Issues and challenges in Emergency medicak care in India

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Emergency Medicine-Challenges and issues in developing countries:

Emergency Medicine-Challenges and issues in developing countries Venugopalan P.P. MB;BS, DA, DNB, MNAMS. Chief of Emergency Medicine Site Director and National faculty ,Masters program in Emergency Medicine [GWU,USA] Malabar Institute of Medical Sciences Ltd., Kozhikode , India [International Academic Training Center-GWU]

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Warm Greetings

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Emergencies are as old as humanity

Background:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Background Not recognized as a separate specialty Not emphasized in Curriculum Not a priority in health care plans Perceived differently in different parts of the world Unique nature Urgent need Costly Challenges are many Emergency Medical Care

Objectives:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Objectives Challenges in emergency health care provider system Barriers in developing proper Emergency Care system Possible solutions and Implementation strategies

Emergency Medical Care :

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Emergency Medical Care Focuses on the provision of immediate medical interventions Medical Decision- making Actions to prevent Death & Disability 900 bulletin of the World Health Organization 2002, 80[11]

Emergency Medicine:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Emergency Medicine The medical specialty with principal mission of evaluating ,managing and preventing unexpected illness and injury It encompasses an unique body of knowledge reflected in the model of the clinical practice

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Access to medical care for urgent and life threatening conditions is a key expectation in many communities Reality….

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 The emergency medical care systems in developed countries are too expensive or inappropriate for many developing countries The emergency medical care – issues and challenges in developing countries are different altogether. Differences….

Primary emergency care givers in developing countries:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Primary emergency care givers in developing countries Primary health centers Preventive care services [Family planning or prenatal care Traditional home remedies MacRorrie RA . Tropical doctor 1998;28:162-5, Wolffers I .Social sciences and Medicine 1998;27:545-52.

Core Components – Emergency Medical Care :

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Core Components – Emergency Medical Care Community Transportation On arrival at Destination Care Bull World Health Organ vol.80 no.11 Genebra Nov. 2002

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Emergency Medical Care at community level Reality Challenges Solutions

Reality:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality Most emergencies starts at home Outcome influenced Early recognition Early medical intervention Most of the deaths are due to delayed detection

Evidences :

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Evidences In Zimbabwe a significant proportion of maternal deaths is caused by avoidable factors, including the failure of health workers to identify serious complications and to refer promptly women who are seriously ill to higher levels of care Fawcus S, etal. A community-based investigation of avoidable factors for maternal mortality in Zimbabwe .  Studies in Family Planning  1996;27:319-27.   

Evidences:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Evidences In Mexico the training of mothers and first-level health care workers in the basic principles of triage led to care being sought more promptly and significantly reduced child mortality Guiscafré H, et al. The impact of a clinical training unit on integrated child health care in Mexico.  Bulletin of the World Health Organization  2001;79:434-41.

Challenges :

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Challenges Lack of basics medical facility Large population Lack of training Lack of awareness Lack of political will and priorities New diseases Economical imbalance

How to overcome:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 How to overcome Awareness Campaign at different levels Political Schools Health care providers NGOs General public National programs in Emergency care

How to overcome:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 How to overcome Training - Basic life support Trauma care training Triage principle training Training basic first aid and critical problem detection Target- Community level H C Ps , Police , Fire force, NGO, Drivers . School children

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 The benefits of pre-hospital emergency care could be realized by teaching community volunteers simple but vital interventions e.g. maintaining a patent airway, controlling external bleeding, and immobilizing fractures Varghese M. Technologies, therapies, emotions and empiricism in pre-hospital care. In: Mohan D, Tiwari G, editors.  Injury prevention and control . London and New York: Taylor and Francis; 2000. p. 249-64. Evidence

Training module:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Training module AHA module – Best evidence based module available Too costly Language barrier Need a version which is appropriate for Developing countries

First responder training initiatives for Policemen in India:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 First responder training initiatives for Policemen in India

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Emergency Medical Care During Transport

Reality:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality Mode transport – Three wheelers, Car, Jeep Ambulances – Dead body carriers No ambulances networks or single access number

Reality…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality… No Paramedic law and paramedic council Paramedic cannot administer drugs in India No uniform protocol

Reality…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality… Not yet identified the need Pre-hospital care is not in the priority Lack of Funds or its distribution

Reality…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality… Transport related mortality and morbidity is so high Poor road conditions Increased traffic congestion and lack of traffic culture

Accident prone roads:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Accident prone roads

Traffic :

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Traffic

Evidences:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Evidences In urban Guinea-Bissau, 20 of 125 acutely ill children died either on their way to hospital or while waiting in the reception area of an outpatient clinic Sodemann M. et al. High mortality despite good care-seeking behavior: a community study of childhood deaths in Guinea-Bissau.   Bulletin of the World Health Organization 1997; 75:205-12. 

Evidences:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Evidences In Malaysia a team assessing the value of the risk-coding system in pregnancy concluded that better communications, a more effective transport system, and better emergency care in hospitals were needed in order to reduce maternal mortality Geefjhysen CJ, Malaysian antenatal risk coding and the outcome of pregnancy. Journal of Obstetrics and Gynecological Research  1998;24:13-20.

Evidences:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Evidences In Sierra Leone, investment in a vehicle and an improved communication system led to a doubling of the utilization of emergency obstetric services and a 50% reduction in case fatalities Samai O, Senegeh P. Facilitating emergency obstetrical care through transportation and communication, Bo, Sierra Leone.  International Journal of Gynecology and Obstetrics  1997;59 Suppl 2:S157-64.   

Evidences:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Evidences In Monterrey, Mexico, an increase in the number of sites of ambulance dispatch and the provision of basic skills training in trauma care reduced deaths among patients en route to hospital . Arreola-Risa C. et al. Low-cost improvement in prehospital trauma care in Latin American City.  Journal of Trauma: Injury, Infection and Critical Care 2000;48:119- 24. 

What can we do?:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 What can we do? Paramedic training and paramedic council Upgradation at least to BLS level Networking of Ambulances through single response number Improvement of road condition

What can we do?:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 What can we do? Trauma transport should be free of cost Group insurance program Ambulance services in Government sector

What can we do?:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 What can we do? Private – Public Participation Service Society Ambulances Awareness among all segments

Ambulances in developing countries :

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Ambulances in developing countries

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 The prevailing models of emergency medical transport used in North America and Western Europe are quite costly and would be impractical for most low-income countries. Facts !!

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 United Republic of Tanzania, modes of emergency transportation include motorboats, canoes, bicycles with trailers, tricycles with platforms, tractors with trailers, reconditioned vehicles, and ox carts Schmid T, etal. Transportation for maternal emergencies in Tanzania: empowering communities through participatory problem solving.  American Journal of Public Health  2001;91:1589-90. Evidences

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 A N G E L S Active Network Group of Emergency Life Savers A Calicut Initiative to develop pre hospital care

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Emergency Medical care on Arrival Human factors @ Structural factors

Reality… Challenges..:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality… Challenges.. No E R or Emergency Departments “Casualties” are emergency treatment area No casualty doctors – untrained , unqualified “Casualties” act like Traffic island

Reality… Challenges..:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality… Challenges.. No triage No special area for resuscitation No trained staff and doctors No policies and protocols

Reality … Challenges..:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality … Challenges.. Emergency is not in the priority No proper infra structure Overcrowded Emergency Room No specific academic or training programs ACLS , ATLS , PALS needs, not yet identified as a priority

Reality … Challenges..:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality … Challenges.. Medical board not yet recognized the need of the specialty Recognized countries – Curriculum and faculty development are dark areas Different centers following deferent protocols in the same countries

Reality … Challenges..:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality … Challenges.. Current medical curriculum focused on “Diagnosis based” clinical approach Internees focus – Post graduate entrance exams and not involving clinical training relevant in saving lives

Reality … Challenges..:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Reality … Challenges.. International EM Medical journal and other academic materials are too costly International structured courses are also costly Disease profile and management needs different from developed countries

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 A study in Malawi revealed that many seriously ill children arriving at clinics had not previously been recognized. Instead of receiving immediate emergency care they were kept waiting for long periods , resulted in avoidable deaths and disability Gove S et al. WHO Integrated Management of Childhood Illness (IMCI) Referral Care Project.  Archives of Diseases in Childhood  1999;81:473-7.       Evidences

Evidences:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Evidences A qualitative study of 21 hospitals in seven developing countries found that poor triage of incoming patients and inadequate provision of emergency care jeopardized the lives of arriving patients Nolan T. et al. Quality of hospital care for seriously ill children in less-developed countries.   Lancet  2001;357:106-10.

Evidences:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Evidences Fourteen of the facilities (including 10 of 13 district hospitals) did not have an adequate triage system. Nolan T. et al. Quality of hospital care for seriously ill children in less-developed countries.   Lancet  2001;357:106-10.

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 A comprehensive review of the management of 131 children treated at these facilities found evidence of inappropriate or delayed triage in 8% of cases, poor clinical assessments in 41%, and potentially harmful delays in treatment in 19% Evidences Nolan T. et al. Quality of hospital care for seriously ill children in less-developed countries.   Lancet  2001;357:106-10.

Evidences:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Evidences In Mexico, verbal autopsies of 132 children who died revealed that poor selection of medications and late referral to tertiary care were judged to be important contributory factors in more than half the deaths Reyes H. et al. [The verbal autopsy on children with a respiratory infection and acute diarrhoea. An analysis of the disease-care-death process.]   Boletín Médico del Hospital Infantil de México  1993;50:7-16.

What can we do?:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 What can we do? Empower human factors Enhance structural factors

Human factors… Can be modified?:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Human factors… Can be modified? Medical board recognition Policy decisions at Government level Revision of medical school curriculum Awareness at multiple levels Post graduate courses for doctors [ Three years]

Human factors…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Human factors… Fellowships and certificate courses Short training program [ one / two months ] Emergency Medicine CME Structured courses – BLS,ACLS,ITLS,ATLS,PALS,NALS Cost effective training programs

Human factors…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Human factors… International academic programs and faculty support at affordable cost Availability of medical journals at affordable or free of cost

Human factors…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Human factors… Curriculum appropriate for less developed countries Faculty development ER administration skills

Human factors…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Human factors… Emergency Nursing training and nursing courses in emergency medicine Separate funds for EM developments

Human factors…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Human factors… EM research – prompt support at all levels Strategies to attract students to EM Multi disciplinary committee to develop EM

Structural factors … can be modified?:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Structural factors … can be modified? Face lift from “Casualty” to Emergency Medicine ER is the real front office of any health care facility Triage system implementation

Structural factors … can be modified?:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Structural factors … can be modified? Set areas for priority patients Equip adequately with monitors and other gadgets Private Public Participation Programs-PPPP

Structural factors …:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Structural factors … Policies and protocols EM compatible medical records Quality assurance system

Structural factors …:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Structural factors … Accreditations Develop supportive specialties – Clinical, Non clinical

Evidences:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Evidences In many developing countries, the private for-profit and not-for-profit sectors are playing increasing roles in health systems Mills A .et al. What can be done about the private sector in low-income countries? Bulletin of the World Health Organization  2002;80:325-30

Silver lines in Emergency Medicine…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Silver lines in Emergency Medicine… World Health Organization has successfully convinced medical publishers to provide physicians and scientist in developing countries with cheap access to research journal via the internet. Sklar DP. Emergency medicine in the developing world.  Am J Emerg Med 1988;6:390–3.

Silver lines in Emergency Medicine…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Silver lines in Emergency Medicine… The  New England Journal of Medicine  and the  BMJ  publishing group are extending free access to over 100 of the low income countries Sklar DP. Emergency medicine in the developing world.  Am J Emerg Med 1988;6:390–3.

Silver lines in Emergency Medicine…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Silver lines in Emergency Medicine… WHO and UNICEF are placing substantial emphasis on the strengthening of triage and emergency care within the context of the integrated management of childhood illnesses Gove S. Integrated management of childhood illness by outpatient health workers: technical basis and overview.   Bulletin of the World Health Organization  1997;75 Suppl 1:7-24.

Silver lines in Emergency Medicine…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Silver lines in Emergency Medicine… Republic of Moldova, funded by the World Bank, is the development of basic emergency care services World Bank.  Project information on Health Investment Fund Project of Moldova.  Washington (DC): World Bank; 2000.

Silver lines in Emergency Medicine…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Silver lines in Emergency Medicine… In Romania, the Health Sector Reform Project, supported by the World Bank, aims to improve emergency medical services as a key component of the overall health program . World Bank.  Project information on Health Sector Reforms Project, Romania.  Washington (DC): World Bank; 2000.

Silver lines in Emergency Medicine…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Silver lines in Emergency Medicine… World Bank's minimum package of health services includes six cost-effective interventions, one of which is a series of non-specialized interventions for emergencies, known collectively as limited care World Bank.  Minimum package of health services: criteria, method and data.  Washington (DC): World Bank; 1995.

Silver lines in Emergency Medicine…:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Silver lines in Emergency Medicine… Medical Council of India recognized Emergency Medicine as a separate specialty on 29 th July 2009 GWU – USA is operating in India and started Two years post graduate fellowship and Three years Master’s Program

PowerPoint Presentation:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 International Academic Training center of GWU –USA & Regional training center AHA

Rural emergency medicine :

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Rural emergency medicine The limited availability of even primary care services is a major concern, in rural areas and highly impoverished communities. Focus separately Need national policies and plans

Conclusion:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Conclusion Health care provider system should be geared up to the need of a comprehensive, cost effective and community based emergency medical care provider system in developing countries .

Conclusion:

2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Conclusion Government and certifying authorities should focus on the essential policies ,protocols and education requirements to meet such a emergency medical care system.

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Emergency Medicine is unique Physically Physiologically Philosophically

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Medical Emergency Care should be the human fundamental right

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2nd Eurasian Congress on Emergency Medicine at Antaliya ,Turkey Oct. 28th - 31st 2010 Thank You

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