Desperately Seeking Timely Care
Emergency Medical Service (EMS) facilities in India are almost non-existent. Nayantara Som and Sushmi Dey express concern over the healthcare system’s failure to sustain EMS and provide timely care to accident victims.
The Mumbai blasts of July 2006, the tsunami of December 2004, the earthquake that rocked Gujarat in 1992, the grotesque road accident of our next door neighbour, the mother-to-be who could not be stabilised on her way to the hospital all beg the same question: Is our medical system equipped to handle emergencies? Statistics reveal some alarming facts. In a country with a population of 1.3 billion, every two minutes a road accident takes place and every five minutes a suicide or a case of infant mortality occurs. It is time Indians got a well-structured Emergency Medical Service (EMS).
Enshrined in the Constitution
Says Dr Percy Bharucha, Director, Lifesupporters Institute of Health Sciences, Mumbai, “To get timely medical aid in the hour of emergency is enshrined in the constitution and reiterated by the Supreme Court of India time and again.” This has been explicitly held with regard to the provision of emergency medical treatment in ‘Parmanand Katara Vs Union of India’. The victim was brutally injured in a road accident and required immediate treatment. However, as accident cases are medico-legal, most hospitals refused to treat him until the police arrived. Bereft of any medical aid, he succumbed to his injuries.
With regards to the case, the Supreme Court held: Every doctor whether at a Government hospital or otherwise has the professional obligation to extend his services with due expertise for protecting life.
The issue of adequacy of medical health services was also addressed in ‘Paschim Banga Khet Mazdoor Samiti Vs State of West Bengal’. Hakim Shaikh, a member of the Samiti, fell off a train on July 8, 1992 in West Bengal, sustaining serious head injuries and haemorrhage. He was taken to more than eight medical institutions, where he was refused admission either on grounds of lack of facilities or of no vacancy. Ultimately, he received treatment on the next day. After this case, it was held that the State has to safeguard the right to life of every person. Providing medical services at the time of emergency was thus established as a sine qua non. It has also been held in this judgement that a lack of financial resources cannot be a reason for the State to shy away from this constitutional obligation.
Economic development and an escalation in living standards have led to a demand for better accessibility to emergency services. With the rise in terrorist groups, there is always a possibility of man-made disasters for which we should be well prepared.
Why the deficiency?
– Dr Mahesh Joshi, Consultant Head Department of Emergency Medicine Apollo Hospitals, Hyderabad
Lack of initiative from policy-makers, unenthusiastic private players: When asked about the reason behind the lack of a strategic EMS, Dr Mahesh Joshi, Consultant Head, Department of Emergency Medicine, Apollo Hospitals, Hyderabad is frank: “Policy-makers would rather focus on issues like vaccination and eradication of diseases. Setting up an organised EMS system in the country was never on their priority list.” The same is echoed by Dr Haren Joshi, Honorary Director, EMS Council, Ahmedabad, “There is absolute lack of leadership from the Central Government. They have formed a committee at the Centre to set up a standardised law for EMS, but nothing could be actually implemented in practice due to a lack of leadership from the Government.”
Private hospitals take some of the blame: “Private hospitals are reluctant to treat emergency cases, especially cases of road accidents, as they do not wish to get entangled in medico-legal cases. Moreover, 70 per cent of the emergency patients come from the lower strata of society and cannot afford to pay the exorbitant prices for emergency treatments,” informs an expert.
What aggravates the matter is lack of proper public-private co-ordination. “EMS is a public venture and hence faces the perennial problem of lack of funds and resources from the Government,” says Dr Joshi from Ahmedabad. Private hospitals have their own reasons for not taking the initiative. “We have our own objectives and constraints and are ready to provide good healthcare services, but it is the responsibility of the Government to push the private sector. No corporate organisation will step back from such initiatives,” defends Dr Talat Halim, Head, Accidents & Emergency, Max Healthcare, New Delhi.
Dr Umesh C Sharma, Head, Department of Emergency Medicine, Indraprastha Apollo Hospitals, New Delhi, declares, “There are clear guidelines from our management not to deny EMS to anybody.”
Dearth of trained Paramedics and Ambulances: There is an acute shortage of trained paramedics in the country as aspiring doctors and nurses opt for more lucrative specialities. Organisations are reluctant to invest in well-equipped emergency ambulances due to monetary handicaps. Each ambulance costs around Rs 21 lakh including equipment, which is not feasible for all organisations.
Lack Of Air Ambulances: India is yet to accept the idea of an air ambulance. Investing in an air ambulance is financially not feasible for both hospital and the patient. The cost per hour for a patient using an air ambulance is above Rs 50,000 and investment for an air ambulance also goes over Rs 1 lakh. Then there are are problems of airspace. Moreover, air ambulances can cater to just a small section of the masses, which is why they are restricted to small pockets (mainly metros) of the country. “New Delhi has air ambulance service which operates from airport to airport and is generally used only to transfer patients,” informs Dr Sharma.
Flawed Reaction of the Masses: “Indians first wait for a relative to arrive at the scene before they decide what move to take. They need a shoulder to cry on rather than take quick decisions,” opines Venkat Changavalli, CEO, Emergency Management and Research Institute (EMRI), Hyderabad. Additionally, Indians are still accustomed to their general physicians or family doctors handling emergency situations.
Is there Room for Hope?
It has been a bumpy road, but the good news is that EMS initiatives are taking shape in some parts of the country. A few cities have tasted success in implementing EMS.
By dialling the number 1066, one is connected to the central control room located at Apollo Hospital, Ahmedabad
Three public and five private hospitals have come together to form EMS Council, Ahmedabad. The city has been divided into nine zones for this. By dialling the number 1066, one is connected to the central control room located at Apollo Hospital, Ahmedabad. The call centre locates the accident site and sends the ambulance from the hospital in charge of that zone.
Ambulance service and life-saving care is given free to the patients. “Till the patient is in a position to decide whether he would like to continue in the same hospital or go to a different one, the service is given free. Even the transport to other hospital is provided free of cost,” says Manjul Joshipura, Honorary Co-ordinator, EMS Council, Ahmedabad. After an year and a half of setting up the facility, the Council has received around 600 calls. The hospitals pay for their own ambulance cost. The only steady cost is that of running the call centre, which amounts to a monthly expenditure of Rs 25,000. This is funded by the Council.
Lack of funds and low awareness about EMS has thwarted the service. But experts are hopeful as the State Government has accepted the suggestion for a state-wide EMS legislation.
Burdened with 7,000 to 8,000 accidents each year, around 800 of them fatal, Bangalore was in urgent need of an EMS facility. Thus, four years back, Comprehensive Trauma Consortium (CTC) was formed to start a rescue service called Operation Sanjeevani (OS) with a common access number of 1062.
Operation of OS covers Bangalore, the highway linking Bangalore to Mysore, and Bangalore to Tirupati. It has 40 networked hospitals (five public and rest private) and 45 ambulances positioned at various places. The target time to reach accident spot is within 15 to 20 minutes of receiving the call.
According to Dr N K Venkataramana, Founder of CTC, “We receive as many as 150 calls per day and have managed to save around 26,000 lives so far.” Upon receiving a call, the control unit logs the telephone number of the caller and immediately directs the nearest mobile ambulance to the accident spot.
The operation has evolved with time. “Initially, we used ambulances that were attached to hospitals. As hospitals could not always free its ambulance for EMS, we developed our own fleet of 45 ambulances,” says Dr Venkataramana.
While OS road facilities are available to the public at no cost, the airlifting comes at a cost. What impedes the functioning is the cost of maintaining the ambulances. “Every year, we have to spend over Rs 60 lakh in maintenance of ambulances, salaries and other expenses which is difficult to get for people involved in the project,” says Dr Venkataramana.
OS has started with tele-radiology consultation on a trial basis. “In two ambulances, we are attempting this consultation. If we succeed, we will take it further,” says Dr Venkataramana.
|Though the government has not responded to demands of legislation and funds, in its golden quadrilateral project, along the highway, it has started erecting first-aid stations. “We have lobbied with the Department of National Highways (DNH) to allocate funds for the establishment of EMS along the highways. So far, funds have been sanctioned in Maharashtra and Andhra Pradesh following our proposal,” says Dr Balasubramaniam. According to PD Arora, official of National Highways Authority of India, “We have ambulances every 30 kilometres. These are equipped with essential medicine and oxygen cylinders.” The ambulance drivers undergo basic training in first-aid and their goal is to expedite transfer of patients from the accident site to the nearest government hospital or to the medical centre of the victim’s preference. The system has been operational since the beginning of 2006.|
The EMS in Chandigarh is operated through Red Cross referral system. According to Dr Haresh Mohan, Medical Superintendent, Government Medical College and Hospital, Chandigarh, “There is no nodal agency in the city to take over the responsibility of emergency medical services. However, there are plans to start a nodal service in EMS.” In a meeting, which was held three months back, the idea of EMS was mooted. “A project tender has been floated for this. Rs 2 crore have has been allocated for the project in Chandigarh,” said Dr Mohan.
Presently, private hospitals in Chandigarh provide ambulances but they are not often used for rescue or retrieval purposes unless there is some disaster. However, the Police Control Room (PCR) of Chandigarh provides ambulances to carry victims from accident or emergency spots to hospitals.
The 108 Emergency Response Service (ERS), launched by the Hyderabad-based Emergency Management and Research Institute (EMRI), is a technologically very advanced EMS system. Started on August 2005 the project is a brainchild of B Ramalinga Raju, Founder and Chairman of Satyam. The Project covers medical, fire and police emergencies and is available in 50 locations in all the 23 districts of AP. The Raju brothers invested around Rs 34 crore from their own funds in building up this service. They also donated 35 acres of land, estimated at nearly Rs 70 crore, for the call centre in Hyderabad. So far, they have successfully received 42.5 per cent of the medical emergency calls out of 3.5 million calls. Average time taken from call receipt to reaching hospital is 35 minutes.
The Government has recognised EMRI as the nodal agency for providing ERS in AP. The Government also provides support by ensuring that the police and fire departments attend emergencies. (for details about the system, see box below)
The 108 Emergency Response Service (ERS), service operates in three distinct phases-sense, reach and care.
Sense: Sitting at the call center in Hyderabad, one can immediately gauge the expertise and dexterity of the call receivers allowing them to sense the type of emergency and the location of the mishap. There, at the click of a button, he directs ambulance nearest to the site of the mishap, be it in any remote corner of the state. After receiving the call, a dispatch officer identifies the nature of the problem and accordingly, decides on the required help (fire engine/police van/ambulance). Dr Prasad Rajhans, consultant to the project explains, “The Global Positioning System (GPS) and Geographic Information System (GIS) help in tracking the vehicle and sending it to its destination. A map showing the road routes of the entire city appears on the computer screen which makes tracking of the ambulance easier.” One cannot fail to notice doctors stationed at the call centre, giving pre-arrival medical instructions before the ambulance reaches the accident spot.
Reach: The nearest possible ambulance is sent to the site of the accident. At this crucial moment, there is a simultaneous co-ordination with the police and the fire departments. Venkat Changavalli, CEO of this project, adds, “These emergency vehicles are even modelled so as to provide maximum comfort to the patient’s relatives who are anxious and tense.” These Emergency Response vehicles are equipped with AVL devices and are designed with public and patient safety in mind. Patient friendly equipment like, detachable stretchers, wheelchairs, life-saving drugs, ventilators, IV fluids and seat belts are seen to adorn these ambulances. Thirty Advanced Life Saving (ALS) Ambulances,40 Basic Life Saving (BLS) and 30 First Responders (Two-Wheelers), are used. The EMRI also provides two-wheeler facilities whereby trained technicians are sent to the patient’s house to give pre-hospital treatment and instructions.
Care: Emergency paramedics or other personnel are seen providing constant pre-hospital care to the patient, en route to the hospital. Meanwhile, these trained technicians are in constant co-ordination with the doctors at the call centres monitor the patient’s health and try to stabilise him before admitting him to the hospital.
Despite several attempts, Mumbai still does not have an EMS facility. In 2000, an emergency service spearheaded by Dr Prakash Kasbekar, Medical Director, Sterling Hospital, Mumbai was initiated on the Mumbai-Pune Expressway. Eight hospitals were involved in this project. The service provided Floating Advanced Casualty Complex (FACC) ambulances not only transported patients to the nearby hospitals but it ensured that within 30 minutes, qualified doctors with all necessary equipment rushed to the site and stabilised patients on the spot before they were taken securely to the nearby hospital. Around 4,000 cases of injury and 1,300 accidents were handled and 822 lives were saved. The death rate too reduced from 25 per cent to five per cent. However, soon funds stopped coming in from the government. For two years, Dr Kasbekar chipped in his own money until it went beyond his limitations and so in 2003, the Government asked him to discontinue the service.
Ambitious plans are on the cards to reintroduce the same service along with the facility of air ambulance. “This operation, known as Operation SuperOctopus, will provide pre hospitalisation infrastructure for the entire Mumbai Metro City. Around 50-60 hospitals from the entire city will come under this model,” Dr Kasbekar informs.
Through special direct access call system, the moment an emergency is reported, it will handle the injured victim of trauma at the site. Moreover, this model also has a GPS system which efficiently tracks the FACC ambulance from the control room at Sterling Hospital. spot and then transport them. “The blue print of the project is ready but we are waiting for government and community support,” adds Dr Kasbekar.
Laments Dr Asif Ali, Consultant – Emergency Medicines, Fortis Hospital, Noida, “The city’s EMS is almost non-existent.” In most of the accident cases, victims are either picked up by police gypsies or by Centralised Ambulance Transport Service (CATS).
Initiated in 1984 during the Sixth Five Year Plan, the administration of CATS changed many hands and consequently the functioning had also been unsystematic. Experts opine that CATS is unable to fulfil the ever-rising requirements of the capital. According to Major General HS Mangat, Advisor – Accident and Emergency, Max Healthcare, “We also approached CATS to help them in covering certain parts of the city for EMS, but with no responses.”
But according to KS Wahi, Project Director, CATS, none from the private sector has approached him during the last one year with any such proposal.
Experts suggest that the city should ideally be divided into nodal areas and there should be networking accordingly to fight the traffic problems. Lately, things have started taking shape in the capital. After the High Court intervention, CATS is also planning to expand its ambulance services with a full support from the government this time. The existing 35 ambulances are to be increased to 450 in years to come. “The government has sanctioned around Rs 80 crore for the expansion. We have taken the initiative to develop well-equipped ambulances which will not be mere patient carriers,” says Wahi.
| “The GPS and GIS help in tracking the vehicle and sending it to its
– Dr Prasad Rajhans, Former President, SEMI
Pune Heart Brigade (PHB) began on August 6, 1999 with a trust formed by Rotary Club of Pune South with Sanjeevan Hospital. From just one ambulance, it now has a network of nine hospitals and nine ambulances. So far, it has attended to over 14,700 cases. For the service, the city has been divided into five zones. Recollects Mohan Audhi, Founder Trustee, PHB, “When I faced a massive heart attack in 1991, the ambulance came only after half an hour. Even as I recovered from the attack, I knew that I had to do something about developing EMS in the city.” After receiving paramedic training from the UK, Audhi, mobilised sources and people to constitute PHB. By dialling the BSNL number, one is connected to the casualty department of the nearest hospital by the use of interactive voice recording facility attached to 1050. The casualty department then sends the ambulance to the accident spot. Initially, the ambulance and first aid were provided free of cost. Faced with the problem of maintaining a free facility, the hospitals are allowed to charge patients for medicine and first aid.
According to Dr S Balasubramaniam, President, American Association of Physican of Indian Origin (AAPI) and also the one who helped in setting up PHB, “The first 2,000 cases treated by PHB showed that the response, treatment rendered and the outcome are similar to what we see in California. PHB has shown 30 per cent reduction in mortality and 50 per cent in morbidity.”
Though the association wants to use GIS and GPS, they have not been able to do so because of lack of funds. In the pipeline is an air ambulance service, along with introduction of an ambulance with ICU facility.
With inputs from Rita Dutta