chapter 4 current state of emergency medical care and laws in india

43 Pages·2017·0.28 MB·English

CHAPTER 4
CURRENT STATE OF EMERGENCY MEDICAL CARE AND LAWS
IN INDIA
Medical emergency where victims require emergency medical care
are not define in the present law Emergencies may arise due to motor accidents,
fire, floods, cyclone, earthquakes etc. or even sudden collapse of victims or
emergent deliveries in pregnancy. Among these, road accidents, however,
contribute the largest number of deaths or injuries. These accidents are
increasing at an alarming rate of 3% annually. About 10.1% of all deaths in India
are due to accidents and injuries. A vehicular accident is reported every 3
minutes and a death, every 10 minutes on our records. During 1998, nearly,
80,000 lives were lost and 330,000 people were injured. Of these, 78% were
persons in the age group of 20-44 years. A trauma-related death occurs in India
every 1.9 minutes. The majority of road accident victims are pedestrians, two
wheeler riders and bicyclists, passengers by motor vehicles, as cited in the paper
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(2006) submitted by Ms. Shradd Deshmukh, ILS, Law College, Pune on
‘Emergency Medical Aid to Victims’, to the Law Commission. The World Report
on Road Traffic Injury Prevention released by the WHO on World Health Day (7th
April, 2004) stated that around 12 lakh people die each year on account of
accidents globally. The National Human Rights Commission constituted an
Expert Group to study the existing system for emergency medical care in India
to suggest appropriate methods of emergency medical care, which should be
developed by different States/Union-Territories and their essential components.
The Group submitted a Report on The Indian Emergency Journal (Aug., 2005) in
its Editorial says: “The fact is that 80,000 people are killed in accidents every
year …. At least 30 to 45 minutes elapse between the time of a crash and arrival
at hospital. 12 percent of institutions in the trauma-care-sector have no access to
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Ms. Shradd Deshmukh, ILS, Law College, Pune on ‘Emergency Medical Aid to
Victims’, to the Law Commission. The World Report on Road Traffic Injury
Prevention released by the WHO on World Health Day (7th April, 2004)
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ambulance. Only 50 per cent of the available ambulance services possess the
acute-care facilities needed to keep an accident victim alive during
transportation… And only 4 per cent of personal staffing these services (have
certified formal training).
1.EMERGENCY MEDICAL SERVICES IN INDIA: CURRENT
SCENARIO
In India, a total 3.57 lakes (0.35 million) accidental deaths were reported dur-
ing the year 2009 with the Male-Female victim ratio of 77 : 23. The major unnat-
ural causes of accidental deaths were road accidents (37.9%), railway accidents,
and rail-road accidents (7.8%), poisoning (8.0%), drowning (7.7%), sudden
deaths (7.4%), and fire accidents (7.0%). Deaths in “Road Accidents” in India
have increased by 7.3% during 2009 compared with 2008. Most of the victims of
accidents were aged between 15 to 44 years. This group of people has accoun-
ted for nearly two-third (60.7%) of all persons killed in accidents in the country
during the year. This is the economically productive age-group and major bread-
earner of their respective families. Their untimely death due to accidents darkens
the future of their families. Many of them die for want of timely EMS. Thousands
of these accident victims could have been saved if timely medical intervention
were available to them Thus, the need of quality EMS in India is an unmet need
of the masses.
The health care delivery system in India starts from the sub-center level
which caters to the need of approximately 5 000 population. At the peripheral
level, there is a vast infrastructure of health services in India which comprises of
4 276 Community Health Centers (CHCs), 23 458 Primary Health Centers
(PHCs), and 1 46 036 Sub-Centers (S/C) functioning in the country (as on March,
2008). Irrespective of this, the country has not been able to provide the timely
and quality EMS to masses, particularly in rural areas. As per a report of National
Commission on Macroeconomics and Health, Ministry of Health and Family
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Welfare (MOHFW), Government of India (GOI), a villager has to travel an
average distance of 2.2 km (kilometers) to reach the first health post for getting a
paracetamol tablet, over 6 km for a blood test, and nearly 20 km for hospital care.
It is the private health sector to whom people look forward. The middle class and
rich people prefer the medical services from the private sector. According to
National Family Health Survey – III, in India, the private medical sector remains
the primary source of health care for the majority of households in both urban
areas (70%) and rural areas (63%).Even the quality of private sector is also
questionable.
Whenever there is medical and surgical emergency including the
emergencies caused due to accidents, the patient is usually referred to the
nearest city hospital after providing first-aid treatment. In very complicated and
serious cases, the patient is further referred to big cities for treatment,
irrespective of his/her family's financial condition. Sometimes, in these big cities
too, the hospitals again refer these patients to specialty/super specialty hospitals
for management. But the problem arises when these super specialty hospitals,
which are the last hope for the poor and helpless families, are themselves ill and
mismanaged. Most of the time, these big hospitals turned out to be of no use for
the common man at the time of need. This happens because there is an
unofficial dual system of health care delivery in India. The kind of services the
people are entitled depends upon their economic status.
Emergency services are said to be the face of any hospital setup. The
reputation of a hospital often depends upon the quality and promptness of its
EMS. Most emergency departments in government hospitals and centrally run
universities in India do not match up to the “Emergency Department
Categorization Standards” proposed by the Society of Academic Emergency
Medicine. In India, the emergency care is offered in areas designated as
“casualties” that are often manned by junior specialty residents with little
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overview and experience. Those who are most experienced in handling
emergencies are usually not posted in causalities. Sometimes, doctors from the
pre-and para-clinic subjects are posted to treat the emergency patients,
particularly in cases of strikes of clinical doctors, and very rarely they are well
equipped with the skills and experience to save a precious human life. By this
kind of arrangement, the hospitals try to put every thing in place on the paper but
compromise on the quality of EMS. So, the ultimate sufferers are the patients in
distress.
The pre-hospital care is a neglected issue in India. No formal pre-hospital
care was offered in 85% of the trauma patients as reported in a south Indian
study. Triage, something that is instrumental to good emergency care, is rarely
practiced. There are no guidelines or regulations on the issue of pre-hospital care
in most of the tertiary hospitals across the country. Most of the time, the emer-
gency/casualty department, particularly of district-level hospitals, merely acts as
“referral points” for specialized care in big cities. Problems are worse in rural
areas where even the most basic emergency obstetric care has been found to be
lacking.The CHCs have not been developed enough to cater injuries occurring
during small accidents. At most of the CHCs, the blood storage facilities are not
available, thus rendering EMS ineffective in cases of emergency delivery cases.
Along with it, there is no centralized emergency response body to coordinate the
EMS in India.
2.RELUCTANCE IN HANDLING MEDICAL EMERGENCIES
It is an accepted norm across the world that in injured and critically ill patients,
the priority of the doctor is to save life. However, often there is reluctance on the
part of doctors to attend to the emergency needs of patients who, in medical jar-
gon, are medico legal cases. This unwillingness is largely due to medical profes-
sionals being unaware of their ethical and legal duties concerning the treatment
of those brought to an emergency department. Also, there is an instinct among
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doctors to evade the inconvenience associated with subsequent lengthy and tire-
some legal proceedings. This is despite of the fact that the Supreme Court of In-
dia has clearly stated that the first obligation of a doctor is to save life and docu-
mentation and paper work could be performed later on. The court ruled that “zon-
al regulations and classifications regarding the jurisdictions of specialized police
stations and government hospitals in a given area could not operate as fetters in
the process of discharge of this obligation (to treat an emergency/injured victim).”
In a concurring judgment, the court observed that “when a man in a miserable
state, hanging between life and death reaches the medical practitioner (either in
a hospital run or managed by the state, public authority, or a private person or a
medical professional doing only private practice), he is always called upon to
rush to help such an injured person and to do all that is within power to save life.
It is a duty coupled with human instinct which needs neither decision nor any
code of ethics nor any rule or law.”
Another factor for showing reluctance to serious emergency cases is to avoid the
mortality in one's own hospital, particularly in case of private hospitals. More
complicated cases are referred to higher center, particularly the government sec-
tor, because death of patient in their own hospital would bring bad name to the
reputation of the hospital. Also, in case of death of their patient, the relatives of-
ten restores to manhandling of doctor/paramedical staff and damaging the hos-
pital property. The action of police and local government administration like im-
mediate arrest of doctor under mob/public pressure is another important issue.
These kinds of incidences are increasing day by day and thus are responsible for
doctors not handling the emergency cases (particularly medico legal cases). This
practice further leads to frequent referral of emergency patients to government
hospitals, thus wasting the crucial time during which the serious patients could
have been saved. Also, at government hospitals, there are no clear-cut demarca-
tion of duties and responsibilities in emergency department. This leads to further
delay in timely emergency services.
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India is a country of paradoxes. On one hand, it has new corporate hospitals for
attracting medical tourism and on the other hand, it has not been able to provide
the basic primary health and necessary emergency services to the masses.
There is a serious scarcity of working diagnostic machines, medicines, and infra-
structure in its hospitals. Following are some issues related to emergency ser-
vices which should be seriously discussed involving various stake holders
without any further delay.
3.CREATION OF CENTRALIZED MEDICAL EMERGENCY BODY
Trauma continues to be one of the major causes of death in India. To
avoid preventable deaths and disabilities, India needs a common effective sys-
tem that could provide quality emergency care with equity of access. As com-
pared with developed countries with proper emergency systems in place, there
was no single system which could play a major role in managing EMS in India.
There was a fragmented system in place to attend the emergencies in the coun-
try. In a bid to address this problem, the Centralized Accidents and Trauma Ser-
vices were set up by the Delhi Government in the early 1990s. This service was
later expanded throughout the country. Unfortunately, it did not succeed despite
having a toll free number -102 which is the emergency telephone number for am-
bulance in parts of India But, there are different emergency numbers in different
states and Union Territories. So, there is an urgent need of a centralized Medical
Emergency body which could provide guidelines for setting up emergency ser-
vices with a single telephone number across the country. The centralized body
should be involved in preparing protocols, imparting technical assistant, training,
capacity building, and accreditation of emergency services. Procedures, proto-
cols, and personal skills need to be standardized along with formation of legisla-
tion in parliament to provide legal protection for the providers of emergency ser-
vices The initiative taken by the Gujarat state government in setting up the Gujar-
at Emergency Medical Services Authority is a welcome step in right direction.
This was the first state to actually pass emergency services regulation in the
country. By bringing together government, non-government organizations
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(NGOs), and other private agencies, a state-wide system of emergency care has
been set up in Gujarat If India could have Securities and Exchange Board of In-
dia, Telecoms Regulatory Authority of India, and Insurance Regulatory and De-
velopment Authority to regulate share market, telecoms, and insurance services,
respectively, then setting up a regulatory body for regulating the health services,
particularly emergencies, could also be considered seriously.
4.FIXING RESPONSIBILITY AND ACCOUNTABILITY.
There should be clear-cut demarcation of duties and responsibilities in the
emergency department. The duty roster including the contact number of con-
cerned doctors should be assessable to public eyes. In case of grievances, there
should be a responsible mechanism to address the complaint right there at emer-
gency. Public relation officers should be posted at the emergency to handle the
public grievances. The guidelines by the Supreme Court of India should be man-
datory displayed publicly at emergency so that the doctors could be reminded of
their duties and rights and the patients could claim treatment without failure. Most
of time, the junior doctors have to face the ire of unsatisfied relatives of patients
even when they are not responsible for procurement and maintenance of logist-
ics. If the logistics are not in place or not working, this information should be
brought to the notice of general public by publicly displaying the list of no avail-
able services and logistics (which are supposed to be available in that hospital)
and contact number of the senior officers/bureaucrats responsible for decision
making. If the government is not providing the required fund and support, then it
should come to the eyes of people through audit by authorized audit agencies.
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5. IMPLEMENTING HOSPITAL MANAGEMENT
TECHNIQUES
The whole system of procurement of manpower and materials (including
machinery and equipments/drugs), particularly in emergency department, should
be managed with hospital management techniques. The time frame for every
step of procurement and maintenance of emergency services should be clearly
predefined. There should be introduction of compulsory "Annual Maintenance
Contract" (AMC) clause for every purchase of medical equipment and its annual
renewal. The companies not honoring the AMC should be black-listed. Strict ac-
tion must be taken against those officials who sit on important files in greed of
personal gains and are responsible for the delay in procurement and mainten-
ance of life-saving drugs and equipments. If private/corporate health sector could
practice good management techniques and succeed in their business ventures,
why it cannot be replicated at government hospitals? To avoid mishandling with
hospital staff, provision of adequate security at emergencies is required to protect
the doctors from the wrath of patient's relatives and friends.
At present, the peripheral level health centers, i.e., S/C, PHC, and CHC, are
nothing more than the referring centers. Even the basic life-saving services, man-
power, and medicines are seldom available at these centers. As on March, 2008,
as compared with requirement for existing infrastructure, there was a shortfall of
70.9% of Surgeons, 70.4% of Obstetricians and Gynecologists, 70.6% of Physi-
cians, and 77.4% of Pediatricians at CHC level in India. Overall, there was a
shortfall of 72.1% specialists at the CHCs as compared with the requirement for
existing CHCsThus, the patients who were referred to CHCs were just referred
there for the sake of referral and to fulfill formalities. If these centers, particularly
the CHCs, were equipped with basic life-saving facilities, then the patient could
be stabilized there and then referred ahead. Thus, life of lot of emergency pa-
tients could be saved. Under the National Rural Health Mission, the Indian Public
Health Standard (IPHS) guidelines have been framed which consists of the ser-
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vices, infrastructure, manpower, equipments, and drugs (to be provided at S/C,
PHC, CHC, and District Hospitals). The IPHS guidelines considered these ser-
vices in two categories of Essential (minimum assured services) and Desirable
(the ideal level services which the states and union territories should try to
achieve. But still, these IPHS guidelines have not been made mandatory and not
implemented fully across the country. The implementation of IPHS will certainly
help in handling of emergency cases at CHC or at least ensure provision of life-
saving procedures before referral to higher centers. In this way, the burden on
higher health centers will also decrease in the long run.
6.MODIFICATION IN MEDICAL EDUCATION
CURRICULUM
The subject of EM has not been given the importance it deserves in Indian
medical education system. The task force on “Medical Education for the National
Rural Health Mission” constituted in 2005 under the aegis of MOHFW, GOI, has
noted that within the time allotted to nonclinical subjects, a considerable portion
is going into practicals. It observed that in some of the nonclinical disciplines—
Pharmacology, Biochemistry—little purpose is served in allotting a significant
portion of time. The task force suggested that the allocation of time to nonclinical
subjects may be reviewed and should be made pertinent to applied aspect. Simil-
arly, in case of internship, the common perception is that the students fritter away
the period of internship. This is a year when the theoretical training is over, and
the student is expected to learn hands-on knowledge during his/her attachment
to various departments Most of the time during internship, the emergency duty is
optional in many medical colleges across the country. The emergency duties
should be made compulsory during internship and their tenure should be at least
one month. After the completion of the internship, there should be a compulsory
practical test to assess whether the interns have gained enough competencies to
provide certain basic emergency care independently or not.
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There is a dearth of Postgraduate (PG) EM professionals in India. Very few insti-
tutes/medical colleges in India offer PG in EM. Thus, most of the emergencies
are handled routinely by the concerned department after getting the call from ju-
nior resident/Emergency Medical officer. There is no separate department of
emergency in many medical colleges in India. The emergencies are run by differ-
ent units of all the clinical departments on rotation. In view of this, there is urgent
need to create separate departments of EM. The PG courses in EM should be
commenced as soon as possible in the medical college hospitals. This will create
a cadre of qualified doctors in EM in the long run and will change the face of
emergency handling in India. Similarly, a cadre of Paramedical staff likes nursing,
technicians, and attendants should be trained specifically in EM.
The doctors from pre- and para-clinical side are involved in teaching and re-
search most of the time. Because of this, they remained cut off from the direct
patient management. After few years of service, these doctors are short of know-
ledge regarding latest emergency management protocols and their clinical skills
got blurred by passing time. So, in case of mass causalities and natural dis-
asters, though these pre- and para-clinical doctors are counted as the available
skilled medical work force, in actual only few are competent enough to handle
emergency patients. This “pseudo-workforce” obliterates rather than facilitating
the emergency relief work. So, there is an urgent need for capacity building of the
pre- and para-clinical faculty. There should be an introduction of one-week “prac-
tical capsule course in emergency medicine” for every faculty member irrespect-
ive of his/her academic post. The faculty should be mandatorily made to attend
this course every year and the curriculum of this course should be revised peri-
odically.
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