Discussion

The successful survival of the present case indicates the potential of mobilizing existing community-based health care resources to improve access to emergency care in remote areas. The trained CEVs in the patient’s neighborhood immediately initiated chest compressions and contacted EMS, constituting the important components of the chain of survival. ^{Reference Perkins, Travers and Berg1} In addition, the CEVs are ubiquitous in the communities and can minimize inequitable access to emergency care, considering the long EMS response time in many rural areas.

The CEVs in this case study also served as VHVs who are the most peripheral health care personnel. They provide outreach services to people as the first points of contact to the health care system. The VHVs are community residents who receive a seven-day training and are responsible for approximately ten households in their neighborhood. ^{Reference Kowitt, Emmerling, Fisher and Tanasugarn6} Their health care services include providing health education and information, connecting those with health problems to health care facilities, and collecting health data. The community people can contact them regarding their health problems.

Many low- and middle-income countries (LMICs) with insufficient health care resources have adopted community-based strategies known as primary health care to expand their health care coverage. Instead of investing in hospital-based care and formally trained staff, they trained lay people in the community as community-based health care personnel and delegated many health care tasks to them. ^{Reference Frenk7} These non-professional health care providers are known as community health workers or volunteers. Thailand is one of the successful countries in improving public access to health care following this strategy with its excellent network of VHVs. ^{Reference Kowitt, Emmerling, Fisher and Tanasugarn6}

Formerly, the community-based strategies focused on maternal and child health care and infection control; this has now expanded to non-communicable diseases and injuries following epidemiological transitions in LMICs. ⁸ Integrating emergency care components into general health services has proven to be efficient in strengthening the existing health care system. ^{Reference Thind, Hsia, Mabweijano, Hicks, Zakariah, Debas, Donkor, Gawande, Jamison, Kruk and Mock9}

The National Institute of Emergency Medicine (NIEM; Nonthaburi, Thailand), the national agency for emergency care, started the CEV program to establish a community-based emergency care network. This program aims to train one percent of the population as CEVs, who serve as the first points of contact to emergency care. ^{Reference Chadbunchachai, Chotkrom, Kulliab, Sophon, Tewela and Tongchiaw4,10} These CEVs are selected from VHVs, police officers, firefighters, teachers, and community leaders. ^{Reference Chaleepad, Impool, Lertsinudom, Chadbunchachai and Nakahara5} The CEV training curriculum includes: (1) how to call the EMS system using the nation-wide unique four-digit phone number of 1669; (2) how to assess and manage serious conditions, such as stroke, myocardial infarction, cardiac arrest, and trauma; (3) judging when to call EMS; and (4) how to provide first aid, for example, wound dressing and splinting to trauma patients and chest compression to cardiac arrest patients. ^{Reference Chaleepad, Impool, Lertsinudom, Chadbunchachai and Nakahara5}

These CEVs, despite their informal nature, constitute the basic community-level prehospital care system and considerably improve access to emergency care, particularly in remote areas. ^{Reference Chadbunchachai, Chotkrom, Kulliab, Sophon, Tewela and Tongchiaw4} If VHVs in every neighborhood are trained as CEVs, they can promptly attend the patient and provide timely first aid while waiting for the formal EMS team. Many CEVs are also VHVs; improving their skills through emergency care training would increase their trustworthiness in the villages.

The lay first responders can supplement the training programs for the general public. ^{Reference Sassers, Varghese, Kellermann and Lormand2} The proportion of those who can provide basic resuscitation is still extremely low, particularly in rural areas in Thailand, despite the NIEM-implemented first aid training courses for the general public at schools and workplaces. While it will take time to increase the number of people who receive first aid training among the general public, first responder programs can efficiently provide care to those who need it. Furthermore, first responders are highly motivated volunteers who would feel lesser barriers than the general public, which sometimes deter them from helping sick patients.

In a resource-constrained setting, integrating first aid training into existing community-based health care programs is a promising and efficient strategy. Community health workers are already providing general health services and are highly motivated to overcome perceived barriers. Additionally, the training is not costly. The first responders’ intervention can provide timely assistance while waiting for the EMS to arrive from a distant place.