By Deepak Sharma
Even as Covid-19 has resurrected epidemiology and indeed broader healthcare education and research to the top of policymakers’ priority list for now, the need to address medical emergencies will remain undiminished forever. Medical emergencies by their very nature – because the loss of a few precious seconds can become the difference between life and death – demand a rapid and fail-proof response system. And this response system can only be manned and executed by specialists duly trained in integrated emergency medicine and care. As such, there is a need for development as well as dissemination of specialized course material that would prepare medical students and professionals in India to address emergency cases in a holistic manner. In other words, structured emergency health courses modeled after advanced curricula and practices in the West while accounting for India’s socio-cultural and demographic uniqueness can show the way forward for emergency care in the country.
What are emergency health courses?
While emergency is an all-encompassing common term, an emergency health course seeks to address an assortment of life-threatening health situations, but in a somewhat unified and systematized way. The different life-threatening situations could range from patients involved in accidents and trauma, to those already in an ER either inside the hospital or outside hospital settings, to those who may have developed sudden post-operation complications with rapid deterioration of their vitals. However, despite the distinct and apparent differences between different emergency situations, India needs to prepare a pool of emergency care professionals who would be able to make a life-saving intervention first triaging and stabilizing a patient before a specialist of that particular condition can take over.
The extraordinarily huge case load
According to a country-level assessment report prepared by AIIMS and submitted to the NITI Aayog, Emergency and injury cases annually accounted for 9-13% of all patients coming to a health facility, 19-24% of admissions in govt. hospitals, and 31-39% admissions in private hospitals. In fact, emergency cases accounted for 11-30% of all OPD patients on a given day. For a country as highly populous as India, even modest estimates derived from these figures would suggest the colossal emergency case load that India faces. According to the same report, the availability of emergency operative care services (for trauma, non-trauma, orthopedic, neurosurgical, and obstetric care) varied between 47-60 percent, again underlining the inadequacy of emergency services in the country.
The staggering number of road accident-led casualties
India bears the dubious distinction of having the largest number of deaths due to road crashes and accidents. Last year, the country lost in excess of 1.5 lakh people to road accidents. Tragically enough, nearly 70% of fatalities due to road accidents had comprised people in the young age group of 18-45 undercutting the much-touted principle of demographic dividend in economic terms. In another estimate, nearly 23% of all trauma cases in India have been traced to transportation incidents with 400 deaths occurring every day on Indian roads. That almost 60% of road accidents occurred in rural areas and 40% in urban areas again highlights the need for ramping up emergency care particularly in the former given the fact that they are already disadvantaged in terms of infrastructure and personnel vis-à-vis the latter. In fact, the percentage of deaths due to road accidents has continued to rise. Therefore, there is a massive need for training and preparing a large pool of emergency care personnel in the country. And they would need this training drawn on latest developed course material and content on emergency medicine and care.
The prevailing inefficient emergency care management
Against the overwhelming load, the existing emergency care has been found to be utterly inefficient. Emergency care is usually provided at what is called Casualty department manned by junior doctors who are not trained for it. Going by the aforementioned AIIMS’ report, most of government hospitals are deficient in terms of SOPs/standard manuals for emergency care, patient transfer and handling of death. Although policies for triaging and disaster management are largely found in private hospitals, only 50% of government hospitals have such policies. In practice, triage, which is critical to effective emergency care, is rarely implemented. Alarmingly, the patient disposition time for the sickest group (Red zone) is as high as a full 90 minutes at government medical colleges against the 15 minutes at private hospitals. More specifically, there are no dedicated trauma surgeons and very few designated trauma centres in India. In fact it is the orthopedic surgeons who lead the trauma response in 50% of facilities and the responsibility is not defined in the rest. As a result, there is delay in clinical decision-making putting patients at risk.
The shortage of Emergency Medicine departments and lack of relevant courses
According to a popular education sector website tracking all-round education in India, there are only 115 colleges offering a post-graduate programme in Emergency Medicine across government and private sectors. This is way below what would be required for a country with one of the most number of accident-related and other health emergency-related deaths in the world. Going by the AIIMS-NITI Aayog report published in 2020, only 28 medical colleges offered merely 60 seats for EM with DNB contributing around 120 seats. Last year, there were only a paltry 196 recognized government-sponsored training seats available in Emergency Medicine. Admittedly, there has been a 78% jump in number of PG medical seats since 2014. This improvement must reflect in EM too.
The need for pre-hospital care
Apart from well-conceived courses and number of EM seats, India also badly needs a well-oiled ecosystem of pre-hospital care including networked ambulances, paramedics trained in first aid and emergency protocols, emergency medical technicians (EMTs) and EM experts. The existing emergency numbers are yet to find credibility and traction and their responsiveness has always been open to question. In fact, going by a research, nearly 50% of trauma victims admitted to a premier hospital in an urban Indian city had received no pre-hospital care. Imagine the state of affairs in rural India.
Against more than 1.5 lakh accident-led deaths many of which could have been prevented, there are nearly 200 EM seats available today. These seats are assumed to be present in 115 or thereabouts colleges out of the total 540 odd medical colleges today in the country. If even 350-400 of the remaining colleges allow only 2 EM seats each, the total count could go up to 900 seats and more, more than 4 times the existing number. Taking a different approach, if only 1% of the existing 81,400 odd MBBS students take up a PG programme in EM, there could be 800 more students getting initiated in the course every year who would come out as specialists in due course. And if these students had access to the best developed and curated course content inspired by globally best and integrated thereafter in the larger nation-wide emergency care machinery, emergency-related deaths could drastically come down. Needless to say, India can’t afford to allow the so-called demographic dividend to be wasted away so easily.
By Deepak Sharma, Co-Founder & CEO, MedLern
(DISCLAIMER: The views expressed are solely of the author and ETHealthworld does not necessarily subscribe to it. ETHealthworld.com shall not be responsible for any damage caused to any person / organisation directly or indirectly)