EMERGENCY MEDICAL SERVICES IN St. VINCENT

AND THE GRENADINES

Michael J. Boros, MD, MS, BS

INTERNATIONAL EMS

ABSTRACT

Objective. This descriptive study reports the status of thehealth care infrastructure and the emergency medical ser-vices system in the nation of St. Vincent and the Grenadines,an eastern Caribbean nation made up of a series of smallislands located 1,600 miles southeast of Miami. Methods.Data regarding the health care system and emergencymedical services in the nation were gathered from varioussources, including the Ministry of Health, governmentpublications, hospital records, accident and emergencydepartment logbooks, and interviews with physicians,nurses, and ambulance workers. Results. The health systemis similar in structure to that of the United Kingdom. Gen-erally, the health infrastructure and available staffing areadequate and comparable to those of developed nations.However, out-of-hospital emergency medical services arelacking in both equipment and trained personnel. Conclu-sion. These data should be useful to both policymakers andhealth professionals in formulating strategies for advancingemergency medical services in St. Vincent and the Grena-dines, and may also be instructive to other countries withdeveloping emergency medical services systems. Key words:health care facilities; manpower and services; emergencymedical services; transportation of patients; developingcountries.

PREHOSPITAL EMERGENCY CARE 2003;7:477–481

Emergency medical services (EMS) systems are quitediverse throughout the world. Part of the difficulty inidentifying EMS needs and targeting countries forsystem improvement is the lack of descriptive studiesfor most developing nations. Kirsch and colleagues

Received November 20, 2003, from St. George’s University, School ofMedicine, Grenada, West Indies.

Presented at the National Association of EMS Physicians annualmeeting, Tucson, Arizona, January 2002.

Address correspondence and reprint requests to: Michael J. Boros,MD, MS, BS, 621 Pinehurst Boulevard, Kalamazoo, MI 49006-3051.e-mail: <mboros_98@yahoo.com>.

doi:10.1197/S1090-3127(03)00225-9

477

have previously described this problem and have alsopublished procedures on how to analyze EMS inforeign countries.1,2

This descriptive study reports the status of the healthcare infrastructure and the EMS system in the nation ofSt. Vincent and the Grenadines, an eastern Caribbeannationmade up of a series of small islands located 1,600miles southeast of Miami.

METHODS

Because of the difficulties that Holliman et al.2 havereported with the disparity between studies involv-ing international healthcare systems, the project inTrinidad and Tobago completed by Kirsch et al.1 wasused as the model for this study. Data were gatheredfrom various sources throughout the country, includingthe Ministry of Health, government publications, hos-pital records, and interviews with physicians, nurses,and ambulance workers. Additional information aboutthe accident and emergency (A&E) department patientpopulation was gathered by conducting a retrospectivereview of A&E logbooks.Permission to conduct this study was granted by

the Ministry of Health representatives at KingstownGeneral Hospital and the A&E department’s adminis-tration.

RESULTS

St. Vincent and the Grenadines is an eastern Caribbeanisland nation located between the countries of St. Luciaand Grenada (Fig. 1). The island of St. Vincent makesup the largest portion of the country in both populationand land mass; the country is 150 square miles in size,St. Vincent being 133 square miles of that. More than115,000 people live in the country. The majority of thepopulation (82%) is black in ethnicity.3 More than 30%of the inhabitants are under the age of 15 years; morethan 6% are 65 years of age or older. The economy runs

478 PREHOSPITAL EMERGENCY CARE OCTOBER / DECEMBER 2003 VOLUME 7 / NUMBER 4

FIGURE 1. St. Vincent and the Grenadines.

mainly off of agriculture, the leading crop beingbananas.4

Health Care System

The health care system of St. Vincent and the Gre-nadines is based on the British system; the majordifferences are the result of technology and costs. Allhealth care issues are delegated to the Ministry ofHealth and the Environment. This agency oversees allof the policies, procedures, plans, and services in-volving health care. According to figures provided bythe Ministry, 23.5% of the nation’s $159 million (USD)governmental budget is designated for health care. TheMinistry’s priorities in allocating those funds are shownin Table 1. Specifically, the country’s emergency med-ical services are funded through the ‘‘hospitals’’ priorityas per the Ministry of Health. However, informationregarding specific amounts was not available.

TABLE 1. Priorities of the Ministry of Health

Primary health careHospitalsChild careFamily planningEnvironmental healthPharmaceutical suppliesNutritionHealth education including a nursing schoolDental healthMental healthCare of the agedCommunicable disease prevention and controlEye healthDrug abuse controlHealth information systemsManpower development

In St. Vincent and the Grenadines, there are 38 clinicsand five rural hospitals. These outlying facilities areserved by one referral hospital, Kingstown GeneralHospital. Overall, 265 hospital beds are availablethroughout the country. Forty-three physicians, 234registered nurses, 155 registered nursing assistants, and16 pharmacists staff these facilities. There is also onemedical laboratory staffed by 14 technologists.

Kingstown General Hospital

The capital city, Kingstown, with a population ofapproximately 30,000,4 is home to the nation’s primaryhospital and most of the health care resources.Kingstown General Hospital has 207 beds and has 39physicians on staff, including one medical director, tenconsultants, four senior registrars, six registrars, 14medical officers, and four interns. Consultants arephysicians who have completed some postgraduateeducation and have worked in the hospital for sometime. Senior registrars have also completed some post-graduate work but have less experience. Registrarshave some type of certification and are working towardbecoming a specialist within the hospital. Medicalofficers have attained an MBBS (equivalent to a MD)and are beginning their postgraduate training. In-terns are student doctors from the University of theWest Indies in Jamaica or St. George’s University inGrenada.There are 249 nurse-related workers on staff at

Kingstown General Hospital. There is one senior nurseofficer, six department assistants, three nurse an-esthetists, one nosocomial infection nurse, one housesister, 16 ward sisters, 88 registered nurses, 89 nurse

479Boros EMS IN ST. VINCENT AND GRENADINES

assistants, and 44 nurse auxiliaries. The house sister isa nurse as well as a religious nun who oversees the 11ward sisters, who are nurses assigned to specific wardsas well as being religious nuns. There is a school ofnursing on the island of St. Vincent, which accepts upto 83 students each year. The program is similar tothose in the United Kingdom. To receive an RN degree,students attend the school for three years, after whichthey may continue training for midwifery or theoperating theater. Most of the nurses at KingstownGeneral Hospital are trained at the St. Vincent school;however, some are trained in the United Kingdom.

Accident and Emergency Department

The A&E Department of Kingstown General Hospitalsees approximately 30,000 patients each year. The ratioof male to female patients is 1.2:1, and the majority ofthe patients are between 15 and 44 years of age. Mostpatients present between 9:00 AM and 6:00 PM. The A&Elogbooks indicate that approximately 75% of patientsare treated and released, 1% are admitted, approxi-mately 19% leave per their own discretion (i.e., patientleaves the department before being seen by a physi-cian), and 5% are otherwise unaccounted for.The discharge diagnoses for A&E patients are shown

in Table 2. The largest proportion of A&E visits (26.1%)are for injuries, and over one-third (35.3%) of theseinvolve patients under the age of 18 years. Respiratoryproblems account for the second highest percentage ofvisits (16.3%).There are five full-time emergency physicians on staff

in the A&E department. There are three shifts per daywith one doctor per shift. One additional physicianworks every weekday from 9:00 AM to 5:00 PM. Noneof the physicians are board-certified in emergency

TABLE 2. Diagnoses (by Anatomic System) of the Accidentand Emergency Department Patients

System Percent of Patients

Respiratory 16.3Gastrointestinal 12.3Genitourinary 6.3Neurologic 4.6Cardiovascular 4.5Endocrine 2.0Dermatologic 3.8Ear, nose, and throat 4.1Ophthalmologic 1.2Psychiatric 1.2Musculoskeletal 13.0Injuries 26.1Test review 1.3Unknown 1.0

Other 2.4

medicine; however, one does have her Master ofScience degree in emergency medicine from theUniversity of the West Indies. All the physicians andmost of the nurses are Advanced Cardiac Life Sup-port (ACLS)-certified, and three of the doctors areAdvanced Trauma Life Support (ATLS)-certified.The A&E Department also conducts weekly inservicetraining tutorials as staffing permits. For cases thatrequire specialists, consultations are available, at alltimes, from the following specialties: medicine, surgery,pediatrics, obstetrics/gynecology, ophthalmology, or-thopedics, otolaryngology, dentistry, radiology, andpsychiatry.The A&E Department physical plant is comparable

to that of a suburban U.S. emergency department.There are four curtain areas, one obstetric/gynecologicroom, three other general closed rooms, one freshwound/trauma room, and an asthma treatment area.One of the closed rooms is designated as a resuscitationroom. It is supplied with the necessary equipment,including an oxygen delivery system, a crash cart,and a defibrillator. There are supplies for intubation,tracheostomy, and chest tubes. The asthma treatmentarea contains eight available units. Oxygen andnebulized drugs can be administered there to thosewith respiratory difficulties.Recordkeeping is done rather well compared with

other developing countries.1 An 8.5 3 11-inch cardspecifically designed for the A&E Department is usedfor each patient. The collected information includes thepatient’s name, address, date of birth, age, occupation,telephone number, sex, religion, and next of kin, as wellas the date and time of the evaluation, chief complaint,vital signs, allergies, medications, history, diagnoses,treatments, tests requested, and test results. Thesecards are filed in the A&E Department. If the patientreturns, the card is retrieved and a new one is attachedfor the current visit; if the patient is admitted, the cardbecomes part of the general hospital notes and ac-companies the patient to the respective department.Along with the card system, the A&E Departmentmaintains a logbook that contains information aboutevery patient. The department has recently acquireda computer to aid in this process, but has not decidedhow to use it as of yet.Laboratory testing is readily available and attainable

at Kingstown General Hospital. From 8:00 AM to 4:00PM, most routine laboratory testing can be completedand received in the department within one hour. Suchtesting includes complete blood counts, liver functiontests, cross-matching, cardiac enzymes, radiography,and ultrasonography. Neither toxicology screening normagnetic resonance imaging is available. Computedtomography scanning is available outside the hospitalat a nearby imaging center. After 4:00 PM, the laboratoryhas technicians on an as-needed/on-call basis.

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Ambulance Services

The island of St. Vincent has five ambulances stationedin various areas on the island. One is stationed at thebase at Kingstown General Hospital. The other four arelocated in the towns of Georgetown, Mesopotamia,Barrouallie, and Chateaubelair. In each of these areas,the patient is transported to the nearest health carefacility and then transferred to Kingstown GeneralHospital as necessary. The vehicles are white minivansthat vary in size and make (Fig. 2). One backup vehicleis stationed in Kingstown in case any of the ambulancesshould be out of service. Ambulance drivers who haveno first aid, basic life support, or ACLS training staffthe ambulances. They do not provide medical care,although they are requested to assist with moving thepatient into the van on occasion. There are five driversin Kingstown and two at each of the other locations.The ambulance services are requested over the

telephone. The call is received by the A&E Depart-ment, which then sends a nurse, a male attendant, andthe ambulance driver to respond. On occasion, a phy-sician may go as well, depending on the type andseverity of the emergency, the presence of a secondphysician on duty at the time, and the number ofpatients in the A&E Department at the time.The equipment in the van is minimal. There are no

radios in the ambulance (nor in the A&E Department).There is one gurney, one backboard, a first aid box,a portable oxygen tank/kit, and a leg splint. The nursemay take extra materials per her discretion dependingon the call. Commonly, intravenous materials, glucose,and a glucose meter are taken. Historically, portable

FIGURE 2. Typical ambulance.

defibrillators have not been available; however, onewas recently acquired and is part of the extra materialsthe nurse may choose to take on the call.The ambulances are used for nonemergent uses as

well. Along with transporting patients to KingstownGeneral Hospital from district clinics, the vehicles alsoprovide a means for doctors outside of Kingstown totravel to various clinics and around respective areas.

DISCUSSION

Health services in general, and EMS specifically, in St.Vincent and the Grenadines are quite advanced whencompared with other developing nations in the easternCaribbean. Still, there are considerable opportunitiesfor improvement. Establishing Kingstown GeneralHospital as the hub for the EMS system has provideda great foundation for the improvement process. Thefacilities and personnel at Kingstown General Hospitalare comparable to those in many developed nationsand should be able to help drive improvements in theEMS system.St. Vincent’s emergency ambulance service is one

area with specific shortfalls that must be addressed andthat could benefit from the assistance of outside EMSexperts. The emergency vehicles, their on-board equip-ment, and the education and training of the attendingpersonnel are all in need of improvement. Specificprograms designed to assist the development of EMS insuch nations have been previously described.5–7 Kirschet al.5 described the development of a two-way phy-sician exchange program to provide better understand-ing and shared insights for physicians from bothdeveloped and developing countries. A program inCosta Rica brought educators from the United States toprovide emergency medical technician training tointerested residents.6 These and other programs couldbe replicated in St. Vincent and the Grenadines.

CONCLUSION

Developing emergency medical systems is a globalissue. St. Vincent and the Grenadines provides an idealexample of how improvements in the EMS systemcould improve medical care for an entire country. Theexisting system works well but offers many opportu-nities for improvement. The results of this descriptivestudy should be useful to both policymakers and healthprofessionals in formulating strategies for St. Vincentand the Grenadines, and may also be instructive toother countries with developing EMS systems.

The author is indebted to Mr. Lawrence Brown and Dr. David Reedof Upstate Medical University in Syracuse, New York, for theirassistance in reviewing and revising the manuscript. Also, theauthor thanks Amy Boros, Aaron Zuidema, and Jason Fischer fortheir enduring patience and support.

481Boros EMS IN ST. VINCENT AND GRENADINES

References

1. Kirsch TD, Hilwig WK, Holder Y, Smith GS, Pooran S, Edwards R.Epidemiology and practice of emergencymedicine in a developingcountry. Ann Emerg Med. 1995;26:361-7.

2. Holliman CJ, Kirsch TD, Green GB, Wolfson AB, Torn PA.Guidelines for evaluation of international emergency medicineassistance and development projects. Ann Emerg Med. 1997;30:811-5.

3. The St. Vincent and the Grenadines Department of Tourism.Welcome to St. Vincent and the Grenadines. <http://www.svgtourism.com>. Accessed March 20, 2001.

4. Cameron S. Footprint Caribbean Islands Handbook 2000, 11th ed.Lincolnwood, IL: Passport Books, 1999.

5. Kirsch TD, Holliman CJ, Hirshon JM, Hirshon JM, Doezema D.The development of international emergency medicine: a role forU.S. emergency physicians and organizations. Acad Emerg Med.1997;4:996-1001.

6. Doezema D, Sklar DP, Roth PB, Rodolico MP, Key G. De-velopment of emergency services in Costa Rica. JAMA. 1991;265:188-90.

7. Brown MD. Emergency medicine in Eritrea: rebuilding after a30-year war of independence. Am J Emerg Med. 1999;17:412-3.