Medical Education Journal: India Lacks Emergency Medical Care- What We Need

Emergency Medicine is the latest academic discipline being introduced in India. Even though currently there is no Medical Council of India accredited residency program, the field’s faculty is said to be continuing medical education looking back planning ahead and dedicating time for development of a national skilled emergency care workforce.

According to the Academic Emergency Medicine Model practices in the United States, Emergency Medicine is only possible if Organized Medicine becomes a part of the medical sector. To abide with the same, India is looking at medical college hospitals as the ideal sites for creating emergency departments and initial development of Emergency Medicine.

Current status of emergency care in India

As a developing country, emergencies and accidents are a commonplace in India. Due to rapid economic growth and urbanization, the country faces challenges as that of a developed and an underdeveloped country.

India is often facing challenges posed by emergencies related to infectious and communicable diseases, and those related to chronic diseases and trauma. There are times when the number of rare medical cases reported is very high, with next to zero available resources for treatment.

The current statistics being pulled in from various Indian hospitals indicate cardiac diseases and stroke to be a major cause of death and disability in 2020. To add to the burden of cardiac diseases, there is an increasing number of emergency cases due to road traffic crashes being reported.

Despite the need for emergency care centres as per the number of cases reported, India is majorly lacking in its efforts to offer the same. An example of the same is the world’s worst industrial accident that took place in Bhopal in 1994 - even though it was caused by both natural and man-made disasters, and terrorist acts, the emergency care offered to those suffering was very poor.

Pre-hospital Care in India

India severely lacks a responsive and time sensitive Emergency Medical System (EMS). The major city services are run by a number of agencies including government, police, fire brigades and private agencies; but none of them are well coordinated with each other.

• Private hospital ambulances operate across the city on a strict fee-paying basis, and air ambulances are not readily available. In rural areas, patients are often transported to the nearest healthcare centres in tractors or bullock carts causing further delay in treatment.

• There is a lack of a uniform country-wide ambulance number as each agency has their own. The ambulances are more often just a little more equipped than the usual transport vehicles; they may include a bed and an oxygen tank.

• The ambulances either have no personnels with medical training or those with bare minimum knowledge of emergency medical care.

• Ambulances are often used for inter-hospital transport and non-emergency calls.

Hospital Based Emergency Care in the Government Sector in India

To aid the victims of emergencies, there are a number of services offered by government hospitals, corporate hospitals and a number of small clinics. Even though the services offered by government hospitals are free, there is a vast difference in the quality between centres and when compared to corporate facilities. There are a lot of university hospitals that offer reasonable level of emergency care; but the district hospitals lack trained staff, adequate infrastructure and supply of consumables.

No dedicated trauma surgeons and very few designated trauma centres in India has led to an increase in reported cases of delayed clinical decisions. Most hospitals term their emergency care sections as ‘Casualty or Accident Rooms’; which lack the presence of trained emergency medicine physicians.

Hospital Based Emergency Care in the Private Sector in India

Even though most private and corporate hospitals located in major cities are equipped with the modern day diagnostic and imaging facilities, they are generally staffed by inexperienced doctors. Over the years, there are several small hospitals and clinics that have opened up across India, but they usually lack multidisciplinary support and trained emergency physicians.

The emergency care offered in these hospitals are also on fee-paying basis just like their other services. Payments for laboratory tests, procedures and physician consults are demanded before hand; and patients who are not able to cope with the fees, are redirected to government hospitals.

In critical situations, these hospitals perform the initial stabilization of the patient, after which the family of the patient is to decide if they would like to pay for further treatment or shift the patient to a government aided facility.

Emergency Care in Rural India

The healthcare delivery system in rural areas are mostly offered by community health centers or privately run small clinics and hospitals. The general practitioners in these areas generally hold only superficial knowledge, skills and abilities to perform emergency medical care; the more experienced professionals rarely opt to serve in these areas.

Rural medicine practitioners face many obstacles in delivering effective medical care, including long distances and terrain, lack of EMS providers and communication, lack of diagnostic modalities and lack of availability of medical specialists.

Disasters and Emergency Care in India

India has experienced several disasters over the years - both natural and manmade, including cyclones, floods, earthquakes, landslides, tsunamis and terrorist attacks. But the prehospital care after so many instances is still non-existent. Even though several governmental and non-governmental agencies come forward to offer emergency medical care during disasters, it usually lacks coordination between them and the hospitals; which works negatively for those affected.

During disasters, there is often a chaos at hospitals thanks to miscommunication, frequent political, media and diplomatic visits. Most hospitals that have a disaster management plan in place lack preparedness. The lack of performance has led to an exponential increase in fatalities.

US Model for Training Medical Students in Emergency Medicine

The US Liaison Committee on Medical Education has stated that the competency in medical care of acutely ill and injured patient is one of the fundamental exit goals of every medical institute.

The medical student’s goal on rotation is to enhance his/her knowledge, clinical skills and develop a caring, compassionate and, empathetic attitude to deal with patients and their families. The students are made to learn the essential emergency medicine procedures as well as their indications, contraindications and potential complications.

The typical goals for a student rotation are stated as:

1. Medical Knowledge: Students will demonstrate a basic level of competency of history, physical examination, procedural, and problem-solving skills required to adequately assess and manage the spectrum of disease processes seen in Emergency Medicine.

1. Practice Based Learning and Improvement: Students will practice evidence-based medicine.

1. Interpersonal and Communication Skills: Students will establish effective and ethically sound relationships with patients, faculty, staff, and peers to provide quality health care.

1. Professionalism: Students will respect and be sensitive to the individuality, values, goals, concerns, and rights of all with whom they interact in the healthcare setting.

1. Systems-Based Practice: Students will effectively integrate ancillary healthcare resources and appropriately utilize business systems for optimal care of their patients. Essential

1. Procedures in Emergency Medicine: Teach essential emergency medicine procedures, including indications, contraindications, and potential complications. These procedures include phlebotomy, intravenous access, arterial puncture, electrocardiogram, tonometry, central venous access, basic and advanced airway management, suturing, cricothyroidotomy, tube thoracostomy, emergency thoracotomy, and trauma FAST ultrasound exam.

Academic Model for Emergency Training in India

The Medical Council Of India is initiating the recognition of a post graduate programme in Emergency Medicine. There is also a proposal being put forward for a three year training program leading to a MD in Emergency Medicine after MBBS. Currently, there are a few institutes and private hospitals that offer diplomas, certificates and fellowships in Emergency Medicine.

The current constraints in the path of offering education in Emergency Medicine are a lack of a structured curriculum, trained faculty and infrastructure in training institutes. A few ways to address the issues include onsite programs for the faculty with a minimum of one year of didactics and clinical experience, international collaboration for faculty exchange program and distance learning via telemedicine technology.

A recommended foundation for Emergency Medicine program should include:

• Administration

• Neurosciences

• Anesthesia

• Obstetrics/Gynecology

• Cardiology

• Ophthalmology

• Critical Care

• Orthopedics

• Dermatology

• Otolaryngology

• Emergency Medicine Services

• Pediatrics

• Psychiatry

• Environmental Illness

• Research

• Ethics

• Resuscitation

• General Medicine

• Toxicology

• General Surgery

• Trauma

• Geriatrics

• Urology

• Infectious Disease

• Wound Management

The curriculum must be aimed at addressing location specific issues in India. For example, the toxicology curriculum must be focussed on regional bites, stings and poisoning; infectious emergencies should include tropical perspectives.

INDO-US JOINT WORKING GROUP (JWG) RESOLUTION-2007

Under the leadership of the Dean of Indian College of Physicians, experts from across the country and US have come together to form the Joint Working Group. The group has set the foundation for an educational model for Emergency Medicine Training in India.

The publication of the group states the following:

Mission

To foster the exchange of knowledge leading to the advancement of academic Emergency Medicine in India in the areas of -

1. Developing Specialty Residency Training

2. Creating Residency Accreditation Guidelines

3. Promoting Academic awareness for best practice models for Emergency Care in India

4. Standardising prehospital and hospital emergency care across India in all sectors

5. Foster Academic Research in Emergency Medicine and Trauma in India

Vision

In the next twenty years a majority of physicians providing emergency care will be residency trained and specialty certified in EM in India.

Objectives

1. Sustain and grow the existing technical academic partnership in the INDO-US program for Emergency Medicine and Trauma.

2. Establish and maintain the Academic Council for Emergency Medicine and Trauma.

3. Conduct annual Emergency Medicine academic meetings to provide a platform for the development of an academic society of practicing emergency physicians in India and the United States.

4. Increase interest in an Emergency Medicine Residency and develop a residency certification process.

5. Develop and implement prehospital and hospital standards of care in Emergency Medicine and Trauma.

6. Develop protocols and educational products to train nurses and paramedics involved in providing emergency care.

7. Foster research and development in the fields of basic and clinical science related to areas of Trauma and Emergency Medicine.

8. Work on integrating newer technologies such as Simulation, Sonography and Information Technology into academic models of education, research, and care in Emergency Medicine.

Conclusions

The missing emergency care cannot be mitigated overnight and as India strides in making emergency and trauma care an integral part of their medical sector, there is a requirement of a concerted effort by the society as well as the medical community to help achieve the end goal. With India’s population around the billion population mark, trained emergency physicians and trauma surgeons will be a boon to the society - decreasing the morbidity and mortality of the country’s citizens.

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Posted by: Vanhishikha Bhargava (http://www.buzz4health.com/blog/authors.html )