1. Global Challenges in implementing
Emergency and Trauma Care Models
Dr Sanjeev Bhoi MD,FACEE
Associate Professor of Emergency Medicine
JPN Apex Trauma Centre
All India Institute of Medical Sciences
New Delhi-110029,India

2. 11.30PM ED
11.30PM: Shifts Starts
11.32: P1@Chest pain, sweating
11.35: P2@polytrauma
11.45: P3@unresponsive
11.50: P4@DKA
12:00: P5@Vaginal Bleed

4. Anybody@anytime@anyproblem
Oh my god………..
How do I manage?

5. Time dependent @acute care
• Golden Hour
• Silver Hour
• Bronze Hour
Platinum period of Golden Hour

6. Burden of Trauma
Trauma: It’s a modern epidemic @low to
middle income group countries
– 16,000 person dies due to RTI@ day@ globally
– 90% of mortality @developing nations
– 1,34,000 died in India (2010-11)
– Every 6 min@ RTI @ India

7. Demands a system to care for acute care

8. World Health Assembly Resolution
60.22 and Its Importance as a Health
Care Policy Tool for Improving
Emergency Care Access and
Availability Globally.

9. USA,UK,Australia
EM and Trauma care Models
•Challenges
•Opportunities
•Leading the way

10. Challenges
in
Establishing
Academic Emergency Medicine model: an
Indian Journey

11. • Current Status of Emergency care
• Current status of Academic Emergency
Department in India
• Academic model for EM training in India.

12. Current Status of
Emergency care in India

13. Be @ Billion

14. Emergency care-Govt .Sector
Ramanujam et al JAPI 2007
• Free care, but quality of care varies
from center to centers.
o Manned by CMOs. Or Non trained staff of junior
grade.
o Lack of equipment and infrastructure
o University hospitals have reasonable care

15. CMO
 Casualty medical officer
 Acts as a Post man
 Usually a non trained Junior
Staff.
 Flying Birds
◦ Residents rotate in Other
specialty
◦ usually those who prepare
for PG.
Allagappan K et al
Ann Emerg Med1998
9/27/2013

16. Prehospital and Disaster care
 Pre-hospital care underdeveloped.
 Disaster response lacks coordination and
communication.
 Negative impact in Outcome.
 26% has definitive disaster plan.
Position Statement: Academic Emergency Medicine in India: JWG: JAPI 2008
Joshipura MK et al Indian J Crit Care Med 2004

17. CYCLE RICKSHAW TO AIR AMBULANCE
9/27/2013 Criticare 2012

18. Pre-hospital care in India
Bullock cart to Air ambulance
 Pre-hospital care underdeveloped.
 Usually a transport vehicle
 Perhaps reinforcing the existing network of informal providers
of taxi drivers and police
 Training, funding quick transport with taxes on roads and
automobile fuels
 Regulating the private ambulance providers, could be more
cost-effective in a culture in which sharing and helping others
is not just desirable, but is necessary for overall economic
survival.
Roy et al : Where there are no emergency medical services-pre-hospital care for the injured
in Mumbai, India. Disaster and Pre hospital care 2010 Mar-Apr;25(2):145-51.

19. • Current Status of Emergency and Trauma care
• Current status of Academic Emergency
Department in India
• Academic model for EM and Trauma training
in India.

20. • MCI recognized Academic ED : Infancy
• Non –MCI recognized : Deemed university
Current Status of Academic Emergency
Department

21. • Lack of national consensus
• Parallel departments: Major roadblocks
• Lack of administrative support .
• Lack of Interest among the faculty.
• Lack of Job Security.
• CMO as derogatory.
Hurdles

22. • Manpower not Trained.
• Lack of united advocacy to Medical Council of
India
• Bright young clinicians who once
demonstrated a keen interest in EM have
eventually migrated to other conventional
branches of medicine, due to the lack of MCI
recognition and the lack of specialty status.
Hurdles

23. • Lack of awareness, importance about EM.
• Lack of coordination among Medical colleges.
Hurdles

24. • Degree
• Duration of Course
• Curriculum
• Faculty Development
Hurdle: Lack of Consensus

25. • Apollo Hospital- Hyderabad & Royal College
Of Emergency Medicine-United Kingdom
• Eligibility For PG program(MCEM): MBBS with
MCI registration.
Duration For PG(MCEM): Three years.
Indigenous Efforts

26. Malabar Institute of Medical Sciences
International Fellowship in Emergency
Medicine
Two Year Postgraduate International
Fellowship in Emergency Medicine (IFEM)
under George Washington University U.S.A.
Indigenous Efforts

27. • Positive Impact:
– Awareness about the importance of EM
Negative Impact:
– No uniformity in degree, duration .
– No Structured curriculum exists.
Indigenous Efforts

28. • Parallel Departments did not allow it to grow.
• Acute care is the cream.
EGO and Power Struggle

29. • Lack of administrative support.
• Equipment and staff to man the ED.
Cold Attitude

30. • Lack of Interest among the faculty because of
shift duties.
• Designation of CMO derogatory.
• Job insecurity
• Bright young clinicians who once
demonstrated a keen interest in EM have
eventually migrated to other conventional
branches of medicine, due to the lack of MCI
recognition and the lack of specialty status.
Disinterested Individuals

31. • Faculty
• Nurses
• Paramedics.
Non-Trained Manpower

32. • Recently (Unconfirmed Reports): MCI has
recognized EM as a specialty.
• The criteria for starting MD EM is difficulty to
meet .
• Lack of EM Trained faculty.
• Difficult to motivate people of different
specialty to devote academic time for the
development of Academic ED
Difficult Criteria-MCI

33. Championing Playing for Change
• Leadership
• Ownership
• Making a Team
• Connecting ideas into reality
• Introspecting within

34. Ownership
Mine Ours

35. Leadership

36. Making a Team
Team- Team

37. Immediate
• Change the Name from
Casualty to Department of
Emergency Medicine.
• Convince the Administration
and the Dean about the
concept of Emergency
Medicine.
• Post dedicated manpower in
ED based on annual patient
inflow.
• Restructure ED based on
existing models
• Train manpower on
resuscitation.

38. • Recognize the specialty of EM as a distinct and
independent basic specialty
• Initiate postgraduate training in EM, thus enabling
EDs in all hospitals to be staffed by trained
Emergency physicians
• Uniform and Democratic tailormade Curriculum
• Ensure that EMs are staffed by trained ambulance
officers.
Long term Measures

39. • American
• European
• Australian
• Indian Model: Needs to be developed
Models Available

40. Indo-US Collaboration – 2005

41. Academic Council

42. Journal Of Emergencies Trauma and
Shock -2009

43. Platform for Research

44. News Letter

45. Milestone

46. • Current Status of Emergency care
• Current status of Academic Emergency
Department in India
• Academic model for EM and Trauma care
training in India.

48.  EMS is Independent - Infancy
 Triage Area (outside or Bedside)
 Trauma & Medical Resuscitation Areas
 Minor Emergency Area
 Intermediate care Area
 ENT, EYE, Gyn Rooms
 Isolation rooms
 Fast Track
 Pediatric ED
 Laboratory & Radiology in the Department
www.acgme.org
Red,yellow,Green Zones
Academic Emergency Department

49. • Poison Center
• Biodefense Center
• EMS Network with EMS Personnel
• GYN Outpatient Network
• Research Center
• Center for Simulation Technology
• Trained Nurses in various Areas
www.acgme.org
Academic Affiliations

50. Academic Training Pillars in Emergency
Medicine and Trauma

51. Faculty Development
www.facetindia.org

52. Do you have in you to move from
parent speciality to EM??
Leadership
Creating Meta-Leader

53. • Students
• Residents
• Fellows
• Nurses
• Paramedics
Academic Training in Trauma and Emergency
Medicine

54. • Mandatory one month training (Adult, Pediatrics,
EMS)
• ED Medical Student Clerkship Director
• Lectures by EM faculty and Senior Residents
• Procedures, Presentation & Practice
• Central Lines, Foleys,, Chest Tubes, Lacerations,
Joint Reductions, Abscess Drainage. (Daily
Evaluations)
• Students can do elective months
15 days @casualty posting @intern
Emergency Medicine Rotation for Medical
Students

55. • Third Year Surgical Clerkship
• Fourth Year Critical Care Clerkship
• One Month Rotation
• Lectures, Practical Ward Work, Procedures
• Daily Evaluations
• Students can do more Electives
• Students graduate with ACLS Training
Recently started @ Final Professional
Trauma Rotation for Medical Students

56. • Core Need for Training
• Branch of Volume
• Three to Four Years Post Medical School
• Speed, Knowledge and Precision
• Procedures, Protocols, Practice
• Residency Director, Residents, Rotations
• Trauma Rotation Two Months in Three Years
• Elective month available
Emergency Medicine Residency
USA Model

57. • Emergency Department 200 hours per month.
(18 months includes Peads)
• Trauma 80 hours a week for (2 months)
• EMS, Orthopedics, Toxicology, ENT, EYE, Anesthesia, Ne
urosurgery, OB/GYN, Research, Elective, Medicine, MIC
U, CCU, Psychiatry, Radiology (16 Months)
Daily Evaluations & Six Monthly Feedback
Need to develop Locally feasible model
Emergency Residency Rotations

58. • Five Years of Surgical Training
• Annual Contract
• Every Year Trauma Rotation one to two Months
• Second Year is Four to Six Months of Trauma and
Surgical Critical Care
• Ward, OR, Units and Resuscitations are run by the
Trauma Teams
• ED Services are very important to a busy Trauma
Team
Trauma Training in Surgical Residency

59. • Integral Part of the Residency
• Working at Level One Trauma Center
• Six Months of Ortho Trauma Services in Four Years of
Residency
• Orthopedic Service assumes care once cleared by
Surgical Trauma
• Orthopedic Trauma consults on Surgical Trauma
Patients
Residents are posted to Trauma Centre@6months
Trauma Education in Orthopedic Residency

60. Nurses and Paramedic Training

61. • Post Bachelors Training
• ED and Trauma Job Exposure
• Clinical Ladder, Leadership and education
• Regular Training Programs
• EMS Curriculum dependent on Hours to achieve
different status to provide Care
• Training is Mandatory to work in Trauma Areas like
ED and Critical Care
Started Academy for Clinical Emergency Nursing
www.acenindia.org
Nurses and Paramedic Training

62.  Mandatory to all Surgical, Emergency and
Health Disciplines including Nurses and
Paramedics
 ACLS and PALS is Mandatory
 EM, Trauma and Surgical Specialties do ATLS
and NALS
 Instructor Status also Available
 AHLS is a new Module but not Mandatory
Resuscitation Training

63. Think Global Act Local
Cost-effective

64. Empowering Skills

66. Will it work
with
school kids ?

67. CBSE Curriculum- 2011
School Systems to
consider “introducing a
fourth „R‟- resuscitation,”
to traditional 3R‟s of
reading, writing and
arithmetic

68. Spreading across India

69. The time is ripe for a paradigm
shift, since the country is aware
that emergency care is the felt
need of the hour and it is the right
of the citizen.
David S et al

70. “Miles to walk before we sleep in the Journey from
Casualty to Emergency Medicine.”