Evolution of emergency medical services in Saudi Arabia

Aim: The purpose of this study was to provide an overview of the evolution of emergency medical services (EMS) in Saudi Arabia to describe its history, organisational service providers, governance, EMS statistics and the educational development of the field with the disparity of educational approaches. Background: The EMS is an important part of the healthcare system as it is often the first point of contact for medical emergencies. The EMS in Saudi Arabia has seen a number of positive changes over the past decade, some of which include the development of several university and college programs dedicated to teaching EMS, the evaluation of the profession from a post-employment first aid model into a pre-employment bachelor’s degree model, the generous governmental scholarship grants overseas and the official accreditation of EMS as a profession. It has been approximately nine years since the first EMS bachelor’s degree programs were developed in Saudi Arabia, some of which were directly adopted from universities in developed countries such as Australia. Despite these positive changes, the current EMS system in Saudi is faced with many challenges, both organisational and educational, including the lack of research, community involvement, the educational status of practitioners and the inconsistencies of statistics relating to response time and rate of transfer. This paper describes the history of EMS in Saudi Arabia with a specific focus on identifying the disparity in the educational outcomes and approaches adopted by colleges and universities in the Kingdom. Methods: The data utilised for the research of the EMS profession in Saudi Arabia were obtained from the literature using search tools such as MEDLINE, Google Scholar, Saudi health journals, Saudi university websites, government reports and statistics. Conclusion: The EMS profession in Saudi Arabia has advanced greatly in the past 12 years. Yet there is still scope for considerable improvement, especially with regards to developing empirically identified core competencies for EMS bachelor’s degree graduates. There is also the need for providing more outreach to the public to improve awareness of current services and available training, building more collaboration between the industry employers and academic institutions and investing further in EMS research through the development of Saudi-based postgraduate master’s and PhD EMS degrees. This paper is the first to provide an overview of the EMS service in Saudi Arabia, for institutions and researchers to gain a better understanding of the history and current standing of the service from an educational and operational perspective.


INTRODUCTION Saudi Arabia
The Kingdom of Saudi Arabia (KSA) was established in 1932.It is approximately a quarter the size of the United States with over 2,150,000 km 2 in size, constituting nearly 80% of the Arabian Peninsula. 1 Saudi Arabia is made up of 13 regions, each of which contains a capital city.Eight countries border Saudi Arabia starting from the north clockwise: Jordan, Iraq, Kuwait, Bahrain, Qatar, Emirates, Oman and Yemen.The geography of Saudi Arabia is varied, with coastlines on the Arabian Gulf and Red Sea, mountains in the southwest and plains and deserts covering more than half the country.According to the General Authority of Statistics in KSA, the estimated population of Saudi Arabia in 2016 was 31,742,580. 2

Healthcare system
In terms of the number of healthcare workers in comparison to the population for every 10,000 people, there are 26.5 physicians and dentists, 53.7 nurses, 7.2 pharmacists and 30.8 allied health professionals, including emergency medical services (EMS) providers. 3The Ministry of Health (MOH) budget for 2014 was 59.985 billion Saudi Riyals, which is 7.01% of the total governmental budget.This does not include the budget for the other healthcare sectors of the country, and 43.5% of the MOH budget was being allocated to staff salaries. 4In total, there are 453 hospitals and 67,997 beds in all of the country, 59.3% of which are run by the MOH. 4 In addition, 29.5% of the population of Saudi Arabia are under the age of 15, and the life expectancy is 74.2 years, which is four years more than the global average and six years in excess of the regional average. 4The five leading causes of death are ischaemic heart disease (21.7%), stroke (16%), lower respiratory infections (6.3%), road injury (5.8%) and diabetes mellitus (4.6%). 3

HISTORY OF EMS IN SAUDI ARABIA
The history of EMS in Saudi Arabia is directly related to the Saudi Red Crescent Authority (SRCA).The SRCA constitutes the beginning of pre-hospital care being provided by the Saudi government for the general public from the early decades of the development of healthcare in KSA. 5 According to the SRCA official site, EMS care was only officially institutionalised by an independent ambulance provider after the formation of the National Ambulance Health Association (NAHA) in 1353 Hijri (Islamic Calendar) equivalent to 1934. 5 The role of the ambulance service was initially part of the Public Health and Ambulance Authority, which was the governmental provider of health and ambulance care for the general public and especially to the pilgrims visiting Mecca and Medina. 5The development of the NAHA came about by the response to the Saudi Yemeni War in 1934 by providing medical care for the military. 5ollowing the Saudi Yemeni War, pre-hospital care was mostly limited to Mecca and Medina and was a charitable and private initiative under the Charitable Relief Society (CRS). 5However, after World War II, the income of these private institutions was greatly diminished, leading to dependence on the government rather than charity.Eventually, in 1383 Hijri (1963), a royal decree from King Faisal was issued to convert the CRS from a private into a public institution under the name Saudi Red Crescent Association. 5,6The name was later amended in 2008, to the Saudi Red Crescent Authority. 7he main objectives of the SRCA encompass providing aid relief, ambulance services and performing humanitarian work through international treaties. 6The SRCA is the 91st member of the International Federation of Red Cross and Red Crescent Societies. 6

ORGANISATION AND SERVICE PROVIDERS
The EMS in Saudi Arabia is a vital first point of contact for pre-hospital patients and the responsibility for providing pre-hospital care and transport falls on the SRCA 8 .This responsibility is inclusive of the entire country with some exceptions.For example, certain areas of the country which are within the catchment zones of the military sectors or large companies are responded to by these organisations.The inter-facility patient transfer is generally the responsibility of hospitals and not SRCA, with these hospitals running their own ambulance transfer service. 8,9The EMS service in Saudi Arabia is based mostly on an Anglo-American model, which aims for the rapid transport of patients to an emergency department by clinically competent paramedics. 10Other countries that adopt this model are the United Kingdom, the United States, New Zealand, Australia and the Sultanate of Oman. 10 The pre-hospital care system in Saudi Arabia is still developing in issues pertaining to community awareness, attitudes and the knowledge deficiencies of pre-hospital care providers.One of the issues reported by Salleeh 11 is that the majority of patients with cardiac arrest in Riyadh are being brought to hospitals in private vehicles by people who are seldom educated in cardiopulmonary resuscitation (CPR).In a recent study, AlHabib 12 compared the EMS and non-EMS patient transfers in the Arabian Gulf countries for acute care and described the importance of clinical arrival within 24 hours of the onset of symptoms of ST segment Elevation Myocardial Infarction (STEMI).The study found that out of the 2,928 patients transferred, only 109 (3.7%) used the Red Crescent EMS service, which the study described as a "disturbing finding". 12In addition, the study reported a significant lack of basic life support (BLS) and advanced cardiac life support (ACLS) certifications of the paramedics involved. 12The majority of patient ECGs were also performed in hospitals and not by EMS providers, 12 which may indicate a limitation in the current clinical and theoretical competence of EMS providers.
In the case of Motor vehicle accidents (MVA), the accident scenes regularly involve friends, family members and spectators, which may lead to significant interruption to on-site patient care. 13urthermore, in a recent Saudi Arabian study, it was found that the majority of the pre-hospital care providers suffered from a lack of knowledge regarding important stroke symptoms.The study recommended addressing educational needs in addition to screening tools. 14This deficiency in knowledge gives an indication of the lack of development in EMS education in Saudi Arabia.
The issue of transferring patients directly to hospitals in private cars by family members or strangers involved in accidents can be linked to many factors, which include socioeconomic, education, public awareness or media. 12,13However, a concept that may also have an effect is the Arab culture of 'Fazaa', which can be explained as helping those in need and is considered a virtue.Therefore, this concept may be turned around and used in the media.For example, to convey the message that the best way to perform 'Fazaa' duty is to be educated in CPR or the Heimlich manoeuvre and to call the EMS hotline, following the dispatcher's instructions and answering their questions.Although, the current and future plans for the EMS development in Saudi are not clear, there are positive examples of how research can help in planning and improving the EMS service.The study by Alsalloum 15 contributed to the development of a model for SRCA to pinpoint the most appropriate locations for EMS stations, with the aim of reducing morbidity and mortality in the Riyadh population by improving response time. 15Another plan, with the aim of significantly decreasing morbidity and mortality of patients with trauma in Saudi Arabia, was proposed by Al-Naami. 16The plan calls for establishing a multidisciplinary trauma system with pre-hospital care focus as an essential component of such a plan. 16However, the ideas proposed regarding pre-hospital care, such as the establishment of a pre-hospital registry and research agenda, have yet to come into effect. 16ther organisational issues facing EMS in Saudi and specifically SRCA is the lack of publications regarding key performance indicators, such as the response time for pre-hospital cases.According to Al-Ghamdi, 17 the average response time for ambulances was 10.23 min.However, another observational cross-sectional study involving 1534 persons, 355 of whom had previous experience of utilising the services of SRCA, reported that 40.3% (n ¼ 143) of the ambulances arrived after 1 hour. 18n addition to the respondents of the study, only a third knew the actual dispatch number for SRCA. 18hese results suggest a substantial lack of public awareness of the services provided by EMS in Saudi Arabia.The SRCA should strive to provide better community outreach programs through universities, municipal and public institutions to better educate the public and to support research in the field of Saudi EMS in order to empirically analyse and empower the profession.

STATISTICS
In 2014, SRCA responded to and transported 260,789 cases throughout the Kingdom. 4When comparing this number to other countries in the same year, Ambulance Victoria, Australia, responded to 840,188 cases, inclusive of emergency and non-emergency cases. 19The population of Saudi Arabia in 2014 was 30,770,375, whereas that of Australia in 2015 was 23,860,100 and specifically the population of Victoria was 5,596,670. 20,21Despite the fact that the population of Saudi Arabia is 5.49 times that of Victoria, their overall utilisation of the EMS services is approximately one-third (0.31) of that of Ambulance Victoria.Moreover, a resident of Victoria utilises EMS 17.7 times more compared to a resident of Saudi Arabia (Table 1).
Although Ambulance Victoria constitutes only part of the EMS providers in Australia and does not represent the entire EMS system, the disparity in the utilisation of pre-hospital care in Saudi is extreme.Another example is the National Health Services (NHS) England Ambulance Services, which had 9,000,000 service calls in 2014. 22Another closer example to Saudi Arabia is Qatar, which has reported, according to Hamad Medical Corporation, 168,332 ambulance service calls in 2014. 23he figures from different countries strongly indicate that the EMS environment and associated variables are very different in KSA from those found in other countries.As such, the unique nature of the entire EMS process in Saudi Arabia warrants a strong emphasis on developing a research-based approach to improve the service specific to the country.Research should investigate all aspects of EMS such as the cultural, ethical and EMS education in the Kingdom, in order to understand these service variables and accommodate them.

GOVERNANCE
The quality and development of an EMS system in any country cannot be measured using a specific classifications scale of the stages of development in EMS, to assess whether the country is developed or underdeveloped.Therefore, it can be helpful to provide a comparison of certain aspects of the current situation between developed countries, such as Australia, the United Kingdom (UK) and the United States of America (USA), and Saudi Arabia, as can be seen in Table 2.
In the KSA, the governance of the EMS practice is split into two parts.The first includes different industry employers, such as the SRCA, MOH, other military and certain private sectors.These institutions do not have an overarching body that regulates the EMS profession specifically. 35ccording to Alanazi "there is no National Saudi Registry of EMS personnel, which ensure professional  23 Ambulance Victoria, 19 Australian Bureau of Statistics, 20 General Authority for Statistics, 21 National Health Service England, 22 Qatar Ministry of Development Planning and Statistics, 24 Office of National Statistics. 25 27 Saudi Commission for Health Specialties, 28 Brooks et al., 29 Whitmore and Furber, 30 Paramedics Australasia, 31 Council of Ambulance Authorities, 32 National Highway Traffic Safety Administration, 33 National Association of Emergency Medical Technicians. 34esponsibilities to adapt new protocols or implement any new courses". 35By contrast, the Council of Ambulance Authorities (CAA) in Australia, established in 1962, comprises EMS employing agencies. 36he CAA has a significant role especially in Australian paramedic education as they have formed an accreditation process for paramedic programs in universities.The aim of which is to guarantee that paramedic graduates from these institutions have attained the necessary entry-level competencies for paramedic employment with an Australasian Ambulance Service. 36The role of CAA in the ambulance industry also includes providing input into the development of public policies regarding EMS and developing exchange information and research. 32The Joint Royal College of Ambulance Liaison Committee (JRCALC) was established in 1989 due to the development of the paramedic role in the United Kingdom.The role of JRCALC is to provide expert consultation to the UK EMS service providers and conduct clinical oversite. 29Furthermore, the first practice guidelines for paramedics in the United Kingdom was published in 2000 by the JRCALC; these guidelines emphasise paramedic discretion and clinical judgment over rigid protocols. 29he second part of governance in Saudi Arabia is undertaken by the Saudi Commission for Health Specialities (SCFHS).The role of the SCFHS is to govern the practice of all health professions (not just specific to EMS).This governance includes clinical practice registration, licensing of healthcare workers, approving health-specific courses and certificates and establishing scientific associations for health speciality. 28In the United States, the National Registry of Emergency Medical Technicians (NREMT) provides certification examination for the paramedic, EMT intermediate, EMT basic and first responder. 33The NREMT is generally accepted by many states as a facilitator that provides uniform competency standards through examining the EMS candidates. 33t should be noted that the health industry employers are required to follow the regulations, registration, licencing and other similar requirements that are set by out by the SCFHS. 28In the United States, the title EMT-paramedic was officially recognised as an allied health occupation in 1975. 37he EMS speciality has also been recognised professionally by the SCFHS and is categorised within three tiers for university and college graduates: specialist for a bachelor's degree, senior specialist for a master's degree and consultant specialist for a PhD holder (Table 3) with other specific requirements, such as experience and certain short courses.
The establishment of scientific associations for health specialities by the SCFHS has led to the creation of the Saudi Association Society of Emergency Medicine (SASEM), which initially included all health specialities in emergency medicine, including doctors, nurses and paramedics. 27Although paramedics can vote in the SASEM, they cannot be nominated to the Board of Directors membership election according to Element No. 19 of the SASEM bylaws and regulations. 27The main activities of SASEM include establishing scientific committees, holding symposia and conferences, encouraging research and providing public knowledge and awareness. 27his was followed with the establishment of the SAEMS (Saudi Association of Emergency Medical Services), which has similar objectives but is oriented towards EMS. 28Although these associations have no governance over the profession or the practitioners, they may play a future role in developing professional healthcare workers in the field of pre-hospital care. 28Such a role can be compared to that of the British Paramedic Association, which is now called the College of Paramedics, whose aim is to provide a professional voice for EMS clinicians in legislation, education and the community. 30These types of associations can also be compared with Paramedics Australasia (PA), which is a professional Note: tier upgrade is granted post-experience.For example, a person who graduated with a PhD will be classified as a senior specialist.After completion of the required experience, he/she will be upgraded to a consultant specialist.They are not required to pass through every tier but are granted the tier on the basis of their current qualification.Source: Saudi Commission for Health Specialties. 28ssociation representing pre-hospital practitioners in Australia.One of the roles of PA is to provide a voice for paramedics in determining the changes in legislation, services and clinical practice, which affect the healthcare system in Australia. 31n conclusion, the EMS system governance in Saudi Arabia is developed in areas such as the SCFHS, where registration and licencing of the profession is concerned.Yet the system also requires support and maturity in other sectors, especially when compared to other countries such as the United Kingdom and Australia, as there is a lack of advocacy for the profession by important groups.There is also no overarching body for employers in the EMS industry, which can enforce competency standards on academic institutions.In addition, the development of associations and authorities that represent the professional interest of the EMS practitioners, similar to the UK College of Paramedics, the Australian PA and the many EMS speciality associations in the United States, 38 can provide another aspect of development for the profession.

EDUCATIONAL TRANSITION
The EMS educational transition in KSA can be identified within three broad stages: . The first stage of EMS education in Saudi was by far the longest when EMS education was somewhat restricted to certain courses, such as BLS, First Aid and First Responder training courses. 5,8These programs were mostly limited to the training provided by the industry, as this was the expectation at that time to provide basic first aid and transport to the nearest emergency department. 5,8n educational parallel to this can be drawn from the history of EMS in Australia, whereby, in the past, several of the mainstream healthcare professional training was originally either industry-based, hospital-based or through private institutions.These professions were eventually recognised in an official manner by the Australian Health Practitioners Regulation Agency (AHPRA) including nursing, osteopathy and Chinese medicine. 36As such, educational requirements for paramedics in the past were minimal and may have been limited to first aid training. 36Another example from the United Kingdom would be the 1966 Millar report, which specified the post-employment training requirements for ambulance staff under the umbrella of the Institute of Health Care Development that provided the certification for the graduates. 29uring this stage, the concept of a paramedic as a separate health profession did not exist in Saudi Arabia; this is made evident by the founding charter of SRCA 1386 H (1966), which states, in the second part (article 6), that the Saudi Red Crescent will strive to elevate the nursing profession and train both male and female nurses on hospital work and emergency situations. 5This was thought to be achieved by training courses and the creation of ambulance and nursing schools. 5In the United States, the start of an organised civilian EMS system was initiated in the 1960s, as the operations of the EMS system continued to develop, so did the educational sector. 37In the early 1970s, physicians and registered nurses were the trainers for the majority of EMS educational courses.Very little of the instructor and student material was related to emergency pre-hospital patient care. 37There was no apparent outline of the pre-hospital scopes of practice as well as no standards for the definition of practice in EMS. 37The second phase in the development of pre-hospital care in Saudi Arabia came with the creation of the first diploma programs in EMS.These programs started to develop in the early 21st Century, with a focus on delivering professional well-trained paramedics. 39By adapting the scope of paramedic education to a new model of advanced life support (ALS) care, these programs had a significant impact on what it is to be a pre-hospital care provider in KSA.Ultimately, the level of professional accreditation was recognised as that of a technician by the SCFHS.With the introduction of the first Red Crescent-operated ALS unit in Riyadh by 2005, 39 the stage was set for a new phase in pre-hospital education and the provision of care in KSA.A comparison can be drawn from the adoption of ALS clinicians for ambulance care in other more developed countries, such as the 1969 ALS trained fire-fighter paramedic adoption in six of the US states. 29The 1971 intensive care paramedics in the state of Victoria, Australia, and the 1979 UK adoption of the Medical Commission on Accident Prevention recommended ALS trained ambulance clinicians to provide pre-hospital care for patients with trauma. 29nlike the previous stage of EMS progression in Saudi, which was a gradual process, the EMS diploma came to an abrupt end.This was a process of social dialogue involving the national media in Saudi, as a large number of health diploma graduates from all specialities in the Kingdom had faced considerable unemployment. 40According to the SCFHS, such an issue, coupled with a recommendation by the WHO to expect a bachelor's degree as the minimum requirement for all healthcare professionals, required change.In 2012, the SCFHS stopped all diplomas in the medical sciences, including EMS, and made the bachelor's degree the new standard. 40age 3: Academic transition: The specialist, bachelor's in EMS 2007 -present The third phase of evolution in EMS education in KSA was the development of the university-or college-based bachelor's degree.These programs were first started in King Saud University (KSU) and King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) following 2007.Although both universities go by the same royal name, they are two different universities. 41According to Alanazi, 9 the reason for the establishment of a bachelor's degree at KSAU-HS was the lack of quality and quantity of Saudi paramedic nationals.In order to establish a model for EMS education and to support research in the field, it should be noted that one of the first programs to begin in Saudi was the paramedic bachelor's program adopted from Flinders University in South Australia.The reason for this choice was the unique approach in developing a problem-based, student-based and patient-based curriculum, which is integrated into work practice. 9cademic institutions providing higher-level EMS educational programs are associated with the improvement of professionalism of EMS as a recognised discipline.These programs also increase the accessibility of educational prospects that may recognise previous EMS educational and academic accomplishments.They also expand the management skills and protect the significance of societal and individual resources devoted to education. 33In general, the lack of research publications in the field of EMS is an international aspect of the profession, as it is considered a developing area in medical and health education programs. 42Therefore, a potential future approach to resolve the lack of research is to develop the research capacity by establishing Saudi master's and PhD programs in order to empirically study the current EMS issues and develop plans to address them.
In different regions of the country, bachelor's programs are now being offered by 10 universities and colleges, both private and public (Table 4), some of which are offering their programs in different campuses.In comparison, Australia has 17 universities that are offering paramedic bachelor's degree programs. 43Moreover, the UK Health and Care Professions Council has 65 recognised programmes that offer the paramedic title. 26ble 4. Saudi universities and colleges with an EMS bachelor's degree.

DISPARITY OF EDUCATIONAL APPROACHES
With the rapid development in the field of pre-hospital care from limited first aid post-employment training courses into recognised university bachelor's programs, the universities and colleges developed their own expectations, and core competencies, which in the case of KSAU-HS, were based on scientific research. 9These disparities are apparent when reviewing the different EMS university and college programs in Saudi Arabia.Moreover, no official discernible competency standards have been adopted from other developed EMS countries and there is a lack of apparent development in local Saudi Arabian competency standards, with the exception of the model developed by Alanazi 9 (which has by itself limitations such as being localised and that 50% of the candidates are physicians with the other 50% having a US background).The ability to analyse the current disparity in the approach of competency standards is limited because of the scarcity of research.Yet, it may be prudent to gain an understanding of these competencies by analysing each college and university program.These academic agencies offer the certification for their graduates and are expected to provide them competency standards.This is defined by the US department of National Highway Traffic Safety Administration (NHTSA) as "Certification -the issuing of a certificate by a private agency based upon standards adopted by that agency that are based upon competency." 37Moreover, to be able to define the criteria by which each college or university specifies their goals, expectations and competencies of their students, the definition by the CAA Paramedic Professional Competency Standard will be utilised "the combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a profession/occupational area" 54 .Another definition stated by the NHTSA National Emergency Medical Services Education Standards report is that for "Competency -expected behaviour or knowledge to be achieved within a defined area of practice." 37The method by which the different EMS program competencies were identified was based on these definitions.The official website of each university or college EMS bachelor's program recognised by the Ministry of Education in Saudi Arabia was analysed.The available competencies under the different headings of values and goals for students in the undergraduate program were extracted and have been included in Table 5.
As can be seen in Table 5, there are 23 competencies.The classic domains associated with learning are cognitive, affective and psychomotor, which are associated with knowledge and intellect, attitudes and values and motor skills, respectively. 55Some of the stated program competencies focus on attitudes, values and intellectual skills, whilst others address the knowledge, practical and psychomotor skills of the profession.Moreover, the only competency with a majority consensus was 'decision making'.In addition, two more core competencies were each endorsed by five programs, which are as follows: safety and communication.Yet, what is apparent in the competencies of each university and college is the disparity in the expectations of the degree graduates.The result of such disparity is that there is an uncertainty about what a paramedic should be in Saudi Arabia.Such inconsistency could cause a mismatch between the educational institutions and employment industry competencies specific to Saudi Arabia.This issue could result in a variation of ways paramedics from different institutions communicate with and treat their patients, as medical oversite and paramedical guidelines have an inherently limited capacity to deal with the range of medical ambiguity, diverse pre-hospital contexts and circumstances. 56Consequently, the degree to which paramedics adequately and safely deliver patient care is dependent on the competency of making reliable and accurate decisions regarding the scene, patient condition, available equipment, safety concerns and the many other factors contributing to the complexities of pre-hospital care.Therefore, providing the correct competency for the students who are expected to be at entry to practice level will probably be a contributing factor in improving patient care. 56n example of how another country has dealt with the issue of standardising the educational competence of academic institutions is the CAA in Australia.The CAA has adopted a UK model of competence as a foundation to build the CAA model, which would then grant accreditation to academic institutions based on this model of competence. 32This type of approach can work for Saudi Arabia but with certain amendments.The complete adoption of certain western core competencies may not be the ideal process to address the needs of Saudi Arabia, as the Saudi context is different from other western countries in many ways, some of which have been previously mentioned in this paper.
improve the level of education of the pre-hospital practitioners.The educational development of EMS programs in Saudi universities and colleges is significant, yet there is a lack of cohesion between the expectations of the graduates from these institutions.Therefore, it is recommended that empirical research should be developed to study and present remedies for challenges facing the advancement of the EMS profession.

Stage 2 :
Development: The professional technician, EMS diplomas 2005-2012 Furthermore, the office of the United Nations High Commissioner for Refugees (UNHCR) was involved in providing an emergency management training programme collaborating with SRCA in 2000.6History of Saudi EMS Timeline:

Table 1 .
Comparison of population and ambulance response rate of Saudi Arabia with other countries and states.
Source: Hamad Medical Corporation,

Table 2 .
Overview of EMS governance in Saudi Arabia compared with other countries.
5ource: Saudi Red Crescent Authority,5Health & Care Professions Council UK,26Saudi Society of Emergency Medicine,
52King Saud University,41Ministry of Education,44University of Dammam,45Umm Al-Qura University,46Prince Sultan Military College,47King Saud bin Abdulaziz University for Health Sciences,48Jazan University,49Inaya College,50AlMaarefa Colleges,51AlGhad Colleges,52King Khaled University.53Timeline of key stages in the educational transition of Saudi Arabian EMS: Source