Episode Transcript
This transcript was compiled using automated software — spelling and punctuation errors are possible.
Jason: Hello and welcome to another episode of the Crisis Response Podcast. Today I am joined by Neil Van Der Merwe from ComMed EMS in Johannesburg, South Africa. Neil, welcome, it’s a real pleasure to have you on the show today.
Neil: Thank you, Jason. Great to join you on the show.
Jason: Please tell us a little bit about ComMed EMS, what do you do, where do you operate, and what services do you provide?
Neil: Certainly. So ComMed is based in Johannesburg, South Africa. We are a nonprofit NPO organization. We are all volunteers that are part of the organization, so all of us have other jobs. Some of us work for private EMS services, as well as in other industries.
We have been running for essentially three years now. Around the beginning of Covid, we saw that there was a need for people who essentially did not have private medical aid or could not afford private medical response services and were waiting for extended periods of time to get things as simple as oxygen. In many cases, people were dying because they just could not get either a service or they just could not afford to get the emergency support that they required.
So we started out at that point by providing oxygen to people and it kind of grew from there. At this point now, we operate in what’s know as Regency, which is a specific part of Johannesburg, a fairly large area.
Most of our activity is at night, so during the day we are either on our own shifts or we are in our regular day jobs. If we have medics available during the day we will assist where we can, otherwise we hand daytime calls over to a different service. At night however we will essentially support those same services by doing it ourselves.
We are a response service, not an ambulance service, we do not run ambulances. So we really fill that gap between someone calling for a response service and an ambulance actually getting there, which in some cases can be three or four hours later. You know, that’s fine if you have medical aid and if you can afford to go to private hospitals or make use of private services because generally those services are very quick, within 10 to 15 minutes you would have an ambulance at your door. But for those that cannot afford that you would rely on either a private service supporting if they were available, or you would really need to rely on government services. And those government services, while I think they are doing a great job, they are just overwhelmed by the sheer volume of the need.
So we fill that gap for those that would otherwise be waiting hours, we go out and stabilize and support you, essentially keep you alive until an ambulance arrives when we then hand you off to that ambulance to be transported to a facility.
Jason: That’s really fascinating. It’s a very different state of emergency medical services than probably a lot of our listeners are used to. So you are in Johannesburg, a very large and expansive city with a population in the millions, and the government services are overwhelmed causing people to wait hours for ambulance service, and you are stepping in to provide life saving support in that gap. It sounds like you are providing advanced life support then, or am I incorrect? What level of care do you provide?
Neil: So in South Africa I think our levels are probably slightly different than many other parts of the world. We have many first responders out there that are really just first aiders. Then we have BLS, or basic life support, ILS, or intermediate life support, and ALS, or advanced life support. So as a service, ComMed mostly provides what we’d consider intermediate life support.
We do have some advanced life support paramedics that do volunteer with us as well and do provide services when needed, but for the most part we provide intermediate life support services, which is usually sufficient.
For our sorts of purposes, we generally have hospitals that are fairly close to where travel times would be 15 to maybe 20 minutes, so we can support and sustain life until such time as we can actually get them to a hospital.
Jason: So what falls under an intermediate life support scope? You know, you spoke about oxygen, is it basic things like that, or does it include IVs, medications, what types of things?
Neil: It most certainly includes IVs, as well as procedures such as chest decompressions and needle crics and so forth that all fall under the general scope. It’s a fairly well developed scope, and from a standards perspective, our intermediate life support medics are generally people that have been on the road for quite some time. They’ve built up their hours, they’ve built up their experience, and we will generally be able to get on to scene and support whatever is needed, but if advanced life support is necessary that we can’t provide then we will request assistance.
Jason: For me, as an American, decompression and needle crics sound very advanced, so I’m wondering what you consider advanced life support in South Africa?
Neil: Advanced life support really has a significant drug related scope. We’ve quite recently changed the whole structure in South Africa. South Africa used to, I’ll say, grow our medics through short courses and in between the short courses there was a certain number of hours that would need to be completed and so forth. That changed a couple of years ago, where it’s now essentially a university degree as the only way to get to be an advanced life support paramedic, or as we call them, ECPs, emergency care practitioners. Those folks have a significant scope, anything from IC drains for example, to chest drains, to a medications scope that goes right up to fentanyl and so forth.
Over time I would expect to see a lot more of these individuals on the road as the university systems start to produce more and more through this new pipeline.
Jason: What is the philosophy driving this change? I mean, here in the US, to what I can speak about, I can imagine a couple professional groups that are not so interested in seeing paramedics get such a wide scope of training and they would rather stay with nurses, physicians assistants, your very traditional clinical levels of care and training. Why is it that South Africa is doing this, giving such advanced training to non-physicians? Do you happen to know?
Neil: I think part of it is really due to the country and the environment. Historically I think we have not had enough hospitals, we have a lot of rural areas for example that are not necessarily close to a hospital, so they would require either flights in or out or long transfer times. And really in those types of situations you want someone that can go out to that rural environment and be able to support to the necessary level.
Then of course, there’s been shortages in the past of doctors, so really the doctors that we do have and the advanced life support work very closely together. In general I would say the pre-hospital side works very closely with the hospital side and I think one can’t do it without the other.
The types of incidents that we see, unfortunately, across the country, are things like a very high incidence of motor vehicle accidents, there are a lot of violent incidents be it shootings or stabbings, those sorts of things. We are on the road and we are able to support in those cases and you know if the pre-hospital teams are not available, it’s a big problem, you just won’t get the necessary coverage to support those folks.
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Jason: That makes a lot of sense. So you mention moto vehicle collisions and stabbings and shootings, are those the predominant types of calls you are seeing in your role with ComMed, or are there others that are most frequent?
Neil: We get pretty much everything. We have a very high incidence of pedestrians being hit by vehicles, that’s very common, we have multiple of those every day.
We have a very high incidence of motor vehicle accidents where speed is definitely an issue. We’ve also got areas of the country, where due to politics or gang related incidents we’ve got high numbers of shootings or stabbings.
Then there are plain medical emergencies, people waking up at three in the morning with chest pain, that is certainly common. I think the biggest challenge though is that these people just don’t have access or they just don’t have immediate access to the necessary care that they need and in many cases these types of incidents can be treated successfully if they’re treated quickly, but waiting for an hour can be a big problem.
Jason: Do you have many calls for substance abuse in general? Particularly illicit drugs or narcotics? Or not so much?
Neil: We do. I would say it’s probably not at the same level that you guys are seeing it at in the US at the moment, but certainly we do see it. We also have a lot of overdoses that are self-inflicted in terms of attempted suicides. Suicide rates are certainly I think higher than we’ve seen in a while which is unfortunate.
But certainly substance abuse is a problem. Alcohol is a big problem. Alcohol in youngsters and alcohol with driving is a big problem.
Jason: So how do you actually get your calls? How do people contact you? Does the government service ask you to send people out or do they call you directly?
Neil: Sometimes that does happen. I think now that we have WhatsApp in the world, I think WhatsApp has really changed how people operate.
So we have lots of community groups and community services that operate in the various communities that have WhatsApp message groups to conduct communication. So pre-hospital services people are generally on those groups, community leaders are in them, people in the community that are essentially patrollers are in them and will put messages into the group stating that they’ve had an incident at a specific location that requires an ambulance. That’s one way things work.
There are also more formal routes, so for example, we have a 24 hour number that people will call and we will then dispatch based on those incoming calls or sometimes other services such as the police service will contact us because they have a suspect that’s been injured or they have a situation where someone’s died and they require a declaration of death to be carried out.
Jason: Wow, that’s really interesting. A lot of different ways that they come to you. So I imagine then you’re probably subscribed to a number of WhatsApp groups and are just monitoring those regularly or do they request you specifically?
Neil: A number of them would be an understatement, there are so many groups we are in, and we really try and prioritize some key groups that people tend to make use of most often.
We do try and get people to actually call us directly when something is very time sensitive, because obviously it’s hard for us to monitor all of the groups all of the time.
Jason: Stepping back a little, you mentioned at the outset that you started during Covid and have now been in operation for three years. I’m wondering if you could share a little bit more about how you got started and what it took to actually put together a consistent service.
Neil: Of course. So when we started, Covid was fairly new, and it was literally as simple as seeing that people were not able to get access to oxygen. That oxygen was all they needed, but services were so backed up.
So we started at that point by delivering oxygen. We’ve been fortunate to have some really great sponsors who helped us get the initial resources, but we still had a limited number of oxygen bottles, and we were filling those multiple times a day. Using them, filling them, using them, filling them again.
As we did this initial service, what we found in speaking to people in the communities was that they really needed more than that. Many of the families that we services had unemployed family members, and for them to get a service to come out to then was nearly impossible as they had a hard enough time paying for food on the table.
We saw that these families would simply ignore or suck it up when it came to illnesses as opposed to trying to get to a clinic or trying to actually get treatment, and in many cases, it was not serious issues. Maybe it was asthmatic, for example, which could be easily treated. But they wouldn’t pursue treatment and were getting more and more ill and eventually dying and that’s really where we saw that gap that people that absolutely cannot afford medical services or cannot afford to pay for the transport to get to a hospital needed our help.
Another aspect of this was these were often areas that private services didn’t like to go into, which, we also don’t like to go into them at time and at times we need to go in with police escorts because they are just dangerous areas where, for instance, ambulances have been hijacked or ambulance crews have been held up. That obviously makes it hard on the services to be able to support people in those areas, but nevertheless people in those areas require service, you know, and we really can’t from a humanitarian perspective just say not to service them. So we try and work together with security companies who also play an important role where we can go in and support these people, these families, while feeling secure in the support we ourselves have.
From there, we just found that the demand for service just started growing. People were talking to other people and telling them about us and we were getting calls coming in from all kinds of people, often outside of our area of work. We keep a specific aerial radius that we operate in as it doesn’t make much sense for us to be traveling, you know, 20 kilometers to an incident, it just takes too long. SO we try and work within a sort of 15-kilometer radius depending on time of day and traffic and so forth.
But that being said, we will often go out to old age homes or to folk that are on home oxygen to check up on them just to get a set of vitals and see that they’re okay. You know, perhaps family will often call us to ask if we think their grandmother needs to go to the hospital. So it’s very much a dual service in terms of just supporting the community with simple things like that. And the other side is really the pre-hospital emergency medicine side, which is emergency situations.
From a growth perspective, it’s just lots of hard work and lots of hours, so it’s always a balance. We all have families, we all have day jobs or work for other services where we work in a shift type environment, so it’s really fitting it in between that and ensuring that we have someone always available to answer the phone and someone available to either go out or where we can pass it on to another service to actually service the patient.
That’s really where Beacon has started to play a role as well, because as part of this, at a point we needed to decide to register under the Department of Health and that’s essentially the government department that registers all emergency services. They maintain the standards, they define what a vehicle needs to look like, what needs to be on the vehicle, what you need to have in your jump bag, et cetera. They govern all of that and we made the decision to register under them which we needed to do, and as part of that we also needed to have in place a mechanism to be able to manage and track incidents to report back to them things like response times for example. So that is really where I think Beacon has been a fantastic platform to support us in doing those things and today now all our calls go into and through Beacon and that really allows us to not worry about the call management side of it and to not worry about things like trip sheets and to focus on what we do which is treat our patients and let the rest of the paperwork things happen in the background.
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Jason: That’s fantastic, and it’s a real pleasure to be able to serve you and know that it is of use to you.
You’ve sort of answered this already, but in terms of government recognition and legitimacy, it sounds like you had mentioned that there are standards that have to be met. What about the training side of it? What level of training do you require for your volunteers to participate? Does it go all the way down to first aider or do you have a minimum set for them to join?
Neil: We require that you are a basic life support medic or above. We do have a small number of what we term level three first aiders, or advanced first responders, that are part of the team. They will work very closely with the registered medics, but they cannot operate by themselves.
Jason: So what are the future plans for ComMed? Is it staying in your current territory and doing everything to improve things within that area, is it wanting to scale outside of that?
Neil: So we are one of the very few, if not the only, registered volunteer groups for pre-hospital medicine, doing what we do. We want to keep doing this, certainly in our current area.
People often ask us, you know, do you want to become a paying service at some point? And, you know, do you want to make money or have a fleet of ambulances and so forth? That’s not what we want to do. We really are here for the community. We will always do this at no cost as long as we get sponsorship and are able to have fuel in our vehicles.
The need is just growing. If you have a look at the demographics and population growth over the next five years in the regions that we’re in, they’re just huge. The problems we have now are certainly not going to get any easier, they’re just going to get bigger. So I think there’s going to be a need for more organizations like us, or for ones like us to grow, which we are certainly always on the lookout for more medics.
But if someone came along and threw a lot of money at us, then I’m sure we’d certainly be interested in operating an ambulance or two or three, but again with the same principles that it’s not going to be a paying service, it’ll be a service for the community for people that cannot afford it and we don’t need them worrying about trying to pay a bill.
Jason: Do you ever get concerned about the possibility that people who can pay are avoiding services because they might come to you knowing they don’t have to pay? Just to play the devil’s advocate here.
Neil: Absolutely. Look, it definitely is a concern, but we will service anyone. We absolutely do service people that could pay or people that have medical aid, because we’re close by or we can respond the quickest, and you know we’ll service them and then hand them over to a private service.
So at the end of the day, for us, it’s about the patient. It doesn’t matter whether they are black or white, whatever language they speak, whatever job they have, if they are employed or unemployed, where they live, it doesn’t matter, you know? At the end of the day it’s about being able to service that sector of the population and every patient that we service we hope that they go out and spread the word, especially those who can afford it because we have a lot of private individuals that on a monthly basis make donations and every dollar helps. None of us earn any salaries, every bit goes straight into the patients and keeping vehicles on the road and so forth.
Jason: That’s a real commitment to your calling. Now, the day jobs that your volunteers work, are they predominantly working as paramedics for other paid services or is it a mix of non-medical professionals with medical professionals?
Neil: Definitely a mix.
Jason: It’s really impressive and inspiring work you’re doing. I guess one last question I would have for you is for other groups that aspire to do what you do, what kind of advice would you give them? What kinds of things that if you knew back then what you know now would have helped get this up and running, or what would you have done differently?
Neil: It’s a good question, you know, I think when organizations like us start out, we often start out with not the right level of governance and structure and formality. That happens because it’s, you know, friends get together or colleagues get together, you start doing something and you’ll think, when we grow bigger, we’ll start to bring that stuff in.
I think it’s important to bring a lot of that stuff in right in the beginning because that structure really sets you up for growth as opposed to growing and then trying to bring the structure back in which is always difficult.
The other thing I would say is not to give up. There are days that we think, you know, is this worth it? It can be really hard, whether it’s that we are tight on cash or have seen a lot of bad scenes that day, whatever it might be. But that next patient that you treat, you know, they will thank you. That’s what it’s about, and that is why we do it, and that’s why we’ll keep doing it in the way that we do it today.
Jason: I think those are two great points. If I could just dig a little deeper in terms of the structure, what specifically would you recommend that they pay attention to? I mean, is it the legality or legal aspects of what you are doing? Is it things like just being able to assign shifts or having an organizational chart? Could you say more about the structure that you were mentioning?
Neil: Sure. It’s quite a big topic, because you have to have specific roles in place, I think that’s very important. When we started out, we had this view that it was a team, everyone would be part of every decision, you know? And that’s great until it’s not, you know? And at a point it wasn’t which led to losing some members.
So it’s important to be very clear on what the organization’s goals and objective are and to stick to those and to make sure that the people that you’re getting into the organization are like-minded.
There are lots of people out there that want to be able to drive a vehicle that has red lights on it, but that’s not why we do it. So we really need people that are patient focused, that want to make a difference in people’s lives, and in their communities, and I think if you get the right kind of people in it then it certainly makes it a lot easier.
From a legal perspective we don’t have the same level of litigation currently that you would have in the US, but certainly it’s a thought. We of course have professional bodies that manage us as medics and paramedics, manage our scope, so one has to ensure that you’re practicing within your scope and are following protocols and treating patients in the right way. You’ve got to have the paperwork for when someone comes back to you a year down the line and wants to see what you did.
You know, people starting out don’t think about the paperwork side of things, they don’t think about possible knock-on effects, and that’s an issue. It’s an issue for the patients, it’s an issue for the medics as well. So it’s important to get the basics right and it doesn’t matter whether you have three medics or fifty medics, make sure that you’ve got the structure, make sure that you’ve got the governance, that the paperwork gets done, that the filing gets done, that you have the right insurances in place, and everything like that. All of it’s important and it just makes it easier to do the job.
Jason: Probably the least sexy part of the job, but it’s so critical.
Well, thank you very much, Neil. It’s been a real pleasure and it’s just awesome work you’re doing. Truly inspiring and I’m sure our listeners will enjoy hearing more about it too and hopefully take some good ntoes from it because in three years you’ve grown quite a bit and are truly bringing a real value to your community. So thank you for your work and thank you for joining us today!
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Neil: Thank you and thanks again for the support that we get from Beacon. We really appreciate it.
What actually changes and what doesn’t is going to be subject to some very, to put it politely, vigorous debate, from these different sorts of polls that I’ve outlined.
But I’d say at the end of the day, it’s having an open mind and seeking out partnerships, seeking out people who operate in worlds that are maybe near ours but not in ours, so that we can better learn how we as academics can do a better job of generating research as well as translating that research in forms that are useful to the good work that really everyone involved, including government, including in industry, including in nonprofits, and including in academia, are seeking to do to build more resilience and ultimately crack the code on what is this ideal structure and idea approach to disaster.
