Introduction: An effective Emergency Medical Service system does not exist in Nepal. For an effective EMS system to be developed the scale of the problem and the existing facilities need to be studied. Methods: Prospective observational study was carried out on 1964 patients attending Emergency Department at Patan Hospital during one month period of September 2006. The patients were specifically enquired on mode of transport used, place of origin and whether they called for an ambulance or not. Patients triage category at the time of triaging was also noted. Information on ambulance service were collected by direct interview with the service providers and the total number of patients attending Emergency Departments daily were collected from the major hospitals of the urban Lalitpur and Kathmandu. MS Excel and SPSS software were used for data entry, editing and analysis.Results: Total 9.9% patients arrived in ambulance whereas 53.6% came in a Taxi, 11.4% came in private vehicle, 13.5 % came by bus, 5.4% came by bike and the rest 6.2% came by other modes of transportation. Only 13.5% of triage category I patients took the ambulance. There were 31 service providers with 49 ambulances and 720 patients per day attend Emergency Departments in the surveyed area. Conclusions: Very less number of patients use the ambulance service for emergency services. The available ambulances are not properly equipped and do not have trained staff and as such are only a means of transportation to the hospitals of urban Lalitpur and Kathmandu.Key Words: ambulance, emergency medical service, para-medics, triage Need of Improvement in Emergency Medical Service in Urban Cities Gongal R,1Dhungana B,1Regmi S,1Nakarmi M,2Yadav B11Patan Hospital, Lalitpur, Nepal, 2Health Care Foundation, Kathmandu, NepalCorrespondence:Dr. Rajesh GongalDepartment of SurgeryPatan Hospital, Patan, Nepal.Email: rajgongal@yahoo.comORIGINAL ARTICLE J Nepal Med Assoc 2009;48(174):139-43INTRODUCTIONThe sophisticated Emergency Medical Service (EMS) is limited to developed country only. Many developing countries are now slowly developing such system although most services are localized to the urban areas.1-5 Although inadquate ambulance services are available in the capital city of Nepa

An eleven year old girl from the periphery of Kathmandu valley presented to our hospital with the history of highgrade fever since the past twenty days, gradually progressive weakness of lower limbs since the last eight days and inability to stand or walk along with loss of bowel and bladder control for two days. There was no history of trauma, altered level of consciousness, skin or mucosal bleeds or any joint symptoms. She received some medications from the local heath post, details of which were not known. There was no signifi cant past medical history and no known TB contacts. She was third of the six children in the family and was not immunized against any of the vaccine preventable diseases On examination she was conscious, febrile, sick looking, pale and had generalized bony tenderness. Vitals were stable. Cranial nerves and sensations were intact. She had complete fl accid paralysis of the lower limbs with diminished but preserved knee jerks and bilateral up going planters. There was doubtful neck stiffness and no papilloedema. Other systemic examinations were normal.Initial investigations showed normal total and differential counts. She had low Hematocrit (24 %) and the Platelet count was (82,000/cu mm). Cerebrospinal fl uid analysis showed WBC 35 with 45% Polymorphs, Protein of 635 mg/dl and Sugar 44 mg/dl. Blood Sugar, Electrolytes, Creatinine, Chest and Spinal X-rays were all normal.The differential diagnoses on admission were partially treated meningitis versus tubercular meningitis (TBM) but neither of them did clearly explain the paraparesis. Besides, to diagnose TBM, an intact sensorium in the presence of neurological defi cits is unlikely. Systemic malignancies and GB syndrome were considered lower down on the list of differential diagnosis. Further investigation showed ESR of 80 mm/hr, strongly positive Mantoux, 5% blasts in the peripheral smear and bone marrow aspiration showed 90% blasts. MRI of the spine revealed proteinaceous fl uid (blood or blood mixed exudates) in the extradural space with spinal cord compression at upper thoracic region.The fi nal diagnosis was acute leukaemia with paraparesis due to spinal compression and extradural bleed. The strongly positive mantoux most probably was due to activation of occult TB with the immunocompromised state because of leukaemia. She was then referred to the Oncology unit for further management.