The ambulance screams down the boulevard, sirens blaring, the driver yelling through a loudspeaker at a truck that, like most cars in traffic in Phnom Penh, refuses to give way to an emergency vehicle.

Flying past Russian Market, the ambulance draws to a halt, parting the noisy mob that has gathered in this usually quiet Tuol Tom Pong street.

A tuk-tuk sidles up, the bloodied feet of a man dangling out of one side, garishly illuminated by the bright lights of camera phones and local TV crews.

A few men are shouting and aggressively trying to get closer to the body but are held back by police.

“It’s a robber. They beat and shot him,” Kim Song, the ambulance’s broad-shouldered, 1.88-metre-tall driver says as he opens the vehicle’s doors.

It’s 8:24pm. Just 10 minutes earlier, Kim Song and the ambulance team were in the middle of a 24-hour shift at their office at the Khmer-Soviet Friendship Hospital.

Most of their shift is spent waiting around – playing chess, watching TV or napping – but they remain alert, knowing that when the phone rings, they have to act fast.

The splayed body of the victim is carefully slid out of the back of the tuk-tuk and onto a scoop stretcher by two emergency medical technicians (EMTs), transferred onto a gurney and wheeled into a secure position in the back of the ambulance.

The crowd of more than 100 huddles closer. People press their faces against the windows to look inside as the doors are closed and the team follows a police escort back to the hospital.

In the back, the victim is convulsing due to shock. His quivering lips are crusted with dried blood, as are his wrists, which remain awkwardly handcuffed together behind his back.

The man’s shirt is rolled up above his heaving belly and he is gasping for air.

Red stains on his legs lead to a pool of coagulated blood around a small hole on his calf – he has been shot while trying to rob the house of a military policeman.

The EMTs continue to check his pulse and hold his body steady as the ambulance pulls into the hospital and comes to a stop.

The victim is wheeled away to an emergency room while the team heads back to their office to wash the bloodstained stretchers and resume the daily waiting game of life in the public ambulance service.

“My job is over when I bring him back,” Kim Song says. “Even though this guy was a thief, we tried our best.”

Night and day

Peter Li, country director of NGO Side by Side International (SBSI), which trains, equips and operates the government ambulance system, known as 119, says that compared to a few years ago, emergency services in Phnom Penh have drastically improved.

“Right now, with the 119 system, an ambulance can get to the scene in Phnom Penh even in the busiest hour within 30 minutes of the person initiating a call. Typically, we can do it within 15 minutes,” he says.

Five years ago, he adds, it could have taken up to two hours to get to hospital because prices would have to be negotiated first with poorly equipped and largely untrained private clinic ambulance teams.

With five road accident deaths every day in the Kingdom – almost all caused by drunk driving, according to Li – an effective emergency response system is long overdue.

The 119 system was established in the early 1990s but only became fully usable around 2009, Li says, when SBSI began to co-ordinate all the ambulances around Phnom Penh to a central dispatch centre at Calmette Hospital.

The effort to establish a workable emergency system was also aided by the donation of a number of ambulances from Japan – with more than 20 now stationed around Phnom Penh in six different locations.

According to Li, private ambulances are still around, though the Wild West days of emergency services have largely passed.

“Two years ago, they would actually go and fight to take the patients . . . I had a clinic that put a gun to my head to take a patient from me . . . And I think when they pulled that [severely injured] patient out, they probably pulled his neck and he died.”

Now, the private ambulances are more conniving, he says, “sneaking around” and monitoring the 119-radio dispatch in order to race public ambulances to the accident scene.

If they arrive at the same time, the private companies are now likely to be co-operative, though they will often still steal wallets and other valuables from patients during transport, Li says.

Since 2004, the Ministry of Health has released a number of directives warning ambulances from private hospitals and clinics not to transport victims from public places.

The ambulances, legally-speaking, are only allowed to transport patients from one hospital to another. The ministry has threatened to revoke licences for those who do otherwise.

But Li identifies a few private ambulance services, including Sen Sok Hospital in Phnom Penh Thmey, that he claims “come out pretty much every night” to look for patients despite being aware of the government directive.

An administrative staff member at Sen Sok Hospital, who wished to remain unnamed, told the Post that his hospital stopped picking up victims of traffic accidents “a long time ago” in compliance with the government directives.

“I do not understand the directive. I think the service of state-run ambulances is late, not fast like private [ambulances] are. So they cannot help the victims on time,” he said, adding that his hospital plans to talk to Minister of Health Mam Bunheng about the issue.

The risk of taking a private ambulance if you are seriously injured, Li warns, is high.

“They do not have any [specialised] equipment, nor are they trained to protect your spine. What happens is, if you have a spinal cord injury, you are going to be paralysed for the rest of your life if no one takes care of it properly.”

Free ride?

Crucially, government ambulance teams are never supposed to charge patients. According to Li, the 119 system is a free, public service available to everyone.

But with 119 ambulance team members telling the Post they earn as little as $50 per month, it’s easy to understand why there might be the temptation to ask for cash.

Sem Sovan, 45, has been working as an ambulance driver at the Khmer-Soviet Friendship Hospital since 2006.

“My salary is meagre, but I love it, because we can help the victims,” he says, adding that his team usually picks up around three patients per shift.

“I see blood, terrible accidents almost every day. I get accustomed to it. I am not scared. The most important thing is to save the lives of people.”

On the subject of payment, he insists that his team never asks for or accepts money.

He says that private ambulances still often get to the scene first because they bribe police officers who notify them when accidents occur.

“They call them, because they give them $10 for every accident. They do not call us, because we do not have money for them,” he says.

A fellow team member, 41-year-old Soch Yet, tells a similar story.

“The private ambulances take only those who have money. When the victims are poor, they will not take them. But for us, we take all.”

However, Chan Vichet, a 34-year-old NGO worker who lives on the outskirts of Phnom Penh, told the Post that last week he called an ambulance through the 119 system for his neighbour, who was suffering from extreme high blood pressure.

Although the ambulance arrived within 15 minutes and speedily transported the woman to the Khmer-Soviet Friendship Hospital, one of the ambulance team asked for money on arrival, Vichet claimed.

“The guy asked for $10 for transportation, and they gave him $7.50. My neighbour was wondering why the guy asked for money, because she was told that you should not pay for state-run ambulances,” he said.

Other villagers have told him in the past that government ambulance teams often ask for a tip because their salaries are low, Vichet added.

Li says that if asked for payment, a complaint should immediately be lodged by calling the dispatch centre, though according to him, they hardly ever receive complaints of that nature.

In the hinterlands

Although a centralised emergency service in Phnom Penh is now operational, the situation in the provinces remains dire.

“The reality is, it’s chaotic. It’s unmanageable,” says Li.

“It’s a system-wide failure, not only on the ambulance side but on the hospital side as well, because referral hospitals by nature cannot handle severely injured patients.”

According to an SBSI report from February this year, under optimal conditions, Sihanoukville has a population to ambulance ratio of 50,000 to one, with 105,000 people per ambulance in Kampot and 98,882 people per ambulance in Kompong Cham.

Kompong Thom has 236,333 people per ambulance, while Oddar Meanchey and Battambang have 64,333 and 148,090 people, respectively, the report says.

Private clinics thus run riot in the provinces, Li says, with taxis, tuk-tuks and other vehicles also used by patients to transport themselves either to provincial hospitals or Phnom Penh.

At present, he adds, it’s better for a severely injured patient in Sihanoukville to wait for a trained 119 team from Phnom Penh to arrive than to ride in a private ambulance.

However, with SBSI planning to expand emergency response training to six different provinces later this year, that may soon change.

Stephen Himley, country director at NGO Medical Teams International, says that his organisation has just completed a pilot program in Kampong Cham, making it “the only province outside of Phnom Penh that has a fully functioning EMS system.”

“We picked the province with the largest number of road traffic deaths and trained hundreds of staff in hospitals and ambulances that would receive a traumatically injured patient,” he said.

Governments in developing countries rarely prioritise emergency services outside the big cities, he added.

“But with Cambodia’s economic growth, I’m hopeful that in the next few years, it will become a priority.”

The ambulance teams don’t have an easy job, Li admits, saying that, unlike in the West, there are no counsellors for medics and the men just have a beer and laugh away the horrific things they’ve seen.

They also have to make tough choices quickly, especially when there are a number of victims at an emotionally charged accident scene.

“Who do you go for? The one that you can keep alive . . . [The ambulance teams] have been beaten up [before] because of this,” he says.

“One guy got injured, his head was cracked open, his skull was coming out. People didn’t understand that he wouldn’t make it to the hospital but his friend would. But when they took the friend, people actually stopped the ambulance, pulled one of the paramedics out and beat him up. So they had to take two, but the other one, you know he’s a goner, but you still have to take him.”