10 Experiences & 8 Aspirations

in Prehospital emergency and trauma care @ 108 GVKEMRI- TN

Dr G. V. Ramana Rao MD
Director Emergency Medicine Learning Centre and Research
GVKEMRI
1. Integrated approach in design stage
Sense- Reach- Care
Medical, Police and Fire
Four wheel and 2-wheel ambulances
Primary Transport and IFT
Individual emergencies and MCI
 Process @ GVKEMRI

Sense Care Follow up

Reach
after 48 hrs
Building Blocks of GVK EMRI

3 digit toll-free No. Accessible Modern, spacious and open ERC GIS / GPS to locate victim / ambulance and
from Land lines and Mobile hospital
phones

Cost effective Trained personnel

ambulances providing PHC
to provide quality care
for Indian emergencies
with facilities for
rescuing and balancing
patient care with
public safety and
patients relatives
comfort
2. Training Standardization
Foundation and Refresher
Emergency Medical Technician (EMT);
Pilot (Ambulance Driver);
Call Agent (Emergency Response Officer- ERO);
Doctor (Emergency Response Centre Physician- ERCP);
Supervisor (Emergency Management Executive EME)
 Glimpses of Internal training

6
 Skill Stations

Skill Station - Airway Management Skill Station - Basic Life Support

Skill Station - Vitals & IV Cannulation Skill Station - Patient Assessment

7
 Training EMT

8
 EMT Preparatory Procedure Log Book

List of Skills to be practiced in Hospital and Ambulance Phase

Goal Completed
Airway Management
Head Tilt and Chin Lift 25
Jaw thrust 25
Oropharangeal airway 20
Nasopharyngeal airway 20
Auscultation of the Chest 20
Bag-Valve Mask Ventilation 20
Airway Suctioning 25
Nebulisation 10
O2 administration - 1) Nasal cannula 2) O2 Mask 25
Pulse Oximetry 25
Vital Signs Assessment
Pulse rate, Quality and rhythm 25
Respiration Rate, Quality, Effort 25
Measure Blood Pressure 25
Skin- Colour, Temp, Condition, Capillary Refill 25
Pupils 25

Controlling Profuse Bleeding 25

IV access and cannulation 25

Blood Glucose level assessment by Glucometry 20
ECG Lead Application 10
Splinting and Bandaging 25
Nasogastric/Orogastric Tube Placement 10
Medication Administration: IV 25
Medication Administration: Oral or Sublingual 10
Medication Administration: Subcutaneos or Intramuscular 25
Medication Administration: Nebulizer/ETT 10
Foley`s Catheterization 10
Cardiopulmonary Resuscitation 10
Removal of Foreign body(Airway) 10
Patient Assessment 25
Assess and Treat Chest Pain Patient 10
Assess and Treat Respiratory Patient 10
Assess and Treat Abdominal Pain Patient 10
Assess and Treat Altered Mental Status/Seizure Patient 10
Assess and Treat Stroke Patient 10
Assess and Treat Syncope Patient 10
Assess and Treat Trauma Patient 25
Assess and Treat Burns Patient 10
Assess and Treat Poisoning Patient 10
Assess and Treat Pregnant Patient 10
Assess and Treat Pediatric Patient 10
Assess and Treat Infant Patient 10
Normal Delivery 10
AED operation 10
Spinal Motion Restriction (Spinal Immobilisation) and Helmet Removal 10
Lifting and Moving 25
PCR Documentation 25
ERC physician communication Observation
Handling of the equipments Observation
Handling of Camera and equipemts Observation
Maintainance of the records of ambulance equipments Observation
Training Kit (Refresher)
 EMLC Training
EMTs 4266
2016 - 345
Foundation
Training
PILOTs 4219
2016 - 252
EMLC
EMT 4996
2016 - 1044

Refresher
Training
Pilot - 5190
2016 - 1263

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 Training

Training

EROs ERCPs EMEs

828 (2017) - 2 53

12
3. Evidence based Pre-hospital EMS protocol
development for India
Chief complaint based
Brief description
Each protocol role of EMT/ role of ERCP/ special conditions example
paediatric age group
Included IFT and ED care in low resource settings
Revised (2nd edition)
14
15
16
4. Care Standardization:

At Ambulance Station On-Scene

Receive information from DO and note down Scene size up
Scene safety
Patient name, age , gender Body substance isolation precautions
Complaints No of patients
Mechanism of injury/nature of illness
Location and address Assess requirement of additional resources
Nearest landmark Cervical spine precautions
Initial assessment
Contact no of caller
General impression
En-Route to Scene Mental status
Airway, Breathing , Circulation
Call back to the caller to confirm address
Focused history and physical examination-examination of body systems
Collect available patient data/complaints
Immediate interventions as per requirement
Pre-arrival instructions to caller CPR
Suction
Keep necessary medical equipment and supplies ready to use.
BVM ventilation
Check the functionality of equipment Bleeding control
EMS (Pre-Hospital Care)

En-Route to Hospital At Hospital ED

Position
Oxygen therapy/ventilation as needed
Inform Casualty
Vital signs monitoring
Check vitals and hand over the patient
Past history (Past illness, allergies, medication)
ERCP advice online medical direction
Hand over valuables and take signature
Interventions as per advice Hand over completed PCR copy and take signature from
Medications as advised by ERCP Hospital authority
IV fluid therapy Back to Base.
Other emergency procedures as needed
Close the case in communication with ERO
Ongoing examination
Clean the ambulance and keep ready for next case.
(5 mts / 15 mts unstable/ stable pts.)
Repeat vital signs monitoring
Repeat initial assessment, mainly mental status and ABC
Repeat Focused physical examination
Re-assess interventions
Document data in PCR form
Inter-facility Transfer (IFT) Guidelines
5. Care - Monitoring and Supervision
Average handling time
Response time
On scene time
Travel time
In hospital time
Total cycle time
4. Pre-hospital Care Services Medical
Oversight
EMT & ERCP Evidence based Protocols
PCR documentation
En-route complications report
PCR based Research and Analytics Report
State level and district level periodic reviews
Critical cases segregation and lives saved processing
 TN ERCP cabin

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OLMD documentation
CONVERGENCE BETWEEN EMS and DMs

24 X 7 Services
Robust communication network
Surge capacity for high call load
Well laid out DM & MCI Protocols
Well Equipped Ambulances
Integrated Ambulance Network
(IAN)
Trained Paramedics
Quick Response Times
Personal Protection Equipment
On-site Triage and Treatment
protocols
Evacuation protocols
En-route treatment
On-Line Medical Direction by
Medical Professionals

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 Quality- Standards and Patient Safety
Quality
Go-live audit
ERC daily quality audit report of EROs
Ambulance: KMPL./ ambulance accidents.
CARE: PCR Audits / ERCP categorization of EMT performance.
SMS based feedback quality of care
SIRO certification by GOI
ISSN number for IEJ

Standards
Patient Safety Technology support for automation of Emergency
Response Center (ERC) Call reception to ambulance
Personal Protection Equipment (PPE)
dispatch.
Vaccination of Emergency Medical Technicians (TT, Hep. B, Case closure
Swine flu) Ambulance specifications vehicle selection
Scene safety Ambulance Committee specifications for medical
Ambulance sanitization equipment, consumables
Safe Driving Practices EMT Training: Standardized training curriculum/ log book
Ambulance Preventive Maintenance for skills practice/ Objectively Structured Clinical Evaluation.
Fire Extinguisher Pre-hospital Care Protocols (with Stanford Collaboration)
Patient moving, lifting and fixing On-Line Medical Direction for critical cases
Public Address System Transfer (Patient Handover and Inter Facility)
Unique ID for every Emergency PCR Documentation
Voice logging 48-follow up process
Life Saved Assessment Process
Business Continuity Plans
Shift handover and take over
Manikin based simulation training Medical Equipment Maintenance

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6. Pre hospital Care
Documentation
 PCR-TN- Trauma Case

28
 TN PCR Department

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7. Care- Analysis and Evaluation
Type of emergencies
Critical and non-critical
OLMD per cent
Government, private and trust hospital
Primary and IFT
 PCR

PCR

PCR form Enroute

Critical cases OLMD
collected Live saved 16684 complication
35519 /month /month 68% 17/month 40465/month
101617/month
25% 0.006% 41%
87%

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 EMT EVALUATION (CHART:07)

PCR RECEIVING FROM TRACKING TEAM

DISTRICT WISE
LOCATION WISE

PCR EVALUATION
BY EMTs

SERIOUS
PDOA VNSH
NON-SERIOUS (AS PER CRITERIA)
(PRESUMED DEATH ON ARRIVAL) (VICTIM NOT SHIFTED TO HOSP.)
REF.: ANNEXURE: 7.1

EVALUATED 6 EVALUATED 12
TO SEND ARCHIVE SENT TO ERCP
CATEGORIES CATEGORIES
DIVISION EVALUATION
REF.: ANNEXURE: 7.2 REF.: ANNEXURE: 7.3

SENT TO DATA
MANAGEMENT
TEAM
 Enroute Complication Report
S. No Parameters Number of Cases - 17
Age
Infant 1
1
Adult 10
Geriatric 6
Gender
2 Male 3
Female 14
Type of Emergency
Medical 10
3
Trauma 6
Environmental 1
Cause of Death
Head Injury 5
Respiratory distress 6
Myocardial Infarction 2
4
Hematemesis 1
Poisoning 1
Unresponsive 1
Renal Failure 1
Type of transfer
5 IFT 15
Scene 2
Enroute stabilization
6 Yes 12
No 5
ERCP Advice
7 Yes 13
34 No 4
8. Care- Research and Development
Sudden Cardiac arrest registry
Recognized by Department of Science and Technology, GOI as research
organization
Member Global Resuscitation Alliance
Consultant Road Safety, Government of AP
National Ambulance Code
Pre-hospital Trauma Care Guidelines WHO/ GoI (2011)
World Health Organization (WHO) -Emergency Care Systems, for LMIC,
2017.
Telephone CPR
Research Publications in 2016
 Cause of Trauma in Paediatrics:

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 Results-Type of Emergency

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 Destination Hospital and Follow-up:

Out of 9517 injuries, 5401(57%) were admitted to the hospitals. Majority (71%)
were transported to the government hospitals, 26% to private hospitals and 3 % to
trust hospital. GVK EMRI follows up the callers at 48 hours for feedback information
on patient status and quality of services. Unfortunately feedback was very poor; only
6% (321) of the callers could be contacted. Of these, 265(83%) said injured were
recovered and discharged from hospital, 11(3%) were still in the hospital but stable
and 5 (2%) children died. 40(12%) said they did not know as they were bystanders.

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 OLMR States: Trauma Sample Distribution

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 Demographics

Overall enrolled patients were predominantly young (median

age 36 years; IQR: 25-50) and male (71.8%; N =2118).

Overall, 40.9% of patients lived on incomes below the poverty

level and 64.4% were BC, SC, or ST. Approximately 74.5%
(N = 2187) of enrolled were from rural or tribal areas.

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 Distribution of Injury Type

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 Distribution of Type of Hospitals Admitted

Of the 2939 patients initially enrolled, 2854 (97.1%) were successfully transported to health facilities.
A total of 22 (0.7%) refused initial care and 3 (0.1%) were transported midway and then refused care mid-
transport. An additional 25 (0.9%) patients were determined to have only minor injuries and the EMT
cancelled transport. Finally, 34 (1.2%) patients were dead prior to arrival and were not transported to
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health facilities for care.
 Transportation Times lines from call to hospital

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 EMT Assessment and Interventions

Of patients with measured vital

signs, 18.1% (N = 527) had an
abnormal blood pressure, pulse, or
respiratory rate.

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 Morbidity and Mortality

Call response rates at 2, 7, and 30 follow up days were 75.6%, 73.2%, 70.5%,
respectively.

The majority of patients died either before ambulance arrival.

The cumulative mortality rates at 2, 7,and 30 follow up days were 4.5%, 5.0%,
and 5.8%.
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 Health status at 30 Days, patient self-report

At 30 days, a significant number of individuals reported some problems or extreme

problems across a broad range of health status domains.

Approximately 1 out every 4 patients surviving to 30 days had some problem with at
least one area, whether mobility, ability to care for oneself, ability to complete usual
activities, daily pain or discomfort, and/or anxiety or depression.

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9. Emergency Care Centres
(Trauma Centre- Level 3B)
 Emergency Care Center
Apr'17 -
Description Sep'17(last 6
Since Inception months)

Total Number of cases 18661 4098

Medical cases 11758 2329

Trauma cases 5163 1355

Environmental cases 1740 414

Critical cases 11540 2551

Live Saved Percentage 94% 94%

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 10. Collaborations (2011-12)
Pre-Hospital Care Protocols
District Hospital Physician Program (DHPT)
Paramedic education
Instructor Development / CME / OLMR

Provider - Basic and Advanced

Instructor Courses
Global Development Committee member
Best trauma case for annual global meet
Indian publication of Manual

BLS/ ACLS/ PALS Provider and Instructor

Programs
STEMI INDIA
Regional faculty CHARITABLE TRUST
Quality conceptualization SERVICE AGREEMENT FOR TAMIL NADU
invitation to Bangladesh first AHA course STEMI PROGRAM

ALSO - Provider and Instructor course

BLSO- Provider and Instructor Course
Joint paper in International conference
Invitation to Ethiopian ALSO

Student Exchange program

Faculty exchange program
Joint research

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National Trauma Research Institute (NTRI)-
Melbourne, Australia
 Stanford GVK EMRI Partnership

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Aspirations
1. Criteria Based Dispatch
Priority dispatch for chest pain, stroke, poly trauma etc.
2. Ambulance crew
Advanced EMT and Basic EMT in every ambulance (to start with
ambulance locations with more than 8 cases per day)
3. Strengthening of medical equipment and
consumables
Supra-glottis airways Laryngeal Mask Airway (LMA)
Haemostatic pads
Injection Tranexamic acid
Use of tourniquet
Ultrasonography use
Colloid usage
ECG tracing
4. Introduction of measurements of severity
of trauma
Injury Severity Score (ISS)
Glasgow Coma Scale (GCS)
5. Backward linkages- Community level
108 app
First Responder Program
Road safety
 Glimpses of training FR

First Responder Training

61
6. Technology applications- next level
ePCR
Pre-Arrival Information (PAI)
Hospital Information Systems updated periodically through
coordination
7. Forward linkage: Regionalization of
emergency and trauma care
Referral matrix for medical, trauma, paediatric and obstetric
emergencies at district and regional level.
Principle of 5S
1. Speak to EMT for patient arrival information
2. Single Point of Contact
3. Speeden case handover
4. Stamp on Ambulance Trip Sheet
5. Share the Diagnosis (CC to Prov. Diagnosis)
(SPOC, SPEAK, SPEEDEN, STAMP, SHARE)
8. MCI and DM focus
108 as disaster management number in addition to medical, police
and Fire.
Emergency Medical Response Triage- Integrated Ambulance
Networking
Prehospital Care TN (Summary)
Experiences
1. integrated model
2. Training - standardization
3. EMS Protocol Development
4. Care- standardization
5. Care Monitoring & Supervision
6. Care Pre hospital Care Documentation
7. Care - Analysis and Evaluation
8. Care- Research and Development
9. Emergency Care Centres
10. Collaboration
Aspirations
1. Criteria Based Dispatch
2. Ambulance Crew
3. Strengthen ME, Drugs etc.
4. New measures of care
5. Community Awareness
6. Advanced Technology Applications
7. Regionalization of emergency and
trauma care
8. MCI and DM focus
TN- Pre hospital services
108 GOTN/ GVKEMRI
Pre hospital services in TN launched on 15th September 2008 as PPP
849 ambulances
13494 calls per day 3603 emergencies responded every day
Since inception 6,667,629 emergencies responded till date
427,258 lives saved
30,651 deliveries assisted till date
 Trauma cases

Trauma

Trauma (Vehicular) Trauma (non MCI(Trauma)

18974/month Vehicular)5429/month 228/month

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Prioritization of Injury problem

RTA 1
Work related 2
Burns 3
Violence/ suicide 4
Poisoning 5
Drowning 6
Pre- Hospital Care
(Emergency Medical Services EMS)
Emergency medical services are
A network of services coordinated to provide aid and medical assistance from
primary response to definitive care, involving personnel trained in the rescue,
stabilization, transportation, and treatment of traumatic or medical
emergencies. Linked by a communication system that operates on both a local
and a regional level, EMS is a system of care, which is usually initiated by
citizen action in the form of a telephone call to an emergency number.
Mosby's Medical Dictionary, 8th edition. 2009, Elsevier
Our legacy
Like so many other things that are Indian, Pre-hospital care was also
addressed by GANDHI (Indian Ambulance Corps 1899)
www.emri.in
ramanarao_gv@emri.in