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Development of EMS in India - 31-Mar-2009

Writing history is always difficult. Writing contemporary history is more difficult. Perceptions of today can and always will be interpreted differently in times to come. As they say, history judges people and incidents differently.

It could not be more true for EMS. When I was asked to revisit and rewrite my very own article for this very publication, which I had first written more than 20 months back, I was shocked at the changes in EMS in India over this short period. The difference in the last 20 months is 20 times more than what had taken place in the last 20 years! Amazing how the country is changing!!

The biggest change is that the general public now knows what EMS is. 20 months prior, I realized, barring those working in the sector, few enlightened government officials and vendors of EMS equipment, the only ones who really understood something of EMS were the close family members of those involved in EMS.

It was very difficult to explain to people what EMS is. The frequent dilemma was answering a common question: Aap kis chij de doctor ho? Kis subject mein specialization kiya hai? If you said EMS, you drew bland looks. The last 20 months has seen a huge shift, both in the eyes of the public and those "government officials" who now see health beyond primary and secondary care and costly superspecialty hospitals. Many more understand EMS than they did 20 months ago.

Yet, despite the "popularisation of EMS" in India in recent times, the situation is far worse than what the former AAPI President, Dr. Balasubramanian had once said, "EMS is its infancy in India." The lack of regularisation is going to hurt us and those who need quality service. Regularisation in terms of training, in terms of those allowed to dispense Emergency Care, in terms of equipment used, in terms of protocol of treatment is still lacking. And we are failing to learn from the US experience.

 
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With more than l lac RTA related deaths 98.5% Ambulances used for transporting dead bodies, 90% of A m b u I a n c e s devoid of Oxygen of any Equipment, 95% Ambulances having untrained personnel, most ED doctors having no formal training in EM, misuse of Govt. Ambulances and 30% mortality due to delay in care, India portrays a worse image than what existed in USA of 1960s

To trace the history of EMS in India, in absence of an EMS historian, can be highly difficult and debatable. I will attempt to divide the history of E M S development into three parts – (1) policies and those who catalysed it, (2) the providers on ground and the difference they have made and finally (3) those involved in training, individuals and institutes.

 (1) Policies and those who catalysed it

The good news for me, now as compared to when I had first written this article, is that EMS has taken firm roots in India. The passing of the EMS Bill in Gujarat in February 2007, albeit fraught with avoidable flaws, is a great leap for EMS.

Credit for this should go to three people besides those in the Government, who pushed for this Act. Dr. Haren Joshi and Dr. Manjul Joshipura of the Academy of Traumatology did the hard word of sourcing details of EMS Acts prevalent in other parts of the world, preparing the initial draft and presenting it to the Govt.

The other was Dr. Subroto Das of the Lifeline Foundation who proved that EMS can be delivered across large geographical areas. Lifeline’s success on ground gave credence to the model prepared by Dr. Joshi and Dr. Joshipura.

However, since then no other state in the country has gone ahead and emulated Gujarat. Gujarat itself has not carried the act forward other than notifying it. The all important Gujarat State EMS Authority (GEMSA) is yet to be put in place, 18 months later!

More surprising is the case of Maharashtra. What was passed in Gujarat as an Act had in fact first been suggested in Maharashtra. Three people, Shaffi Mather, Ravi Krishna and Dr. Paresh Navalkar put together the first ever proposal in India for a State level EMS Act, this one for Maharashtra.

That it is still sitting on the desk of officials of the state health department is a story of a lost opportunity.

While Gujarat and Maharashtra failed to deliver after the initial promise, Delhi went ahead and achieved considerable success. Close on the heels of a High Court stricture on misuse of ambulances and the Court’s directives to lay down standards, the Delhi Government in 2007 notified the first ever " Ambulance Standards" in the country.

Parallel to these developments to regularise EMS, the Ministry of Road Transport and Highways formed a committee to lay down the guidelines for Trauma Care on Highways. Chaired by the Joint Secretary, MoRT&H, S K Dash, this was a unique multi-stakeholder committee. Its report, however, is yet to be implemented upon. The Health Ministry, GoI also prepared a plan for reducing deaths and disabilities due to Road Traffic Accidents. This plan suggested allocating Rs. 732.75 crores during the plan period of 2007-12 plan for setting up trauma care facilities on the Golden Quadrilateral.

 central

The Central Health Ministry also has taken steps to regularise the activities and courses of paramedics. The Paramedical and Physiotherapy Central Councils-Bill, 2007 introduced in the Lok Sabha has been referred to the Parliamentary Standing Committee on Health and Family Welfare headed by Amar Singh, M.P. for examination and report. The sad part is that it does not include EMTs as paramedics. EMS providers across the country are trying to bring ‘Emergency Medical Technicians’ within the scope of this Act to enable EMT’s to get duly registered and recognized.

While all this has helped institutionalise EMS in bits and pieces, what really has made the difference in large areas of the country for EMS to be visible is the outsourcing of EMS in seven Indian states to a single entity. Though there can be endless debates on this outsourcing, truth of the matter is EMS has become visible.

This development, EMS being a national health issue now can be credited to two things. One, the National Rural Health Mission (NRHM) funds, which till 2011 guarantees sustainability of these initiatives in states that have implemented scaling up of EMS services. The funds available have created ultra-modern ambulances and state of the art 24x7 control rooms operated through Satyam Computers non-profit initiative EMRI (Emergency Management Research Institute).

Second, EMRI has, driven by Ramalinga Raju, Chairman of Satyam Computers and Venkat Changavelli, its CEO changed the face of EMS in India. They Catalysed policy changes and subsequent implementation of EMS in various states of the country.

While 7 states have nominated EMRI as its so called "PPP" partnership, two states have taken a more open path – Delhi for its NCT and Bihar for Patna city. More are following.

While Delhi upped the bar for policy making with regard to EMS by floating a RFQ (Request for Qualification) with very open parameters to run a full fledged EMS even admitting that hospitals should be part of EMS, unlike other states who could not think beyond ambulance providers, Bihar floated a tender for a pilot project for Patna city. Great things are happening for EMS in the country as far as government initiatives are concerned – level playing fields are being created. The going has to be better form here on, making working easier for providers.


(2) The providers on ground and the difference they have made

 
I will make short references to the key providers who pioneered EMS in pockets, setting up their own unique and successful models, some of them highly sustainable and replicable across larger geographical areas. There might be some names not mentioned here because of our lack of knowledge of their work rather than any other reason.

These models differed on three key issues:

 Source of funding: Some are totally funded by government, some partly while rest are independent of government funding.

User charges: Some took recourse to the FREE model (either because of inadequate means of recovery of payments or due to altruistic feelings towards the cause or because they were covered by government). Others who delivered EMS at a cost used a successful cross-subsidy model.

Networking: While some providers used the currently prevalent networking model, which has been so successful in other sectors of service industry, some just stuck to their ownership plans for infrastructure.

 

1997-BANGALORE (EMS helpline 1062) – EMS CITIES

Though the first ever EMS in India was conceived for Delhi, the first EMS implemented was at Bangalore in 1997. Burdened with 8000 accidents annually, Bangalore was in urgent need of an EMS. Comprehensive Trauma Consortium started Operation Sanjeevani with 1062 as common access number. Today, it covers Bangalore and highways around it with a network of 40 hospitals and 45 ambulances.


1998-HYDERABAD (EMS Helpline 1066) & PUNE (EMS Helpline 1050) EMS CITIES

 In Hyderabad, Dr. K Hariprasad of Apollo Hospital implemented a hospital based EMS across a network of Emergency Departments managed by Apollo Group with 1066 as its helpline. This later inspired similar services in India across the entire Apollo group.

At the same time another EMS proponent, Dr. Prasad Rajhans started the first "Group EMS" of India in Pune (helpline 1050) with a consortium of hospitals as partners. The "Pune Heart Brigade" helped develop a symbiotic approach amongst hospitals. Over time, an EMS Council has developed unifying all EMS players of Pune. Within years, other cities developed EMS, different in approaches yet addressing similar issues.

 
2000-DELHI (EMS Helpline 1099) EMS CITIES

16 years in making, Centralised Ambulance Transport Service (CATS) in Delhi is still the only Government driven EMS in India CATS was conceptualized in 1984 during the Sixth Five Year Plan. Unfortunately, CATS and private hospital based EMS facilities of Delhi have yet to form a common EMS for the capital.

 
EMS HIGHWAYS

Without any role clarity of Health, Transport or Home Departments, public efforts on highways have been erratic. Efforts like EMS on Mumbai Pune Expressway have remained stand alone as has the Haryana Government’s Highway patrol. The Rotary International’s efforts on Kerala highways are yet to crystallise.

 
2002-July-HIGHWAY RESCUE PROJECT (HRP): (Gujarat 9825026000/Maharashtra 9850026000)

Initiated in 2002 July on Gujarat highways, HRP was set up by non-profit Lifeline Foundation. It goes beyond a regular EMS and is a Comprehensive rescue system incorporating ambulances, cranes, metal cutters, police, fire and emergency services as part of its vast network, to respond to highway accidents.

Today, HRP, the only EMS honoured with a National Award and internationally feted as "a highly replicable project in third world countries" covers 3500 kms of highways in Gujarat, Maharashtra, West Bengal, Kerala and Rajasthan.

 
2002 July EMS CITIES-MUMBAI, KERALA (1298)

A self sustainable ambulance EMS in Mumbai was created as a non-profit by Ambulance Access for All (AAA). Its advanced and basic life support ambulances guided by GPS transport patients to nearby hospitals while providing quality "pre-hospital" care. AAA has an active partnership with London Ambulance Service and New York based Presbyterian Hospital.

 
2004 July EMS CITIES -AHMEDABAD (1056)

Three public and five private hospitals formed EMS Council of Ahmedabad. However, it had to be dissolved once the Government of Gujarat had outsourced its EMS plans to EMRI. Till it existed, the control room, dispatched ambulances from hospitals within respective zones that the city was divided into.

 
2005 August EMS STATE (108)

The 108 Emergency Response Service, launched by Hyderabad-based Emergency Management and Research Institute (EMRI) is technologically advanced EMS system, since it is backed by Satyam Computers. 108 covers medical, fire and police emergencies. Following its success in AP, EMRI since then has tied up with state Governments of seven other Indian states.

Even while big cities were establishing EMS, two cities having population below 2 million had become the first "B" cities in India to have their EMS.

 
2005 December BARODA (65 000 00) EMS CITIES

Lifeline Foundation initiated EMS Vadodara as a Public-Private-NGO partnership with 9 hospitals (including two public ones) and two corporates. Hospitals are graded into 3 levels. Digitalised maps help dispatchers guide ambulance drivers; the service is free.

 
KOTTAYAM (3259110) EMS CITIES

 
As an initiative to establish EMS for Kerala, a pilot EMS in Kottayam was started under the aegis of Indian Institute of Emergency Medical Services.

(3) Those involved in training, individuals and institutes.

trg

Training, the most important component of EMS, sadly in India has never been given its importance. It should have been approached first and regularised at the earliest. Despite the significance of EM, the Medical Council of India (MCI) has not recognized it as a subject specialisation for MBBS. At present, EM is offered as an MCI unrecognised specialisation course in a few private institutes in India. Some cover this lack of recognition by affiliating with foreign universities.

Various figures put the requirement of EM personnel to more than 40000 in the coming two to three years. Yet, it is strange that the government has not taken concrete steps to recognise or regularise training. This 40000 figure is itself understated, since there is a requirement for trained personnel in corporate houses. One can work as emergency medical officers on ships, in railways, in airlines, in disaster management teams, pre-hospital emergency development sector, etc.

Interestingly, EM is a very sought after study specialization area globally.

Unlike EMS providers, whose work has been documented, tracing out the beginning of EM training in India is a very difficult task. Though we could find the initiation dates in major training institutes, it is quite possible that there were individual crusaders who started training in EM (for paramedics or first responders) in small pockets and never could scale it up due to lack of resources. Like the freedom movement of India, it is very difficult to document those pioneers. Hence I will restrain from tracing the chronological development of EM training in India.

A few private institutes now offer courses in EM in collaboration with foreign institutes. The Sri Ramachandra Medical College of the Sri Ramachandra University in Chennai has its own standing in training in EM, being the first institute to have a training program for EM backed now by an alliance with Harvard Medical Institution.

The symbiosis Institute of Health Sciences (SIHS), Pune would compete with Apollo Hyderabad to be in the second spot; SIHS now has a postgraduate diploma course in emergency medical services in collaboration with the Los Angeles County Paramedic Training Institute, USA. Apollo hospitals, Hyderabad, offers a three-year full-time course in emergency medicine accredited by the College of Emergency Medicine, UK.

What started as a one-year fellowship program for MBBS students at Apollo; it has become a full-fledged three year course. Apollo created its own training since there was need for its own services. In 2004, Stanford University took interest and conducted a one year EMT-I course. Apollo Hyderabad still conducts the same in house training program. Plans are on to tie up with other foreign agencies. In an attempt to broad base training, Apollo Ahmedabad and R Tolat Foundation jointly started a paramedic training program of six months in association with New York Long Island Jewish Hospital.

This training in Ahmedabad had the backing of the Academy of Traumatology (India) which in 2000 had started its own National Trauma Management Course (NTMC) that has trained more than 4000 doctors in India. It is modeled on ATLS. The Academy also has created courses for undergraduate medical students in collaboration with foreign faculties.

Vinayaka Mission University (VMU), Salem, started The Department of Accident and Emergency in the year 2005 with the intention of providing quality and timely emergency services to the surrounding locality. It started a three-year structures post-graduate course, M.D. in Accidents & Emergency Medicine as well as a master program (M.Sc Emergency & Critical Care) and B.Sc Emergency & Trauma Care Technology for paramedics in 2006. The department of A&E at Salem has been expanded to extend emergency and critical care services to all three medical colleges under VMU at Salem, Karaikal and Pondicherry.

On similar lines of the NTMC, Dr. Rajendra Prasad, a Neurosurgeon of Apollo Hospital brought to India (through Pakistan) the UK based Primary Trauma Care Course (PTC). The first course was held in New Delhi’s Apollo Hospital two Years Back. Besides these two, the Christian Medical College, Vellore also has a ATLS inspired course called the Early Management Of Trauma Course (EMTC). The sheer number and variety of courses that the institute has, coupled with the fact that some of them are recognised as WHO training courses for South and South East Asia, makes it a leader amongst the pioneers. The Emergency Department is recognised as an International Training Centre for Accident and Emergency Care by the WHO as is its Diploma in Emergency Nursing by WHO and Nursing Council of India. Its Fellowship in Emergency Medicine for medical graduates was started in 1998.

While NTMC, PTC and EMTC have initiated changes in the outlook of trauma care, the real ATLS would soon be available in India; AIIMS and the Association for Trauma Care of India have joined hands to bring the course to India.

Equally early to realize the importance of training in EM, was George Abraham who set up IIEMS in Kerala, which besides being an ITO of AHA has used the Concept of networking to creat the largest chain of affiliated training centres across India.

The AIIMS’ department of Emergency Medicine has forth a proposal to offer a three-year MD program in EM. It is catalysing the formation of an academic council with representation from 253 Indian medical colleges. The council will deliberate upon the larger vision of offering emergency medicine as a specialization subject across medical colleges in India.

EMRI, followed these initiatives created, in partnership with Stanford University, its own training modules. Ranging from structured Post Graduation to short courses to train its ambulances staff, EMRI’s tryst with training has just begun. Big things are expected from EMRI in this sector too.

A lot is being done being done in training of first responders. Various organizations ranging from Red Cross and St. John’s Ambulance, Baroda’s Lifeline Foundation, Jaipur’s Dr M N Tandon Memorial Trust, CTC Bangalore all with their networks to train volunteers to address site care, Delhi’s CATS training of school and college students, Mumbai’s LIHS’s and Livewire’s training of the common man, the industrial physicians who train factory workers,… the count is endless.

 

THE FOREIGN HAND: As stated earlier, the foreign hand in EM training in India is big and it’s reach ever increasing.

AHA: The leading players include the American Heart Association with its more than a dozen International Training Organisations, each with its Regional Training Centres. The AHA modular courses include the Basic Life Support, Advanced Cardiac Life Support and Paediatric Advanced Life Support; the first ITO in India was Apollo Hyderabad and the first course was conducted by IIEMS founder, George Abraham and David Romig in 1998. The best ITO as certified by AHA is the Mumbai based LIHS.

CORNELL & COLUMBIA UNIVERSITY: The Life Supporters Institute of Health Sciences started off in 2005 It conducts affiliated courses with C&C in collaboration with Hinduja Hospital and Mumbai University.STANFORD UNIVERSITY: Since its initial days of working with Apollo Hospial, Stanford University School of Medicine has come a long way into establishing a formal partnership with EMRI as part of a "Stanford Challenge", an initiative of the University in reaching out globally.

GEORGE WASHINGTON UNIVERSITY:The Ronald Reagan Institute at the University has tied up with IIEMS to extend credibility and accreditation to their courses since the last couple of years.

INTERNATIONAL CENTRE FOR EMERGENCY TECHNIQUES: The Dutch have been working in Emergency Rescue for long in India and ICET created the SAVER module for training in Emergency Rescue and Medicine for first responders and EMS practitioners after Bhuj earthquake in Gujarat.ICET invites trainees to their bases in Netherlands and Germany to receive training in rescue and onsite care.

INTERNATIONAL TRAUMA LIFE SUPPORT: ITLS is a global organization dedicated to preventing death and disability from trauma through education and emergency trauma care. The ITLS training centers in India are M.S.Ramaiah Medical College at Bangalore, IIEMS and SIHS, Pune.

INTERNATIONAL TRAUMA ANAESTHESIA AND CRITICAL CARE SOCIETY: Comprehensive Trauma Life Support (CTLS) is an initiative of ITACCS India and supported by International Trauma Care (ITACCS). The course is again designed on the ATLS model.

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