Roles and functions of Pre Hospital Care System, and communications services and
network in activation of the response system during a pandemic.
Introduction
Pre hospital Care System means examination and care of a patient by medical
professional’s responders in the hospital such as medical assistants and nurses. Pre hospital Care
system or pre hospital emergency care services include urgent assessment of the patient's state of
health, pre hospital emergency care and where necessary, transportation of the patient into a health
care unit for follow-up care. The pre hospital emergency care service treats patients who have
fallen seriously ill or sustained a severe injury, but assessment of the patient’s state of health and
need for care is also carried out in less urgent situations. Typical pre hospital emergency care
service missions include chest pain, difficulties in breathing, cerebrovascular disorders as well as
traffic accidents and falling and slipping accidents. As the usual situation, a call to 999 will activate
the pre hospital care system service where needed. The emergency response centre operator who
act as the earliest responder will evaluate the need for assistance over the phone and alert the
appropriate resources to address the situation based on the evaluation made. These procedures are
the crucial process in the pre hospital care system in order to make sure that the patients will get
the best treatment for them.
When the pre hospital emergency care service arrives on the scene, a new assessment of
the situation will be made, the necessary pre-hospital emergency treatment will already be given
on-site, and the patient will be transported to the most appropriate health care unit where necessary.
In pre hospital care system, the assessment of vital functions includes the measurement of blood
pressure, pulse, cardiac function, level of consciousness, blood glucose level and where applicable,
alcohol content. The field management and physician-staffed unit is also capable of conducting
more extensive tests on-site. Where necessary, the patient's vital functions will be supported. For
example, breathing will be assisted by means of a variety of technical aids and blood circulation
will be treated with fluid or medicinal therapy. Effective pain management is also an important
part of pre hospital care system services. Every patient or case will be differ from each other, so
the pre hospital care service will classify the threat and direct the patients to the best treatment
based on their cases. Overall, pre hospital care system can be called as the frontline healthcare
service in the hospital and this system is very important in order to maximise the efficiency of the
hospital in handling their patients.
Vital roles and functions of the Pre Hospital Care System
As in Malaysia, the pre hospital care system is called Emergency Medicine and Trauma
Services (EMTS). This EMTS is seen as the frontline and a critical service by Ministry of Health
(MOH). It is a special department that offers clinical care to a wide range of acute medical
infirmities, illness or injuries. This involves the provision of emergency critical medical care that
includes diagnostic, resuscitation and stabilization components and life saving interventions. The
EMTS general scope includes pre hospital and hospital based medical care. It advocates clients
focus care which is holistic and total in nature which instill a corporate culture value of caring,
teamwork and professionalism. The clients and functional register assumed by the national EMTS
do not differ much from its contemporaries in most parts of the world. Therefore, the construct of
Malaysian Emergency and Trauma department also could discharge roles for the management of
major trauma patients, pediatrics patients, mental health patients, contagious patients, pre hospital
care, transport and retrieval services. This department also always in the state of readiness for the
management of mass casualty, disaster victims or pandemic.
The main objective of this EMTS is to provide a prompt, accurate and definitive emergency
medicine and trauma care service. On the other hand, this department focus is to provide “total
quality management” in all the critical management inters phases from the pre hospital care to the
triage services and sorting out to the various dedicated management zone namely, critical (red)
zone, semi-critical (yellow) zone and non-critical (green) zone. The patient’s condition will be
systematically assessed by means of a method where the patient is always examined according to
a specific protocol and the sufficiency of vital functions is assessed. In the assessment, account is
taken of factors such as the patient’s respiration, blood circulation, level of consciousness and
potential trauma findings. In mass casualty incidents, the patients are always classified in a
predefined manner in such a way that they receive treatment and potential transportation to the
hospital in the proper order of priority. The case or patient who is in the most critical condition
will be treated and transported first. The detail elaboration about the zone categories can be
understand as below statement and table 1.

Zone Critical (Red Zone): a severe disturbance of vital functions or imminent threat.

Zone Semi Critical (Yellow Zone): a minor disturbance of vital functions or other reason
due to which the situation must at least be checked on-site. The target time for reaching the
patient is within 30 minutes of the alert.

Zone Non Critical (Green Zone): a non-urgent prehospital emergency care mission or a
pre-ordered scheduled mission. The target time for reaching the patient is within 2 hours
of the alert.
Table 1
Beside focusing on treatment and early health screening, pre hospital emergency care
system also provide transportation services to the patients whether from accident scene to hospital
or from triage room to the specific treatment room. The real situation does not always make it
necessary to transport the patient to a health centre or hospital. The solution that is most suitable
for the patient will be chosen based on the situation assessment and examinations carried out by
health care professionals or the responders. Based on the examinations carried out and the potential
treatment given on-site, the patient may sometimes stay home or, for example, take a taxi to the
emergency clinic. Ambulance transportation is only necessary if the patient's condition calls for
constant monitoring or medicinal treatment or the admission to a treatment facility is otherwise
urgent. The patient will be transported to a hospital when, following the assessment of the situation,
it is concluded that the illness or injury calls for follow-up care in a hospital and other forms of
transportation such as taxi are precluded. Helicopter will be used for transporting the patient to
follow-up care when this is assumed to yield a clear time benefit for the patient. Patient
transportation is not the primary purpose of a physician-staffed helicopter, even in the event where
a helicopter lands on the scene of the incident. The principal goal is to provide on-site doctor level
medical expertise to treat a critically ill or insured patient.
Pre hospital system in handling patients with infectious disease during COVID-19
Pandemic is a rare and stressful time for health care providers especially hospitals with
overwhelming caseloads, rapidly evolving information, and competing priorities of selfprotection, while maintaining a high level of patient care. Two previous coronaviruses caused
international responses; the severe acute respiratory syndrome (SARS-CoV-1) in 2003, and the
Middle East respiratory syndrome (MERS-CoV) in 2012 (Yee J, 2019). The current coronavirus,
SARS-CoV-2, has become a public health emergency and global pandemic. While the terms are
often used interchangeably, SARS-CoV-2 refers to the virus, and COVID-19 refers to the illness.
For simplicity, we will use the term COVID-19 for both. As the pre hospital system acts as the
first responder to this dangerous COVID-19, the medical assistant or nurses will make sure that all
patients will be screened for potential symptoms before patient contact starting with the dispatch
center. Given the extent of community transmission, patients no longer need a travel history to be
considered for having COVID-19. Firstly, responders will remain diligent even after prescreening
by dispatchers. Personal protective equipment (PPE) will be used all the time when handling this
type of case based on the risk of exposure and the transmission dynamics of the pathogen such as
contact, droplet or aerosol (WHO, 2020).
When no interventions are performed, health responders providing care or who are in close
proximity to the patient will wear a surgical type mask, gown, gloves, and eye protection, either
goggles or a face shield. Safety glasses are not sufficient for eye protection. For aerosol generating
medical procedures (AGMPs), health responders will wear a N95 mask, eye protection, gloves,
and fluid resistant gowns. PPE will be removed while driving the ambulance as long as the driver
compartment is separate from the patient. This is important to limit contamination to the front of
the ambulance. If there is no separation, the driving health assistant will wear a mask. Additionally,
a mask will be provided to the patient as tolerated (Murthy S, 2020). Other than that, proper use
of PPE and frequent hand sanitizing/washing among the health responders is essential to prevent
disease transmission in the hospital. On the same hand, Van Doremalen (2020) also recommended
that surfaces will be disinfected frequently as the virus remains viable for extended periods of time
on different materials, such as copper (4 hours), cardboard (24 hours), stainless steel (48 hours),
and plastics (72 hours). The majority of patients with COVID-19 will experience mild symptoms
and do not require emergency care. Usually, these patients will be isolated at home to prevent
transmission. For patients who require further treatment or transport to hospital, the health
responders or health responder who involve with the case, must wear appropriate PPE before
patient contact or initiating care. Initially, only one health assistant will make patient contact, and
perform an initial assessment to determine if additional providers are required. Unnecessary
personnel will be removed from the scene to limit exposure, and will not accompany health
responders during transport to the hospital.
Another important procedure that must be performed by the pre hospital system in Covid19 case is Aerosol Generating Medical Procedures (AGMPs). Airborne transmission is possible
when AGMPs are performed. AGMPs include advanced airway insertion, bag-valve-mask (BVM)
ventilations, chest compressions, open airway suctioning and tracheostomy care, nebulized
treatments, and noninvasive positive pressure ventilation. These procedures will be avoided, unless
absolutely necessary (WHO, 2020). Health responders could consider alternatives, such as a
metered-dose inhaler or parenteral administration of medications, for example intramuscular
epinephrine or withholding care in less severe cases. When providing ventilations by means of
BVM, health responders will use a two-handed approach (one person holding the mask and another
squeezing the bag) to ensure a good seal is being maintained. This situation really need good
cooperation and teamwork among the health responders in order to make sure the process could
perform smoothly. In general, two-handed BVM will not lead to exposure of additional health
responders. Early placement of an advanced airway will be considered. The risk of exposure during
intubation may be minimized by using the most experienced and skilled health assistant, video
laryngoscopy, a bougie and pausing chest compressions. This will provide more protection to
responders as post intubation ventilation limit exposure to secretions. Supraglottic airways (SGAs)
may offer an alternative to endotracheal intubation, which may limit exposure during placement.
It is not known if SGAs reduce exposure or provide the same level of protection as intubation, but
these devices will be considered when a good mask seal with BVM is difficult to achieve.
There is no evidence on outcomes or specific interventions for out-of-hospital cardiac
arrests related to COVID-19. Even though patients may have COVID-19, it is important to
consider other pathologies of cardiac arrest. Health responders will initiate resuscitation as per
standard practice, and use previously validated termination of resuscitation (TOR) rules to limit
transportation of nonviable patients. Application of a TOR rule will limit the time of exposure and
avoid transfer of futile patients to hospital. In the event of a prolonged surge event that limits
intensive care unit (ICU) bed availability, anticipate changes in the protocols that may limit the
conditions under which initiate resuscitation. Health responders will wear PPE for all calls into
long-term care (LTC) settings regardless of the patient's complaint. Patients in LTC settings can
have atypical symptoms of COVID-19 infection or be asymptomatic (Kimball A, 2020). It is
important to consider that staff can also be contagious. Patients will only be transported to hospital
when there is a need for a higher level of care than what the LTC setting can provide, not for the
purpose of COVID-19 testing. Facilities will contact their local public health unit for guidance or
consider using community health responders to perform testing. Patients with mild symptoms will
not be transported to hospital. However, this can be problematic if patients require isolation or a
negative pressure room. If unsure, health responders will contact online medical control for advice.
Whether or not to transport more severely ill patients depends on local ICU capacity and COVID19 disease activity. These decisions will be discussed at a local level.
Transport and treatment decisions will be patient-centered and focused around goals of
care. The pre hospital responders have up to date version of the patients’ advanced directives, as
their wishes might have changed with the pandemic. Health responders will consider the patient's
or substitute decision-makers request not to transport the patient to hospital. Health responders
will prenotify all receiving hospitals if a patient is suspected of having COVID-19. Resuscitation
and other treatment will be continued in the ambulance until directed by receiving staff. Health
responders must be mindful when passing other stretcher patients, colleagues, and other health
care providers who are not wearing PPE. Only providers with appropriate PPE will maneuver the
stretcher. While moving a patient between the ambulance and the resuscitation room, steps must
be taken to minimize or eliminate aerosol and respiratory droplets. The patient can continue to
receive supplemental oxygen and chest compressions, but manual ventilations will be withheld
unless the patient has been intubated. After the call, health responders will remove their PPE in a
designated area under observation of a trained observer. This ensures that proper procedures are
being followed to limit any cross-contamination occur during or after the treatment. Based on these
complicated process, we can ensure that pre hospital system is really an important system that had
been used in order to ease the expertise work to deal with the patient who had infected or noninfected with the COVID-19.
Conclusion
Malaysia has had relative success in responding to the COVID-19 pandemic, with deaths
at time of writing standing at 120. This is despite a mass religious event setting off large numbers
of infections in early March 2020. Based on testimonials in this report, this relative success is
owing to early pandemic preparedness and planning, established contact tracing to enable a robust
public health and primary healthcare response, a system of learning established through WebEx
mortality reviews, various Whatsapp groups among infectious diseases clinicians in different
countries and from genomic sequence information obtained off open science platforms such as
GISAID, and strict lockdown measures. The report also highlights the importance of a publicly
funded health system to ensure testing and treatment for all. The experience of Mr Lambert
highlights this; that he did not pay for any services during his stay in hospital and the quarantine
centre from 21st March-15th April 2020. Diagnostics, treatment, and all meals (breakfast, lunch,
tea, and dinner) were funded by the public health system. The importance of a public health system
has started to be realised elsewhere, even in countries dominated by private insurance companies
and capitalist health systems. In New York, for example, Governor Andrew Cuomo established a
regional supply and procurement chain along with other North-eastern American states to procure
USD$5b worth of equipment and supplies, and mobilised private and public hospitals to share
patient capacity, equipment, ventilators, and staff. Cuomo stated: “That had never been done. We
did this all basically on-the-fly. We put together a de facto public health system.” (Dr. Suresh
Kumar, 2020)
Malaysia’s relative success was also reflected in a number of other countries in the East,
including Taiwan, South Korea, and Vietnam, dismantling belief that health security, expertise,
and robust health systems were concentrated in the West. In fact, the 2019 Global Health Security
Index ranks the United States and the United Kingdom first and second in terms of global health
security. Given that these two countries are also the top two countries for COVID-19 deaths, it
would perhaps be prudent to have a reassessment of criteria for this index (Dalgish, 2019). More
importantly is the need for a separate analysis on the middle-income country response. Middleincome countries have relative resource scarcity to the Global North, but responded in ways that
would prevent hospitals being overwhelmed. Vietnam, a lower-middle income country, for
example, knew that it would not have diagnostics capacity to deal with a full-blown outbreak and
began initiating responses in January 2020, with ‘urgent dispatches on outbreak prevention to
relevant government agencies on January 16 and to hospitals and clinics nationwide on January
21’, in addition to border control measures such as temperature screening, and extended contact
tracing where once a positive case was identified, contacts through five generations were traced
(Minh Vu and Bich T Tran, 2020). Malaysia as an upper-middle income country had more
diagnostics capacity, but largely had similar responses and with quicker responses relative to the
Global North.
Like many countries, however, the response has had its imperfections. The response among
migrants in particular have attracted close scrutiny. While in early May 2020, the Health DG
emphasised that it was the MOH’s responsibility to test and treat all individuals in high risk groups
regardless of immigration status (Adam Aziz, 2020). A series of immigration raids and arrests of
undocumented migrants occurred in neighbourhoods with COVID-19 clusters and large migrant
populations later that month, conducted by the Ministry of Home Affairs (Emily Fishbein, 2020).
While the Health DG has continued to stress non-discrimination in access to healthcare for
migrants, including calling for immediate medical and decontamination procedures at detention
centres and the need for housing conditions for migrant populations to be examined, the response
in this regard requires policy coherence and human rights assessments, including on the right to
health (Datuk Noor Hisham Abdullah, 2020). Immigration raids and arrests are likely to drive
migrants underground, impeding the COVID-19 response and presenting infection risks.
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