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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

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Skill Stations

Skill Station - Airway Management Skill Station - Basic Life Support

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

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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

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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)
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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

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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

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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 Aspirations
• 1. integrated model • 1. Criteria Based Dispatch
• 2. Training - standardization
• 2. Ambulance Crew
• 3. EMS Protocol Development
• 4. Care- standardization • 3. Strengthen ME, Drugs etc.
• 5. Care – Monitoring & Supervision • 4. New measures of care
• 6. Care – Pre hospital Care Documentation • 5. Community Awareness
• 7. Care - Analysis and Evaluation • 6. Advanced Technology Applications
• 8. Care- Research and Development
• 9. Emergency Care Centres
• 7. Regionalization of emergency and
trauma care
• 10. Collaboration
• 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