Eight physicians were interviewed, one female and seven males. Because of our narrow and specific aim and the in-depth nature of our interviews, the sample size was considered adequate [16]. The physicians’ experience ranged between 2 months and 11 years. Four participants were non-specialized medical officers, two were junior registrars, and two were medical officers with specializations in general practice and emergency medicine. The physicians described numerous challenges in their daily work that we divided into four main themes and associated subthemes, which are presented in Fig. 1. All themes were interrelated to various degrees and evolved around the premise that Nepal is a developing country.
The patient’s socio-cultural and financial factors
All participants highlighted aspects of the patient’s financial, educational, and socio-cultural situations as challenging in the emergency treatment.
Financial issues and inequality
All participants reported that the financial difficulties of the patients were the greatest challenge or barrier to high-quality treatment. The participants described daily encounters with patients who were unable or unwilling to pay for treatment. This resulted in the discontinuation of further investigations and treatment. If patients accepted to pay for the treatment, many would get into debt as a result. The participants were frustrated by the financial aspects forming obstacles to the provision of treatment. One physician noted:
Basically, we can treat disease, we can treat disease but we can’t treat poverty. I can’t give from myself, from my pocket, I can’t spend for the benefit of the patient. That is the main challenge. (P2)
Most participants reported that some patients avoided the hospital due to a fear of the cost of the treatment. A consequence of this was that some patients only went to the hospital when the disease had progressed to a more serious stage. For example, some patients with simple conditions such as gastroenteritis were first brought to the hospital when the patient had deteriorated to reduced levels of consciousness caused by severe dehydration. Ultimately, many of such cases resulted in the death of the patient. Many participants reported that health insurance has been introduced in Nepal and considered it a great asset in combating the economic barriers to proper treatment. However, the participants reported that several patients were not aware of the government healthcare schemes or did not know how to sign up for the healthcare programs. However, the participants also described that they found it difficult to treat the richer patients as these patients expected and demanded special treatment.
Educational, cultural, and regional differences
The participants reported that patients not only came to the hospital with advanced stages of the disease due to a fear of the cost but also due to a lack of education regarding common diseases and symptoms. Most patients did not know when to react to symptoms and would often remain at home or seek alternative methods of treatment. Often the first line of treatment was pain management, and the physicians noted that some patients were unwilling to remain admitted to the hospital once the pain had been managed even though the underlying condition was not treated.
If you see hydronephrosis or anything like that, we will counsel them for admission, but they will say: “No, my pain has already been relieved. I want to go from the hospital and home. It has been like this for many years. Why do I need to admit [to the hospital]? Why do I need to take medicine? Why do I need to spend a lot of money?” That’s the challenge I think. (P5)
The majority of the participants described that treating patients from rural areas was challenging. The participants attributed the lack of knowledge of health issues to the level of education but also to differences in culture. Not only were rural patients more likely to be poor, but they often had a different culture regarding the management of diseases. Patients from rural areas would often seek traditional healers first. The participants were at times frustrated by these different ways of perceiving healthcare and found it challenging to inform and counsel the patients:
And as I said, in the periphery, people go to the traditional healers. And they just take the 3 grains of rice and the patient seems to be okay. Most patients in the periphery go there. I don’t know how it works, I don’t believe in that. But if we go there and tell them that this doesn’t work, they will blame us and say that we are against their traditional beliefs. (P8)
The emergency department’s organization and resources
All participants stated that they enjoyed working in emergency medicine. They felt that their jobs were fulfilling, and they were proud of their profession. However, the structure and resources in the emergency department were described as challenging.
Human and material resources
Some participants described a lack of educated personnel in the ED. This led to the discontinuation of a triage system and was thus a factor in delayed diagnostics and treatment. One participant specifically mentioned that ultrasonic investigations were challenging as these were performed in a separate department and that there was a shortage of personnel to transport patients from the ED to the department of ultrasonography. Likewise, two participants pointed out that the lack of equipment to perform point-of-care investigations in the emergency department was a challenge in their daily work.
We can’t do even FAST [Focused Assessment with Sonography in Trauma] scan in the emergency ward. And we don’t have point-of-care investigations, so we need to send all the investigations to the central lab. We don’t have an emergency lab. (P4)
The lack of human resources was aggravated by a large patient flow. Several physicians described overcrowding in the ED due to a large patient flow. This led to delays in admissions and treatment. This had worsened during the COVID-19 pandemic when patients were required to have polymerase chain reaction (PCR) tests for SARS-CoV-2 performed before they could be admitted.
Sometimes there is … It’s overcrowded, which causes a lot of problems in admissions, and there is an access block upstairs because there is, like, this PCR problem. (P4)
The patients arrive from the east of Nepal and west of Nepal to here cause this is the centre. That is a big challenge because the patient flow is extremely high. (P3)
The physicians working in the ED were mostly junior doctors with limited experience in emergency medicine. The specialists in emergency medicine described having 6 months of training in emergency medicine, but lacked training in specific procedures such as, for example, handling transportation of critically ill patients from the ED to the intensive care unit:
Moving the sick patients from emergency to the ICU. Nobody is actually trained in moving. We need to have training. To move the patient, it’s kind of difficult with no training. (P4)
Protocols and guidelines
Many participants described the unstructured arrival of patients to the ED as challenging. Obtaining the patient's medical history had to start from scratch every time, even in cases of readmission, as there is no registry showing a patient's history. The participants reported that a triage system had existed previously in the emergency ward. This system separated the patients into zones based on how urgent they needed care. The system had been discarded due to a lack of space and resources. However, several participants described that a simpler form of triage with subjective measures to shift the patient to one of either two sides of the ER, yellow or red, had been implemented. This simpler form of triage was an adaptation of the previous system that had four zones.
Yes, big problem - then red zone. Otherwise yellow zone. It is a subjective thing. We don’t have a proper framework. But we know which case we have to shift to red zone and which case we have to shift to yellow zone. (P1)
Some participants were content with the current system, while others believed that they need a more structured system to detect critically ill patients in time. However, the participants had opposing opinions and knowledge on the current way of assessing patients. While some participants triaged patients according to a color scheme of red, yellow, and green, others reported not using any colors but instead assessed arbitrarily:
We don’t have such colour coding and triaging, but we try triaging if patient is seriously ill or if the patient is less ill. If the patient is seriously ill, requiring immediate assessment, requires monitoring, then we send the patient to one side. (P7)
If the triage doesn’t work properly, or if there is not enough manpower to do the triaging, then the needing person does not get cured properly. (P5)
However, some participants believed that the implementation of a triage system would be difficult due to a lack of knowledge.
But we have been working for it [triage system] for a long time now. But still, we are not able to establish a triage system. And we have no idea whatsoever how we will do it because we are not trained in that, no? (P4)
The emergency medical service’s quality and availability
Most participants were positive about the number of available ambulances, and the fact that ambulances did indeed exist and could transport patients from rural and remote areas to the hospital. However, they also described challenging aspects of emergency treatment concerning prehospital systems, the available prehospital resources, and the integration and implementation of the EMS system.
Prehospital resources
All participants highlighted that ambulances were not well-equipped and that the prehospital personnel lacked education on how to assess and treat prehospital patients. The participants described three main types of ambulances: one purely for transport, the second type with oxygen equipment only, and the third type with more advanced equipment and health personnel. The physicians dealt with patients arriving by the first and second types of ambulances daily, but most physicians reported rarely seeing the third type of ambulance, and some even reported never having seen one. This was perceived as a major problem because critically ill patients often had not received any kind of treatment before arrival at the emergency room and could come from rural areas with long transportation times. Some described a scarcity of ambulances in rural areas compared to urban areas.
Once I admitted a patient that had travelled around 100km, no not 100km but 50km from the west. He had travelled in ambulance. The roads are very very bad. And he had travelled without oxygen. And the patient, I received him in the ER [emergency room], when I put on the oximeter, the reading showed about 40% in saturation. And I say, “Why you didn’t get ambulance with oxygen?”. He said, “No there was no ambulance with oxygen available at my place”. (P2)
Some participants described the ambulances as “taxis with sirens” and did not consider them as a part of the healthcare system. The participants were interested in increasing the quality of the ambulances and especially in having educated healthcare personnel available in the ambulances. They felt that this would have positive effects on the care.
Not like abroad, like I have seen in movies and series, there are proper paramedics that can manage the cases in between as well. But here in Nepal, there are no paramedics, no well-trained paramedics. (P1)
However, one participant noted that the implementation of more well-equipped ambulances probably would not have a large impact on the patient’s mode of transportation because the cost of these ambulances would be higher, and as such, the patients would disregard them.
Insufficient integration of emergency medical services
The integration of the current EMS with the hospital was described as poor by the participants. All participants reported a lack of communication between the ED and the ambulances. No mobile communication or radio communication existed between the ambulances and the ED. When patients arrived by ambulance, they were dropped off at the gate, and in-hospital personnel would take the patients from the gate into the ED. The physicians did not know if a severely ill patient was on his way and could not prepare for such scenarios. Only when the patient arrived at the gate they would know. This lack of communication was both due to the EMS providers’ lack of education and because the system was not designed to encompass this feature. The only communication physicians received from prehospital providers were from the police, who would contact the hospital in case of mass casualties.
And the negative thing is communication. We seriously lack communication. We don’t know if the patient is coming or not. Only after the patient arrives at the main gate. Only then do we get the information that the patient is coming. And we only get the information that the patient is coming. Nothing more than that. (P6)
The participants described that the patients arrived at the hospital by two means: private transportation or ambulances. Patients arriving by private means were often in less critical conditions compared to patients arriving by ambulance. The mode of transportation was influenced by the patient’s financial condition, but the participants also mentioned other reasons why patients did not utilize ambulances. The most often mentioned reason was the lack of a nationwide central emergency telephone number.
Usually, people get really panicked when they are going to call ambulances. Like a decade ago, we used to have a common number like 101 or 999. This kind of number used to be there. But right now, there are these individual clubs and you gotta become a member of a club, and get the healthcare benefits from these clubs. There is still a specific number for the government but for the private ambulances, there is no specific number. (P3)
The participants had opposing opinions and knowledge about the prehospital system. Some believed that there was a nationwide central emergency telephone number, while others did not believe that to be the case.
Financial interests in the emergency medical services
All participants noted that the EMS consisted of several providers: government, NGOs, and private providers. Most ambulances were believed to be run by private providers. Some participants had experienced patients who were brought to a private hospital without their knowledge or despite a specific wish to be transported to a government hospital. This influenced the treatment course, as these patients could not afford treatment at a private hospital. The physicians speculated if the ambulance drivers and the EMS providers had financial ties to specific hospitals and would get higher wages when transporting to an affiliated hospital.
But in our experience, there is a kind of syndicate. A syndicate of ambulance drivers. Even if the patient wants to go to a government hospital, they bring them to our hospital. They are unaware of it, the patients think this is a government hospital, but the ambulance drivers bring them to our hospital which is a private hospital. (P1)
Some participants were sceptical about improving the quality and the structure of the current EMS system due to the various financial interests in the service.
But it’s going to be a challenge, because like a lot of people are earning a lot of money. It’s going to be a big challenge. (P4)
The surrounding healthcare system’s impact
The participants indicated that many of the challenges or obstacles they faced were a direct consequence of the surrounding healthcare system. They called for the government to improve the healthcare system and in turn improve the working conditions in the emergency departments.
Lack of organized primary care
Some participants described the lack of a well-ordered primary care system as a part of the reason why patients were more critically ill when arriving at the emergency department. They noted that patients often went to health clinics with few, or no educated healthcare professionals available, or to traditional healers. The general practitioners were not described as forming a part of the primary healthcare system, but instead, patients had the option to visit a specialist physician of their choice to attend to their symptoms. Appointments or referrals were not used. This led to patients having to wait for hours to see a physician. In some cases, the patients visited pharmacies that would prescribe antibiotics. This subsequently led to drug-resistant microorganisms. This complicated treatment in the ED as they thus often had to initiate broad-spectrum antibiotics as the initial treatment.
That is the main cause of antibiotic resistance in our country. They go to the nearest pharmacy, say, they have fever and pain abdomen and then the pharmacist prescribes antibiotics. And after that, if the symptoms don’t subside, then they come to the hospital (P8)
Government responsibilities
Some participants believed that the government had an unfulfilled responsibility in both the implementation of the EMS system and in addressing challenges in the healthcare system as a whole.
We are not rising the quality, we are just rising the quantity. The quality can be improved. I cannot improve the quality, I am not one in power. It should be from the governmental level, it should be from the central level. (P2)
While many acknowledged that the Nepalese government was working on improving the healthcare system, they still underscored the need for these measures to be widespread and not only focused on Kathmandu. Most participants mentioned the lack of quality in the government hospital and displayed frustration with the lack of possibilities for the poorer patient population, as these could not pay for the treatment in a private hospital, and instead received poor quality care or even no care at all:
And there is only one government hospital, Bharatpur hospital, and doctors are not available because they go to private clinics. Even if we send patients to government hospitals they return and say they can’t find doctors (P1)
