International Notes

Emergency Medical Services Development in the Seychelles Islands

ERIC SAVITSKY, MD, GWEN BOURGEAULT REHNBORG, AND KATHRYN IBARRA

The Republic of the Seychelles enjoys a sophisticated health care system by developing country standards. Basic food, water, sanitation, and preventative health care needs have been addressed and the Seychelles Ministry of Health has recently focused on the need to improve the country's emergency medical services (EMS). In response to this need, a joint international collaborative effort designed to improve the island's EMS was launched. This report profiles the current health care system in the Seychelles, with special emphasis on EMS. It also describes an international collaborative effort between the Seychelles Ministry of Health and the UCLA Center for International Emergency Medicine designed to improve existing EMS. (Am J Emerg Med 2000;18:332-335. Copyright © 2000 by W.B. Saunders Company)

The Republic of the Seychelles consists of 115 islands located 1,367 miles off the coast of East Africa between the equator and the 10th parallel south (Fig I). The Seychelles Islands have a land area of 176 square miles, approximately twice the size of Washington DC. Of the nearly 80,000 residents of the islands, more than 70,000, or 90% of the population resides on the main island of Mahe. The island of Mahe, which has an area of 56 square miles, has a developed infrastructure with adequate road, airport, seaport, telecom- munication, and postal systems. The remaining 10% of the population inhabit La Digue, Praslin, and some of the other smaller islands. Electricity, running water, motor vehicles, and paved roads may be found on Praslin and La Digue, the remaining islands remain undeveloped. The primary mode of transportation between islands is by boat. However, there are 14 airstrips on the islands, eight of which have perma- nent surface runways. 1 French and English are the official languages of the Seychelles, although Creole is the most widely spoken language among the population. The islands have limited fishing, farming, and small scale manufacturing capabilities, but are predominantly dependent on tourism as the primary source of revenue for the economy. The tourist sector employs 30% of the labor force and accounts for up to 70% of the country's hard currency earnings.

From the UCLA Center for International Emergency Medicine, and the UCLA Emergency Residency Program, Los Angeles, CA.

Manuscript received March 5, 1999, returned April 8, 1999, revision received June 14, 1999, accepted June 22, 1999.

Address reprint requests to Eric Savitsky, MD, UCLA Division of Emergency Medicine, 924 Westwood Blvd, Suite 300, Los Angeles, CA 90024-1777. E-mail: esavitsk@ ucla.edu

Key Words: Emergency medical services, Seychelles islands. Copyright © 2000 by W.B. Saunders Company 0735-6757/00/1803-0020510.00/0 doi:10.1053/JE.2000.6319

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The Seychelles has enjoyed a relatively stable govern- ment and cohesive political history compared with that of many of its African neighbors. The islands were uninhabited until the 17th century and remained unclaimed until falling under French control in the early 18th century. In the early 1800s, the British assumed control over the islands lasting until 1975 when a coalition government led by President James Mancham and Prime Minister Albert Rene was established to lead the Seychelles to independence. On June 29, 1976, Britain granted the colony total independence and the Republic of Seychelles became a sovereign nation, with Mancham as president and Rene as vice president. The two had considerably divergent political ideologies. Mancham favored continued ties with Britain and a democratic state, whereas Rene's party preferred a socialist, worker-oriented structure of government. In 1977, a coup led by supporters of Albert Rene was successful in deposing Mancham and establishing Rene as president. In the first election held in June 1979, Rene was the single candidate for president and won with 98% of the vote. The results were viewed as a popular endorsement of Rene's socialist policies. In the 2 years after the coup, Rene and his Seychelles People's Progressive Front (SPPF) political party proceeded to estab- lish an autocracy following socialist doctrine. In the years that followed, a struggling island economy and lobbying by exiled political and business leaders prompted Rene and the SPPF to liberalize the political system. Opposition leaders were invited to return to the Seychelles and help rewrite the constitution to permit multiparty politics. Still, Rene won the country's first multiparty democratic election in 1992, was reelected in the 1998 presidential election, and remains president of the Seychelles today.

In comparison with other developing countries in the region, the Republic of the Seychelles is far advanced in areas related to food, water, sanitation, access to healthcare, and overall public health indicators (Table 1). The popula- tion growth rate of 0.7% and an infant mortality ratio (IMR) of 15 deaths per 1,000 of the population are closer to developed country statistics than to those of other sub- Saharan African countries. 2

The country's water supply, collected from rain catchment systems, is potable and poses little health hazard. The favorable tropical climate and extensive coastline allow for plentiful and readily accessible food for the Seychellois population. Endemic diseases such as malaria and yellow fever, evident in much of the African region, are absent in

SAVlTSKY, REHNBQRG, AND [BARRA • EMS IN THE SEYCHELLES 333

FIGURE 1. Map of the Sey- chelles (Courtesy of Maps.corn).

the Seychelles. Leptospirosis and acquired immunodefi- ciency syndrome (AIDS) are the two primary infectious disease public health concerns on the islands. 3 The first case of AIDS was confirmed by the Ministry of Health in 1992, and as of 1996 there were 18 confirmed cases of AIDS in the Seychelles. 4

HEALTH CARE ORGANIZATION

All Seychellois citizens have free access to health care. Routine health care is delivered at local health clinic outposts located in several communities on the main islands. These health clinics provide basic outpatient care but are limited by a paucity of equipment and health care provider

TABLE 1, Profile of Health Indicators

United South 1995 Data Seychelles States Africa Tanzania Sudan Kenya

Infant Mortality Rate (deaths per 1,000 births)

Life Expectancy (years)

Literacy Rate (%)

15 8 50 93 73 61

72 76 65 51 54 54

84 99 82 68 46 78

Data adapted from UNICEE 2

availability. The majority of the population does not have a continuity physician, and m most cases, only chronically ill patients (eg, renal failure on dialysis) have personal physi- cians. Victoria Hospital, a 500-bed facility located on Mahe Island, is the only comprehensive health care facility in the country. Anse Royale Hospital, the one other hospital on Mahe Island is much smaller, and provides only basic health services. It does not provide any casualty unit services. All critically ill patients on Mahe or any of the other Seychelles islands are transported to Victoria Hospital for evaluation and care. Victoria Hospital has separate medical, surgical, and pediatric wards and a 6-bed intensive care unit (ICU). The hospital also has immediate operating room, dialysis, plain radiography, ultrasound, and computed tomography capabilities.

The hospital staff consists of a broad spectrum of physi- cians whose medical specialties include internal medicine, nephrology, hematology/oncology, noninvasive cardiology, dermatology, ophthalmology, and infectious disease. The facility also has general pediatricians, radiologists, anesthe- siologists, psychiatrists, and dentists on staff. The surgical specialties at Victoria Hospital include general surgery, orthopedics, and head and neck surgery. The most notable services that are absent include all pediatric subspecialties, pulmonary and critical care, neurology, neurosurgery and emergency medicine. Because no medical schools exist in the Seychelles, all of the physicians working at Victoria

334 AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 18, Number 3 • May 2000

Hospital obtained their medical training outside of the Seychelles, primarily in French, British, and Czech medical schools. Nurses, pharmacists, and nursing assistants are trained at a technical training center located on Mahe Island.

EMERGENCY SERVICES

An organized emergency medical response system does not exist in the Seychelles. Most acutely injured or ill patients rely on bystanders or family members for transpor- tation to the hospital. Although the island of Mahe has seven ambulances, no "911" emergency number or equivalent way of routinely activating a coordinated medical response is available. Ambulances are located at Victoria Hospital and at several of the local health clinics. When an emergency call is made directly to Victoria Hospital, an ambulance may be dispatched to the scene. In these cases, a driver, nurse, and casualty unit physician staff the Victoria Hospital-based ambulances. Ambulances dispatched from outlying health clinics are routinely staffed only by a driver and a nurse. The ambulances are equipped with basic life support equipment (intravenous cannulas, bag valve mask apparatus, portable oxygen tanks, and so on) and resuscitative medications (saline, epinephrine, atropine, and so on). The ambulances are not equipped with advanced cardiac life support equip- ment such as portable defibrillators and cardiac pacing units. Intubation equipment is not routinely available on the ambulances, unless specifically taken aboard by the respond- ing physician. There are no standing treatment protocols. Treatment and transportation to the hospital are initiated in the field at the discretion of the ambulance physician.

Acutely ill patients on the remainder of the Seychelles islands experience long delays receiving medical care. Because there are no ambulances or hospitals on the other islands, acutely injured victims depend on bystanders or family for transportation to Victoria Hospital. They are either flown or transported by boat to the main island of Mahe for their medical care. Because no dedicated aeromedi- cal transport service exists on the islands, air transportation is typically performed by government-owned airplanes on an as-needed basis. Because the Seychelles islands cover an area of 176 square miles, patients from surrounding islands present to health care providers many hours to days after the onset of their acute illness or injury.

The United States equivalent for an emergency depart- ment at Victoria Hospital is the casualty unit. It is the only casualty unit in the country and manages an annual census of between 25,000 to 30,000 patient visits per year. 5 This is a remarkably high number of patient visits considering the population of the islands is approximately 80,000. A major- ity of these patient visits are nonemergent cases that could easily be cared for in a separate urgent care or walk-in clinic setting, if there were one available. The Victoria Hospital casualty unit provides emergency services 24 hours per day. The casualty unit is small, consisting of only seven gurney beds within several partitioned rooms. The patient care areas each consist of a solitary gurney bed and an overhead light source. They are not equipped with any additional patient care devices (eg, otoscopy, oxygen sources, cardiac monitor-

ing, and so on). There is only one bed capable of serving as a resuscitation area for a critically ill patient. This critical care bed is equipped with cardiac and oxygen saturation monitor- ing equipment. A resuscitation cart, with airway intubation equipment, central venous access kits, and medications is located nearby. The cart does contain a cardiac defibrillator and external pacing unit. Laboratory specimens are typically hand-carried to the inpatient laboratory. The computed tomography scanner and the main radiography suite are located in two separate buildings adjacent to the casualty unit. Portable radiography and ultrasound equipment are available and routinely used in the casualty unit.

The casualty unit schedule primarily relies on single physician coverage with double physician coverage pro- vided only during the mid-day and early evening hours. Casualty unit physicians typically work five 12-hour shifts per week. Four of these shifts are in the casualty unit and one shift is worked in an outlying health clinic. With the exception of the senior casualty unit physician who has approximately 10 years experience working in various casualty units, the remainder of the physician staff has very limited emergency medicine training or experience. No specialized training beyond internship is required to work in the casualty unit and casualty unit employment is often viewed as a springboard to better training opportunities. The casualty unit physicians primarily manage the ambulatory care patients and are heavily reliant on their consultants for help with the more seriously ill patients. An on-call panel is maintained and updated daily. The panel physicians provide a broad spectrum of subspecialty care. The on-call trauma surgeon and anesthesiologist are in charge of trauma patient care. The casualty unit physicians possess limited airway, venous access, and surgical skill experience (tube thoracos- tomy, and so on) that limits their ability to care for some of these patients.

MASS CASUALTY INCIDENT RESPONDER COURSE

Currently, emergency care services in the Seychelles are not readily accessible, and existing emergency care facilities are underdeveloped. Motor vehicle-related trauma resulting from poor road conditions, and reckless or drunk drivers prompted the Ministry of Health of the islands to identify the lack of adequate emergency services as a public health concern. Furthermore, the Ministry of Health expressed concern over the limited number of adequately trained housestaff available to respond in the event of a mass casualty incident (MCI) such as a bus or commercial airline crash.

In an effort to improve EMS for the Seychelles popula- tion, a joint international collaborative effort was launched in the fall of 1998. Representatives from the UCLA Center for International Emergency Medicine traveled to the Sey- chelles to provide a 2-week training course designed to improve MCI response capabilities on Mahe Island. 6 The UCLA Center for International Emergency Medicine is a nonprofit organization dedicated to improving EMS world- wide through education. Responding to the limited availabil- ity of emergency services outside the United States, the center collaborates with Ministries of Health and hospital staff to develop and implement training programs that meet

SAVITSKY, REHNBORG, AND IBARRA • EMS IN THE SEYCHELLES 335

TABLE 2. Mass Casualty Incident Responder Course Syllabus

Day 1 Opening ceremonies Mass casualty incident response overview Primary and secondary trauma survey overview

Day 2 Airway management Day 3 Shock and vascular access Day 4 Spinal trauma Day 5 Head trauma Day 6 Chest trauma

Abdominal trauma Pelvic trauma

Day 7 Pediatric trauma Day 8 Burn patient management Day 9 Disaster response principles

Moulage Day 10 Course evaluation

Closing ceremonies

the individual needs and facilities of each country, This training initiative was jointly sponsored by the Seychelles Ministry of Health and the World Health Organization.

The course focused on the initial field evaluation and triage of trauma victims, stabilization, and transfer of these victims to the nearest definitive care facility. The skills- based course integrated lectures, case studies, and simula- tions to provide participants with both theoretical knowl- edge and practical skills. The curriculum was designed to help course participants develop skills in trauma patient assessment and care (Table 2). The morning sessions consisted of didactic teaching whereas the afternoon ses- sions focused on procedural skill development. The after- noon skills sessions used human volunteers, airway (adult and infant) mannequins, extremity and torso intravenous mannequins, and an intraosseous line mannequin as teaching tools. Procedural skills that were taught included bag-valve mask ventilation, endotracheal intubation, intraosseous line placement, central venous line placement, and spinal immo- bilization and extremity splinting techniques. Over the 2-week period, the three UCLA emergency medicine physi- cians trained 35 doctors, nurses, and emergency medical technicians in basic MCI response principles and tech- niques. On completion of the course, the participants were asked to take part in a simulated MCI. All of the course participants performed well in the simulation, successfully showing their newly acquired skills in MCI response.

CHALLENGES AND FUTURE DIRECTIONS

The primary objective of the course conducted by the UCLA Center for International Emergency Medicine was to improve the MCI response capabilities of Seychellois health care providers. On completion of the course, the participants showed the ability to translate their newly acquired skills into practical patient care. The extent to which local health care providers retain their skills will be dependent on how frequently their skills are used, either in actual patient care or in simulated scenarios. A second MCI response course administered by representatives from the UCLA Center for International Emergency Medicine is planned for the sum- mer of 2000. In addition to providing 35 more Seychellois health care providers MCI response skills, the second course will provide an opportunity to identify several local Seychel- lois healthcare providers to serve as future instructors. In the future, these local Seychellois instructors will indepen- dently, on a regular basis, administer refresher courses on MCI response to their colleagues.

The impact of an isolated MCI response course on the quality of EMS is likely limited. Optimizing the training of first responders to a MCI is of minimal benefit if prehospital care transport and adequately staffed and equipped receiving hospitals are not available. Ministry of Health officials and representatives from the UCLA Center for International Emergency Medicine identified several areas for future collaboration. These included the development of an emer- gency medicine training program, an emergency medical technician training program, and a coordinated EMS re- sponse system. With the continued strong commitment of the Seychelles' Ministry of Health towards improving available health care for its citizens, the outlook for further development of EMS in the Seychelles islands is optimistic.

REFERENCES

1. US Central IntelligenceAgency: Available at http://www.cia.gov/ cia/publications/factbook, Accessed July 1998

2. UNICEF': Statistical Table. Available at http://www.unicef, org/ sowc98/tabla,htm. Accessed April 1998

3. Yersin C, Bovet P, Merien F, et al: Human leptospirosis in the Seychelles (Indian Ocean): A population-based study. Am J Trop Med Hyg 1998;59:933-40

4. WHO GIobal AIDS Surveillance: Available at http://hivinside.ucs- f.edu/cgi-msql/who_db2.p 1. Accessed September 1996

5. Ministry of Health: Victoria Hospital casualty unit quarterly report, Seychelles Ministry of Health. 1997; Oct-Dec

6. Seminar focuses on emergency preparedness and response. Seychelles Nation Newspaper 1998;Sept 15;1-2