Integrated Clinical Clerkship in Emergency Medicine AY 2021- 2022

In the Philippines, numerous GIDAs have healthcare that is inaccessible due to lack of nearby health facilities, lack of human and non-human resources in the medical field, geographic disadvantages, expensive medical services, and the government’s overall lack of action to solve or alleviate these problems. These affect patients with acute life-threatening conditions who need to be transported as soon, as fast, and as cheap (if not free) as possible to the nearest health facility with health workers and services capable of definitively managing their conditions. Pre-hospital care encompasses everything and everyone involved since the onset of those conditions until those patients arrive at their respective health facilities. 

As seen in the video, GIDAs generally have poor pre-hospital care mainly in terms of geographic accessibility. This is also due to the lack of health facilities nearby, and lack of human and non-human resources which may compensate, though uneconomical, for those inexistent nearby health facilities. Every human being deserves to receive the highest possible level of healthcare, which includes pre-hospital care. Patients with life-threatening conditions demand immediate treatment to increase their chances of survival, and this is where the ideal pre-hospital care comes in — providing the patient with the highest possible level of monitoring and symptomatic care before and during the fastest possible and the most cost-effective transportation to the nearest capable health facility.

Acute life-threatening conditions such as hypovolemic shock as depicted in the video, can often have rapid and precipitous courses. Sequelae such as decreased sensorium, multiple organ dysfunction, and death can often follow within minutes to hours of these disease entities. Therefore, time is of the essence in instituting management for these patients especially if they are far from the nearest hospital and without the necessary resources for definitive management.

Pre-hospital care, then, plays a role in stabilizing these patients before they reach the hospital. This form of early care can delay the usually rapid natural history of these conditions, hopefully, long enough for the patient to be transported to a competent healthcare facility. Pre-hospital care buys time. It increases the frame of opportunity for medical practitioners to intervene, thereby increasing a patient's chances of survival.

In terms of accessibility, pre-hospital care provides an avenue for those without medical training to provide some forms of emergent care to declining patients. Since some maneuvers in pre-hospital care are often more practical and easier to comprehend than more complex measures such as medications or drips, it can be taught to lay persons with relative ease. This is especially helpful for Filipinos in far-flung communities with limited resources such as those seen in the documentary. By equipping more people with these skills, we can increase the chances that patients with life-threatening conditions receive pre-hospital care, thereby improving their chances of reaching a healthcare institution. It can also provide the entire community with a sense of social responsibility for one another's health, which may lead to better health-seeking behavior as a whole.

It is a sad reality how Filipinos are very dependent on the Bayanihan spirit in order to replace the duties the government is unable to fulfill. In the big cities such as Manila, we currently see stark inequalities in public hospitals vs private hospitals. These inequalities are much more pronounced in provinces and geographically-isolated and disadvantaged areas (GIDAs).

"Health is multifactorial."

There are many factors affecting the health system and health delivery, or lack thereof, in farflung areas. One factor is government shortcomings and lack of funding/prioritization. Another is maldistribution of health goods and services, as well as human resources for health, in these areas. Another possible factor is lack of proper health education and poor healthseeking behavior. These factors must be addressed in order to alleviate disease prevalence.

Pre-hospital care is important in emergencies. Proper and adequate pre-hospital care decreases morbidity and mortality as well as decreases risk for prolonged disease/sequelae. For example, pre-hospital care includes optimization of nutrition and first-aid of burns. Optimization of nutrition includes adequate intake as well as proper composition of diet. This allows the body to adjust to the disease, fight the pathogens, and recuperate faster with the help of medications. First aid of burns include passing the affected area with running water and prevention of secondary infections by proper wound care.

However, pre-hospital care already assumes that the injury already occurred. As public health advocates, we should also push for prevention of disease/injury. This includes childproofing the house, or watching closely on the infant/toddler and preventing spills especially from hot substances. This also includes optimizing nutrition in order to prevent contracting communicable diseases and strengthening the immune system. Prevention also includes having regular checkups.

In farflung areas where basic health needs are not delievered adequately, we must emphasize the need for disease prevention and health promotion. And for instances where injury or disease has already occurred, prompt consultation and ER visit should be done without delay.

All emergencies are time-sensitive. What is and what isn't done between the arrival of first responders and arrival at the hospital could spell the difference in the severity of the outcomes faced by victims of life-threatening events. This is why pre-hospital care or immediate life-sustaining interventions are so important in improving the outcomes faced by those who are victims of disaster. It's because in many cases, many adverse outcomes and even prolonged hospital admission can be prevented with adequate pre-hospital care. 

Unfortunately, in the Philippines, good pre-hospital care is scarce if not absent in its many rural provinces as evidenced by the documentary Ambulansyang-de-Paa. Many factors contribute to this deficiency such as the natural lay of the land, lack of traversable roads for vehicles, and even the municipial budgets as allotted by the national government.  Consequently,  millions of Filipinos die before they even reach a health center, let alone a hospital when they could have been saved by an efficient, and working emergency health service system.

In this way, pre-hospital care is important since it delays the progression/improves outcomes of life-threatening illnesses, and improves the access to health care by providing immediate life-saving care and transportation to better equipped facilities for those in emergency situations, assuming of course that these systems are functional and accessible, which they aren't.

Pre-hospital emergency care is a critical component of the healthcare system and is necessary to improve the outcomes of trauma injuries and other time-sensitive illnesses. In low to middle income countries like the Philippines, these cases lead to preventable disabilities and early death. Prehospital emergency care provides  early, fast, and effective treatment needed to sustain the patient and prevent further complications as they are transferred to a facility equipped with advanced medical care. It is necessary for timely access to healthcare needed by patients to prevent premature mortality and early disability. As seen in Ambulansyang de paa, the coverage of our pre-hospital emergency care is far from ideal, only existent in urban areas where people have arguably, more access to healthcare services. Even with adequate pre-hospital care and transfer services, health facilities in rural areas and GIDA are not equipped to handle emergency conditions, or even advanced illnesses which just goes to show that pre-hospital care is just one part of a system. Without other proper functioning parts, ergo a fully equipped and functioning end transfer facility and accessible roads/ terraine-appropriate transfer vehicles, the contribution of  adequate and effective pre-hospital care in the improvement of patient outcome, would only be negated. In the Philippines, with limited health resources, due to many socio-political reasons that will require a separate section, the country could  benefit a lot from pre-hospital care as it decreases hospital stay of patients, prevent further complications, and improve disability outcomes of patients reducing health costs and burden for both the patient and the healthcare system leading to a more effective use of our health resources.

 Mehmood, A., Rowther, A.A., Kobusingye, O. et al. Assessment of pre-hospital emergency medical services in low-income settings using a health systems approach. Int J Emerg Med 11, 53 (2018). https://doi.org/10.1186/s12245-018-0207-6

Prehospital care is important especially in cases wherein adequate tertiary or specialized care is not made readily available to patients in far-flung areas, as is depicted in the documentary. This comprises the manpower, resources, and skills needed to temporize certain life-threatening conditions before patients get transferred to higher-level centers. Unfortunately, many places in the Philippines do not have access to good prehospital care, let alone basic healthcare. This is detrimental to patient outcomes, as there are certain readily available materials (oxygen, fluids, inotropes, among others) that could be ideally provided by rural health centers and that can improve patient condition before being handed off for definitive treatment. Prehospital care can also comprise health education and prevention, another way in which the incidence and progression of disease can be abated through preventive measures such as smoking cessation, antibiotic prophylaxis, etc. All these put together, prehospital care improves access to further healthcare in two ways: 1) by temporizing disease progression in acute life-threatening diseases, thereby making longer wait times for higher-level centers feasible and making these centers accessible; and 2) by preventing disease incidence and progression, thus making healthcare more accessible for other more emergent concerns.

In emergency medicine there are injuries and illnesses that are very time sensitive and require immediate attention. Some of these things include doing CPR, stopping bleeds, etc. In many cases, if these are not addressed immediately, the patient can deteriorate quickly or even die. It is important that patients get proper and adequate pre-hospital care to prevent this from happening and to decrease the patients that are dead on arrival. Pre-hospital care can also improve access to health care as there are injuries and illnesses that can be solved without a hospital, such as solving dehydration with ORS, providing proper nutrition, and CPR if there is someone that knows BSL. This is seen in the case of John Llyod he had dehydration. His condition could have been improved with pre-hospital care. For people that live in areas with no nearby hospitals, pre-hospital care can be a solution or temporary solution to their problems for while they are on the way to the hospital. Like the other parts of emergency medicine, pre-hospital care can be the difference between life and death.

The situation in Ambulansyang de Paa provides a glimpse into a system with multiple problems of pre-hospital care, particularly, the lack manpower, the lack of proper transportation and roads, the lack of facilities and equipment, the lack of protocols and systems in addressing disease burden. Transportation and access to facilities are factors of timely disease management, while manpower and equipment are factors of appropriate and effective healthcare. Protocols, meanwhile are factors for the efficiency and accuracy health care delivery. All of these together contribute to the treatment of life threatening conditions, since these conditions are often time-sensitive, and require expertise as well as specific resources. 

For example, for the case of Lowen, the journey required traversing uneven terrain as well as exposure to the elements. In the middle of the journey, several people huddled around Lowen without regard to his contagious disease. Upon arrival to the Health Center, Lowen was given medication for his tuberculosis (the documentary did not show what procedures, i.e., Hx/PE, were performed on Lowen at the Health Center, but we will assume that the decision to provide medicine was based only on clinical findings). There are numerous problems in this case. Firstly, there were no trained personnel to assist Lowen prior to beginning the journey. There was no documentation of important data such as subjective and objective findings such as history or vital signs performed prior to beginning the journey. There was no communication to the Health Center that there would be a patient arriving. The patient was not stabilized nor monitored for vital signs during the journey. Exposure of both volunteers and the patient to each other may have contributed to spread of disease. Upon arrival to the Health Center there was no proper handoff. At the Health Center, the doctor was not able to order necessary diagnostic procedures such as
GeneXpert or X-ray due to the lack of resources. There did not appear to be any documentation performed at the Health Center (although perhaps this was simply not shown in the documentary but otherwise performed). Lastly, a less than ideal management plan was decided for the patient, again due to the lack of resources (given the patient’s appearance and history, he should at least be classified as an ESI 2 case and should be admitted to a hospital and screened for other health problems, e.g., malnutrition, psychological disease such as depression, extrapulmonary TB, other infections such as intestinal parasites/ head lice, etc.) If all the important pre-hospital care elements were in place, many of the above problems would be avoided, and the patient would have received better care with improved outcomes.

 The situation shown in Ambulansyang de Paa is rather extreme and requires multi sectoral improvement for there to be any real outcome. Even if transportation were improved, trained manpower increased, and facilities built and equipped with resources and with protocols to guide procedures, the disease burden will still likely be the same. I.e., the population will still have the same burden of trauma, infectious, and nutritional diseases. To address this aspect of health care, a strong intersectoral collaboration in the management and promotion of health must be developed. Communities must be empowered, educated, as well as provided with the basic necessities of life such as shelter, and clean food and water. This, in combination with improved prehospital care is an important step toward improved outcomes for all patients.

Emergencies are abundant in developing countries like the Philippines where logistical and financial barriers hinder people from seeking preventive care and early consultations. This should be an impetus for us to have a well-organized and well-prepared emergency care system. However, as can be seen from the Ambulansya de Paa, we still have a long way to go. Instead of riding an ambulance or a chopper with medical equipment and professional paramedics trained to perform life-saving interventions, we have severely ill Filipinos relying on generous volunteers to transport them using a hammock slung from a bamboo pole through rough terrains for 4-8 hours. In the slight chance that they make it to a health facility alive, sometimes, there is no doctor or the center lacks the expertise, equipment or drugs needed to address their condition. In the documentary, we can also see how the lack of education hinders ordinary Filipinos from recognizing the severity of their illness and performing first-aid to prevent its escalation. They also have fears about medical procedures and the catastrophic costs associated with them that make them hesitate to receive care. When asked about their plans for their constituents in geographically isolated and disadvantaged areas, local government officials in the documentary would answer that they can only do so much with the budget they have. This illustrates the failure of the national government to provide financial and technical assistance where it is very much required. To think of it, putting priority on our emergency care systems would indeed be a cost-effective way to solve a lot of problems. If our national government would stay true to the WHO ECSA framework, Filipinos would receive timely interventions and be safely transported in the most appropriate facilities for them. 

Pre-hospital care is defined as the initial care provided at the scene. It includes triage, initial treatment, and transport of the patient. This is usually provided by emergency medical services (EMS) responders. Pre-hospital care is a very important part of the continuum of emergency health care. It is especially important to life-threatening conditions. As the initial point of contact, pre-hospital care providers such as EMTs and paramedics are in a position to give timely life-saving procedures and drastically improve patient outcomes. It is an understatement that without them, there will be higher rates of mortality due to the considerable delay in treatment.

An excellent pre-hospital system also improves access to health care. This is especially relevant in our situation in the Philippines. Since the Philippines is an archipelago composed of 7,107 islands, it can be difficult to access health care, especially in rural areas or isolated islands. This inequity in access is also magnified by the devolution of our health care system, meaning the delivery of health care programs will depend on the prioritization of the local government unit. If health is not a priority of the LGU, health care quality will be poor. Pre-hospital care bridges the gap between the community and the health care system. In countries with limited resources like ours, it can be helpful to establish a pre-hospital system at the community level. This can be done by recruiting and educating selected volunteers from the community. An example of this pre-hospital care at the community level is the human ambulance from the documentary “Ambulansyang Paa”. Due to the lack of doctors and the lack of safe roads that ambulances can traverse, residents of Sitio Dyandang are forced to bring their ill community members to the nearest health care facility by foot. The human ambulance symbolizes the Filipino ingenuity and the Bayanihan spirit. However, in my opinion, there are only so much things that the human ambulance or pre-hospital care can do. It is important to improve the overall health care system, not just pre-hospital care. Hence, in the case of Sitio Dyandang, instead of a human ambulance, it is much better if there is a doctor or health facility nearby. 

Pre-hospital care bridges people with acute life-threatening or high-risk conditions to have immediate access to critical care in emergency and urgent situations. Having enough and accessible facilities, transportation services, materials, and human resources are a must for this to take place. In our country, it is a sad reality that many of the far-flung areas still lack in pre-hospital management resources and thus impair their access to emergency care.

Ambulansiyang de Paa showed the lack in ready services that could bring people from the remote areas of Oriental Mindoro to the appropriate health facilities in case of emergencies. The locals depend on sheer and raw ambulatory strength and traverse mountains for long hours to transport the sick.

Building new hospitals and health facilities is useless if people would not be able to access them anyway. And even in the presence of many ambulances or any transport vehicle in a health facility, if there are no roads by which these can pass and reach the far-flung areas, the access to pre-hospital care would remain unresolved. Support from the government to build access roads in these isolated and disadvantaged communities is also a concern, resulting in the perpetuation of the problem.

Another issue that surfaced in the documentary is the lack of health care workers in the rural areas. Only one physician is assigned to a municipal health office or health center. If the physician must attend conferences or any personal matter, no one relieves him or her. Thus, a community is left with no medical help. This issue on the distribution of healthcare workers and facilities must be dealt as well.

Even if pre-hospital care is available and there are adequate facilities, access roads, and health care workers, these services would still be inaccessible if it is not state-funded or if the services are costly. Thus, government support is definitely needed.

It is heart-breaking to witness people dying to treatable conditions and know that the lack of access to care is what actually killed them. More so, it is disturbing to feel comfortable in the availability of all these resources in the suburb while the rural or remote areas seem to have been left behind.

Pre-hospital care is the provision of emergency medical services in the field and in transit before arrival at a health care facility. In "Ambulansyang de Paa", pre-hospital care is rooted in the Filipino "bayanihan" concept, with communities banding together to create systems and makeshift resources to respond to emergencies. However, humans get tired, supplies get used up, money runs out, and resourcefulness can only get you so far. The point of emergency medical services is rendered obsolete when you have to travel 4 hours to get down a mountain. Moreover, the patients are accompanied by good samaritans who have limited or no knowledge at all of acute life-saving interventions. Should the patient's status deteriorate, how are they expected to help this patient? This problem is further aggravated by the lack of health care facilities with capabilities to actually respond to emergencies. Pre-hospital care is an important pillar of the health care delivery system. It bridges the gap between the acutely ill patient and the emergency care provider. Even just the human resource aspect can potentially improve survival outcomes in patients with acute life-threatening conditions. The provision of medical resources (i.e., stretchers, splints, IV fluids, etc.) that may be present in the ambulance depending on their capabilities can be the deciding factor that will determine whether or not that patient will be dead on arrival. Modes of transport as a factor is also contributory not just in improving outcomes but also in improving patient's access to health care that they would normally not be able to get due to distance alone. In this way, pre-hospital care is an important component of health care delivery and must be improved in our country.

Pre-hospital care is essential in improving outcomes and reducing morbidity and mortality among patients not only with acute life-threatening conditions but also those with chronic treatable illnesses with no access to health care. With pre-hospital care, immediate interventions in life-threatening conditions can be provided. However, in the Philippines, immediate access to health care is a pressing problem particularly for people living in geographically isolated and disadvantage areas. For them, going to the hospital is geographically and financially exhausting, as it would entail not only time and effort but also financial resources for transportation or loss of the day’s income. Commonly, for this population, time-sensitive injuries are not addressed immediately and may cause death.

Hence, an improved and strengthened pre-hospital care can provide timely recognition and management of emergency injuries, including mass emergency events or disasters, which can reduce morbidity and increase survival. Moreover, complications and acute exacerbations of current illness may be prevented. However, it should be noted that achievement of an effective pre-hospital care for all requires the involvement and support of different sectors of the community.

Pre-hospital care refers to the timely care given by the emergency medical personnel at the site of injury. It aims to provide care that can limit or delay the cascade of events that would otherwise lead to death or lifelong disability. It is a vital part of the overall healthcare system of a country since it improves the chances of survival of those who experience acute life-threatening conditions. Deaths occurring at the first hour of injury are mostly due to a compromised airway,  respiratory failure, or uncontrolled bleeding. These are conditions that can be readily addressed by professionally trained prehospital frontliners. These emergency responders are equipped with the necessary know-how to manage the scene, stabilize the patient, and coordinate the transport of patients. Having a system that allows for the quick and efficient response, initial management, and transport of injured patients to the nearest health facility increases the likelihood of survival and improves outcomes for these patients. 

The challenge for our government officials and policymakers is to make pre-hospital care and ambulance services accessible especially to the geographically-isolated and disadvantaged areas. It is heartbreaking to see people dying of readily treatable diseases just because they do not have access to an ambulance or the distance to the nearest health facility is hours away.

Pre-hospital care is an essential first touch-point to the health care system because it improves access to services and provides patients with immediate, life-sustaining interventions (i.e., resuscitation, transportation) prior to receiving definitive management for their condition in a hospital. Hence, such emergency medical services can greatly improve outcomes of injuries and other time-sensitive conditions (i.e., acute diseases or acute exacerbations of chronic disease). 

In the Philippines, a lot of geographically isolated and disadvantaged areas do not have access to basic health care services, including pre-hospital care. The documentary, “Ambulansiyang de Paa” highlights this inequity. It shows how residents of far-flung sitios in Mindoro Oriental face numerous barriers because of their area’s lack of resources to build infrastructures that would improve access to health care services. Residents resort to carrying patients on make-shift hammocks and trekking for hours over difficult terrain in order to reach the nearest local health center where their needs may or may not be met due to the lack of resources. 

Despite the necessity of pre-hospital care in managing life-threatening conditions, our fragmented health care system, coupled with blatant corruption, prevents patients from receiving immediate and continuous health care due to the lack of infrastructure and transportation services, universal protocols for field triaging, and communication to receiving facilities. Therefore, it is important that we advocate for the implementation of primary health care which aims to improve health access for all. Moreover, the primary health care approach also integrates and strengthens pre-hospital care and referral systems to improve health outcomes, and give priority to those who are most in need.

Prehospital care is important in improving outcomes for patients because it ensures that especially those requiring acute care have access to healthcare facilities, in a manner that is timely, fast, and reliable. A hospital might have the best facilities, but if the acute patient cannot make it on time, then the best facilities might not be useful at all for the patient. There are many factors in effective pre-hospital care. Some factors include a reliable communication system from the location of the patient to the hospital and ambulance. Another factor is the knowledge of what a bystander must do in an event he/she witnesses an emergency.

In the documentary, barriers to effective pre-hospital care in the rural setting include the following: geographical barriers, extreme weather conditions, communication challenges (e.g. lack of cellphones), difficulty recruiting health personnel, and patient tracking. (Reference: https://www.ncbi.nlm.nih.gov/books/NBK201058/) Another barrier evident in the documentary is the absence of transportation services, roads, and distance to healthcare facilities.

Pre-hospital care is an essential part of our healthcare system, as it is lifesaving in most cases. This is seen across different healthcare systems across the world, from urban areas which avail services from EMS such as ambulances, first responder personnel during natural and manmade disasters, to rural, far-flung areas which provide basic primary care with their scarce resources before and while being transported to health facilities with appropriate resources to tend those in need, especially patients with acute to chronic life-threatening conditions. Given that we live in an archipelagic country, some geographically isolated distant areas (GIDA) have little to no access in healthcare as seen in the iWitness documentary “Ambulansyang De Paa”. Regardless of the situation, it is warranted that the population must be seen by a healthcare professional before availing services which might not be available in this specific GIDA, as health is a basic human right.

Ideally, these resources should be available to the population residing in these areas so that there is equitable healthcare access even among GIDAs. However, with the scarce allocation of resources in our country which is an unfortunate reality, the healthcare professionals and even the community providing pre-hospital care have been trying to make ends meet for these patients. For the lack of infrastructures such as roads and vehicles especially those in mountainous areas, people opt to go on foot and carry the patient via a hammock or a stretcher just to bring the patient in a more accessible area to be transported to a medical facility and be treated. Some health professionals also go on foot by themselves or using a motorcycle with their backpack full of medications and essential equipment to go on GIDAs with little to no access to healthcare and provide pre-hospital care. Others, with no resources at all resort to traditional and alternative methods without being seen by a doctor, let alone a health professional. Eventually, these people meet their demise due to these factors which should have been addressed by agencies other than the health sector. This proves that health is multifactorial, and problems from other sectors that have not been addressed also affect the health sector, which makes these problems systemic and must be addressed sooner rather than later. Proper budget allocation, infrastructures built for the use of the people, and more human resources with adequate pay and support are only a few of the possible solutions to address these problems to provide better healthcare, specifically pre-hospital care among populations residing in GIDAs.

The Philippine health care system has much to improve on. Many patients still cannot be brought to the hospital even when they urgently require medical attention. This is a problem that is very keenly felt particularly in the geographically isolated and disadvantaged areas of the country. As shown in the documentary “Ambulansyang de Paa”, many Filipinos remain unable to seek treatment for even the most easily treatable illnesses. Because of this, their health conditions typically worsen to the point that they require emergency care. Yet, even when such is already the case, these patients still cannot receive the medical attention they need because the nearest health care facility is mountains and rivers away from them.

So, this brings us to the discussion about the importance of pre-hospital care in improving outcomes for these patients. The number of hospitals is limited. And even health centers can be inaccessible in rural areas. There is a strong need to establish a working pre-hospital care system everywhere so that the patients who cannot reach these health facilities can receive at least some temporizing measures until they can be attended to by a medical practitioner. With the Philippine health care system as it is today, it cannot be avoided that there will be patients with life-threatening conditions who cannot be brought to a health facility that can provide their needs in a timely manner. However, we can make it such that pre-hospital care is brought closer to them. And hopefully, this intervention would be able to buy them time to reach the facilities that can better care for them.

According to the Disease Control Priorities project of the World Health Organization (WHO), more than half of the deaths that occur in lower middle-income countries each year are from conditions that could be addressed by organized prehospital and facility-based emergency care, but the numbers could go higher in developing countries who are yet to achieve universal health care such as the Philippines, which has a particularly unique health situation  – devolved and decentralized.

Emergency care systems for universal health coverage are essentially about ensuring timely care for the acutely ill and injured. For the Philippines where roads and highways are not the only problem for people to access health care, the need for an organized and efficient  pre-hospital care system is both an urgent and crucial piece in the yet unachieved (and quite unimaginable) picture of universal health care. It is not only an additive to the health system, but an essential key to reduce morbidity and mortality in acute life-threatening conditions, especially for time-sensitive illnesses, as well as to reduce the overwhelming load channeled to the emergency medical services (EMS). 

"Ambulansya de Paa" is a stark example of a systemic failure to provide such a key component of a basic national healthcare, and yet at the same time, a truly remarkable initiative of one person to meagerly but very courageously patch such a gap of the government so as to at least alleviate much or some pains and sufferings of the unjustly marginalized people of our country. 

Prehospital care system reduces the morbidity and mortality associated with acute life-threatening conditions if properly conducted and provides an effective protocol during mass casualty events. It improves the outcomes of injuries and other time-sensitive illnesses. This ensures that the patient in need of medical attention is properly attended to, triaged, treated, and transported safely to the appropriate health care facility for definitive care.

Prehospital care is an essential part of the continuum of health care yet also an often overlooked component. This is provided by emergency medical services (EMS) responders, who serve as the initial health care providers. They provide prehospital care through careful triage, initial evaluation and treatment and immediate transfer of patients to the appropriate health care facility, where definitive care is ultimately provided. Prehospital care plays a critical role in the treatment of emergencies and acute life-threatening conditions and yet the lack of available and accessible prehospital care in many areas in our country is an unfortunate reality many Filipinos have to face everyday. This was clearly evident in the documentary “Ambulansyang de Paa”, where patients in Sitio Dyandang and Villa Pag-asa are unable to access the healthcare they need. The documentary showed just how people residing in GIDAs need to walk for hours on treacherous roads just to be able to visit a local health center. The 3 to 4 hour travel is not something that a person experiencing an emergency would be able to survive and even in the slimmest chance that they do, the health center they arrived at might not even have a doctor present or the center may have a shortage of the necessary equipment and medications to address the patient’s condition. 

 Emergencies and acute illnesses often require immediate resuscitation and stabilization that cannot be provided without an adequate prehospital care system. In order for us to be able to achieve better outcomes for Filipinos experiencing health emergencies and acute illnesses, effort must be exerted into building a reliable prehospital care system across the country. The documentary reveals many of the flaws of our healthcare system that requires correcting before we are able to provide the best care for our patients. Ideally, “ambulansyang de paa” should no longer be a thing in our country. Instead, these should be replaced with fully-equipped ambulances and well-trained EMS providers that are able to respond to emergencies. The documentary also shows how other social determinants have a big impact on the healthcare (or lack thereof) that patients receive. Lack of paved roads, out of pocket spending and lack of health education are some of the other determinants that further hinder access to immediate healthcare. Political will and allotting an appropriate budget to address these are necessary for us to be able to leave stories like those seen in the documentary in the past. Addressing these underlying issues and determinants are a prerequisite for us to be able to provide better care, especially to the emergency patients who need immediate access the most.

Prehospital care minimizes the consequences of acute illness and injury by providing treatment to patients in urgent need of medical care on-site, conducting timely transfers to the nearest medical center, and supporting patients however possible. The lack of health facilities and shortage of health workers makes prehospital care non-existent in many Geographically Isolated and Disadvantaged Areas (GIDA). Patients often need to be transported over long distances to reach a healthcare facility. The laypeople are often left to decide independently whether and where to transfer their patients. The lack of prehospital care negatively affects the outcomes of medical emergencies. Thus, access to prehospital care should form an integral part of the care regime available to the communities. For it to happen, there should be a focus on strengthening the provision of primary care. We need to address the fragmented service delivery brought about by the devolved health system and move towards providing comprehensive and integrated care. We also need to deal with several issues, such as sustainable funding, clinical training, staff recruitment and retention, construction and maintenance of roads, and transport infrastructure.

There is only so much pre-hospital care can do in the setting of an emergency. An emergency situation needs urgent management from institutions with sufficient capabilities. The goal of pre-hospital care is to do as much as you can while preparing and transporting the patient to an able ER which is why pre-hospital care and QUICK access to health care go hand in hand. If we want good pre-hospital care, we should also improve the access to healthcare.
In the video, even if we deployed trained EM service responders to the rural communities, the responders cannot sustain an acutely ill patient's life long enough if the travel time to the nearest ER is ~4 hours. The documentary highlights this deathly insufficiency in our country's far flung communities where physical access like roads and  presence of trained professionals are non-existent. Whatever we learned in this emergency medicine module, such as the ABCDE's, could not go beyond stabilizing the patient for only a short amount of time. Even the ABCDE's would prove to be almost always futile in the communities as neglected by duty-bearers as those shown in the documentary.

For patients with acute life-threatening conditions, time is of the essence. Pre-hospital care is essential in providing immediate interventions that can save lives and improve outcomes for these patients. Unfortunately, in geographically isolated and disadvantaged areas, the administration of pre-hospital care is nearly impossible. The necessary resources are often lacking, the nearest healthcare facility is at least a few hours away, and there may be no doctors available to attend to the patients.

There are several factors that hinder access to healthcare including infrastructure, finances, governance, and health literacy. Even common and treatable diseases like tuberculosis cause morbidity and mortality because of the lack of access to healthcare resources. Maintaining a good health status requires not only a one-time consultation but rather, a continuous follow-up, which can only be achieved if the country has an efficient healthcare system in place. Both national and local efforts are important in order to address the several issues concerning the country’s healthcare system altogether.

The fact that the Philippines is an archipelago subjects many places like Sitio Dyandang, at a significant disadvantage in terms of health service delivery and resource allocation, hence being called geographically isolated and disadvantaged areas (GIDAs). The Alma Ata definition of health is hard to grasp in areas where resources, government prioritization are scarce, hospitals and health professionals are non-existent, and whose people’s priority is mere survival instead of living to their fullest.

The documentary showed an issue on public health, which is in general, given less priority relative to curative, specialized interventions. Many people lack the awareness that health is a right, believing this is a luxury instead. They are placed under several misconceptions which may explain their belief that, for instance, TB is a “death sentence” and their provision of Spirulina for it, besides, of course, the fact that they are in a state of helplessness and resource scarcity.

The long journey to the “nearest” health facility severely limits access to healthcare. People then seek hospital care when symptoms are already at their worst. The ED is therefore the first and even last point of entry of the underprivileged. It does not help that prehospital care, which is an essential part of continuum of emergency healthcare is basically non-existent in GIDAs. Ideally (our favorite word), prehospital care provides fast evaluation and temporizing measures to resuscitate and stabilize patients needing immediate care so that these patients are transported to a hospital deemed appropriate for definitive care all under a “golden period.” However, for those in GIDAs the period is not golden, not even bronze. There are no proper vehicles, so people walk through muds, rivers, mountains for hours, with the risk of dying along the way, just to go to a destination that does not even guarantee definitive care due to lack of resources.

In accordance with WHO ECSA Framework, there should be a governance mechanism that will create policies to sustainable funding and partnerships, effective governance and universal access to safe high quality, needs-based emergency care for all, without regard to sociocultural factors. There should be multisectoral involvement to address infrastructures, livelihood, education, and other needs of people in GIDAs. It is my 4^th time watching this documentary and heartbreak is all the same each time. Even after a decade has passed, nothing ever changed. The documentary should not be viewed as a glorification of resilience, kindness, nor bayanihan—roundabout things abused by higher ups. Instead, it is a demand for the attainment of people’s right to health.

The Philippines is an archipelagic country consisting of thousands of islands with some towns/cities having very low doctor allocation (or sometimes even none) to a given set of patients. A lot of towns in the Philippines are very distant from the heart of society, they are known as geographically isolated and disadvantaged areas (as shown in the documentary). Accessibility of health services (including transport to and fro the health facility) has already been a longstanding problem to a lot of Filipinos and many are dying from common, treatable, and preventable medical conditions. This is a result of a lot of factors mainly from poor public health promotion, education, and administration since the Philippine healthcare system today looks like it focuses more on the curative aspect of medicine as opposed to preventive care.

The concept of pre-hospital care refers to the provision of essential and emergent medical services before/during transport to healthcare facilities. This aims to provide measures to resuscitate and stabilize the patients and even provide initial life-saving treatment to prevent further complications while definitive treatment at the healthcare facility is not yet administered. In the end, it aims to reduce the mortalities arising from this time interval which leads to better treatment outcomes once the patient receives the definitive treatment. Pre-hospital care services, when made accessible to every barrio in the Philippines, can somehow make healthcare more accessible since it also includes the immediate transport of the patient towards the nearest health facility. If the nearest health facility is far and transport will be delayed, at least initial/emergent measures shall be done to prevent deterioration of the patient.

 It is sad to admit that even in the aspect of pre-hospital care, not all filipinos are able to have pre-hospital care prior/during transfer to the nearest health facility due to a multitude of reasons some of which include: maldistribution of healthcare professionals in the country, the lack of focus in Public health and preventive care, mis-allocation of resources, lack of intersectoral collaboration, and poor governance. Therefore, future health policies should center on the core problems of the current health system and aim to address the roots as well as take into consideration the social determinants of health which play a big role on why health inequities exist.

     Pre-hospital care is a crucial part of healthcare that is provided by emergency medical responders. It is a developing and exciting area of emergency medicine that encompasses a variety of domains aside from what many may believe as just simply “load and go” transportation of patients to healthcare facilities. Rather, it includes ambulance and emergency practice, medical rescue, prehospital physician response and medical direction, retrieval medicine, dispatch and communications, telemedicine, trauma and even disaster medicine. Perhaps this is also one of the areas wherein medicine interacts with other emergency authorities such as fire service, police and the military. It ensures the well-being of patients as soon as a call arrives at health care facilities of a patient in acute distress, to the point of arrival at the emergency rooms of health care facilities.

     Well, one of the great challenges in taking care of patients with emergency cases is to first ensure that they are well taken care off at the point wherein they experience the distress and subsequently, to get seen in more detail at the various health care facilities. The last sentence alone exemplifies the great importance of pre-hospital care after watching the documentary entitled “Ambulansya de Paa”. The documentary showed the hardships faced by people living in Geographically-isolated-areas (GIDAs) on a daily basis, especially when it comes to access to health care. There was a young male who has been suffering from Tuberculosis and a malnourished baby with a multitude or problems such as pneumonia and diarrhea. The nearest local health center is located hours away and they need to travel on foot as they have very few utility vehicles. Another complicating thing is the fact that the people usually don’t have electricity and the roads are underdeveloped, making it hard for vehicles to use. There is the possibility of sick patients dying along the way to the local health centers.

     Now, the situation would be very different if pre-hospital care would be there to attend to those patients. The simple presence of teams of emergency response units would already be making a difference. The patients in distress could be stabilized on site by providing them medications, intravenous fluids, oxygen support and more. The risk of patients dying while on the way would be drastically reduced. The subsequent transportation would be much easier as the patients would more or less be already stable when they reach the various health centers for more definitive treatment. Based on this, pre-hospital care already improves access to healthcare simply by showing up to those in need. Of course, pre-hospital care also involves ambulances and other means of transportation such as helicopters. A helicopter with complete equipment would very much transport patients in a blink of an eye, bypassing the obstacles of nature.

     All of the aspects covered by a well-developed pre-hospital care system would make a tremendous change in the lives of people especially the underserved by improving the outcomes for patients with life-threatening conditions by giving them first-rate, high quality healthcare at the time and place they need it the most and ensuring a smooth, safe arrival to the various healthcare facilities. Therefore, pre-hospital care improves access to healthcare.

In the Philippines, health care has always been a problem for decades. Aside from the fact that in the Geographically Isolated and Disadvantaged Areas (GIDA) are very difficult to be reached by healthcare professionals, the healthcare facilities in the Local Health Center are also ill-prepared. Some GIDAs are so isolated that it took the family of John Lloyd 4 hours to reach the nearest Local Health Center. The center itself was also ill-prepared as the basic emergency equipment could not be found, as well as a licensed Physician. Furthermore, many in the GIDAs had not been well-educated with regards to their health and as such, have poor health-seeking behavior, causing what could have been an easily treatable disease such as TB or Nutrition to further increase in severity. It is also important to note that in GIDAs acute injuries are fairly common as most GIDAs are not equipped with proper safety protocols to shield them from nature or burns

As such, in many of these areas, it is important to further increase funding for pre-hospital care. There should be first aid and emergency procedures in place in these areas especially since many of the patients in GIDAs are prone to infection, malnutrition and injuries. Furthermore developing patient education in the GIDAs will increase awareness of possible life-threatening conditions, allowing the community to take action immediately

It is very unfortunate that there are people who are suffering and dying due to diseases which should be treatable, but not managed due to lack of access to healthcare. In addition, they also lack information regarding their diseases, making them believe that these are just simple cases but are in fact, very complicated.  For example in the documentary, Lowen, the person diagnosed with TB at the age of 12, was forced to be in quarantine for 10 years because his disease was perceived to be a curse by the community. They also believe that food supplements and coffee can treat his condition. This documentary highlights the lack of facilities and infrastructure in these areas. Although there are available ambulance vehicles, the roads could not be fixed due to limited budget. There are hospitals but their personnel are lacking. We can see the effects of limited funding and poor resource allocation by the government. The infrastructures and roadworks are simply a political front for the people. Most health workers choose to work in urban areas due to minimum pay and benefits. We need to educate the community so that they can be capable of solving health-related problems. We need to provide them information regarding basic life support, and other necessary knowledge regarding common diseases. Health workers should be encouraged to work in rural communities by giving them better opportunities like increasing their pay and benefits. Lastly, we need to elect government officials who are willing to change the current system and strengthen primary health care.

Medicine as a profession entails a holistic approach as physical illnesses are intrinsically linked to social injustices, science should benefit all, not just those who have the means to profit from it. The documentary depicts how we are all bounded by different societal forces such as power, structures, facts. Without a proper pre-hospital care in place, trauma patients die in the field without being treated or transported to the hospital. A good pre-hospital care provides timely and appropriate emergency care and even buys time in some situations until definitive care is available especially for patients with acute life-threatening conditions. Funds of our government should strengthen the public health system down to the communities by improving emergency services including strong information structure, emergency equipment, health promotion, and making medications accessible and affordable. In addition, creating referral system with better linkages that promotes timely referral and access to prehospital care improves access to health care. Providers should be able to consolidate into integrated health care provider networks where there could be easier referral systems and more efficient use of resources and delivery of comprehensive care. Integrated health care provider networks lead to better communication amongst emergency care providers which promotes timely referral and appropriate emergency care. With these in place and operating, health for all is attainable where needs are met, and no one is left behind.

Management of acute life-threatening conditions is usually time-sensitive. Pre-hospital care can prevent further morbidity and mortality since an initial assessment and simultaneous management of the problems detected can already be done before or during transport to an acute care facility or hospital if the necessary medicines, medical supplies, and equipment are available. At the least, it should be able to sustain and stabilize patients until they can coordinate transfer to a facility more capable of providing definitive management. 

Pre-hospital care is an important entry-point to the healthcare system, so if that alone is already unavailable, then more people are denied their right and access to health care. The documentary showed that this is the case for many Filipinos, especially those residing in geographically isolated and disadvantaged areas (GIDAs), for whom pre-hospital care is not accessible. Aside from the lack or misallocation of funds, poor governance, and lack of resources (both human and non-human), the Philippines being an archipelagic country makes the provision of timely and appropriate pre-hospital care all the more difficult. For those in GIDAs, the nearest health facility could be a mountain, a river, or an island away. In their long and arduous transit, those with life-threatening and emergent conditions can deteriorate and die before they reach the health facility. It explains why many would not bother seeking medical care at all, since the journey subjects the patients and their communities to suffering they wouldn’t have had to experience if only pre-hospital care were available. Even for those who are able make it to a local health center, there is no guarantee that they can receive the treatment they need because their resources may be inadequate.  The persistence of these problems until present indicates that several aspects of our healthcare system still need improvement, and it may be prudent to exert greater effort in establishing and strengthening our pre-hospital care system on a local and national scale.   

Pre-hospital care is important in improving the outcomes for patients with acute life-threatening conditions since it will help stabilize the patient before definitive treatment can be initiated. This is where the ABCDEs of the primary survey comes in, with appropriate management for each step. However, as seen in the documentary, many have still no access to these services. Aside from the lack of personnel and resources, pre-hospital care is also impeded by the lack of decent roads and transport options for patients in far-flung areas. Because of these problems, it was mentioned that sometimes, patients just die on their way to the nearest health facility. These issues show the great health inequities in our country. Thus, we must strive to improve health access to these patients. We need to improve and ensure adequate health personnel and resources. We should also aim to improve the transportation options in these areas. Together with other options, we may be able to deliver quality pre-hospital care to patients with acute life-threatening conditions. 

The truth of the matter in the country is that most areas outside of the main city do not have proper access to health care. And watching the story of the patient with chronic TB, unable to travel to the hospital and isolated in a shack away from the main village was heartbreaking. While it is a testament to the Filipino spirit of bayanihan, that volunteers from the village agreed to carry him down the mountain, I cannot help but wonder if it was by virtue of the journalist who came to interview them with the camera crew that they went above and beyond to transport the young man down the mountain to get him to the hospital. It begs the question - why is this still a problem? It is not just a matter of lack of facilities, it is also a matter of transportation and infrastructure set in place to get these remote areas access to the many amenities they are removed from. From this it is evident that the problem of providing adequate public health is multi-factorial and multi-sectoral. 

In emergency situations or when there is an acute threat to life, pre-hospital care will be the primary determinant as to whether or not that patient will get a chance to survive the initial injury and eventually have a full recovery. Most of these conditions require an initial assessment and some form of intervention. The series of actions that take place from the site of injury until the patient is able to reach the emergency department of the hospital or a center capable of providing intensive care play a big role in determining the prognosis of the patient. This is why proper training and adequate supply of emergency and resuscitative equipment are extremely important. In addition to that, most of these conditions also have a “golden period” or an amount of time from injury in which intervention should be done in order to prevent permanent or significant damage. Beyond this golden period, interventions would be of little significance, sometimes even futile. These highlight how important it is to have a functional and efficient pre-hospital care system. Functioning prehospital care systems also improve access to health care in that patients are able to make it to a health institution, be it a local health center or tertiary hospital, faster and easier. 

For patients with acute life-threatening conditions, prompt intervention is needed in order to prevent the patient's condition from progressing even further and to prevent morbidity and mortality. The documentary highlights just how alarming the situation in the Philippines is with regards to pre-hospital care. Accessibility is such a glaring problem affecting the portion of the population in most need of healthcare. Those in far-flung areas are unable to get the care they need even for relatively common or (supposedly) non-life-threatening diseases due to the lack of resources in their community and the costs of receiving proper healthcare. Suppose a proper pre-hospital care system were in place, then people like those seen in the documentary may have more of a fighting chance.

This systemic problem is painfully evident and it needs to be handled properly. Proper support and provision/allocation of healthcare resources are needed in order to help communities improve their pre-hospital care systems. Inter-sectoral collaboration is also needed so that the problem may be tackled from different fronts. Problems in physical accessibility, personnel, and material resources all have to be addressed so that local health centers may be able to provide the proper and much-needed care for patients and improve outcomes.

Public health has repeatedly emphasized the necessity of pre-hospital care to improving individuals' prognosis and quality of life. Despite this fact, the majority of the Philippine population remains untreated due to the absence of facilities and human health resources. This problem will unfortunately affect all patients, irregardless of the severity and diagnosis of any patient. The problem with this inaccessibility is that even the simplest diseases that can be easily treated are unfortunately presumed fatal for patients. 

Indirectly, this violates the rights of these Filipinos to access to proper healthcare and yet there still is no tangible solution in sight. Promises have been set by the recently passed Universal Healthcare Law, and hopefully it tackles the increasing morbidity and mortality related to the lack of community health resources. The end goal should be the existence of local health centers capable of a.) stabilizing acute life-threatening conditions,  b.) treating common benign diseases, and c.) immediate transportation to higher healthcare institutions should local facility be unable to control patient's medical concerns.

Pre-hospital care aims to improve patient health outcomes prior to a more comprehensive and definitive management in a healthcare facility or hospital. This is through the early recognition of signs and symptoms, and the application of timely, basic, yet potentially lifesaving measures, thereby reducing patient morbidity and mortality. Time is an important resource, which pre-hospital care recognizes and hence tries to make full use of. By ‘stabilizing’ patients prior to their transport or transfer to a more capable healthcare facility, pre-hospital care grants ‘more time or leeway’ for patients to tolerate transport and other possible delays to definitive management, minimizing possible disease complications.

The documentary highlights the importance of pre-hospital care, or rather, shows what the lack of it can lead to: patients needlessly suffering from, or even dying to curable diseases. Lack of access to primary care is another thing altogether, but in the mountains of Bansud, Oriental Mindoro, even pre-hospital care is unavailable. There is no doctor or healthcare worker in the village who can see and provide early management to patients prior to the grueling 3- to 4-hour trek to the healthcare center at the urban part of town, and as a consequence, there are times when patients die in the middle of the journey down the mountain, and simple diseases spiral uncontrolled and develop otherwise preventable complications. With the village’s pre-hospital care lacking, the village people who develop acute conditions pretty much have to leave it to fate that they arrive just in time at nearest clinic or hospital for delayed treatment. 

It is horrifying to know that the story of the people of Bansud is one amongst many in this country. For a relatively modern country boasting an improving economy and rapid urbanization, the Philippines should be doing more for the health of her people.

As time and immediate intervention is necessary to save acute life-threatening events, pre-hospital care is essential in decreasing morbidity and mortality. Unfortunately, this is very much insufficient in the Philippines especially in geographically-disadvantaged areas. The documentary showed an extreme example of how poor or no pre-hospital care can result to increasing mortality among patients who could have been saved. This scenario is quite common in the country but what makes it even worse to think is that pre-hospital care is still insufficient even in municipalities or urban areas. It is still caused by a poor referral system, lack of resources, and the like but also because of traffic and need for out-of-pocket expenses that pre-hospital care is insufficient. 

With this, there is an increasing need for the country to improve its pre-hospital care. This starts with the government’s support in providing the healthcare workers and other essential personnel the resources needed to establish an effective pre-hospital care. This is followed by an effective collaboration among multiple sectors in the national and local level. When pre-hospital care is improved, lives of several people can be saved. 

Pre-hospital care prevent further clinical deterioration and, by extension, allow a patient to survive longer by being assisted in aspects of the primary survey such as improving the airway access, breathing, circulation and the like. Many a Filipino will die without even being able to see a doctor, but pre-hospital care is one of the many measures that exist to mitigate this issue. By helping stabilize the patient even before definitive treatment is given, more time can be given to reach the definitive care these patients need. Acute hospital care will not only help save lives, but will also mean cases admitted to hospitals may end up less complicated thereby requiring less resources to address.

It goes without saying that pre-hospital care can be life-saving for patients with acute life-threatening conditions. Few, if any, emergency conditions will have a good prognosis if it takes 3-4 hours before the patient is even triaged by an ED nurse.

Two important aspects of pre-hospital care that come to mind are disease recognition and actual patient transport. Both require multisectoral cooperation not limited to public health, education, infrastructure, and communication. People should be able to at least recognize that something is wrong. They should be able to identify or deduce aggravating factors and avoid them accordingly. They should be able to judge which conditions require expert intervention or at least be able to immediately consult someone more knowledgeable. Ideally, every household, sitio, and barangay would have 24/7 access to a healthcare worker; that can be via landline, mobile phone, internet, or in person which requires electricity, cell towers, roads, healthcare personnel, among others.

“… Marami ka pang makikita na … gusto mong tulungan pero para kang may tanikala.”

Dr. Marjorie Vizconde’s words succinctly describe the feeling I get every time we’re asked to watch this documentary. Even with the paucity of our patient interactions in PGH, I, too, have felt this sense of futility.

“Alam kong hindi mapapagaling ng isang araw ang batang ito. Alam kong hindi masosolusyonan ng isang tableta ang sakit ng mga taong nasa bundok. Alam kong hindi lang gamot ang lunas sa isang malalim na sugat. Pero hangga’t may mga taong handang tumulong, hangga’t may mga handang magmalasakit, hangga’t may mga balikat at paa na handang maging ambulansya, hindi natutulo ang pag-asa.”

While I understand that Kara David’s final words aim to put a positive spin on this all-too-common depressing situation, I can’t help seeing it is a misplaced message of hope. I agree; our efforts can't end with building hospitals and providing medicines. These short-term solutions that politicians often tout to get elected do nothing about the underlying cause of our problems. However, the onus to improve access to healthcare should be on society as a whole with the government taking charge rather than on communities and individuals. At this point, it seems that even LGUs are helpless without the national government’s support.

The status quo should be disturbing all of us, especially those in positions of power who can readily do something about it. Doctors shouldn’t feel weighted down by our society’s shortcomings and malprioritizations. Patients and their families should never spend half the day climbing down a mountain only to find out no one can see them. None of the changes we need can come from one person or one department alone. We need informed policymaking directed at developing the capabilities of healthcare personnel, retaining healthcare personnel, and improving the capacity and reach of healthcare facilities. We need policies that account for individualized needs of communities. A sitio found in the mountains won't have the same issues as one on an island. As long as the list may be, it’s good we know what problems we have. That way, we know where to focus our efforts.

The health-seeking behaviors of common people and their knowledge with regards to their health and diseases remain to be important points of improvement among Filipinos. In the documentary, a father refuses to have his severely malnourished child confined in the local hospital out of fear of expenses and that no one will watch over the child as they live hours away. A tuberculosis patient is being given supplements instead of anti-TB medications. These are representative of lapses in prehospital care which can turn life-threatening conditions into a mortality instead of being able to save the life of the patient. The picture is not complete without the availability of adequate funding, resources such as access roads, motor vehicle ambulances, and health facilities, as well as availability of doctors in health centers when locals arrive for consult. Ideally, along with improved health-seeking behaviors through patient education, these should be made available to make healthcare more accessible especially for those residing in far-flung and isolated areas.

In everyday life, the phrase, "time is of the essence", is applicable in most situations. This cannot be any more relevant than in emergency situations where the life of a person can be at stake if timely intervention is not provided. The community in the documentary was located in what could be considered a far-flung and isolated area with no roads and no access to vehicles. It would take members of the community hours of walking through uneven terrain, made more arduous by rains, before reaching the riverbank where they would have to rely on chance for a truck to ferry them across the river. In a situation wherein the difference between life and death is the time it takes to trek through the forest, the fate of the acutely injured person is practically sealed at the moment of injury.

What stands out in particular from the documentary was the apparent awareness of local government officials about the plight of the members of the isolated community who do not have access to the local healthcare facilities. On the one hand, it appeared as if there were efforts to address the problem by building a hospital/health center but on the other hand the infrastructure needs (i.e. roads, bridges) for getting people to the facility were grossly overlooked. 

In the WHO Emergency Care System framework, there are three elements that I would consider to be summative: human resources, functions, and technologies (including vehicles, equipment, and information systems). As shown in the documentary, the local government unit involved is lacking in all three areas, thus exhibiting a poor emergency care system. There are few medical personnel to take care of the members of the community, poor public health education, no mention of communication technologies to alert officials of accidents, no roads, and no vehicles or equipment to transport the acutely ill or injured. In order to prevent the inevitable death of community members from otherwise curable diseases (e.g. tuberculosis, malnutrition) or salvageable situations (e.g. trauma), appropriate pre-hospital care needs to be developed. This would mean improving in the areas mentioned from the WHO ECS framework. With adequate reinforcement of health personnel and improvement of access (in terms of infrastructure and economic access) to healthcare facilities, significant morbidity and mortality can be prevented for a larger portion of the population.

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.

Pre-hospital care is essential in the preliminary management and diagnosis of acute life-threatening conditions. Patients can be given IV fluids, oxygen, or even be manually ventilated as necessary. In urban areas, ambulances are equipped with the necessary equipment to prevent the deterioration of the patient. Even simple things such as an ECG or monitoring the patient's vital signs can give clues towards the patients diagnosis and needs even before reaching the hospital.

As seen in the documentary, however, not all areas can afford this luxury. In far-flung areas, it can take hours to reach the town proper on foot. Not everyone has cellphones which can be used to call for emergency, and even  if they did, there are no roads for ambulances or cars to pass through. In the documentary, we see that the community in the mountains did not even have electricity, and they needed to carry their sick by foot down to the village. In certain conditions, such as an MI or stroke, any patient would surely be dead or at least suffer major neurological damage before even being treated at a hospital.

Pre-hospital care has certainly improved patient outcomes, and is a vital component of the healthcare system. However, it begs a few important questions -- how do we get more people to benefit from this? How do we make this accessible to those in underserved areas? And lastly, how can other institutions help in building the necessary infrastructure and putting systems in place for more people to benefit from our advancements in healthcare technology?

Patients with life-threatening conditions, especially those in far flung areas, will benefit the most if access to health care and pre-hospital care was improved. Access to health care is not only just constructing local clinics or hospitals in some remote area, but also improving the roads, availability of emergency transportation, and insurance coverage for those who need it. The main reason why ambulances can’t reach these areas is because of the road being basically dirt in the dry season and mud in the rainy season. They will just get stuck while going there therefore; people rely on “duyan” to carry the sick down the mountain. If only politicians bothered to finish their projects rather than just leave it behind when the budget had ran out or election is over, roads will be paved and there are so many people that ambulances might be able to reach. Another hindrance to people lacking access to healthcare is the lack of insurance. Despite the Universal Healthcare Law being signed, there is no insurance coverage to those who can’t pay monthly contributions thus; people who don’t have it are forced to pay out of pocket. With these kinds of people who just eat corn or root crop three times a day to survive, money is a big issue for them. That’s why they are reluctant to get admitted because they know, they will not survive the aftermath. Improvement in pre-hospital care involves having a physician go to those remote areas to check on them regularly, and manage them with primary interventions and send them to the hospital if necessary. It also involves having access to basic medications which can be given to these people to treat conditions which are treatable when managed right. If this is done, we will not frequently see patients who are already terminal because they have been managed beforehand. However, that is not the case. There is a physician shortage; doctors prefer to go abroad or to the city to practice because the government does not give enough incentive to healthcare providers when they go to these areas. Pre-hospital care is important, but it is being ignored, especially by the government who are supposed to do things that are for the benefit of its constituents.

Prehospital care is an essential part of emergency healthcare which involves medical personnel who are trained to immediately identify the problem, evaluate the situation, and determine the necessary resources, and proper coordination among dispatch centers, ambulances, hospitals, and/or specialized health centers. This is especially necessary to save the lives of patients who suffer from life-threatening illnesses. In the documentary, we saw that almost none of the components of prehospital care could be found in Bansud, Oriental Mindoro, where many of the people were malnourished and suffering from various diseases. To get to the nearest health center, patients and their caregivers had to travel on foot or via "ambulasya de paa," a duyan which was carried on foot, for several hours on muddy and unpaved roads. Due to this, many of these people have never been to a health center and only went once the disease became very severe. Some patients even died on the way. Besides the difficulty of transport, there was a lack of medical personnel. For example, there was only one doctor for a for a population of 3000, whereas a barangay health worker had to traverse five mountains to get to the community. While the local government realized that the solution to these health issues would be to improve infrastructure and pave the roads, the lack of funding from the national government made them unable to carry out these plans. Furthermore, the lack of finances serves another impediment toward giving proper healthcare. Thus, patients with treatable diseases such as tuberculosis, or conditions requiring emergency care such as burns, diarrhea, or dehydration, reach severe stages or even die before being able to receive proper care. This documentary highlighted that the solution to these health problems does not lie solely in giving medicines, but in improving the economy, infrastructure, accessibility of health centers, and increasing the number of trained medical personnel.

Pre-hospital care improves outcomes for patients with acute life-threatening conditions by stabilizing the patient en route to a medical facility capable of giving a definitive management to the patient's condition. There is a stark difference in prehospital care or the lack thereof between urban areas and far-flung communities. This was shown in the documentary wherein people living in GIDAs have difficulty with accessibility to health services. Being far away from health facilities is one problem but the lack of personnel to address common conditions within their communities is a contributing factor to this self-perpetuating problem wherein health conditions worsen through time and take a toll on the people’s finances which in turn worsens their quality of life making recovery more difficult to achieve.

Pre-hospital care is essential in the early recognition, assessment, and management of patients, especially those requiring immediate, life-saving measures. The documentary revealed that several patients who have medical emergencies or chronic, debilitating conditions are forced to delay seeking medical attention due to the lack of paved roads, appropriate transportation, and nearby health facilities. Because health centers/hospitals are located in towns that require hours of walking and using makeshift “ambulances” to reach, people from the mountains and other remote places are often forced to deal with their injuries or diseases on their own, with some only deciding to seek consult when their status is severe, while others do not even attempt to leave anymore. As a result, treatable cases become complicated ones as patients’ diseases worsen or even occur with new diseases.  These realities, interlaced with poverty and insufficient funding for health, further impede efficient and effective emergency care, causing patients with potentially reversible conditions to suffer from significant morbidity or even death.