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Water ambulances and the challenges of delivering mobile emergency healthcare to riverine and maritime communities

Unlabelled image American Journal of Emergency Medicine 47 (2021) 258-266

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American Journal of Emergency Medicine

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Alessandro Jatoba ^a^,?, Hugo Bellas ^a, Rodrigo Arcuri ^a, Barbara Bulhoes ^b,

Paulo Victor Rodrigues de Carvalho ^c

^a Centro de Estudos Estrategicos (CEE), Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil

^b Instituto de Medicina Social (IMS), Universidade do Estado Rio de Janeiro (UERJ), Rio de Janeiro, Brazil

^c Instituto de Engenharia Nuclear (IEN), Rio de Janeiro, Brazil

Introduction

The present article aims to highlight the main challenges faced by the teams of mobile emergency healthcare in delivering care to river- side and maritime regions of Brazil. Considering the continental dimen- sions of the Brazilian territory, its socio-cultural diversity, regional economic disparities, and other complexities, several challenges are faced in order to ensure universal and comprehensive coverage of the Brazilian Unified Health System (SUS).

In Brazil the mobile emergency services are entitled to the so-called

SAMU framework. SAMU is the main health service that delivers pre- hospital emergency care at the scene of an incident in Brazil. It covers about 83% of the country’s population (about 170 million people) and is available 24 h a day following the French pre-hospital care model - providing on-scene care for patients and not just transport to health care facilities.

SAMU performs Emergency medical care anywhere: residences, work sites, and public locations. Dispatch is made after dialing a com- mon single-access number (192). The telephone call is answered by a regional Dispatch Center, which determines the appropriate medical re- source to provide to the patient and mobilizes the closest intervention team to the event, which are geographically dispersed along strategi- cally located decentralized bases. Meanwhile, the Dispatch Center com- municates to local health care facilities and keeps track of bed and service availability. In land, SAMU is commonly related to the use of am- bulances. However, to reach riverside and coastal areas, the SAMU teams use water ambulances in the form of speedboats, known in Brazil as “ambulanchas”. In comparison with land transport and care, the particularities of the waterway environment increases the complex- ity of the provision of a safe service.

Due to the criticality of urgent care, SAMU is especially affected by Brazilian diversity [1-3]. This scenario becomes more complex in coastal and riverine areas. In comparison with inland traffic, the waterway en- vironment presents different challenges and peculiarities, such as the

* Corresponding author.

E-mail addresses: [email protected] (A. Jatoba), [email protected] (H. Bellas), [email protected] (R. Arcuri), [email protected] (B. Bulhoes), [email protected] (P.V.R. Carvalho).

unpredictable conditions of navigability, adverse geographical condi- tions, long, deserted and tortuous routes, in addition to inherent limita- tions of the boats, the support equipment, and conditions to access the communities [4-7]. All of these factors make situations harmful for both healthcare teams and patients.

Thus, the present research approaches the influence of work conditions on mobile emergency care in riverine and maritime areas on the access of the communities to different Levels of care. In this sense, this study explores the water ambulance service in different coastal areas in Brazil: Paraty, in the State of Rio de Janeiro; Salvador and Bom Jesus da Lapa, in the State of Bahia; Manaus, Tabatinga, Benja- min Constant, Sao Paulo de Olivenca, Santo Antonio do Ica, and Tonantins, in Amazonas.

Recently, the Brazilian Ministry of Health has been posing efforts in improving the access of remote populations to quality healthcare ser- vices. Thus, through in-depth analysis of the operation of the water am- bulance service, this study highlights difficulties and advantages, working conditions, and opportunities for improvement, contributing to the elaboration of guidelines and regulations that encompass the di- verse regional aspects to this essential component of the emergency services framework of the Brazilian Unified Health System (SUS).

Methods

This paper presents an exploratory study of qualitative nature, with data collection procedures through in-depth interviews and ethno- graphic observations, underpinned by the Grounded Theory [8].

1. Research settings and recruitment of participants

All Brazilian regions in which the water ambulance service was op- erational in December 2019 - the date on which the present research obtained ethics clearance - were selected for this study. This totaled 9 municipalities, as only the Municipal Health Department of Belem, in the state of Para, refused to participate. No reason was expressed by the aforementioned participant regarding the refusal.

The SAMU managers from each region formed the initial group of participants, having been contacted by the leader of the research group by telephone and/or e-mail. There was no prior relationship

https://doi.org/10.1016/j.ajem.2021.05.012

between the members of the research team and the participants. Thus, the contacts of the managers were obtained from public data available on the internet, such as the websites of the health departments and re- cords in the Brazilian registry of health facilities, a public database [9]. From the initial contact, the managers were tasked with inviting other participants to the study. During fieldwork, new professionals were re- cruited by indications of their colleagues, in a “snowball” probabilistic sample method [10]. Therefore, the number of interviews was based on data saturation during the interviews.

101 professionals were interviewed, totaling more than 270 h of field work, carried out during the period of 39 days, distributed as shown in Table 1. The only refusal to participate in the study comes from the municipality of Belem (PA).

1. Data collection procedures

Fieldwork focused on the organizational context (structure, relation- ship between different levels of government, availability of human and material resources, protocols) and work environments (geographical and climatic elements, in addition to epidemiological aspects of the cov- ered populations) experienced by the rescuers and other SAMU profes- sionals. For this purpose, the fieldwork followed the steps:

Visits to dispatch central;
Semi-structured interviews with dispatch managers and SAMU team coordinators;

Table 1

Locations, facilities and participants recruited.

Locations Facilities observed Interviews carried out

Observation of the dispatch facilities;
Visits to the facilities of operational bases:
Observation of the work as performed by the rescuers, when allowed by the participants;
Semi-structured interviews with rescuers;
Observation of water ambulances.

Data collection was carried out by three members of the research team, sent to the locations. Only the three team members and the par- ticipants were present during the observation sessions and interviews. The interviews were conducted at the locations and times chosen by each participant. Some interviews were recorded, when the participants allowed. Non-recorded interviews were registered in field notes. It is also worth noting that the collection procedures were pre-tested with four participants from Paraty, Rio de Janeiro. The script used to guide in- terviews and the topics for observation are described in Tables 2 and 3.

1. Analysis procedures

Once coded, the content of the field notes and interviews underwent content analysis [11]. The meaning units encompassed the sentences by interviewees. Thus, the categories were chosen in order to highlight the alignment or misalignment between the demands on the water ambu- lance service and its capacity. Subsequently, these categories were then divided into two groups: “Capacity” and “Demand” [12,13].

For the “Capacity ” group, the focus question was” What should be the elements to be regulated for the proper functioning of the SAMU

Baia de Ilha Grande - RJ

Dispatch central
Base
Dock
water ambulance
Base coordinator
Coordinator of civil guard
Dispatch physician
Hospital manager
2 nursing technicians
3 pilots

water ambulances? “. For the” Demand ” group, the focus question was “What are the elements that affect the performance indicators of the SAMU water ambulances?”

Salvador - BA o Dispatch central

- Dock
- water ambulance
SAMU’s coordinator
SAMU’s technical advisor
2 dispatch physicians
3 nurses, including 1 nursing coordinator
1 pilot
2 rescue teams, totaling 2 pilots and 2 assistant pilots

Results

The results of the study are organized according to the data analysis procedures, i.e. in two groups (Capacity and Demand), which are subdivided as shown in the next subsections.

Bom Jesus da Lapa - BA

Municipal Health Department
Dispatch central
Municipal health secretary
Special care director
SAMU’s coordinator

Table 2

Data collection protocols - script for semi-structured interviews.

- Inland base o Nursing coordinator
- Fluvial base
- water ambulance

Manaus - AM o Dispatch central

- Fluvial base
- 2 water ambulances
- Maintenance workshop
- Docking location
- Primary care clinic
Dispatch physician
Rescuer physician
3 pilots
2 nursing technicians
SAMU’s coordinator
6 boat pilots
6 nursing technicians
3 nurses
Manager of primary care clinic
Community health worker

Could you describe how SAMU is activated to rescue victims?

Are there enough trained SAMU professionals to face service demands in your region?

How does water ambulances’ mooring and Patient transportation happen, from the arrival at the location to moment the victim is boarded?

Are there problems created by gaps in technological support, such as ones regarding phone and radio coverage and devices, information systems, equipment to provide emergency care, uniforms, PPEs, navigation equipment, as well as the water ambulance itself?

Do people external to SAMU usually collaborate during the rescue of victims? Are there specific persons in each community that are sought to or are viewed as

Alto Solimoes -

Dispatch central
5 inland bases
4 docks
5 water ambulances
Fluvial base
Maintenance workshop
Hospital
Emergency walk-in clinic
SAMU’s coordinator
Coordinator of medical dispatch
Dispatch physician
Radio operator
Municipal secretary of health
5 Coordinating nurses
18 Waterway pilots
14 Nursing technicians
Municipal hospital director
Emergency walk-in clinic director
Emergency walk-in clinic nursing coordinator
Emergency walk-in clinic nurse

supporters during these moments?

What are the main difficulties or challenges to perform your work, from

Which strategies do you and other members from intervention teams employ to face the unforeseen events and challenges posed by your work?

How are SAMU professionals trained to operate the SAMU service in riverine and coastal areas?

How would you describe the work conditions while performing the service, including hygiene, safety, physical and cognitive demands?

Would you suggest improvements toward redesigning SAMU water ambulances and their equipment and internal elements, so as to better support the provision of emergency care to riverine and coastal communities in your region?

Would you suggest other improvements toward restructuring the SAMU’s emergency care service to riverine and coastal communities in your region?

Table 3

Data collection protocols - themes for observation of work activity, worksites and material resources.

Conditions of SAMU Dispatch Centers

Conditions of the SAMU bases and the actual place where intervention teams await activation from the regional SAMU Dispatch Center (stand-by location)

Time taken and means of transportation for intervention teams to travel from stand-by location to water ambulance’s docking site

Conditions of water ambulance’s docking site, including access conditions to board the boat

Geographical characteristics of regions and their water bodies and shores

Access conditions to board and remove victims from water ambulances across the urban area, communities and natural locations

Conditions of handling victims inside water ambulances

Presence of necessary equipment and materials for teams to attend to victims Presence of navigation instruments and equipment

External and internal dimensions Pilot workstation and visibility Water ambulance’s engines

Uniforms and Personal protective equipment (PPEs)

1. Capacity
  1. Rescue teams - composition and training

The basic composition of water ambulance rescue teams comprises two pilots, one or two nursing assistants and, in more complex situa- tions, a nurse. However, the teams are usually smaller, with only the boat pilot and a nursing technician. In the latter case, it was observed that both would be occupied during the occurrences in many circum- stances, e.g.:

- - - Navigation: while the pilot drives the water ambulance, the nursing technician communicates with the dispatch and the base, in addition to monitoring obstacles in the watercourses;
    - Docking: the nursing assists docking by handling cables and position- ing the water ambulance;
    - Embark and disembark of patients: both workers are needed to em- bark patients on the stretcher). Moreover, it is usually necessary to seek help from residents;
    - Stabilization and care: depending on the nature of the occurrence, at least two people are needed to stabilize patients.

In regions where the transfer takes two or more hours, it has been reported that health workers based in the community - doctor, nurse, nursing technician or, more commonly, Community Health Worker (CHW) - assist in the patients’ boardings and crew the water ambulance on the return trip, in order to assist the team in caring for the rescued.

- 1. Dispatch central

It was reported by rescuers that dispatch teams have limited knowl- edge about the particularities of waterway assistance, which translates into difficulties in relation to the following aspects:

Decision making regarding the dispatch of the water ambulance to the occurrence:

Participants state that, in general, and independent of the region of Brazil, SAMU is only requested in severe cases. Interviewees affirm that it is essential the presence of at least one experienced dispatcher in every shift;

Collection of information regarding the location of the occurrence

As reported, dispatchers sometimes do not realize homonymous lo- cations. Additionally, for regions with communication difficulties be- tween rescuers and dispatchers, more experienced dispatchers are more likely to understand scenarios, since the occurrence attendance can last for several hours and the communication signal may be unavailable.

- 1. Communication issues

Communication between Dispatch, rescuers and base varies, some- times on radio, cooperative cell phones, or personal cell phones. Com- munication between requesters and the Dispatch, on the other hand, is mostly on regular telephones or, when internet connection is avail- able, via WhatsApp texting.

Communication difficulties are reported as a major challenge in the water ambulance service. To mitigate such difficulties, satellite phones have already been tested, unsuccessfully. With the exception of densely populated regions (in general, capitals), there are vast areas where communication is unreliable or non-existent, with the following consequences:

- - - Suppression of demand and underreporting of occurrences, since in many cases the requesters depend on rural telephones, or you just can’t get in touch with SAMU;
    - Inaccuracy in dispatching, as rescuers have difficulties in contacting the Dispatch Central;
    - Increased risks for rescuers.

The last two points are aggravated the more remote and compre- hensive the area of action of the rescue teams is, since in these cases the CRU is “blind” to the unfolding of the occurrence for many hours in a row.

According to the interviewees, these questions make the assistance protocol unsuitable for waterway rescue, since rescuers are unable to deliver immediate assistance or more complex interventions during pe- riods when there is no radio or telephone signal, as shown in the follow- ing testimony:

“According to the protocol, even if we see an occurrence by chance, we would always have to call Dispatch beforehand, but drowning and other cases cannot be followed up, we have to help immediately, then we call Dispatch after we stabilize the patient”.

“At certain times you can’t follow the protocol, it (rescue) has to be instantaneous”.

Regarding the decision-making by the dispatcher, comparing occur- rences of land-based assistance with waterways, it was also reported that some variables have a greater effect in the waterway, e.g. location, the way the symptoms are manifesting, the size of the community and which health workers are on duty on the moment of the occurrence.

- 1. Design issues

According to the pilots’ statements, the stability of navigation is largely provided by the shape and material of the vessel’s hull. Among the analyzed water ambulances, two operate in maritime regions, in rel- atively sheltered waters: in the bay of Ilha Grande (Paraty), with alumi- num hull, and in the bay of Todos os Santos (Salvador), built in fiberglass, both shown in Fig. 1.

The teams in these places do not consider the aluminum hull suit-

able for maritime navigation because it is very light, with lower stability when the engine is at full power. They consider fiber hulls to be more

Image of Fig. 1

Fig. 1. From left to right, water ambulances from Paraty and Salvador.

suitable, which are heavier and guarantee greater balance and safety. In the riverine regions, welded aluminum hulls are used, but almost all vessels needed to be reinforced because they were built with very thin plates. The logs and stones in the riverbeds or strong currents require thicker hulls, capable of resisting eventual collisions.

Regarding propulsion, only outboard and inboard engines were found, with the latter in only one of the analyzed boats; although lower fuel demand, it is more difficult to access and proved to be inad- equate for the speed requirements. The outboard motor is preferred by the teams for reaching greater speed, for being easy to access (for main- tenance and cleaning) and also for being liftable - especially useful in shallow waters.

The boarding of patients is difficult (Fig. 2), having been seen entry procedures from the stern, the bow and even through bow and side windows. With the exception of a single water ambulance, all the others were adapted from touring boats, prefabricated models that do not nec- essarily meet the characteristics of healthcare work.

In several places the windows were broken due to inadequate mate- rial or low thickness; on a speedboat the windows tilt inwards manually

and are fixed to the ceiling, with accidents having occurred due to their size and weight.

In almost all boats, difficulties on using seats and stretchers could be observed, insufficient numbers for the team, patient(s) and companion

(s). Rescue teams reported safety problems. The position of the stretchers must also be considered according to the type of service to be provided (basic or advanced). Other common factors are the lack of support bars and inadequate lighting inside the vessel, little useful height, lack of cabinets, and lack of adequate storage of medical equip- ment and general accessories, as shown in Fig. 3.

The navigation system is almost always insufficient. Depending on the climatic and geographical characteristics, it may be necessary to use sonar and/or radar in order not to depend exclusively on the driver’s experience. Outdoor lighting is a problem in Alto Solimoes, where com- munities are isolated, making rescuers depend on the boats’ light- houses. Rescuers report that electronic or very sophisticated headlights quickly spoil, and they end up using the hand lantern, put- ting their arms out of the window, or leaning insecurely on the bow, holding a reflector.

Image of Fig. 2

Fig. 2. Procedures for entering and exiting patients. In the upper a patient on the stretcher being embarked. At the bottom, the tracks used for positioning stretchers.

Image of Fig. 3

Fig. 3. Internal space of the water ambulance. On the left, the space for accommodation of users; on the right, the driver’s seat.

The driver’s position is uncomfortable, as the type of seat, support for the spine and feet, safety, visibility of the bow, position of the instru- ments and controls were reported as uncomfortable by the interviewed drivers. In one of the speedboats, the driver has to stand for the entire trip, as he has no visibility when seated.

- 1. Personal protective equipment

The suits are unsuitable to water activities, and workers also com- plain of receiving insufficient suits. In fact, patched and frayed clothing due to excessive use could be observed during fieldwork. They also lack other items, such as: raincoats, headlamps and insect repellents.

According to most teams, the standard suit is very heavy when wet and tugs on the hook of the pants when moving with the arms raised. Others say that it is necessary to be of thick fabric to protect against scratches and bites when walking in the wild. The boots are also heavy when wet, and the laces are difficult to withdraw. Participants

complained about the slippery sole, and some are made of plastic rather than rubber.

- 1. Structure of the River Base (or the absence of it)

Most of the municipalities visited had no bases. Fig. 4 shows the river bases of Manaus and Santo Antonio do Ica, in Amazonas. The existing river base’s structure is very limited, without toilets and refrigeration, despite the high temperatures in the region.

According to the interviewees, the absence of river bases increases Response times and makes it difficult for the rescue teams to access the water ambulances, as the teams are then assigned to land bases. In addition, the absence of adequate river bases prevents workers from storing their equipment on the water ambulances, under the risk of theft and damage.

Another point highlighted in the interviews is the lack of docks in most of the communities covered, which increases the effort required

Image of Fig. 4

Fig. 4. In the left corner, external view of the Manaus river base (AM); in the right corner, internal and external views of the Santo Antonio do Ica river base (AM).

Image of Fig. 5

Fig. 5. Difficulties in locomotion at users ‘rescue sites.

for the teams to access the locations and to transport and handle the pa- tients. Fig. 5 shows some of the most difficult accesses.

Regarding the location of the docking places, it was observed that

both maritime and fluvial locations lack floating or fixed docks.

1. Demand
  1. Geography of the territories

The testimonies of the participants highlight, essentially, that the configuration of the rescue teams is a determining factor in coping with aspects of the geography and infrastructure of the territories. For example, the number of rescuers must be taken into account when re- garding docking procedures. Most of the analyzed locations do not have bases or docks. Likewise, the water ambulance must be properly equipped in order to deliver care, depending on the geography of the area. In some cases, the water ambulance is not even able to dock. In others, it needs to intercept another boat on the way and transfer the patient. In some cases, the local population helps to remove the patient from the boat, given the difficulty of docking.

With regard to the available equipment, different interferences occur - from the need for a boat to reach areas inaccessible to the water ambulance, to the lack of personal protective equipment for health workers. There are also design issues, like unsuitable dimensions. The integration with teams from other services and the existence of primary healthcare clinics are also factors to observe - it is worth men- tioning that few riverside locations in Brazil have health facilities of any kind. Especially in the most serious cases, patients might be transported by air means, like helicopters - when available. In the municipalities of Salvador, Bahia, and Paraty, Rio de Janeiro, the SAMU service has established partnerships with local police and civil defense depart- ments, which own and operate rescue helicopters. This allows these Dispatch Center to coordinate rescues using a helicopter in cases when the dispatch and intervention teams jointly decide that it is neces- sary. The areas under the coverage of SAMU in these municipalities in- clude communities in islands and coastal areas that are located around 1:30 h by water ambulance from the bases and, in the case of Paraty, de- mand that part of the trip is executed in open sea, which makes it much more exposed to weather and sea conditions and prone to aggravate the

victim’s health conditions and increase total response time.

When SAMU is activated to perform a rescue in these communities, the intervention team boards the water ambulance and makes the trip to the community, as usual. However, as it arrives and performs first

aid, depending on the urgency of the case and medical conditions of the victim, it will call the Dispatch Center to debate whether to activate the air team by the police or civil defense. In critical cases, the external air intervention team will be activated to transport the victim to the city. Moreover, during exceptionally rough weather and sea conditions, the water ambulance will not be able to navigate in open sea areas, and thus the water intervention team will board the helicopter (if available) directly from the start. At both ends of helicopter transportation, a transfer is made from and to land ambulances, as with water ambulances.

In the Upper Amazon River region, support by air vehicles is pro- vided in the form of amphibious aircraft, but since these amount to a very small number and are state-managed, they are employed in coor- dination with SAMU solely (and when available) for urgent transfers of patients between the municipalities in the region and the state- capital, Manaus, about a thousand kilometers to the east, down the Am- azon River. Therefore, these planes, which are kept docked in Manaus, are not employed for rescues at the communities but are instead acti- vated by the SAMU Dispatch Center of the Upper Amazon River region in cases when patients - already stabilized at municipal Specialized care facilities - need complex care that cannot be provided in the region. At both ends of plane transportation, a transfer is made from and to land SAMU ambulances, as with water ambulances.

- 1. Environmental issues

Very heavy rains prevent water ambulances from leaving in all loca- tions analyzed. Even in cases where the boat is dispatched, the patient’s discomfort, especially in more severe cases, can be increased by waves and excessive bumping. Also, many of the docking locations are dark or poorly lit, which makes it difficult for workers to move around, espe- cially at night.

In other cases, the route for the water ambulance to arrive on the riv- erbeds are embarked is narrow, difficult to navigate, or affected by nat- ural events, such as rain or sandbanks. It is often necessary to use auxiliary equipment, such as inflatable boats. It is also important to highlight the effects of storms on the health of workers. The lack of pro- tective equipment, such as hats, ultraviolet protection clothes, special shoes, etc., increases the chance of accidents, illnesses and puts the lives of the teams at risk. Likewise, navigation at night is dangerous, in- cluding with regard to exposure to cases of violence, such as robberies and piracy.

- 1. Occurrences

The types and severity of occurrences vary predominantly from typ- ical clinical events (stroke, heart attack, hypertension, etc.), alcohol abuse, to work-related trauma Drownings, mental health problems and animal bites also appear eventually. Some critical but predictable situations, such as childbirth, have different referrals.

Some demands vary according to the specific characteristics of the regions, such as the lack of stable electricity supply, the presence of ven- omous animals or seasonality. For example, the fishing season, when there is a higher frequency of occupational accidents among fishermen, or the summer, holidays and periods of regional festivals, where there is a greater presence of tourists.

Especially when attending to more critical situations, cooperation between first rescuers (including the driver) with other professionals, such as health workers from the locations, Firefighters or the Military, is essential for successful Delivery of care.

- 1. Communication

Communication problems hinder both the deliver - when users have no means of making the call, such as a telephones -, and timely assis- tance - when residents use indirect means of communication, such as radio contact with an intermediary who can activate the SAMU Dis- patch, or move to another nearby community that has a signal. There are also difficulties arising from language differences, such as those spo- ken in indigenous communities and regionalisms.CHWs are commonly sought both to help carry out the call to the Dispatch, and to be “trans- lators” of indigenous communities’ languages.

In addition to the communication of the population to request the service, the team needs to communicate adequately with inland physi- cians. This is also hampered by the lack of telephone signal in many lo- cations. Some strategies are used in these cases, such as seeking guidance from the dispatcher, or buying chips from different cell phone operators (by the workers themselves or by the centrals) in order to increase the range of mobile phone signals.

Communication also affects the safety of the team, as they might be unable to request support during the trips, as shown in the testimonial below.

“He had already run aground, then he jumped into the water (to fix the boat), risking stingray stings’. Without contact, there is no way to ask for help. We have already had to request help from a private boat”.

- 1. Social circumstances

Another point that makes it difficult for the population to use the service is that the riverside communities often do not know the service is available. According to a testimony from Alto Solimoes, even among those who know the service and have telephone signal, there are resi- dents who believe that the call is paid, which means that they do not re- quest the service, preferring that an acquaintance takes them to the Healthcare facility.

The interviewees also report that in the riverside communities the population usually adopts traditional or homemade health measures, only requesting the SAMU when they see that the patient does not im- prove. In Alto Solimoes, for example, indigenous populations in general seek healing through their traditions and cultural methods. Again, the figure of the CHW stands out in supporting the populations and in acti- vating the SAMU.

Discussion

Many of the situations highlighted in the present study are common to the locations, despite their evident geographical distinctions. For ex- ample, docking difficulties and problems for boarding and transferring patients are similar in all locations studied. Likewise, it is possible to find similar situations in other countries that have mobile waterway

services [14,15]. The lack of information exchange between different lo- cations hinders the dissemination of successful experiences, as well as the anticipation of problems, which is more serious as the scarcity of re- sources increases.

The gap between the resources of the water ambulances service and the pressures imposed on the service is demonstrated in the Demand x Capacity relationship. The fact that there is no spare boat in any of the locations studied, and the scarcity of other public waterway vehicles, such as police, firefighters and local guards, makes SAMU rescuers’ teams dependent on boats made available by the municipal health de- partments that were not designed for this purpose, or even informal ar- rangements based on personal connections of SAMU workers such as relatives or members of the community who own private boats.

In this case, it is important to raise people’s awareness of the services available as a way to overcome local infrastructure limitations. The role of primary care, especially the CHW, is highlighted as the link between remote areas and health services, but also as important players in health promotion, monitoring of families and prevention of injuries, important actions to strengthen the resilience of the SAMU [16-19].

The large areas where communication is hard, in addition to long distances to be covered, reflect the regional disparities in Brazil, which increase the vulnerability of the territories and, consequently, the risks for health workers and populations. This vulnerability has other facets, such as violence, and the inability of security forces to deal with it. The solution of these aspects is beyond health work, requiring investments in infrastructure projects that need to have priority on the governments’ agenda [20,21].

In order to deliver adequate health services it is important to under- stand local specifics and devise strategies and processes that are in- creasingly adherent to the contexts in which they are inserted. Although this practice is already incorporated into the work of SAMU teams, this situation should not serve as a way to naturalize the suffer- ing and difficulties of workers, already affected by issues inherent in the territory and the criticality of the work [22]. It is worth noting that some regions are especially overloaded, such as Tabatinga, which is located on the “triple border”, admitting patients from Colombia and Peru [23,24]. The majority of riverine and maritime communities covered by SAMU are remote or peripheral, distant from major urban centres. These locations pose a unique challenge to SUS, i.e., to ensure patients’ access to inland services. One major finding of this study is that SAMU assumes, in fact, a big role in this regard. Especially for Amazonian river- ine communities - who don’t own boats nor can afford fuel for trips over the nearest city -, water ambulances’ intervention teams and riverine (boat) primary care clinics are the only bridge to healthcare. Riverine and maritime communities in other Brazilian regions are not covered by primary care clinics, although these communities are not as remote as the Amazonian ones. Finally, although at least one CHW is present in the majority of remote riverine and maritime communities, these

workers lack adequate resources to assist their communities.

Taking these findings into account, strengthening the coordination between the SAMU and primary care services is essential to ensure uni- versal coverage, encompassing remotely located communities. We be- lieve this could be achieved by training local CHWs in the following aspects:

Assisting the SAMU at the following steps of the rescue process:

(A) mediating communication between the patient/community and the SAMU service at call to Dispatch Centre; (B) performing first aid care to patients; (C) facilitating the patient’s extraction by the water ambulance crew, from guiding the crew to the patient location to sometimes coordinating an early transfer of the patient’s from the oc- currence location to the water ambulance’s docking location;

Promoting campaigns to publicize SAMU water ambulance service within the community, as well as the scope of SAMU services, foster- ing awareness of the population on when and how to call the SAMU Dispatch Centre.

Finally, some additional recommendations are listed to improve the performance of water ambulances service:

The deployment of river bases in all municipalities, in order to reduce response times and physical workload. In addition, many of the existing bases are in urgent need of renovation, such as the one lo- cated in Santo Antonio do Ica, in Alto Solimoes;
The creation and implementation of a SAMU service evaluation model with focus on patients’ experiences;
Due to the difficulty of hiring physicians in the Alto Solimoes region, creation of advanced teams with nurses;
Detailed inventory of the needs of emergency equipment, respecting the specificities of the population and geography of the territories;

Conclusions

This article presents a diagnosis of the difficulties and challenges of SAMU in riverside and maritime regions, through the analysis of the water ambulances service in Brazilian municipalities. Thus, it was possi- ble to understand how the service works, considering the effects of op- erating conditions on the deliverance of care in isolated communities. Thus, it was possible to propose alternatives for the restructuring of the service in order to make it operate according to regional realities, in addition to the formulation of processes to support the service that encompass the territorial dynamics.

1. Principal findings

The major findings of this study relate to five key areas that present obstacles with broad implications over the service as well as to some service specifications produced as recommendations to counter them. Here we summarize such correspondence in these five areas:

Communication means between victims, Dispatch Center and interven- tion teams. In regions with scarce cell phone coverage such as the bay of Ilha Grande and the Upper Amazon River, a communication network via long-range radio devices should be established, facilitat- ing the coordination of care and the safety of expeditions, being cru- cial for cases where problems during trips create the need for SAMU teams themselves to be rescued. When such solution is not available due to financial or technical restrictions, Dispatch Center and inter- vention teams should be equipped with cell phone SIM cards includ- ing satellite internet plans for all mobile carriers operating in the region (in Brazil, typically up to four), so they can use the ones provid- ing best coverage locally;
Navigation, mooring and docking in riverine and oceanic environments. Riverine and coastal bases featuring nautical hangar and dedicated rooms should be implemented across the regions once they provide im- portant support to SAMU service by reducing response times, facilitat- ing victim boarding in and out of the vehicle, facilitating transport of emergency care equipment and increasing service reliability due to a dedicated and adapted docking and maintenance site. Water ambu- lances should feature access points in both sides as well as in the prow, two stretcher bases (one in the middle, facilitating victim manip- ulation from all sides), sonar and a minimum of 5-mm-thick hull to bet- ter fare against bumps at the riverbed, rocks and debris. Water ambulances should also always feature a washroom, due to the long trips performed. Partnerships with construction departments at munic- ipalities should be put forward as to facilitate building simple docking sites at communities, thus greatly improving boarding of victims;
Care and communication protocols.A “briefing” protocol should be im- plemented at shift changes of intervention teams. Also, it is very impor- tant that a protocol for rescuing water intervention teams is produced and implemented, considering scenarios such as lack of communica- tion means to reach the team. In addition, given that it is common to

advise communities’ residents or health workers to start transporta- tion of victims toward the SAMU intervention team on their own boats in an effort to somewhat reduce the long response times, a pro- tocol for supporting dispatch teams regarding this decision should be implemented;

Intervention teams’ composition. Given that in many occasions the inter- vention team needs help from the local residents to transport and board the victim in the water ambulance, and also given the risks faced during expeditions, it is advisable that basic water intervention teams incorporate a nursing aide as a third professional. Due to long re- sponse times in water ambulances’ assistance and scarcity of physi- cians in remote and isolated regions, it is also recommended that intermediary teams - composed by a nurse, a nurse technician and the pilot - are implemented so as to be available for both land and riv- erine/coastal occurrences.
1. Limitations

One of the limitations of this study concerns the fact that it did not focus on the identification of the main barriers of access of the riverside and urban population to the use of the water ambulance service, al- though these aspects have appeared in some of the interviews carried out. Thus, identifying access barriers is a significant opportunity for fu- ture work. Likewise, studies focused on indigenous peoples must be car- ried out to identify specific aspects of these populations.

In this regard, one important limitation was that this study did not

cover the riverine and coastal health services (covering mainly primary care scope) provided specifically for indigenous populations through the Federal Special Secretary for Indigenous Health. Another limitation regards the fact that two of the municipalities visited had their water ambulances under maintenance, and so it was not possible to observe them in operation.

Compliance with Ethical Standards

This study was conducted according to Brazilian regulations regard- ing research with human subjects, and obtained clearance from an ethics committee in December 2019.

Declaration of Competing Interest

The authors declare that they have no conflict of interest.

Acknowledgements

The authors aknowledge the Brazilian Ministry of Health for supporting this study, as well as all the workers that participated in it. Paulo Victor Rodrigues de Carvalho aknowledges the National Council for Scientific and Technological Development - CNPq (grant 304770/ 2020-5) and the Carlos Chagas Filho Foundation for Research Support of the State of Rio de Janeiro - FAPERJ (grant SEI-260003/001186/2020).

References

AJEM

Water ambulances and the challenges of delivering mobile emergency healthcare to riverine and maritime communities

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