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Prehospital Emergency Medical Services in Malaysia

Article  in  Journal of Emergency Medicine · June 2007

DOI: 10.1016/j.jemermed.2006.08.021 · Source: PubMed

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Prehospital Emergency Medical Services in Malaysia

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N.A.R. Nik Hisamuddin, MBCHB, MMED , M. Shah Hamzah, BSC, C. James Holliman, MD, FACEP
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DOI: http://dx.doi.org/10.1016/j.jemermed.2006.08.021
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I. Introduction Order Reprints
II. Overview of the Health Care System (100 minimum order)
III. Training Program for Prehospital Personnel
IV. Development of Emergency Medicine
V. Prehospital Emergency Medical Systems in Malaysia
A. Communications and Response
B. Ambulances, Equipment, and Supplies
C. Prehospital Care Providers
D. Interfacility Transport
Related Articles
E. Prehospital Disaster Response and Event Coverage
VI. Future Direction of Prehospital Care in Malaysia
VII. References

Jump to Section Go
Abstract
Once a very slowly developing country in a Southeast Asia region, Malaysia has undergone considerable
change over the last 20 years after the government changed its focus from agriculture to developing more
industry and technology. The well-known “Vision 2020,” introduced by the late Prime Minister, set a target for
the nation to be a developed country in the Asia region by the year 2020. As the economy and standard of
living have improved, the demand from the public for a better health care system, in particular, emergency
medical services (EMS), has increased. Despite the effort by the government to improve the health care system
in Malaysia, EMS within the country are currently limited, best described as being in the “developing” phase.
The Ministry of Health, Ministry of Education, Civil Defense, and non-governmental organizations such as Red
Crescent and St. John’s Ambulance, provide the current ambulance services. At the present time, there are no
uniform medical control or treatment protocols, communication systems, system management, training or
education, or quality assurance policies. However, the recent development of and interest in an Emergency
Medicine training program has gradually led to improved EMS and prehospital care.

Keywords:
emergency medical services, prehospital care, Malaysia, Vision 2020, emergency medicine
Introduction Jump to Section Go

Emergency medicine (EM) and prehospital care in Malaysia are still in an early phase of development but have
improved significantly over the last 5 years since the start of an EM physician training program. Increased
demand from the public for a better emergency medical services (EMS) system and an increase in the incidence
of road-related accidents has partly contributed to the urge to improve prehospital EMS. This article reviews the
current status of prehospital care within the context of the country’s health care and emergency medical
environment throughout Malaysia. It also reviews the efforts and steps taken by a local medical school and the
Ministry of Health (MOH) to improve prehospital EMS. This article is based predominantly on the authors’
experience working in the country and reflects their observations and interactions within the emergency medical
and prehospital care services. Additional information was gained from literature searches utilizing PubMed and
local publications.

Jump to Section Go
Overview of the Health
Care System
Malaysia is located in Southeast Asia, internationally bordered by Thailand in the north and Singapore in the
south. It is divided into the Peninsula of Malaysia and East Malaysia (Borneo), consists of 15 states, and has a
democratic government. It is comprised of multi-ethnic groups, the Malay group being the majority (80%), and
includes others such as Chinese and Indians. The Malaysian language is the official language, although English
is widely practiced as a second language. The land area is 330,252 square kilometers with a population of just
over 24 million. Life expectancy at birth in 2002 for males was 70.3 years and for females, 75.2 years. Malaysia
has undergone considerable change over the last 20 years after the government changed its focus from
agriculture to developing more industry and technology. The well-known “Vision 2020,” introduced by the late
Prime Minister, set a target for the nation to be a developed country in the Asia region by the year 2020 (1). As
the economy and standard of living improved, the demand from the public for a better health care system, in
particular EMS, increased. The Ministry of Health (MOH), Ministry of Education (MOE) university hospitals, and
private sectors provide health facilities such as hospitals and clinics. Each of the 15 states is provided by the
MOH with a general hospital that performs as tertiary referral center (2). The total Ministry of Health portion of
the National Budget is 6.33%, amounting to Malaysian Ringgit (RM) 5,765,553,410, 80% of which was for the
operating budget and the other 20% for the development budget. The principal causes of hospitalization and
causes of death in MOH hospitals in Malaysia in 2002 are shown in Table 1, Table 2, respectively (3). Injury is
one of the major medical problems in Malaysia and contributes to a high incidence of fatalities and hospital
admission. Admission to government hospitals due to accidental injuries has risen by 5% from 156,073 cases in
1999 to 169,837 cases in 2002. Statistics from 1999 from the MOH have shown that common locations for
accidental injury occurrence are on the roads (42%), at home (29%), workplace (18%), recreational places (7%),
and at school (4%). Motorcyclists and pillion riders contribute 65% of the injuries sustained from motor vehicle
crashes (MVC), followed by bicyclists (10.5%), vehicle occupants (16%), and pedestrians (5.3%). The
government spends over 5 billion Malaysia Ringgit (USD 1.5 billion) a year as a result of injuries (4). Figure 1
illustrates the statistics of road traffic accident (RTA) cases from 1997 to 2003. Even though the total number of
accidental injuries increase each year, the total number of victims that sustained severe injuries due to road
traffic accidents alone is declining; this could be due to a few factors such as the introduction of road-related
injury prevention programs organized by the government agencies, implementation of vehicle and road safety
factors, and improved in-hospital acute care (5). Despite the effort, sadly, the number of deaths has remained
unchanged over the years. This is partly attributed to poor prehospital EMS such as long ambulance response
times, untrained ambulance personnel, and poor public cooperation.

Table 1
Principal Causes of Admission in Government Hospitals in Malaysia in 2002

1 Normal delivery 18.91%

2 Complications of pregnancy 11.84%

3 Accident 9.16%

4 Diseases of the circulatory system 6.94%

5 Diseases of the respiratory system 6.61%

6 Perinatal conditions 5.62%

7 Diseases of the digestive system 4.87%

8 Ill-defined conditions 3.57%

9 Diseases of the urinary system 3.49%

10 Malignant neoplasms 2.62%

Table 2
Principal Causes of Deaths In Government Hospitals in Malaysia in 2002

1 Heart diseases and diseases of pulmonary circulation 15.99%

2 Septicemia 14.51%
 3 Malignant neoplasm 9.16%

4 Accident 6.76%

5 Perinatal conditions 5.56%

6 Pneumonia 4.98%

7 Cerebrovascular diseases 4.48%

8 Diseases of digestive system 4.38%

9 Kidney diseases 3.72%

10 Ill-defined conditions 2.74%

Figure 1
Road traffic accident cases in Malaysia (Royal Police Malaysia Report 2004).

View Large Image | View Hi-Res Image | Download PowerPoint Slide

Jump to Section Go
Training Program for
Prehospital Personnel
At present, the ambulance services are manned by nursing staff and non-medical ambulance drivers. Training
for nursing staff and medical assistants (male nursing staff) is governed by the Malaysian College of Nursing
and the Medical Assistant College, respectively. The nursing training program lasts over 3 to 4 years and offers
a diploma certificate. After completion of basic nursing training, the newly qualified nurses and medical
assistants will be registered under their own boards before they are allowed to work in government hospitals.
They can choose to serve either in the MOH or MOE hospitals. At present, prehospital EMS are provided by
both governmental and non-governmental bodies. Untrained personnel who basically practice a “scoop and
run” approach man the ambulances. Not much patient stabilization occurs in the field and this might contribute
to significant morbidity and mortality in victims. However, there is still ongoing debate over the “scoop and run”
vs. “stay and play” approaches to prehospital care. No formal curriculum for emergency medical technicians is
available in the country even though the need to upgrade the ambulance services has been realized for many
years. Recently a local medical school (School of Medical Sciences, Universiti Sains Malaysia) initiated the first
Emergency Medical Dispatcher (EMD) program and preliminary outcome has shown that it has improved
ambulance response time and, most important, increased public awareness concerning prehospital emergency
care (Table 3). A short survey was conducted in 2004 in one of the teaching and tertiary university hospitals on
the East Coast of the Peninsula of Malaysia. The primary outcome was ambulance response time (ART) before
and after the EMD training program. The survey was done for the first 1000 emergency phone calls before and
after the implementation of the EMD training program and the establishment of a call center in the university
hospital. The presence of the EMD resulted in a 45% reduction in ART. This program will be the foundation for
initiation of a paramedic training program in the country.

Table 3
Ambulance Response Time (ART) Before and After Emergency Medical Dispatcher (EMD) Training
Program (Statistics January–December 2004 from Call Center, Hospital Universiti Sains Malaysia)

Ambulance
Call Processing Time Taken to Time Taken To Arrive Response Time
Group Time (CPT) Prepare Team (TTP) At Scene (TTTS) (ART)

Without
EMD

 Mean 117.00 203.91 1325.29 1646.21

 Number 1000 1000 1000 1000

of calls

 Standard 54.93 115.24 1572.30 1609.39

deviation

With EMD

 Mean 117.67 117.00 676.83 911.50

 Number 1000 1000 1000 1000

of calls

 Standard 55.20 54.93 1451.08 399.34

deviation

Mean time in seconds.

 Ambulance Response Time (ART) = Call Processing Time (CPT) + Time Taken to Prepare Team (TTP) +
Time Taken to Arrive at Scene (TTTS).

Jump to Section Go
Development of
Emergency Medicine
Emergency Medicine (EM) is a relatively new specialty, still in its infancy, but rapidly expanding in Malaysia. The
specialty is increasingly recognized within the health care system. It follows the Anglo-American model for
emergency care (6, 7, 8). A 4-year program “masters in EM” is offered by only one medical school, namely the
School of Medical Sciences, Universiti Sains Malaysia (USM) (9). More medical schools (at least two) have
forwarded their proposals to the MOE to initiate similar postgraduate training in EM. The present number of
emergency physicians throughout the country is 20 and most of them are employed by the MOH hospitals. The
subspecialties of EM in Malaysia are starting to develop, particularly in the fields of disaster management,
prehospital care, critical care, and observation medicine. Much of the opportunity for subspecialty development
goes to those certified physicians employed by the medical school for reasons such as the availability of grants
for research and sponsorship for further studies overseas.

General practitioners, surgeons, or orthopedists staff the majority of emergency departments or “accident and
emergency units” with little to no advanced training in EM. However, recent years have seen the development of
more advanced EM practice in limited locations throughout Malaysia. Since the development of the EM training
programs, there has been an increasing interest among emergency medical providers to improve the prehospital
care system. Areas of improvement include upgrading equipment, increasing manpower, developing training
and courses related to prehospital care, and public education. New ambulances provided by the MOH and
MOE are trauma and cardiac life support capable. These ambulances are more spacious and are equipped with
better equipment than the basic ambulances. Training and short courses conducted by emergency physicians
specifically targeting particular areas such as life support, communication, field management, mass casualty
incidents, and disaster management have been started (Table 4). At present, most of the effort is in urban areas,
but gradually, primary health care providers in rural areas are starting to show similar interest and have assisted
in the effort to improve prehospital EMS.

Table 4
Type of Training And Short Courses For Prehospital Care Personnel From Year 2002 Till 2004

Total Number of
Number of Training
Type of Personnel Trainer’s Programs from
Training Training Organizer Involved Qualification 2002 to 2004

Emergency Emergency Department, 26 Emergency 2

medical School of Medical Sciences, physicians and
dispatcher Universiti Sains Malaysia prehospital care
(EMD) coordinator

Basic life Malaysian Association of 230 Emergency 12

support (BLS) Emergency Medicine Physicians

Automated Malaysian Association of 90 Emergency 9

external Emergency Medicine Physicians
defibrillator

Prehospital Emergency Department, 26 Emergency 6

communication School of Medical Sciences, Physicians and
skills for EMD Universiti Sains Malaysia Prehospital care
coordinator

Disaster and Emergency Department, 120 Emergency 6

mass casualty School of Medical Sciences, Physicians and
incidents Universiti Sains Malaysia Prehospital care
coordinator

Jump to Section Go
Prehospital Emergency
Medical Systems in
Malaysia
Multiple providers offer ambulance services to the Malaysian community, especially in urban areas such as the
city of Kuala Lumpur, from both the private and government sectors. Government ambulance provision is under
control of the MOH, MOE, and Civil Defense (CD). The police and fire departments do not contribute to
prehospital EMS. Private sector ambulance services include Red Crescent, St. John’s Ambulance, and some at
private hospitals. Ancillary services such as rescue and air medical support are very limited and rarely used
unless in a mass casualty incident. Royal Malaysian Police, Armed Forces, and Malaysian Helicopter Services
(MHS) offer air medical evacuation services. When EMS assistance is required, patients, families, or bystanders
have several options available to them: self or family transport to the nearest medical facility, transport via
bystander or police vehicles at the scene, telephone contact to a local hospital, which incorporates a hospital-
based ambulance services, telephone contact to the MOH or MOE ambulance service via the “999” telephone
number, or telephone contact to the CD service via “991.” Most government ambulances are based in hospital
facilities (10). CD and private sector ambulances have separate facilities. Recently, CD gradually incorporated
their services into urban teaching hospitals. Mutual agreement has been reached between the two providers
such that the CD provides ambulances, manpower, and equipment, whereas the teaching hospital conducts
training and continuous medical education programs. The scope of services provided by CD includes EMS,
search and rescue, fire fighting, and disaster management.

Jump to Section Go
Communications and Response
One of the major limitations of prehospital care in Malaysia is deficient integration between agencies such as
ambulance services, police and fire departments during an emergency situation. The so-far futile effort to
integrate the system is partly attributed to lack of interest from various agencies and administrative coordination
at higher levels. There is no uniform EMS communications and dispatching for the entire country. Individual
provider agencies rely on their own communications system of call-receiving and dispatch, typically via
telephone directly to the hospital ambulance station or hospital emergency department (ED). These phones may
be answered by a variety of personnel, some with little training. There is no system in place for call screening,
interrogation, or prioritization, and pre-arrival instructions are not provided. Identifying patient location and
gaining call-back information can be extremely difficult due to lack of street addresses and poor information
from the caller. Automatic number and location identifiers are incorporated only in tertiary referral centers.
Occasionally, the ambulance personnel must rely on landmarks, families/friends, and patients to accurately
locate calls. Two-way communication between the field and hospital exists; however, there is no consistent
system or protocols that govern utilization. Thus, advanced notification to hospital personnel before arrival of a
critically ill or injured patient does not routinely occur. Sometimes providers rely on personal mobile phones for
communication.

Average ambulance response time varies from one location to another (Table 5). The effectiveness of response
time depends on three components, namely, emergency call processing time, crew mobilization time, and travel
time to the scene. Faster response is usually seen from tertiary referral centers, partly due to adequate
manpower and better communication. Response can be delayed due to poor communication, untrained
providers, and traffic congestion on major roads in big cities. The public responds to the existence of poor
ambulance services by sending sick patients or relatives using their own transport to the nearest medical
facilities and these facilities may or may not be appropriate for the patient’s condition. Often, a severely head-
injured patient is sent to a facility without a neurosurgical unit and this contributes to further delay in patient
definitive management and hence high morbidity and mortality.

Table 5
Mean Ambulance Response Time at Tertiary Hospitals in Three Different Cities in Malaysia

Mean Call Mean Time Taken To Mean Ambulance

Processing Time Mean Time Taken to Arrive At Scene Response Time
Cities (CPT) Prepare Team (TTP) (TTTS) (ART)

Kota 117.67 117.00 676.83 911.50

Bharu

Penang 154.07 218.56 896.33 1268.96

Kuala 135.48 196.22 1208.08 1539.78

Lumpur

Mean time in seconds.

Jump to Section Go
Ambulances, Equipment, and
Supplies
Recently, MOH has replaced some of the light duty van ambulances with modular type vehicles that are more
life support compatible. The old ambulances are equipped with basic equipment such as scoop stretcher, neck
collar, and orthopedic splints, and manned by untrained staff. The personnel cannot stand and it only allows the
transport of a supine patient and a sitting ambulance technician. Due to the lack of room, patient care cannot
be performed during the transport (these vehicles tend to disappear). The new modular-type ambulances are
more spacious and equipped with life support equipment, ranging from basic life support to highly technically
advanced life support including portable ventilator and ultrasound. These ambulances are manned by either
doctors or trained support staff. The maintenance of the ambulances is the responsibility of the hospitals that
provide the services. Equipment provision for the ambulances often relies on the annual budget of the ED that
controls the ambulance services. This places the burden on the ED that already struggles for its own
development. At the present time, air ambulance services are very limited, mostly provided by helicopters
owned by the Ministry of Defense. Occasionally, cases from oilrig platforms offshore are transported by
helicopters privately owned by Malaysian Helicopter Services (MHS) to tertiary hospitals. Currently, no public
sectors or government agencies provide emergency air ambulance services in Malaysia.

Jump to Section Go
Prehospital Care Providers
There are no designations or certification standards for prehospital care providers within Malaysia. Ambulances
are staffed by a variety of providers, depending on the organization involved, and may include physicians,
nurses, or medical assistants working in the ED. Emergency medical technician (EMT) training is not available
and has not been recognized by the MOH in Malaysia. Some individuals do have an expanded knowledge base
and interest in prehospital medicine, but most seem to have little formal medical teaching. Most providers
employ two personnel as their primary response team, an ambulance driver who typically has no medical
training and contributes little to patient care activities, and a medical staff (physician, nurse, or medical
assistant) who performs medical care alone in the field. Recently, non-governmental organizations (NGOs) such
as St. John’s Ambulance and Red Crescent employ two “paramedics” as their primary response team who are
trained for basic trauma and cardiac life support.

Jump to Section Go
Interfacility Transport
Most health care centers in Malaysia are involved at some level with inter-facility transport of ill patients. The
majority of these transfers are made with the same ambulances that are used for primary response. A nurse or
medical assistant often accompanies patients’ transfer from rural health clinic to general hospitals with little to
no critical care equipment (or experience) available for use during the transport. Inter-facility transfer from
tertiary centers often involves a physician, medical officer, or nurses with fully equipped ambulances for critical
care.

Jump to Section Go
Prehospital Disaster Response
and Event Coverage
Often, general and district hospitals under MOH and MOE are involved either in drill exercises or real mass
casualty incidents (MCI). Examples of MCI in the past include the tsunami wave, train derailment, landslides,
flooding, and a collapsed apartment building. During the Southeast Asia tsunami in December 2006, Malaysia
was fortunate that only small parts of the country were affected (three states on the west coast). The shadow
wave of the tsunami resulting from the undersea earthquake hit the holiday islands of Penang and Langkawi.
Peninsular Malaysia was spared the full impact of the tsunami as it is sheltered by the island of Sumatra and not
directly exposed to the Indian Ocean. Casualties in Malaysia involved local picnickers and anglers. The death
toll was 68, with 6 missing and 300 injured people. Approximately 700 houses were destroyed. No foreign
tourists were reported dead or missing. Fortunately, lifeguards and the observation tower system at international
beach hotels and resorts in Penang and Langkawi Islands provided a warning to their guests to stay indoors
due to the choppy waters sighted earlier. Ambulance services were activated by public and police phone calls
throughout the affected area and were provided by various agencies such as Royal Police Marine, Civil Defense,
St. John’s Ambulance, and MOH services. All of the prehospital care responses were either via ground or water
ambulances, and the casualties were dispatched to various health facilities, including tertiary centers.
Fortunately, both of the affected islands are within easy reach of the tertiary centers.

Very few incidents of terrorist acts have occurred, and the majority were linked to international groups or
organizations abroad, including the Mujahidin and the Abu Sayaf Groups. The number of victims in each event
so far has been small. For instance, in 2000, three Sipadan Island Resort workers in Borneo were kidnapped
and injured by Abu Sayaf militants but fortunately, all of them were released alive after political negotiation.
However, the government under the National Security Council has set up policies of Directive 18 and Directive
20 that specifically detail the role and responsibilities of various agencies in managing terrorism and disasters,
respectively (11). The presence of an EM postgraduate training program has, to some extent, disseminated the
interest in disaster medicine among the health care providers throughout the country.

Jump to Section Go
Future Direction of
Prehospital Care in
Malaysia
Growing interest in prehospital medicine is in parallel with the development of training in EM in the country. The
presence of emergency physicians with special interest in prehospital care has contributed to improvement in
prehospital emergency services, particularly in urban areas. As the number of emergency physicians increases,
the quality of prehospital care is expected to improve (12). In fact, prehospital medicine has been gradually
recognized informally as a subspecialty of EM. Although still in its early phase, development in prehospital
medicine is expected to grow fast in the next decade. Some areas have been targeted by the MOH for further
development, such as training programs, manpower, and equipment provision and upgrading. In cities like
Kuala Lumpur, the services are provided mainly by NGOs such as St. John’s Ambulance and Red Crescent
personnel, who are trained by qualified emergency physicians. There is a more structured training program
planned for NGO groups who show similar interest in prehospital care (13). Similarly, organized training
programs from basic life support technique to more advanced medical management have been gradually
introduced to MOH and MOE hospital-based ambulance personnel, both in district and urban areas. Recently, a
university hospital-based ambulance service initiated an Emergency Medical Dispatcher program. The training
curriculum is based on syllabi from overseas but has been modified according to local needs. Proposal for a
degree course (Bachelor of Science) in prehospital care has been forwarded to higher education centers and
the MOH. This will be the foundation for a structured and accredited training program for prehospital care in the
country. At the same time, the MOH is replacing most of the ambulances with properly equipped vehicles and
more spacious interior design. Communication systems upgrading and efforts to integrate various agencies
(hospital, police and fire departments) are very important steps that should be looked at seriously by MOH.
Increasing public awareness is another major obstacle in improving prehospital care. Educating the public in
basic life support and proper use of emergency medical dispatch are essential in reinforcing the prehospital
chain of survival. Undoubtedly, prehospital care is a major component of a health care system and this
particular area requires more attention from health administrators.

Jump to Section Go
References
1. Prime Minister of Malaysia official website. The way forward—Vision 2020. Available at:
www.pmo.gov.my/website.
2. Department of Statistics. Malaysia’s health 2002. Putrajaya, Malaysia. Ministry of Health Malaysia.
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4. Health in Malaysia, Achievement and Challenges 2000. Putrajaya, Malaysia. Ministry of Health Malaysia.
5. Royal Malaysia Police website. Statistics on road traffic accident cases in Malaysia. Available at:
 www.rmp.gov.my/.
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9. (Kubang Kerian, Malaysia. School of Medical Sciences, Universiti Sains Malaysia)Master of Medicine
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View in Article | Crossref | PubMed

11. Abdul Aziz, A. The burden of terrorism in Malaysia. Prehospital Disaster Med. 2003; 18: 115–119
View in Article | PubMed

12. Holliman, C.J., VanRooyen, M.J., Green, G.B. et al. Planning recommendations for international
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917
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13. Hauswald, M. and Yeoh, E. Designing a prehospital system for a developing country: estimated
cost and benefits. Am J Emerg Med. 1997; 15: 600–603
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International Emergency Medicine is coordinated by Jeffrey Arnold, MD, of Tufts University School of Medicine and
Baystate Medical Center, Springfield, Massachusetts

© 2007 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

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