equipped to handle their cases. What more for those our geographically isolated and disadvantaged areas (GIDAs)?

Pre-hospital care is vital, if not, a backbone to the whole healthcare system. With proper allocations for manpower, logistical and financial resources, access to healthcare, and whatnot, healthcare delivery becomes much more efficient. There are several conditions which are preventable if they were promptly catered to by these mentioned resources, such as several comorbids commonly affecting Filipinos (e.g. TB, DM, HTN). This also goes for acute, life-threatening conditions, which may still be managed if immediately addressed. Ambulansyang de paa gave a glimpse of how lack of access to healthcare, a vital part of prehospital care, drastically affects the healthcare system.

Pre-hospital care allows an improvement in the outcome of patients because of the earlier detection and management of conditions. This allows health professionals to be able to give preventive care, based on the resources easily available to them.  Though this sounds like what should be the norm in our world today, the concept of pre-hospital, or even hospital care, is not attainable to all Filipinos. The lack of access to healthcare, both due to physical and financial plants, prohibits patients from receiving care that they should be receiving. This documentary highlights the importance treating health issues not just by giving medications and by one-time checkups, but rather it reminds us the importance of treating the root problem of inaccessible healthcare. Diseases like TB, burns, and malnutrition, may be somewhat easy to treat here in the metro. But for areas where access to basic healthcare is scarce, these disease will continue to exist, and coexist, leading to a never ending health problem for many Filipinos.

The importance of pre-hospital care for patients with acute, life-threatening illness is on the timeliness of quality emergency healthcare interventions. First of all, pre-hospital care should be timely. This does not only apply in emergencies, but also in health maintenance of patients. Severe manifestations of preventable diseases and Complications from comorbid conditions will less likely manifest if health prevention and maintenance is good. Secondly, the capacity to respond depends on the accessibility of roads, adequate transportation with the basic equipment for emergency interventions that may be done even enroute to the ED, and skilled responders. These determine the quality of health care that the patient with a life-threatening condition will be given. Subsequently, good quality health care will result in good patient outcomes. In Ambulansyang de Paa, it is revealed to us that there are still areas in the country where the standard health care is inaccessible. The reality of the situation in our country is that many still die from preventable diseases. Many still do not get to see a doctor even once in their lives despite having conditions that warrant consultation. All Filipinos are deserving of accessible good quality health care. Any improvement on accessing healthcare by placing the infrastructure and building the capacity for emergency response will help attain that goal.

Based on the documentary, the importance of pre-hospital care is in its ability to begin managing (or at least surveying and stabilizing) the patient even before they reach a healthcare facility. This is especially important for patients with acute life-threatening conditions, because these patients may rapidly deteriorate and experience significant morbidity or even mortality if not surveyed and/or managed urgently. Aside from improving patient outcomes, good pre-hospital care can also reduce the burden on emergency departments, as patients would need less resources upon arriving at the ED. Thus, the ED would be able to serve more patients compared to a setting where pre-hospital care were not available.

Improving access to healthcare is also important because good and equitable access to healthcare will promote better health-seeking behavior in the population as a whole. This means that people with health conditions will generally be seen by a healthcare professional earlier in the course of their diseases, thus allowing for earlier intervention. Conversely, poor access to healthcare means that patients are more prone to seeking medical attention when their conditions are already severe. This not only results in poorer outcomes for these patients, but also increases the burden on emergency departments as these people are more likely to present with advanced disease which requires emergent care.

Pre-hospital care is only one aspect in improving outcomes in acute-life threatening conditions and improving health access. Improvements should be multisectoral and multi-institutional. In emergency cases, faster transport means faster definitive management but, in the nation’s current health system, pre-hospital care is forced through innovation instead of being standardized. Nonetheless an efficient, effective and swift prehospital care and transport is still a start than none at all. With proper systems adapted to an environment in the diverse terrain of the country coupled with trained personnel for transport, financial support, present resuscitative and supportive resources and a clear referral system pre hospital care can be improved in the nation’s context and provide better patient care before they are received in a health institution. There are many social determinants in play in providing emergency care and the documentary has shown that providing a better prehospital care can provide better health outcomes in patients.

In an ideal world where everyone has equal access to healthcare, pre-hospital care doesn't play as big a role in the outcome of a patient. Patient-outcome would predominantly be dependent on the disease, its severity, and hospital management. However in this country, it's no secret that access to healthcare remains a problem. In many remote-areas, the social determinants of health are stacked against patients. Often times, patient outcome is pre-determined even before (the patient) gets to the hospital. In areas like this, emphasis must be placed on pre-hospital care and its development should run alongside improving access to healthcare. This would come in the form of improving transportation, increasing manpower, and proper education (on proper protocols) to name a few. If the long term goal is to equalize healthcare access for all Filipinos, the short-term goal is to bridge the gap between acute life-threatening emergencies and urgent hospital management. In doing this, we could effectively limit the number of untimely deaths. This would give everyone, even those in the most far-flung of areas, a fair shot at survival. Dramatic as this may seem, these measures can be pivotal in saving thousands of lives.

Pre-hospital care helps in directing patients to appropriate health centers where their condition can be managed. Pre-hospital care can give stabilizing measures that reduces mortality and morbidity in patients. In the documentary by Kara David, we saw firsthand how pre-hospital care dictates access to healthcare in far-flung areas. There we saw how social determinants of health contribute to pre-hospital care - public infrastructure, such as roads, dictate access to healthcare. It is simply not enough to build hospitals in each province but to ensure that necessary components of the healthcare system are able to connect the patient to the appropriate care. 

The Philippines is vulnerable geographically and socioeconomically. Given the numerous calamities, GIDAs, and the glaring inequity in our country, these are also reflected in our response to crises and the state of our health care. This context further highlights the importance of pre-hospital care when it comes to improving health outcomes. Since pre-hospital care is the first response and care given to a patient, it is vital in improving the prognosis of the patient’s condition. Oftentimes, a lot of patients are unable to afford long-term care, which leads to the different acute life-threatening conditions that are addressed in the ED. Thus, prevention and primary care are essential in moving towards a better health care system. This would mean increasing the capability of barangay health stations and rural health centers to respond to emergency cases and end up with a proper plan for disposition. Timeliness, together with non-discriminatory access to emergency care are important elements of providing quality primary and emergency care services to the Filipino population. Timeliness and universal access can be achieved through interlinkages of institutions, efficient coordination systems, and having enough resources including prehospital providers and facilities even in the geographically isolated and disadvantaged areas. To accomplish this, adequate funding is needed, which is strongly related to the first point of improvement—political will. By improving this level of care, many deaths and long-term disabilities could be prevented.

The provision of timely and appropriate pre-hospital care indeed has an impact on delaying progression, prevention of complications and improving the outcome of the patient's condition. This has been proven time and again in the common scenarios of trauma/motor-vehicular accidents and other acute life-threatening conditions where mortalities are prevented by early intervention addressing the ABCDEs and transfers to well-equipped facilities are made possible by availability of transport vehicles and first responders on the grass roots level. There has been an apparent decrease in disability and a higher rate of survival due to interventions done during pre-hospital care. However, in order for timely and appropriate pre-hospital care to be effectively administered, there has to be accessibility to and from geographically-challenged areas, adequate training of health professionals, provision of resources, as well as prioritization of rural or primary care health units. There has to be a multisectoral effort to address these barriers in order to improve healthcare delivery in the community setting.

While hospital care is an important aspect in improving patient outcomes, pre-hospital care and services play an essential part in ensuring patient survival especially in acute life-threatening conditions since these are, more often than not, very time-sensitive situations that require prompt interventions. Unfortunately for countries like the Philippines, pre-hospital care is lacking not just in geographically isolated and disadvantaged areas (GIDAs), but even in more developed provinces and cities as well.

Because prehospital care already involves providing initial assessment and management to patients while transitioning to definitive management, patient morbidity and mortality could be decreased or avoided if this were provided promptly and adequately for both acute and chronic conditions. Aside from increasing the number of health workers trained in emergency services and equipment/ vehicles, improving prehospital care should also involve providing basic first aid education for those not in the medical field, make hospitals and health centers more accessible by improving roads and transportation services, and create a proper coordination system between the parties and institutions involved.

Appropriate and adequate pre-hospital care can improve outcomes for acute life-threatening conditions. For instance, in trauma, cervical stabilization with an actual or makeshift cervical collar can prevent further cervical spine injury while a patient with suspected tension pneumothorax can benefit from an emergency needle thoracostomy. Provision of first aid on wounds and injuries before actual hospital care can also lower the chances of infection. Pre-hospital care also includes availability of patient transport from the place of injury to the hospital. This means that timely transport of patients using functional ambulances or transport vehicles is necessary for timely definitive treatment in the hospital. Since patient transport is influenced by other factors aside from ambulances, the Ambulansyang-de-Paa documentary now brings us to this question: “Does pre-hospital care also concern provision of access roads and availability of trained first-aiders and medications in remote areas?” I believe so. Appropriate and adequate pre-hospital care is only possible not just with a functional ambulance but also with accessible roads, pre-hospital care manpower, and good governance.

Providing pre-hospital care by trained EMS personnel can greatly improve outcomes of emergency cases. This can be achieved by providing timely care which greatly alters the course of the disease progression. Without providing treatment as early as within the first hour, patients with good survival probabilities may eventually worsen, leading to their demise. Especially in trauma cases, when first aid is not given, these patients may succumb to airway compromise, respiratory failure, or uncontrolled hemorrhage, either on site or en route to the hospital. This can also be said for cases such as acute myocardial infarction wherein ECG monitoring and administration of initial drugs, such as aspirin and heparin, within the first 90 minutes, can improve in-hospital stay and consequently, patient outcome. Overall, mortalities can be reduced with proper and timely pre-hospital care, which is especially true in geographically isolated areas. If interventions can be done as early as possible, then it could provide the patient adequate time for transport to the nearest facility where s/he could receive the proper management, without risking deterioration of the patient along the way.

Pre-hospital care decreases risk of disability and mortality for patients with acute life-threatening conditions. Time-sensitive conditions need timely interventions. Without pre-hospital care, patients with good chances of survival would die at the scene or en route to the hospital.

Pre-hospital care is important to save time and to prevent worse outcomes from occurring. Immediate assessment and management to stabilize the patient is very important in improving the prognosis of a life-threatening condition. This allows patients to have a better chance of survival. As seen in Ambulansyang-de-paa, there is poor accessibility to proper healthcare and treatment in the far-flung areas of the country. Locals need to endure a long and troublesome travel to the medical facility, which discourages the sick from seeking treatment, causes diseases to worsen, and eventually, causes death from manageable cases. This shows that pre-hospital care is important for the prevention of morbidity and mortality in the community setting.

In emergencies, any delay in management can lead to limb- or life-threatening consequences. In an ideal setting, any individual who needs urgent care will receive it at the incident scene prior to transfer to a hospital. However, the pre-hospital care in our country remains largely limited by long-standing systemic problems, including poverty and health inequality, translating to suboptimal patient outcomes. Pre-hospital care is considered an emergency medical service and should thus be considered a priority to promote effective clinical decision-making and improve patient care. To ensure early recognition and management of emergency cases, we should also put focus on the primary prevention strategies and initial interventions according to clinical guidelines. This can be done through increasing awareness and public knowledge about common emergencies and their corresponding protocols. Ultimately, for truly improved patient outcomes, the root causes should be analyzed and addressed. 

Pre-hospital care is of utmost importance in providing the best outcomes for patients. In acute, sub-acute, and immediate scenarios, pre-hospital care buys time for definitive management. The ambulansyang-de-paa just shows how inaccessible pre-hospital care is, as people have to travel for hours on foot just to acquire the proper medication and treatment. It is especially frustrating for diseases that have long since been easily treated, such as tuberculosis. Improvements in healthcare delivery is tantamount to creating better pre-hospital care to GIDA so that morbidities and mortalities are reduced as much as possible.

Pre-hospital care is vital in the improvement of patient outcomes, and this is especially true for those with acute life-threatening conditions who require immediate intervention. During our EM rotation this year, we were taught that any delay in the management of patients can translate into catastrophic consequences for their health. Therefore, pre-hospital care must be improved so that patients may still be managed sufficiently even prior to hospital admission since access to large healthcare facilities may not always be immediately possible and resources at these facilities may not always be sufficient. With this, greater efforts should be made to ensure that pre-hospital care and healthcare as a whole are made more accessible and available to less serviced areas in order to lessen the burden of disease and mortality in the country.

Effective pre-hospital care is needed to decrease preventable long-term morbidity & mortality and improve outcomes of injuries and time-sensitive conditions, a pre-hospital care system. To achieve this, pre-hospital care systems must have prompt communication and activation, prompt response, and assessment, treatment, and transport to formal healthcare facilities.

Pre-hospital care is especially important to prevent deaths that occur during the intermediate or subacute phase of injury, which occur within several hours of the event and are frequently the result of treatable conditions. Prompt provision of care can limit deaths during this phase. In rural & geographically isolated settings, access to healthcare is even more challenging due to lack of infrastructure, scarcity of vehicles, poor quality of roads, and prolonged response and transport times. These must be addressed to provide at least a basic level of pre-hospital care. Without this, most injuries may face mortality at the scene or on the way to the hospital due to conditions that may otherwise be readily treated using basic first aid measures.

Pre-hospital care helps patients in need of advanced care to be treated before going to the hospital to buy them more time for proper more definitive management at the hospital. The documentary just shows us how bad pre-hospital care at the community level as well as the Philippine healthcare system as a whole. How can we buy our patients time if we don’t have the equipment, infrastructure, human resources and leaders that will promote proper pre-hospital care to our patients? “Human ambulances” such as that shown in the documentary where they walk for hours just to seek medical care obviously is not an ideal setup for patients seeking emergency care. According to the video, there are still Filipinos who die without even seeing a doctor. This just shows how healthcare is still inaccessible in the disadvantaged areas of the country. 

Nearly 5 million deaths per year are recorded due to injury alone. These deaths may be preventable with timeliness, which can be achieved through effective pre-hospital care. Ideally, information is provided by emergency medical personnel about a patient prior to arrival to the hospital. Prehospital notification allows team members to be alerted so that a team meeting can be held, and preparation can be tailored to specific information provided about a patient. Giving the team ample time to discuss would lead to better decision-making and improved patient outcomes. Having a system-wide telecommunication can also improve access to healthcare by informing initial responders the nearest institution with the available resources needed by the patient. The public can also contribute to this endeavor by being informed of when and how to call help so as to increase the timeliness of the response.

Pre-hospital care encompasses all processes and efforts made towards assessing, treating, and stabilizing the patient prior to arrival at the hospital. It is especially important in patients with acute life-threatening conditions, as these may require on-site assessment and stabilization. There should be a universally accessible dispatch and EMS communication system, wherein patients, family members or bystanders can easily contact a service for EMS dispatch to their area. EMS response should be prompt, with assessment and stabilization occurring upon arrival to the scene. Prior to arrival, there should be open communication between the bystanders and the dispatch, so that pre-arrival instructions may be given and carried out. Once the patient is stable, it is dire that a system of dispatch and transport is available to transfer the patient to a facility capable of definitive care. In the case of the patient in the documentary, his tuberculosis remains untreated because of the distance between his house and that of the healthcare facility. There is no extant dispatch and transfer service that can reach their home in the mountains. Thus, the weakened patient must be carried and brought to the facility on foot in order to be assessed and treated. There is also limited signal in their remote village, limiting the usability of telecommunications. This is far from the ideal. An efficient pre-hospital care system should be capable of reaching patients geographically isolated places. Especially in emergent cases, the lack of an efficient EMS worsens patient outcomes as they do not have access to evaluations and treatments that are time-sensitive. 

Pre-hospital care is the assessment and stabilization of patients prior to or while mobilizing them into the hospital and often includes transport. With this, patients are being given the care that they need immediately without having to wait to be accommodated in a facility. Healthcare is accessible even at the scene of injury or tragedy and is not boxed in a building. It was shown that survival rate becomes much higher for patients with adequate prehospital care given.

              In the Philippines, prehospital care is inefficient, and the video showed a few aspects as to why this is so. Transport is laborious, there are no equipment available, and there is no support. And this is just the beginning of deeply rooted issues surrounding pre-hospital care in our country.

Without doubt, pre-hospital care is critical in improving outcomes for patients. The time between an acute life-threatening event and hospital intervention is important, thus the interventions provided before arrival to the emergency room would help increase chances of survival and decrease possibility of morbidity. However, not all Filipinos have access to such services. This is especially true for those who live in remote areas. Availability of pre-hospital care that encompass life-saving medications and equipment, as well as healthcare workers with sufficient emergency care training, is extremely lacking. They would need to cross rivers and walk through mountains just to get the care they need. The delay in providing important pre-hospital care especially in acute life-threatening conditions can lead to devastating outcomes for the person and his community, thus it is imperative that access to healthcare be improved. Provision of pre-hospital care services especially in remote areas would also be one way of bridging the inequity that is prevalent throughout the current Philippine healthcare system. It is only just that each Filipino will be given a fighting chance against acute life-threatening conditions through pre-hospital care.

Prehospital care is a very essential part of emergency healthcare since they provide immediate response at the scene of the disaster or event. EMS personnel are trained to immediately identify the problem, evaluate the patients, give appropriate immediate management, and coordinate the referral among dispatch centers, ambulances, and hospitals. Having quality prehospital care is especially important in improving outcomes for patients, particularly those with acute-life threatening conditions since this would ensure immediate relief and management and prevent unnecessary disease or injury progression before reaching the actual hospital.

In ambulansya de paa, we were able to witness how care done on-site is crucial in ensuring that patients are stabilized and are able to be transported to an emergency care hospital for definitive care. Hence, it essentially leads to patients' survival, with even earlier institution of care possibly leading to better outcomes in terms of emergency, life-threatening conditions. To be able to deliver effective on-site emergent care, there is a need to have an organized system and designated roles for each member of the team, as well as complete basic equipment and transport systems into place sp that there are no or lesser delays in transport. In addition, there must a continuing channel for communication from site to hospital so that needs and materials are endorsed ahead of time. All in all, administering proper on-site emergent management is very important, such that all other interventions to be done before that would depend on the stabilization done on-site, as well as the effectiveness in terms of communication and handoff for actual management of the underlying condition. 

In the documentary, the fact that the area is a geographically isolated and disadvantaged area (GIDA) puts its citizens at risk for delays in the institution of crucial prehospital intervention as well as the time between this until transport to the hospital. Thus, there must be a system overhaul in such cases, such that barriers to timely intervention are reduced, coordination between health providers and stake keyholders is prioritized, and patients are given the care that they need in a timely and effective manner.

Thus, given the consenquential nature of on-site care on subsequent management, it is no less important than any other step in emergency medicine. In fact, one can argue that it is most important in that most of the time, it can spell the difference between life and death for a patient with an acutely life-threatening condition. There is definitely a lot to overhaul in the community in Oriental Mindoro that was featured in the documentary, with more emphasis given on making the system solid enough for emergency medicine to lead to favorable outcomes for its citizens.

Pre-hospital care has a huge impact on the health outcomes of patients with acute life-threatening conditions. As seen in the documentary, the lack of healthcare professionals, medicine, and means of transportation in geographically isolated and disadvantaged areas (GIDAs) drastically delays the patient’s access to treatment and decreases the patient’s chances of survival. Many Filipinos in far flung areas of the country are affected the unequal access to healthcare and are at a significant disadvantage as compared to Filipinos in urban areas. From this documentary, I learned that we must re-evaluate our current health system because of the evident discrepancy in healthcare between urban and rural areas.

To improve patient outcomes and quality of life, it is important to invest in better pre-hospital care, especially in provincial areas, by allocating more health funds, buying more equipment, and hiring more health professionals. Investing in pre-hospital care will improve the delivery of health services and thus increase patient survival.

Pre-hospital care serves as a bridge between the emergency site and the hospital or facility where appropriate treatment can be provided, with the goal of reducing morbidity and mortality of individuals in acute life-threatening conditions. Proper and timely pre-hospital care will increase the individual’s access to health care services because response by trained care providers and transfer to the healthcare facility will be facilitated. Through the ABCDE approach, patient will be stabilized enough to be transported for definitive treatment.

The video Ambulansya de Paa showed how failure of providing pre-hospital care will significantly aggravate health outcomes and quality of life. It is a frustrating fact that many Filipinos are not given appropriate management because they are not at least provided with pre-hospital care, which could have been the first step to access health care services. It is therefore important to improve pre-hospital care if we aim to improve access and delivery of healthcare services.

Pre-hospital care is essential due to the potential benefits that may be provided to patients who are given proper care before they even arrive in the hospital. Various interventions may already be started as soon as trained healthcare personnel arrive at the scene, and without these, some patients may not even have a chance at surviving at all. This form of care is even more important in areas wherein there are no nearby hospitals, as the time between the acute life-threatening event and proper hospital care will be prolonged. If healthcare personnel can arrive on time and give assistance to these patients, they may prevent the rapid deterioration of the patients and their present conditions.

            Even if patients do not necessarily have to be brought to a hospital, pre-hospital care can provide numerous advantages for those they assist. For instance, the personnel may be able to assess if any interventions they can provide will already be enough to resolve the situation, without the need of the patient being admitted to a hospital. This is especially important in patients who also live in areas far from hospitals, as this may prevent them from having to spend large amounts of money for an admission that was not necessary.

Reaching treatment as soon as possible without endangering the patient is the key to reducing patient morbidity and mortality. Through improvement of pre-hospital care, we can have the necessary trained personnel, equipment, telecommunications, transportation services, and referral system to be able to reach patients in time and stabilize them enough so that they can be safely transported to the appropriate facility. In the Philippines particularly, there is a weak pre-hospital care system which results in a high morbidity and mortality rate especially in young Filipinos who are at most risk to vehicular accidents and violent means of injury.

Many sudden conditions require urgent pre-hospital care, and delay in starting these interventions directly contribute to the rise of morbidity and mortality. Inequity is extremely apparent in certain remote areas (Philippines or otherwise) where hospitals are extremely far from each other - and the mere time it takes to get from where you are to the hospital is simply too much, and so it is not unusual for patients to reach the hospital alive.  

In the documentary Ambulansya de Paa, not only were the institutions extremely far, there was also a lack of roads that allow them to bring him there easily. While in other areas in the philippines, the standard is a speeding ambulance (although traffic is also an issue), in the documentary they have portrayed people carrying their sick loved ones. It is clear that improving pre-hospital care to improve outcomes to save the lives of these patients are extremely important to reduce the morbidity and mortality from these live threatening conditions.

Aside from the distance between hospitals, funding and proper training is also a significant issue. There was a lack of trained professionals in the area that can administer emergency pre-hospital care. It was shown in the video that there was only one midwife who had to travel as far as five mountains just to reach her patients, a blatant proof of disregard from the government for the health of the citizens in the area.

Pre-hospital care is responsible for the initial care of patients in a pre-hospital environment, and it can improve the health outcomes of patients with time-sensitive illnesses. This refers to the timely provision of emergency medical services, including the initial evaluation, management, and prompt transfer of patients to definitive care. If appropriately and timely provided, it can reduce the morbidity and mortality of patients with life-threatening conditions. With its ability to aid more people, it is crucial in decongesting the overburdened hospital system in our country.

Pre-hospital care is essential since many emergency situations require immediate patient interventions since they may involve life-threatening conditions comprising airway, breathing, circulation, life and limb including disabilities, and environmental exposures. Immediate interventions will greatly increase the probability that patients involved in emergencies will reach the hospital and receive complete emergency care. Many Filipino rural communities are far from hospitals. In these scenario, the importance pre-hospital care in every community is emphasized due to the reasons stated previously.

As seen in the documentary, Ambulansyang de Paa, pre-hospital care plays a very important role in addressing acute and urgent needs of individuals. Pre-hospital care should have been the first contact of patients with acute life-threatening conditions to the health system and that this should be readily accessible and available to cater to the most immediate needs of a patient. Sadly, however, our country still has not been able to establish an efficient pre-hospital care system. There is still a tendency for people to go directly tertiary or specialty hospitals for their consults, bypassing lower-level health facilities. However, this is not only bound to the patient’s preference but also by their access to the services available nearby. Just as emphasized in the documentary, unavailability of services in the GIDA communities remain to be an issue. There are still people who die without seeing a doctor and there are also people who die because their condition became so severe and yet had only seen a doctor after years of enduring their disease. A lot of lives could have been saved if only there is a proper pre-hospital care. Indeed, admissions to higher level hospitals could have been lessened if the needs of the people would already be catered within their communities. This would save travel time, resources for transportation, more procedures and medications, and the needed manpower and equipment in the receiving higher level hospital. Consequently, this could also allow re-allocation of resources to focus more on public health which will also include the improvement of the service delivery network, provision of local health units with functioning equipment and trained manpower and provision of education to promote health, prolong life and prevent diseases.

Pre-hospital care increases the chance of survival of patients with acute life-threatening conditions by providing initial care (e.g. first aid, basic life support) prior to arrival in a hospital with more complete facilities. there also needs to be a working and efficient emergency dispatch system so that patients with real emergencies can be detected and reached as fast as possible. In addition to well-trained health professionals, there is a need for more accessible roads and transportation services. Reducing emergency response time and time to reach hospitals is also an important component of pre-hospital care, and this will increase the chance of survival of acutely ill patients. Thus, strengthening pre-hospital care involves training healthcare professionals, establishing a working and efficiency dispatch system, procurement of complete equipment, and improving road and transportation access.

Every day, people with acute illness and injury—such as accidents, infections, heart attacks and strokes, asthma, and acute complications of pregnancy—seek medical care. As a result of this daily incidence, an emergency care system has been developed that can recognize early and manage acute illnesses and injuries that can save a lot of lives. Thus, there is a need for a working, quality, and properly implemented emergency care system to be able to achieve this goal, particularly pre-hospital care. 

Pre-hospital care, a part of emergency medical services, is the initial care provided in the pre-hospital environment. It improves outcomes for patients especially for those with acute life-threatening conditions and in improving access to health care—with the help of human resources, transport, equipment, and information technologies. This is achieved by providing time-sensitive diagnosis and interventions to prevent mortality and morbidity in the pre-hospital setting, affecting the final outcome or prognosis. Proper coordination of these components is important as this can decrease transport time, and thus decrease time from incident to the definitive intervention, which can affect the rate of mortality and complications.

Pre-hospital care is vital. However, after watching Ambulansya de Paa and even by just looking at the patients in PGH or from our case discussions and SGDs, in a third-world country like the Philippines, there are a lot of aspects that need to be improved on in our pre-hospital care systems—human resources, transport, equipment, and information technologies. These are just components of a bigger whole, a system. To address these systemic problems interconnected in a complicated web, good governance, political will, and policies are needed. That's where public health comes in. When health is prioritized, so will be the improvement of our pre-hospital care and emergency care system.

An adequate pre-hospital care will change the outcome of all acute life-threatening conditions, it can extend the patient’s life by minutes, crucial minutes that make all the difference between life and death. This is done by immediate and thorough assessment using the primary survey to improve the airway access, breathing, circulation, deformities, and exposures with subsequent swift and decisive management for each step.  If we had a good and adequate system of pre-hospital care, we could bring quality health care to those who live in distant areas and lessen the time they would need to travel to hospitals that have the equipment or medication that they would need to survive. A proper pre-hospital care would also extend the time needed to give patients their definitive treatment for survival and would also lessen the need for admission and extended hospital stays.

Pre-hospital care is a  part of emergency medical services that is responsible for the initial care provided to patients in the pre-hospital environment. It is an important component of the general health system that is vital in order to improve health outcomes of time-sensitive illnesses. As part of the emergency services, appropriate and adequate prep-hospital care may significantly decrease or at most prevent morbidity and mortality of patients. After seeing the documentary Ambulansya-de-paa, I can say that the concept of pre-hospital care and even emergency medicine in general, still has its public health component as these are directly affected by accessibility to health care. 

In line with the principles of universal health coverage which aims to provides quality, accessible, and equitable health programs to Filipinos, I believe that there are a lot of improvements to be done in our current pre-hospital care system in order to achieve the ideal situation of “Health for all"

During our EM rotation, it was emphasized time and again how important every second is when saving people from acute life-threatening conditions. We are taught the ABCDE approach as a quick assessment and urgent management of life-threatening conditions because seconds lost can mean life or death. If you miss out on a tension pneumothorax, the patient can die. If you miss out on sources of bleeding, the patient can die. We are taught that seconds can mean a heart muscle dying or a part of the brain dying.

 Emergency care bridges the gap between the community and the hospital for the acutely ill. They bridge a potentially life-threatening condition to stability by ensuring that the right life-saving interventions are given at the right time and to the right patient who needs it. Part of emergency care is the pre-hospital care system which is all of the care received by the patient from an emergency medical service before arriving at the hospital. The initial stabilization given by pre-hospital care not only gets the patient through from a life-threatening condition to a state of stability. At the top of my head, i can imagine c-spine immobilization to prevent further cervical trauma, application of pressure to prevent massive bleeding,  to giving epinephrine to a patient with anaphylactic shock. 

However, it does not stop at helping someone through that life threatening condition,. There is a need to bring the patient to a facility that can address their needs and make the resources accessible to them for the definitive management and hopefully improve outcomes for the patient. But how do we get there when pre-hospital care remains difficult to access, when there is difficulty in reaching patients in far-flung areas, and when there are no nearby hospitals available for the patient? That’s why we need to improve the bridge between the community and the resources for their health needs -- while also empowering the community and ensuring resources for health are available for those who need it.

Healthcare is an umbrella term for health-related services delivered by healthcare workers (health human resources) to people. Hospital care is only a part of healthcare, since a huge part of it is pre-hospital (from the time of injury or onset of chief complaint until the patient is brought to the hospital) and post-hospital care (rehabilitation, follow-up care).

It can be argued that all life-threatening conditions are time-sensitive; that is, the longer it takes for the patient to be treated, the worse his or her prognosis is. This is why we say "time is muscle" in patients with STEMI, or "time is spine" for patients with spinal cord injuries, or even "time is brain" for patients who suffered a stroke.

With this, in accordance with the 1978 Alma Ata Declaration, there is a need to strengthen pre-hospital care in order to save lives & promote health because health is a fundamental human right of every individual. In order to strengthen pre-hospital care, we can utilize clinical decision support systems, which leads to:

• More accurate diagnoses,
• Improved patient triage, and
• Reduction of prehospital time.

Bashiri, A., Alizadeh Savareh, B., & Ghazisaeedi, M. (2019). Promotion of prehospital emergency care through clinical decision support systems: opportunities and challenges. Clinical and experimental emergency medicine, 6(4), 288-296. doi:10.15441/ceem.18.032

By improving pre-hospital care, patients such as those in the documentary may receive prompt management, observe improved outcomes, and ultimately, obtain improved quality of life. These services may prevent (or at the very least palliate) potentially non-emergency situations. Take for example the case of the young male with tuberculosis. The treatment for this disease is relatively straightforward and free. However, he had yet to receive the medication required. Had he not been brought to the local health center, he might have faced possibly fatal consequences of his illness that would have required life-saving interventions only a hospital can provide. By virtue of its ability to aid more people, pre-hospital care thus becomes crucial in potentially decongesting the overburdened hospital system in our country.

As highlighted by the documentary, pre-hospital care plays an important role in the management of emergency cases and life-threatening situations in transit to the hospital that may result in the death of patients. In the video, cases including tuberculosis, severe burns, and complications of pneumonia and malnutrition were examples of emergency cases that received delayed management due to the lack of access to healthcare. It was commendable to see the unity that was displayed by the community to bring their fellow neighbors to the hospital, even by foot. However, the documentary also shows that aside from the lack of resources in Emergency Medicine, the lack of funding to make clear and flat roads, the lack of education among the residents, and their fear in the exorbitant prices that accompany in-hospital care all exacerbate this issue. As such, changes in our healthcare system beyond improving EMS is needed to definitively address these problems.

Pre-hospital care allows patients with acute, life-threatening conditions to reach hospitals and receive more definitive management that otherwise would not have been possible. Aside from providing immediate and potentially life-saving interventions for these patients, pre-hospital care also allows easier and more efficient handoff to the hospital emergency department. This is due to emergency medical services being able to collate information regarding the patient’s personal information, their injury, and their current status, which could help guide emergency department personnel in deciding which problems must be immediately addressed.

The documentary is able to shed light on these problems, wherein farflung areas with no access to prehospital care are most affected. If anyone from these areas were to have grave and immediately life- or limb-threatening conditions such as injuries, it would be very unlikely for them to make it to the hospital unscathed. Aside from the inability to provide life-saving interventions, these areas have no safe routes toward the hospital and no ambulances can reach them. This forces acutely-ill patients to endure their conditions much longer and likely worsens patient outcomes.

In the documentary, “Ambulansya de Paa,” the people had to travel by foot and carry patients on using bamboos just to get to the nearest local health center. This is an example of poor pre-hospital care. On the other hand, good pre-hospital care includes presence of systems available at the sites of scene of emergencies and transport including presence of trained health provider, smooth roads, and ambulances. These, if available, will greatly help in improving survival of patients with acute life-threatening conditions, and can help decrease congest in hospitals especially if hospital care is not necessary.

Proper pre-hospital care can greatly improve the outcomes in patients with acute life-threatening conditions. For example, in the setting of trauma, some patients survive their injuries but die at the scene or en route to the hospital due to lack of first aid. Others may reach the hospital but will have more complications, including death, or will have an increased length of hospital stay. Good pre-hospital care therefore, will not only save lives and improve patient outcomes, but will also help decongest hospitals. More importantly, those patients in the far flung areas, often do not have easy access to hospitals, so a good knowledge on basic pre-hospital care can help in the initial management of their conditions while their transport is being processed.

Ideally, pre-hospital care involves a systematic approach to care of an acutely injured individual from the place of injury to the hospital, where definitive care will be provided. However, in our country, majority of the trauma cases die at the scene without being treated or transported to a proper facility. The lack of an effective pre-hospital care in our country leads to unnecessary and preventable deaths. This is a problem in both the urban and rural setting, but more so in the latter since they have to work with limited and scarce resources, on top of the geographic barriers and communication challenges due to lack of signal/internet connectivity in most areas. Strengthening pre-hospital care in our country will reduce the morbidity and mortality rates. Being able to stabilize those with acute life-threatening conditions, even just for a few minutes, will make a huge difference on the outcome of the patient. 

Pre-hospital care is the treatment provided to patients before they arrive at a hospital. This is somewhat the initial evaluation and care necessary to improve the outcomes of patients. In our country, this is an essential aspect as not all people have access to hospitals. Sometimes, pre-hospital care is the only medical help they experience due to inaccessibility and financial constraints. The video “Ambulansyang de Paa” shows us the current situation of many communities, especially in the far-away provinces in the Philippines. Many people succumb to death, without having the chance to see a doctor. There are no hospitals in the near vicinity, and it would take several hours for one to reach a hospital. Apart from that, there are no healthcare practitioners in those communities to even provide the pre-hospital care that could prolong the lives just enough before they can be delivered to hospitals that could provide definitive management for their conditions. Ideally, this could be addressed in the near future by policies providing opportunities for doctors and nurses to practice in far-flung areas to deliver care for patients that are acutely ill. Hopefully, along with this, more healthcare facilities will be established that could cater to these people who have been deprived of the right to health since they were born. A solution that I could think of would be providing adequate allocation of budget and funding to health especially to communities in the rural areas where healthcare services have been scarce. However, this is only a small piece of a very large problem we have.

No matter how difficult a situation is, Filipinos possess the innate characteristic or trait to always be resilient and be creative to be able to surpass the numerous challenges that are constantly thrown with their respective lives. However, in the context of receiving adequate and timely pre-hospital care during emergency situations, are these traits sufficient enough to actually save the lives of our fellow citizens? Delving deeper into the documentary and the actual experiences of people especially in the rural areas, the importance of proper and well-established pre-hospital care is of great significance. Inadequacy of pre-hospital care or emergency medical services in all parts of the country would most probably translate into higher number of mortalities and morbidities. Furthermore, there are several flaws in our country’s current healthcare system. Yes, there might be signs of improvement in the urban areas; however, there still remains a concept of being “left out” especially in the far-flung areas or GIDAs. Hence, for patients with acute-life threatening conditions or those that necessitate immediate medical attention, the implementation of a well-structured and responsive pre-hospital care should be established as soon as possible. The government and policy makers also have a huge role and responsibility to fill-in through proper allocation of resources and funding to the medical sector. Through this support, proper distribution of the competent and trained medical professionals not just in the urban areas but also in the rural areas should be done.

Optimizing pre-hospital care should be one of our top goals for this country. At the barrios, it is important to have a competent person who could identify and evaluate the problems, and have the initiative to make a difference. The documentary reminded me of my immersion in Sirawai, Zamboanga del Norte; just like Bansud, there is difficulty in transporting patients there. Sirawai is lucky to have the option of land travel, unlike Bansud patients who have to be transported by foot. In Sirawai, if patients are transported via land, it would take them 6 hours to arrive at the closest hospital in Zamboanga city; sadly, they do not have any working ambulance and have to rely on knowing people who have private vehicles. The travel time could be shortened if transported via boat but then, even the fishermen in the area don’t have enough bangkas. Very much like the documentary, Sirawai lacks medical personnel. They have one DTTB now, but for some time before they had to struggle for 5 years without a doctor in the barrio. When I spoke to the doctor, he said he could function properly due to the lack of drugs, and equipment. He stressed out that they have no med techs which makes diagnosing difficult. Watching the documentary made me remember the reality I saw during my immersion. Most patients in the barrios die without a fighting chance and I have nothing else to blame but the incompetent health care system we have. 

Pre-hospital care is vital in improving outcomes in those with acute life-threatening conditions because prognosis for these conditions rely heavily on how swift the proper interventions are initiated. However, not all patients have access to this, and expire even before receiving proper treatment. The “Ambulansiyang de Paa” documentary brings this problem to light, depicting the struggles of people from far-flung areas undergo to receive the most basic medical attention. Those behind these initiatives lack the proper skills, training, and equipment to provide the necessary pre-hospital care; this results in higher mortality/morbidity in people with life-threatening conditions from these GIDAs. People from these areas also do not have access to the proper health infrastructure within their vicinity, resulting in the need for longer transit times without the proper pre-hospital care, which significantly contributes to poorer prognoses for patients.

Pre-hospital care is performed by healthcare workers at the scene of the disaster. It consists of recognizing an emergency, evaluating the situation, determining the patient’s immediate needs, and transporting the patient to the appropriate healthcare facility. The documentary, Ambulansyang de Paa, depicted numerous flaws in the Philippine healthcare system, that have resulted in poor pre-hospital care provision. Some identified barriers to treatment included the inaccessibility of healthcare facilities to geographically isolated and disadvantaged areas, inadequate funding for health infrastructure, and lack of medical and paramedical personnel in far-flung regions, which need them the most. Pre-hospital care plays an essential role in improving patient outcomes since it aims to alleviate the patient’s most urgent symptoms. Even before the patient is seen by a specialist to be diagnosed, their needs should be properly attended to. This is depicted in the documentary when an IV line was inserted to address the dehydration of John Lloyd before they investigated his other conditions. For patients with acute life-threatening conditions, pre-hospital care ensures that deteriorating patients survive long enough to be seen by the appropriate physician.  

Throughout our medical school education, we have learned that many acute life-threatening conditions are treatable. It was frustrating watching the documentary and even encountering patients who weren't able to seek or receive adequate care that could have lessened the complications they are experiencing right now. It's also important to note that it's not only the medical field that holds the responsibility, but also the government and the people themselves. The medical sector is responsible for providing the best care for the patient and for screening and endorsing preventive measures to improve prognosis. They also hold responsibility in educating the patient and ensuring that they are aware of symptoms to watch out for and what steps to take when these occur. Furthermore, the government's role is to implement suitable medical emergency policies and providing the logistics and infrastructure to make these policies possible and address the people's needs. Lastly, good health seeking behavior would be the most ideal for the patient especially since most of these life threatening conditions (i.e. myocardial infarction) are time-bound, and fast interventions are life-saving. Overall, these things play a part in improving outcomes for the patient and reducing morbidity and mortality.

Surviving acute life-threatening conditions is heavily influenced by how fast intervention can be given. Examples of such conditions include MI and stroke, common causes of morbidity and mortality in the Philippines. In fact, guidelines provide ideal timeframes for intervention in these conditions, stressing the importance of quick intervention.

Seeing these “ambulansya de paa” in the documentary and probably in many other places, one cannot help but think these people do not even have a fighting chance. Their fates were sealed when they got afflicted with these acute life-threatening conditions that need timely intervention in places the government chose to leave behind. They will likely not make it to or leave the hospital alive, or if they do, they will probably emerge from the situation with considerable morbidity. Investment in roads, ambulances and more healthcare facilities for farflung areas should be a key focus of the government to give these people a fighting chance.

Besides this, prehospital care also involves basic emergent, potentially life-saving care like CPR, staunching areas of bleeding, and immobilizing the neck in trauma that help stabilize the patient to give us time to transport them to a healthcare facility for definitive management. Some of these can actually be taught to laypeople and health worker volunteers even in farflung areas. These measures would buy patients time to actually get to a hospital alive, improving access to healthcare.

Lastly, early recognition by patients that something is seriously wrong will lead them and their family to make haste in going to a healthcare facility instead of hoping for symptoms to resolve. For example, educational campaigns, featuring lessons like the FAST mnemonic can be taught so people recognise stroke early and know to seek help right away.

As seen in the documentary, a lot of conditions could be managed before reaching hospitals, or even require hospitalization. One of the most important aspects in proving appropriate pre-hospital care is preventing dreaded complications, or even mortalities. For instance, in the documentary, if a person with TB was clinically screened, diagnosed, and given the initial medications early on, then malnutrition, anorexia, and secondary infections could be prevented, which themselves create a cascade of even more complications.

Strengthening pre-hospital care systems should not only involve infrastructures and well-trained personnel within proximity, but also the members of the community. Properly equipping them with first-aid techniques and initial management protocols that match well with the available resources would improve outcomes prior to definitive care. Therefore, as we strengthen pre-hospital care systems and empower members of the community, this would entail improving access to geographically isolated individuals, especially during life-threatening situations.

As we have learned not just by reading but through experience, pre-hospital care is crucial because a lot could be addressed/a lot could escalate in the time where the patient is being brought to the hospital. Especially in accidents or trauma cases, proper management and emergency treatment done can make it or break it for the patient. In emergency medicine, we must think fast but also take into mind that we should not compromise the quality of pre-hospital care the patient receives.

Events starting from the onset are important to account since everything can affect the health outcomes of all patients. This is emphasized in EM because there is a small time frame to manage the patient as soon as possible. As stated in the question, other events are life-threatening, and every bit of management is going to be important to stabilize the patient before he/she reaches the hospital. With better initial management comes better prognosis if the patient reaches the hospital safely, and this represents a big chunk of emergency medicine. As physicians, we have to consider a lot of factors – especially social determinants which differ from area to area to be able to properly manage our patients.

Ambulansya de Paa is but one of many instances showing the inadequacy of pre-hospital care in our country, particularly in GIDAs. As the documentary shows, whether a patient is experiencing an immediate life-threatening disease or a chronic illness, there is a gross lack of adequate systems in place designed to provide them with proper and timely medical care. This is not even to mention the inadequacy of healthcare services once patients get there. Ultimately, this leads to worse outcomes for these patients. This short documentary summarily shows the deficiency in almost all of the essential functions of a responsive ECS as described in the WHO Framework – particularly human resources, functions, and technologies (vehicles, equipment, supplies, and IT); all in the context of the scene, in transport, and once the patient reaches the facility.

This problem not only highlights issues on accessibility and adequacy of healthcare facilities, but the inadequacy of pre-hospital care as well. At the outset, it is easy to say that pre-hospital care undoubtedly improves outcomes for patients. Clearly, if healthcare workers (BHWs, even ordinary community members) are more adept at recognizing when a certain complaint requires medical attention, if these personnel are able to administer basic life-saving interventions or temporizing measures, and if they are supported by a system designed to make more capable services easily accessible, then surely rates of morbidity and mortality, as well as patient satisfaction with healthcare services will improve. However, this is easier said than done, and implementation is a whole other concern plagued with the all-too-real issues of political will, lack of resources, improper resource allocation, and corruption; further complicated by our country’s complex geography.

In the Philippines where very, few cities have a public emergency service system in place, prehospital care and emergency services are lacking. These translate into more significant morbidity, poorer treatment outcomes and even death in involved critical cases. Emergency medical service personnel in the country (emergency medical technicians, prehospital care responders and paramedics) should be recognized in legislation and in existing healthcare systems as a profession as they received appropriate education and training for emergency responses. The inefficiency and pluralistic disorganization of our prehospital care systems is a substantial contributor to the country’s top sources of acute morbidity and mortality. This will continue to be so unless policy makers and stakeholders realize that the key to advancing our systems lies in a multisectoral approach with systemic changes in national financing, infrastructure and legislation.

Pre-hospital care, especially in rural areas should be well established because they are a means to providing timely intervention and prevention of mortalities secondary to emergent clinical scenarios. Acute life-threatening conditions encompass a wide spectrum of management because external factors are considered in the success of providing emergent patient care. External factors such as transport to the nearest accessible hospital and first-aid or basic life-saving skills training for healthcare workers, and in low-resource settings there is a demand for medical and surgical innovation with the scarce resources. Discrete methods to ensure patient stability while in-transport ensures better chances of survival once they reach the tertiary referral hospitals for the definitive management.

Pre-hospital care is an area of emergency practice, which is time-sensitive and logistics-requiring. The documentary showed that we don’t have the luxury (although it should be our right) of time, resources, and immediate access to health care, especially in GIDAs and rural areas. With effective pre-hospital care, we will not have treatable diseases turn into life-threatening conditions. There is no hesitation that effective pre-hospital care is vital in preventing premature mortality and morbidity. Nonetheless, some follow-up questions we should ponder on– How can we provide early and effective medical care? Who is responsible for our right to health? What resources, skills, and EMS systems do we need? Knowing that health is multifactorial, what are the factors we need to address delayed medical care? Moreover, how can we take advantage of our Bayanihan spirit?

Emergency medical services (EMS) responders are the first to provide prehospital care to those with acute life-threatening conditions. With proper training, these individuals are able to evaluate an event, identify the resources needed, triage, and provide crisis standards of care (CSC) to ensure that scarce resources are allocated effectively and that the most severe cases are transported first. These individuals are also responsible for transporting these patients to an appropriate healthcare facility where definitive care can be given. Without EMS personnel, the prognosis of individuals with acute life-threatening conditions would be poorer, or worse, they may not even make it to a facility that can adequately provide definitive care; this is how pre-hospital care is integral in providing access to health care in emergency settings. 

 In the Philippines where healthcare is generally underfunded, GIDAs suffer the most because there is an overall lack of hospital resources and even more so for pre-hospital resources. The lack of EMS personnel results in lower access to life-saving interventions and a poorer prognosis for anyone with acute life-threatening conditions, thereby increasing morbidity and mortality rates.

Reference: Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations; Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington (DC): National Academies Press (US); 2012 Mar 21. 6, Prehospital Care Emergency Medical Services (EMS) Available from: https://www.ncbi.nlm.nih.gov/books/NBK201058/