Global Challenges in implementing Emergency and Trauma Care Models


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  • Whether it’s a bomb blast or Pseunami ,there is chaos in 1st hour which is critical .So how do we sort it out. Tht is the story I am going to tell in next 20min
  • Whether its ACS,PPH,Stoke,Trauma can stike any time whether its america or Srilanka or India
  • Whether it US,Europe,australia,
  • Talk through the stories of USA-3decadesUK-2 decadesIndia-present decade of fight
  • Similar issues relating to low-to middle income countries where infrastructure,skilled manpower and accountibility is a problem
  • Talk about the tiers of Heath care In indiaPrimary,secondary and tertiary
  • EMRI-108 11 states of IndiaPolice still is the first responder
  • Cements and buildings does not make institutions of learningTalk about ED Area/Trauma center Concept-govt of India project Challenges are to train manpower
  • Buildings does not make institutesDivided the ED into RED,Yellow and Green zones
  • ProfessorAddlAssocAssistantLeadership Training is not existant
  • At present only 15 days of casualty posting
  • Emergency Nursing is upcoming in India
  • Global Challenges in implementing Emergency and Trauma Care Models

    1. 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. 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
    3. 3. Anybody@anytime@anyproblem Oh my god……….. How do I manage?
    4. 4. Time dependent @acute care • Golden Hour • Silver Hour • Bronze Hour Platinum period of Golden Hour
    5. 5. 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
    6. 6. Demands a system to care for acute care
    7. 7. World Health Assembly Resolution 60.22 and Its Importance as a Health Care Policy Tool for Improving Emergency Care Access and Availability Globally.
    8. 8. USA,UK,Australia EM and Trauma care Models •Challenges •Opportunities •Leading the way
    9. 9. Challenges in Establishing Academic Emergency Medicine model: an Indian Journey
    10. 10. • Current Status of Emergency care • Current status of Academic Emergency Department in India • Academic model for EM training in India.
    11. 11. Current Status of Emergency care in India
    12. 12. Be @ Billion
    13. 13. 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
    14. 14. 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
    15. 15. 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
    16. 16. CYCLE RICKSHAW TO AIR AMBULANCE 9/27/2013 Criticare 2012
    17. 17. 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.
    18. 18. • Current Status of Emergency and Trauma care • Current status of Academic Emergency Department in India • Academic model for EM and Trauma training in India.
    19. 19. • MCI recognized Academic ED : Infancy • Non –MCI recognized : Deemed university Current Status of Academic Emergency Department
    20. 20. • 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
    21. 21. • 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
    22. 22. • Lack of awareness, importance about EM. • Lack of coordination among Medical colleges. Hurdles
    23. 23. • Degree • Duration of Course • Curriculum • Faculty Development Hurdle: Lack of Consensus
    24. 24. • 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
    25. 25. 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
    26. 26. • Positive Impact: – Awareness about the importance of EM Negative Impact: – No uniformity in degree, duration . – No Structured curriculum exists. Indigenous Efforts
    27. 27. • Parallel Departments did not allow it to grow. • Acute care is the cream. EGO and Power Struggle
    28. 28. • Lack of administrative support. • Equipment and staff to man the ED. Cold Attitude
    29. 29. • 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
    30. 30. • Faculty • Nurses • Paramedics. Non-Trained Manpower
    31. 31. • 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
    32. 32. Championing Playing for Change • Leadership • Ownership • Making a Team • Connecting ideas into reality • Introspecting within
    33. 33. Ownership Mine Ours
    34. 34. Leadership
    35. 35. Making a Team Team- Team
    36. 36. 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.
    37. 37. • 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
    38. 38. • American • European • Australian • Indian Model: Needs to be developed Models Available
    39. 39. Indo-US Collaboration – 2005
    40. 40. Academic Council
    41. 41. Journal Of Emergencies Trauma and Shock -2009
    42. 42. Platform for Research
    43. 43. News Letter
    44. 44. Milestone
    45. 45. • Current Status of Emergency care • Current status of Academic Emergency Department in India • Academic model for EM and Trauma care training in India.
    46. 46.  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 Red,yellow,Green Zones Academic Emergency Department
    47. 47. • Poison Center • Biodefense Center • EMS Network with EMS Personnel • GYN Outpatient Network • Research Center • Center for Simulation Technology • Trained Nurses in various Areas Academic Affiliations
    48. 48. Academic Training Pillars in Emergency Medicine and Trauma
    49. 49. Faculty Development
    50. 50. Do you have in you to move from parent speciality to EM?? Leadership Creating Meta-Leader
    51. 51. • Students • Residents • Fellows • Nurses • Paramedics Academic Training in Trauma and Emergency Medicine
    52. 52. • 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
    53. 53. • 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
    54. 54. • 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
    55. 55. • 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
    56. 56. • 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
    57. 57. • 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
    58. 58. Nurses and Paramedic Training
    59. 59. • 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 Nurses and Paramedic Training
    60. 60.  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
    61. 61. Think Global Act Local Cost-effective
    62. 62. Empowering Skills
    63. 63. Will it work with school kids ?
    64. 64. CBSE Curriculum- 2011 School Systems to consider “introducing a fourth „R‟- resuscitation,” to traditional 3R‟s of reading, writing and arithmetic
    65. 65. Spreading across India
    66. 66. 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
    67. 67. “Miles to walk before we sleep in the Journey from Casualty to Emergency Medicine.”