Visit or live in Ho Chi Minh City (HCMC), Vietnam, and you’ll find a densely crowded urban environment that lives and moves with the pace and frenzy of any other big city. What you won’t necessarily find are the typical sights and sounds of emergency vehicles, as the national EMS and fire system is fledgling at best.
HCMC, also called Saigon, has an official population of around 13 million, perhaps 20 million if you count the undocumented immigrants from neighboring countries. Couple that with more than 7 million motorbikes roaming the city streets, and you get hordes of people on the roads, day in and day out. While that sounds like a recipe for major trauma, one saving grace of the population density is that speeds often don’t get much faster than 25 mph.
So for an ambulance or any other emergency vehicle, it’s next to impossible to navigate the gridlock and arrive at an emergency in a reasonable amount of time, much less to a hospital with a sick patient. Most residents instead opt to take a taxi, scooter, or personal vehicle to the hospital.
Dr. Rafi Kot thought a lot about this problem while treating patients at his medical clinics in HCMC. If you’re forced to sit in traffic with a patient, why not make it a spacious, well-equipped ambulance, staffed with a nurse and a physician and all the latest medical equipment you’d find in a Western EMS system?
That’s the thinking behind Kot’s “EMR *9999” subscription EMS service, which, for a fee of $25 USD per year, will provide a well-staffed and expertly dispatched private ambulance to treat and transport patients to the hospital of their choice. Those without a paid subscription can still use the service and pay a flat fee of $168 USD for a call.
“Sometimes our patients are so happy with the high-quality treatment and professional care of our providers, they ask if they can just be treated in the ambulance instead of going into the hospital,” says Kot.
Kot, an internal medicine physician born in Israel, launched the EMR *9999 service in 2017. He originally came to Vietnam in 1988 to work with an NGO organizing humanitarian medical camps in rural areas of the country. After various stints as a diplomatic attaché, rural physician, consultant, and part-time medical director for Vietnam Airlines, Kot opened his own company, Family Medical Practice (FMP), which has grown to include three clinics in HCMC, one in Hanoi, and one in Da Nang.
Kot understood the EMS system in his city was mostly ineffective. While Vietnam does have emergency numbers, callers cannot count on a reliable response. Confusing and compounding factors include the fact that until recently there were three separate numbers to call depending on the emergency: 1-1-3 for police, 1-1-4 for fire, and 1-1-5 for medical emergencies.
In addition, Vietnam does not have any formal EMT or paramedic certifications, so most prehospital care is carried out by nurses and physicians. Ambulances are typically driven by a trained driver.
While Kot would like to employ expat paramedics and EMTs from outside Vietnam, he’s hamstrung by Vietnam’s requirement that prehospital providers hold a minimum of an RN certification. It also means Vietnamese physicians and nurses employed by fixed facilities like hospitals must seek additional training to operate in a prehospital environment, mostly on their own dime and time or through NGO partnerships with Western trainers from charitable organizations or universities.
“I realized I could offer a much better alternative,” Kot says.
‘Do You Want to Save a Life?’
Kot’s journey to the launch of the EMS subscription service began more than eight years ago. He began with the number.
“We settled on ‘*9999’ because it was easy to remember,” he says. “Even a 4-year-old preschooler would be able to memorize it.”
Most important, Kot realized, was the need to provide instructions over the phone to the *9999 caller. Because response times are almost always delayed by severe traffic congestion, he needed his staff to immediately help people over the phone.
Enter Priority Dispatch and ProQA. One day Kot’s young son was watching a 9-1-1 reality show, and Kot watched in awe as call-takers calmly and efficiently ran through a script of questions. He was sold: He bought the system, brought ProQA trainers to Vietnam, worked through some challenging language and translation issues, sought advice on system status management from IAED Board of Accreditation Chair Jerry Overton, and began recruiting to train his own dispatchers.
The Vietnamese culture made this part a challenge. In Vietnam, according to Kot, people are averse to drama and any situations that might call for them to intervene with a stranger’s problem, medical or otherwise. Instead they often turn away. For these reasons Kot’s initial group of new hires had many poor fits. After weeding through more than 1,000 applicants, Kot finally landed on what he calls “the Magnificent 12.”
Initially some were shocked at the duties of a call-taker and dispatcher. “They were frozen and afraid,” says Kot.
Kot found and hired a British theater company based in HCMC that trains actors. He asked them to create dramatic emergency scenarios so trainees would learn how to deal with people screaming, panicking, and not following directions.
The training experience took eight months. Kot challenged new employees with the question, “Do you want to save a life?”
Emergency medical dispatch (EMD)-trained employees Huoy Pham and Phuong Nguyen say they are proud to work in a system that’s the first of its kind in their home country and for a man who believes in quality patient care and extensive training. FMP’s *9999 EMDs are trained to provide telephone CPR instructions and adept in figuring out exactly where patients are in the large and confusing city. Both Pham and Nguyen would like to be EMTs someday.
“I haven’t given prearrival instructions for childbirth over the phone yet, but I am looking forward to doing so,” says Pham.
Building a Fleet
The other need, of course, was ambulances. In 2010 Kot traveled to the U.S. to examine a Western-style ambulance, a vehicle he hadn’t actually seen before.
Impressed by the Demers Ambulance group’s offerings at EMS World Expo in Dallas, Kot purchased four ambulances, and Demers sent them on a ship to HCMC.
Kot is now proud to have 10 ambulances in his fleet, with plans to double that number in the next few years. He’s equipped each of the vehicles with mechanical CPR devices and cardiac monitors that transmit patient data in real time back to the clinics for consultation purposes. He owns and has used the only portable ECMO machine in the country.
Recently Kot has begun upgrading the alerting systems to include low-frequency sirens after a trip to New York City, where he experienced firsthand the vibration of a low-frequency siren on an approaching ambulance.
“Vietnamese people aren’t necessarily accustomed to the typical scary ambulance siren, and we don’t want to shock them with a loud noise because they might fall off their motorbikes,” he says. “This is a perfect solution.”
Kot notes that of the 20–30 calls to *9999 each day, only about 20% warrant a response. Interestingly, most callers are not subscribers but are willing to pay the single fee for professional help.
There are the typical cardiovascular and respiratory emergencies and a fair share of motorbike trauma calls. The Southeast Asian population is also currently experiencing a higher per-capita rate of type II diabetes, and Kot wants to focus on preventive solutions.
Through the experience of developing the system, Kot has learned to press on past the challenges of the culture. He is sometimes frustrated by what he says is the Vietnamese tendency to follow rather than lead, for fear of loss of face.
“Look, I created an EMS system I think works well,” Kot says. “I say to my fellow citizens: If you want it, take it.”
Hilary Gates, MAEd, NRP, is senior editorial and program director for EMS World.