“Prospective Observational Study to Assess The Awareness

And Level Of Prehospital Care Given In Cases Of Severe

Trauma Coming To Tertiary Care Hospital In India”

DISSERTATION FOR THE AWARD OF

DIPLOMATE OF NATIONAL BOARD

IN
EMERGENCY MEDICINE

NATIONAL BOARD OF EXAMINATIONS, NEW DELHI

2015-2018

BY

DR AKASH SINGHAL

DEPARTMENT OF EMERGENCY MEDICINE

FORTIS HOSPITAL
SECTOR 62, NOIDA-201301
 CERTIFICATE OF GUIDE

This is to certify that this dissertation entitled “Prospective Observational

Study to Assess The Awareness And Level Of Prehospital Care Given

In Cases Of Severe Trauma Coming To Tertiary Care Hospital In India” is

a bonafide work of Dr. Akash Singhal and he has carried out this study

under my guidance and supervision in the department of Emergency Medicine,

Fortis Hospital Noida. He has done this work with dedication and integrity.

Data included in the thesis is genuine. This thesis has been modified as per

suggestion of the assessor.

It is also certified that no work has been done on this topic in this institution

earlier.

Guide:

Dr. Dina J Shah

Principal consultant and Head
Department of Emergency Medicine
Fortis Hospital Noida, Uttar Prades
 DECLARATION

I hereby declare that this dissertation titled “Prospective Observational

Study to Assess The Awareness And Level Of Prehospital Care Given

In Cases Of Severe Trauma Coming To Tertiary Care Hospital In

India” has been undertaken by me, under the guidance and supervision of

Dr. Dina J Shah, Principal Consultant and Head of Department of

Emergency Medicine, Fortis Hospital Noida in fulfillment of the national

board regulations for the award of the Diplomate of National Board (DNB

Emergency Medicine).This thesis has been modified as per suggestion of

the assessor.

Place: Dr. Akash Singhal

Date:
 CERTIFICATE OF INSTITUTE

This is to certify that Dr. AKASH SINGHAL has carried out this work of

his dissertation entitled “Prospective Observational Study to Assess The

Awareness And Level Of Prehospital Care Given In Cases Of Severe

Trauma Coming To Tertiary Care Hospital In India” in this institution.

All the work and relevant investigation with this study have been carried

by the candidate himself and is based on his sincere and scientific

approach. This thesis has been modified as per suggestion of the assessor.

This dissertation is forwarded and recommended for the award of degree

of the Diplomate of National Board (DNB Emergency Medicine).

Dr. Mehar Kumar Bedi

Medical Director
Fortis Hospital, Noida (U.P)
 Acknowledgement

From the depth of my heart, I express my deep sincere

gratitude to the Almighty for the blessings he had bestowed upon

to do this work.

I express my sincere gratitude to Dr. Dina J Shah, Principal

Consultant and Head, Department of Emergency Medicine and

my guide; she was a pillar of encouragement and support. Her

constant guidance suggestion and invaluable encouragement has

all served the purpose of accomplishment of this work.

I greatly acknowledge the work of the all authors whose

work I read, screened assimilated and adapted for arriving at

conclusion and comparison for this study.

I extend my heartfelt thanks to the patients in my study,

without them this study would not have seen the light of the day.
 I am also thankful to my seniors, colleagues, all nursing and

paramedical staff of our unit.

My parents are my pillars of strength. I express my

innermost gratitude to them, for without their support it would

have been impossible to achieve whatever little I have today.

I owe my thanks to My Wife, Dr Rashi Singhal for her

encouragement, moral support and constant help that helped me

to carry out this work. Her unfailing love and confidence in me

has always been a source of my strength.

Dr. Akash Singhal

 TABLE OF CONTENTS

Titles Page No.

1. Introduction 1-9

2. Review of Literature 10-19

3. Aims and Objectives 20

4. Materials and Methods 21-34

5. Results and Observation 25-30

6. Discussion 31-41

7. Conclusion 42

8. References 43-49

9. Annexure

• Data Sheet

• Patient Information Sheet and Consent Form

• Hindi Consent Form

• Three Category Triage Acuity System

• Master chart
 LIST OF ABBREVIATION USED
(In Alphabetical Order)

ED Emergency Department
EMS Emergency Medical Services
MOA Mode of Arrival
H/O History Of
UHID Unique Health Identification
IPID In Patient Identification
RTA Road Traffic Accident
MVA Motor Vehicle Accident
DNB Diplomate of National board
GEMSA Gujarat Emergency Medical Services Authority
IKDRC Institute of Kidney Diseases and Research
Centre
EMRI Emergency Management and Research Institute
 INTRODUCTION

Incidence of severe trauma cases is high at our hospital. In our

emergency department, we see 2000 to 4000 patients in one year. Out

of which 10-15% are severe trauma patient. Being a tertiary care center

in western U.P. We get the patient shifted from scene of accident,

primary and secondary care center in surrounding regions. Only few

of these patients receive primary care before coming to us. So, we

decided to study “Prospective Observational Study to Assess The

Awareness And Level Of Prehospital Care Given In Cases Of

Severe Trauma Coming To Tertiary Care Hospital In India”.

Injury is the fourth leading cause of global death; the World Health

Organization estimates a further 40% increase in trauma deaths by

2030. Almost 90% of injury deaths occur in low-and middle-income

countries. Each year, more than 5 million deaths and more than 100

million disabilities are related to injuries. (1) In 2002, the global death

rate due to injuries was 82.52 per 100 000 population. In the South-

East Asia Region, it was 106 per 100 000 population. It is likely that

the death rate is under-reported. The injury death rates in other WHO

regions range from 63/100,000 in the Region of the Americas to

1
133/100,000 in the African Region (adjusting for age of population).
(2)

The major causes of injuries in the South-East Asia Region are -

1. Road traffic injuries


2. Intentional injuries (violence, suicide and assaults)

3. Drowning


4. Burns

5. Unintentional falls

Numerous factors contribute to the high rate of injury in developing

countries. These include, but are not limited to, hazardous

environments and workplaces, income and gender inequalities, poorly

designed roads, inadequate enforcement of traffic regulations, poorly

maintained motor vehicles, alcohol abuse, lack of efficient emergency

medical response systems and overburdened health-care

infrastructures. Most of the major causes of injuries are also major

(2)
causes of death and disability. Prioritizing in each country should

2
be done by local researchers, but little research on injuries emerges

from low- and middle income countries. (3)

Injury is the first cause of years of life lost (YLL) in developing

countries such as Iran. According to a burden of diseases and injuries

(1)
study, 28% of YLL in Iran are attributed to injuries. Injuries,

whether due to road traffic crashes, violence or other causes, affect not

only the immediate victim, but also his or her family and members of

the surrounding community. Injuries exact a large societal and

economic toll on society. The economic burden of injury is great –

both in terms of the direct costs of medical care and the indirect

economic costs of premature death and disability. Countless hours of

productivity are lost as family, friends and society adapt to the death

or disability of loved ones. (2)

The incidents that produce serious or fatal injuries are not random or

unpredictable events. In many cases, they can be identified and acted

upon. During the past few decades, research has shown that many

injuries can be prevented or their severity reduced through the

implementation of simple measures. Examples include the use of

motorcycle helmets and restraining systems, such as seat belts and

child restraints in automobiles; the design of safer workplaces; the

3
development of flame-resistant sleepwear; the use of smoke detectors;

and the installation of fencing around hazards such as wells or deep

pools of water. (2) To reduce avoidable deaths from injury all links in

the chain of survival after trauma needs strengthening. Without new

or improved interventions, road traffic injuries will be the third leading

cause of death worldwide by the year 2020.(3)

Many fatal injuries may be prevented or their severity reduced by

adequate pre-hospital trauma care. The major benefits of prehospital

care are realized during the second phase of trauma, when the timely

provision of care can limit or halt the cascade of events that otherwise

quickly leads to death or lifelong disability. Most deaths in the first

hours after injury are the result of airway compromise, respiratory

failure or uncontrolled hemorrhage. All three of these conditions can

be readily treated using basic first aid measures. Prompt prehospital

care may also prevent a number of delayed deaths from trauma.

Measures that are useful for preventing deaths in this phase include

proper wound and burn care, adequate immobilization of fractures,

support of oxygenation and blood pressure during the first hours after

a traumatic brain injury, as well as other measures that reduce the

likelihood of complications developing later. (2)

4
Unfortunately, most of the world’s population does not have access

to prehospital trauma care. In many countries, few victims receive

treatment at the scene and fewer still can hope to be transported to

the hospital in an ambulance. As a result, many victims may

needlessly die at the scene or during the first few hours following

injury. (2)

Prehospital care in the community

Considerable good may be accomplished by ensuring that victims

receive life-sustaining care within a few minutes of injury. Even in

countries with limited resources, many lives may be saved and

disabilities prevented by teaching motivated people what to do at the

scene. Ideally, each community should identify the best locally

available means of transporting injured people to the nearest

appropriate health-care facility, whether it is a community clinic or a

district hospital. Once there, a health-care provider who has received

more formal training can assess and treat the victim. If the victim’s

injuries can be managed at the local level, treatment may be provided

there and the patient can return home. If, however, the extent of injury

exceeds the capabilities of the local provider, the patient should be

transferred to the nearest hospital or trauma unit for definitive care.

5
Widespread adoption of simple prehospital care strategies could

produce many benefits including:

● engaging motivated citizens in the care of their neighbor’s;

● providing these citizens with the knowledge and skills they need to

provide first-aid to people with severe injuries;

● creating community capacity to render assistance to injured victims

at the scene. (2)

An Emergency Medical Service (EMS) can be defined as "a

comprehensive system which provides the arrangements of personnel,

facilities and equipment for the effective, coordinated and timely delivery

of health and safety services to victims of sudden illness or injury. (4,5) The

function of EMS can be simplified into four main components; accessing

emergency care, care in the community, care on route, and care upon
(4,6)
arrival to receiving care at the health care facility. Since 1970s, the

mode of emergency health care delivery in pre-hospital environment

evolved around two main models of EMS with distinct features. The

delivery of emergency medical services in pre-hospital settings can be

categorized broadly into Franco-German or Anglo-American models. (4,5)

These categorical distinctions were obvious during the 1970s until the end

6
of the 20th century. Today, most EMS systems around the world have

varied compositions from each model. The Franco-German model of EMS

delivery is based on the "stay and stabilize" philosophy. (4,6) The motive of

this model is to bring the hospital to patients. It is usually run by physicians

and they have extensive scope of practice with very advanced technology.

The model utilizes more of other methods of transportations alongside land

ambulance such as helicopters and coastal ambulances. (4,7) This model is

usually a sub-set of the wider health care system. This philosophy is widely

implemented in Europe in which emergency medicine is relatively a young

(4,8)
field. Therefore in Europe, pre-hospital emergency care is almost

always provided by emergency physicians. The attending emergency

doctors in the field have the authority to make complex clinical judgment

and treat patients in their homes or at the scene. This results in many EMS

users being treated at the site of incident and less being transported to

hospitals. The very few transported patients are usually directly admitted

to hospital wards by the attending field emergency medicine physician

bypassing the emergency department. Countries such as Germany, France,

Greece, Malta and Austria have well-developed Franco-German EMS

systems. (4,9-13)

In contrast to the Franco-German model, the Anglo-American model

7
is based around "scoop and run" philosophy. (4,7) The aim of this model

is to rapidly bring patients to the hospital with less pre-hospital

interventions. It is usually allied with public safety services such as

police or fire departments rather than public health services and

(4,14)
hospitals. Trained paramedics and Emergency Medical

Technicians (EMTs) run the system with a clinical oversight. It relies

heavily on land ambulance and less so on aero-medical evacuation or

coastal ambulance. In countries following this model, emergency

medicine is well-developed and generally recognized as a separate

medical specialty. Almost all patients in the Anglo-American model

are transported by EMS personnel to developed Emergency

Departments rather than hospital wards. Countries which use this

model of EMS delivery include the United States, Canada, New

Zealand, Sultanate of Oman and Australia. (4,14-18)

Another way to classify emergency medical service systems is

according to the level of service and scope of practice provided. These

are usually classified as a Basic Life Support (BLS) level and

Advanced Life Support (ALS) level. Basic Life Support is tightly

associated with the ‘load and go’ philosophy providing non-invasive

basic interventions and rapid transport to definitive health care facility.

8
Interventions are usually basic and include non-invasive

cardiopulmonary resuscitation (CPR), fracture splinting, full

immobilization and oxygen administration. On the other hand, the

Advanced Life Support (ALS) fits more with the ‘stay and stabilize’

approach. It includes all the BLS procedures with the addition of

invasive procedures such as endotracheal intubation, intravenous line

placement, fluid replacement, needle-chest decompression and the

administration of controlled and potent medications. (4,16)

The superiority of ALS over BLS has not been demonstrated and the

World Health Organization warn about the trap of glamorous ALS

skills appearing better than the simple BLS that a variety of people

might benefit from. (2,4) Thus, it is essential to determine the strengths

and weaknesses of both levels of care and utilize the one that suits the
(4)
local context most. Outcome following injury is affected by the

magnitude of injuries, the early care at the scene and transport to the
(1,4)
hospital. Today’s global EMS has advanced so much that it

contributes widely to the overall function of health care systems. The

World Health Organization regards EMS systems as an integral part

of any effective and functional health care system. (2)

9
EMS has changed since the time it was commonly stated that, "EMS
(17,18)
systems in India are best described as fragmented”. Today, India

boasts an EMS system that's expanded exponentially and geographically.

It's gone beyond the early concepts, and the focus has shifted from being

injury centric to covering all emergencies. It's changed from being urban

oriented to being pan-India. Like in the United States, the primary focus is

no longer on road traffic accidents. EMS is fast evolving as an integral part

of healthcare system.

The first attempt toward establishing EMS in India wasn't a countrywide

movement, but a city-based effort in 1985 in Mumbai where 15

ambulances were connected to a central wireless dispatch center by the

Association for Trauma Care of India. This typically exemplifies the

development of EMS in India, which hasn't had a watershed moment like

the U.S.; there was no white paper nor was EMS born out of a structured

national policy. It was driven by passionate individuals and organizations

desirous of changing the "transport vehicle concept of ambulances" to

"lifesaving emergency medical transportation," and keen on having an

evidence-based EMS driven by technology and trained personnel and not

restricted by wallet biopsy. (17)

India has adopted primarily the older "scoop and run" model and not the

10
Franco-German model. The country learned a lot from the U.S.; however,

it has developed and continues to evolve its own systems to match its

socioeconomic needs. The provision of emergency services is enshrined in

India's Constitution. Failure on the part of any hospital to provide timely

medical treatment to a person results in violation of the person's "right to

life," as guaranteed under Article 21 of India's Constitution. (17,18) Although

India has the fastest growing population and an ambitious growth

aspiration, it's always had a disproportionately small health budget, with

one doctor for every 1,700 people and 21% of the world's burden of
(17,19)
disease. Almost 23% of all trauma that occurs in India is

transportation-related, with 1,374 accidents and 400 deaths taking place

every day on Indian roads.4 The rest of the 77.2% of trauma is related to

other events such as falls, drowning, agriculture related, burns, etc. (17,20)

The first change started in the mid-1980s in Mumbai, the financial capital

of India. At the same time, similar but government driven steps were taken

in Delhi, the nation's capital. Work had started on the first state funded

EMS in the Indian sub-continent, which in 1991 was launched as the

Centralized Accident & Trauma Services (CATS) with 13 ambulances.

CATS continue to be the backbone of National Capital Territory EMS with

11
151 ambulances stationed across the region attending to more than 150,000

calls a year. (17,21) In 1989, in the first of the many judicial interventions in

EMS, the Supreme Court gave a big impetus to trauma care by its landmark

judgement on a public interest litigation. In a prime example of solitary

effort by an individual, Parmanand Katara, the judgement, colloquially

named after him, directed doctors and hospitals to provide treatment to

road traffic accident victims without paper formalities necessary for other

emergencies. It ensured that treatment of the injured would not be held

ransom to police work delays. (17,22)

Alongside this early evolution of EMS, various healthcare institutions

initiated revolutionary changes inspired by global practices in the early

1990s. India started moving from "casualty departments" to protocol-

driven E.Ds.

Historical Perspective

In 1994, the Christian Medical College (CMC) in Vellore became the first

ED in the country to have a formal accident and emergency department.

(17,23) The same year, 100 miles away in Chennai, the Sundaram Medical

12
Foundation (SMF) established the first ED in the private sector. Modeled

on the American community hospital emergency system, the endeavor was

supported by the Long Island Jewish Medical Center.Another Chennai-

based medical institution, Sri Ramachandra Medical College and Research

Institute (SRMC), initiated ED-monitored ambulance retrievals. SMF

started nursing triage systems, the first for the country, followed soon by

CMC, which also became the first center to organize protocol-based multi-

specialty synchronous involvement replacing sequential consultation in

poly-trauma management. The following year, CMC conducted the first

formal training program in poly-trauma in India, the Early Management of

(17,24)
Trauma Course. In addition, a few visionary EM proponents got

together to host India's first national conference on emergency

management. EMCON 1999 was hosted by Hyderabad-based Apollo

Group. This gathering catapulted EMS to a national level. (17)

Close on the heels of EMCON 1999, the early proponents got together to

form SEMI. Today, SEMI has grown to be the flag bearer of emergency

medicine across South Asia, representing India at the International

Conference on Emergency Medicine. (17,25)

13
Tectonic Shift

The public healthcare delivery system in India starts at the sub center level,

each of which caters to the need of approximately 5,000 people. There's a

vast infrastructure of health services in India which is comprised of

146,036 sub centers; 23,458 primary health centers, and 4,276 community

health centers as of March 2008.Irrespective of this, the country hasn't been

able to provide timely and quality EMS to masses, particularly in rural

areas. As per a report by the National Commission on Macroeconomics

and Health, Ministry of Health and Family Welfare, Government of India,

a villager has to travel an average distance of nearly 20 kilometers (12.4

miles) for hospital care. (17,26)

The year 2005 changed that permanently, and brought about unalterable

changes in EMS that continue to impact the lives of millions of Indians-the

provisions of free universal access to prehospital care.Another significant

partnership between the Association of Trauma Care of India and the

American College of Surgeons brought advanced trauma life support

courses to India. In 2007, the Indian Council of Medical Research (ICMR)

and Centers for Disease Control (CDC)started a collaborative effort toward

motor vehicle injury prevention and control in south Asia. This was later

scaled up to create a road map for trauma system development in India. (17)

14
Law & Policy Changes

As countrywide activism and support for EMS emerged, there were

important changes in law and policy that helped EMS to evolve.

National Numbering Plan: A key issue in India has been universal

accessibility to EMS. That changed in 2003 when India formalized the

National Numbering Plan, leading to three-digit and four-digit short code

helplines. The Emergency Disaster Management Service helpline was

identified as 108; this became the de facto EMS helpline starting in 2005.

Gujarat EMS Act: In 2007, Haren Joshi, MD, a vascular surgeon from

Florida, along with various national and international experts championed

and enacted the Gujarat EMS Act in the Western India state of Gujarat.

This was a watershed landmark in the development of EMS across the

entire subcontinent, because it defined infrastructural and functional

frameworks of EMS providers.

Highway Trauma Care: Also in 2007, following intense persuasion by

various groups of individuals and nonprofits, India's government approved

the establishment of an integrated network of trauma centers along India's

busy highways connecting the major cities; the ongoing project, the biggest

15
such exercise in Asia, aims at creating layers of prehospital and hospital-

based trauma care along highways.

National Disaster Management Authority (NDMA): On the heels of the

disastrous Gujarat earthquake in 2001, the Indian government enacted the

Disaster Management Act on December 23, 2005. Over time, the NDMA

has come up with guidelines relating to the preparation of action plans for

medical preparedness and mass casualty management, the prevention and

management of heatwaves, and the management of hospital safety and

chemical disaster.

National Ambulance Code: Judicial interventions have always been part

and parcel of India's policy change initiatives, and EMS and ambulances

have not been exceptions. In 2005, the Delhi High Court intervened to

force the capital region government of Delhi to lay down standards for

ambulances.

Taking a cue from this, the Ministries of Road Transport and Highways

and Health worked to create the National Ambulance Code, which will be

applicable to ambulances across the country. The code defines structural

and functional requirements for road ambulances.

Good Samaritan protections: For years, Indians hesitated to help an

16
accident victim and Good Samaritan laws weren't in place to protect lay

rescuers. Eighty percent of road accident victims in India don't receive any

emergency medical care within the so-called "golden hour”. Seventy-four

percent of bystanders are unlikely to assist a victim of serious injury

because of fear of legal hassles, including police questioning and court

appearances. And many citizens who desired to help victims are unaware

of where to take them for emergency trauma care. In 2015, due to a judicial

intervention following a public interest litigation by the non-profit Save

LIFE Foundation, the government passed guidelines to protect Good

Samaritans against harassment by police, hospitals and all other authorities

under the directives of the supreme court. These guidelines now empower

the community to respond to medical emergencies. (17,27)

National EMS Hotline

The National Rural Health Mission (NRHM), a central government-funded

program, is at the core of India's public EMS, and the 108 is predominantly

an emergency response system primarily designed to attend to patients of

critical care, trauma and accident victims. Started in Andhra Pradesh in

2005, this flagship initiative is executed through a public-private

partnership model in various states of the Indian federation where it was

17
being implemented. It was then replicated on a larger scale in Gujarat,

followed by other states.The federal outlay for this project has been

consistent with capital expenditure of ambulances being supported under

NRHM and operational cost is supported on a diminishing scale of 60% in

the first year, 40% in the second year and 20% thereafter. (17,28)

India's EMS Globalization

India's healthcare industry is growing at a rapid pace. Improvement in

healthcare infrastructure and facilities and ease of access to them is the only

way India can fight against diseases. EMS is an integral part of India's

health and its growth is irreversible.

Indian EMS has gone beyond the national boundaries and many

international organizations and manufacturers have partnered with Indian

EMS providers. There are over 100,000 vacancies available in India for

trained EMTs who can be deployed in ambulances.30 India needs training

organizations and investments to bridge this gap. EMS education is an area

that invites global attention. There's been a surge in training programs for

nursing and paramedic training. (17,18)

Though significant development has taken place, the continued evolution

18
of EMS in India will require collaborative input from various stakeholders

in EMS and emergency medicine, academia and industry, as well as

activists and lawmakers.

There are huge gaps yet to be addressed, such as the lack of legislation and

accreditations for the EMS workforce. This gap has resulted in a very low

level of accountability amongst the smaller EMS providers. Procedures,

protocols and personal skills need to be standardized along with the

formation of legislation in parliament to provide legal protection for the

providers of emergency services. (17,26) Health information gathering, a

key component of any working health system, is weak in low and lower-

middle income countries such as India, which are perennially plagued by

problems of having data that aren't only poor in quality but also inadequate

for properly informing health policy. (17,29)

The foreign literature usually focuses on how the patient was managed in

prehospital settings and its impact on patient mortality and morbidity and

lots of data has been collected on injuries and their implication. But there

have been no studies assessing the availability and level of prehospital care

in developing nations such as India. Furthermore, as mentioned above there

is lack of Indian studies which have been done in field of emergency

19
medicine and though we have come far, we are still in nascent stages of

development of emergency medicine.

Looking at that, we hypothesize that in our part of community, level

of prehospital care is poor and people are not using EMS even in cases

of severe trauma.

20
 REVIEW OF LITERATURE

Paravar M et al studied Prehospital care and in-hospital mortality of

trauma patients in Iran. Prehospital Disaster Med. 2014; this study was

a retrospective study of trauma victims presenting to a trauma center

in central Iran by Emergency Medical Services (EMS) and

hospitalized more than 24 hours. Demographic and injury

characteristics were obtained, including accident location, damaged

organs, injury mechanism, injury severity score, prehospital times

(response, scene, and transport), interventions and in-hospital

outcome. They found that in- hospital mortality was more common for

patients with severe injuries and a long prehospital transport times.

While more severely injured patients received ALS interventions and

died, these interventions were associated with positive survival trends

when conducted in suburban and out-of-city road locations with long

transport times.(1)

Sasser S, Varghese M, Kellermann A, Lormand JD. Prehospital

trauma care systems. Geneva: World Health Organization, 2005 and

found that the most basic elements of the system are easily affordable

and will benefit large numbers of victims of serious and life-

threatening injury. One of the most basic ways to provide prehospital

21
care is by engaging community members. Involving them in this

process may have the additional benefit of helping them identify and

address hazardous conditions and behaviours in their local

environment. Thus, promoting trauma treatment may further the goals

of injury prevention. The financial and social benefits of reducing

premature death and minimizing disability from injury are potentially

enormous, and these benefits may play a major part in promoting a

nation’s economic and human development. Finally, adopting these

principles will dramatically increase a nation’s capacity to respond to

natural and man-made disasters. The best way to prepare for mass

casualty events is to establish a prehospital care system that functions

efficiently and well and that is able to effectively manage emergency

events on a daily basis.(2)

Wisborg T, Montshiva TR, Mock C.et al studied Trauma research in

low- and middle-income countries is urgently needed to strengthen the

chain of survival. Scandinavian J Trauma Resus Emerg Med.

2011;19:62,and found that Local researchers are the key to this

knowledge, and need to disseminate their experience to the

international audience. It should, however, be acknowledged that the

challenges faced by most local researchers in LMICs are great, and

with limited resources, research is usually given one of the least of

22
priorities. Support from the international community will therefore

play a very important role, not just in funding but also from the

expertise of other experienced and well published researchers in the

developed countries and institutions.(3)

Demetriades D, Kimbrell B, Salim A, et al studied Trauma deaths in a

mature urban trauma system: is ‘‘trimodal’’ distribution a valid

concept? J Am Coll Surg. 2005;the study of trauma registry and

emergency medical services records of trauma deaths in the County of

Los Angeles was conducted over a 3-year period. The times from

injury to death were analyzed according to mechanism of injury and

body area (head, chest, abdomen, extremities) with severe trauma

(abbreviated injury score [AIS] >/= 4) and found out that the classic

"trimodal" distribution of deaths does not apply in our trauma system.

Temporal distribution of deaths is influenced by the mechanism of

injury, age of the patient, and body area with severe trauma.

Knowledge of the time of distribution of deaths might help in

allocating trauma resources and focusing research effort.(30)

World Health Organization. Developing prehospital trauma care

approach for South-East Asia. Inter-country consultation,

Ahmedabad, India. New Delhi: Regional Office for South-East Asia;

July 2-4, 2003.In this study a questionnaire was developed and mailed

23
to investigators in countries of the Region. Then the available data

related to injury burden, the national representatives gathered impact

and ongoing activities from various sources. Published and

unpublished literature was included for pooling relevant information.

The compilation of information was undertaken by the lead

investigator and circulated among all members and reviewed by the

WHO Regional Office for South-East Asia. They concluded that

evidence from countries of the South-East Asia Region shows that

injuries place an enormous burden on the health services. The existing

institutions and processes are not adequately empowered or equipped

to deal with the situation. Reliable data on the injury situation

(especially by causes) are not available in some countries. There is

need to generate data, based on the country priority and motorcycle

related injuries are growing concern in several countries of the

region.(31)

Ball et al studied the impact of shorter prehospital transport times on

outcomes in patients with abdominal vascular injuries.2013; A

retrospective review of all patients with ABVI at an urban level 1

trauma center was completed. Patients injured prior to prehospital

transport improvements (1991–1994) were compared to those

following a reduction in transport times (1995–2004). They found that

24
shorter prehospital time in patients who would have previously died at

the scene, or en route to the hospital; appear to result in increased

mortality among patients with major abdominal vascular injuries.(32)

Stiell IG et al studied The OPALS Major Trauma Study: impact of

advanced life-support on survival and morbidity. CMAJ. 2008 The

Ontario Prehospital Advanced Life Support (OPALS) Major Trauma

Study was a before–after systemwide controlled clinical trial

conducted in 17 cities. They enrolled adult patients who had

experienced major trauma in a basic life-support phase and a

subsequent advanced life-support phase (during which paramedics

were able to perform endotracheal intubation and administer fluids and

drugs intravenously). The primary outcome was survival to hospital

discharge and found that the implementation of full prehospital

advanced life-support by trained paramedics was not associated with

lower mortality rates relative to basic life-support measures for

patients with major trauma. Furthermore,there evidence indicates that,

for patients with suspected head injuries and a Glasgow Coma Scale

score of less than 9, mortality was greater during the advanced life-

support phase of the study than during the basic life-support phase. On

the basis of these findings, they suggested that emergency medical

services should carefully re-evaluate the indications for and

25
application of prehospital advanced life-support measures for patients

with major trauma.(33)

Carr BG, Brachet T, David G, et al studied The time cost of prehospital

intubation and intravenous access in trauma patients. Prehosp

Emergency Care. 2008; performed retrospective cohort studies of

secondary data using ordinary least squares (linear) regression to

determine the marginal increase in on-scene time associated with

performing an average procedure. To do this, they used on-scene

duration as the dependent variable while controlling for multiple

potential con- founders. They developed multiple models (five

separate regressions) to demonstrate the stability of the estimate.

Although largely unproven, the ideas of the “golden hour” and the

trimodal distribution of death are firmly entrenched in the framework

of trauma care. The degree to which definitive care at the trauma center

should be delayed for prehospital procedures has been debated for

decades, without clear consensus. In their analysis, intubation was

associated with an increased scene time between 2:36 and 3:39

(minutes : seconds), and IV access was associated with an increase in

on-scene duration of 3:17 and 5:4.They believed that providing

quantifiable time costs for IV access and endotracheal intubation will

26
help EMS and trauma planners to perform cost–benefit analysis and to

optimize the prehospital care of trauma patients.(34)

Roudsari BS, Nathens AB, Arreola-Risa C, et al studied Emergency

Medical Service (EMS) systems in developed and developing

countries. Injury. 2007 They collated de-identified patient-level data

from either regional trauma registries (in Australia, Austria, Canada,

Greece, Germany, New Zealand, the Netherlands, the United

Kingdom, the United States) or databases developed expressively for

the purpose of evaluating either pre-hospital or hospital care

research(in Mexico, Iran) used multiple imputation (MI) using

predictive mean matching in order to deal with missing values on key

variables in the trauma registries. They found out the international

variability in patient mix, process of care, and performance of different

pre-hospital trauma care systems worldwide. International efforts

should be devoted to developing a minimum standard data set for

trauma patients. They also found that the standardized data set could

eventually be promoted worldwide, with standardized definitions

accompanying it, which would facilitate and extend future

international pre-hospital trauma care collaborative research

projects.(35)

Carr BG, Caplan JM, Pryor JP, et al studied A meta-analysis of

27
prehospital care times for trauma. Prehospital Emergency Care.

2006.they did a systematic literature for all articles reporting

prehospital times for trauma patients transported by helicopter and

ground ambulance at national level. They then sought to determine

national averages for prehospital times based on a systematic review

of published literature.They concluded that the emphasis on time in

the prehospital and trauma literature there has been no national effort

to empirically define average prehospital time intervals for trauma

patients. They provided points of reference for prehospital intervals so

that policymakers can compare individual emergency medical systems

to national norms.(36)

Newgard C, Schmicker RH, Hedges JR studied Emergency Medical

Services intervals and survival in trauma: assessment of the ‘‘Golden

Hour’’ in a North American prospective cohort. Ann Emerg Med.

2003;they did a secondary analysis of an out-of-hospital, consecutive-

patient, prospective cohort registry of injured persons with field-based

physiologic abnormality. They suggested that in their current out-of-

hospital and emergency care system time may be less crucial than once

thought. Routine lights-and-sirens transport for trauma patients, with

its inherent risks, may not be warranted.(37)

Tyburski JG, Wilson RF, Dente CD, Steffes C, Carlin AM studied

28
Factors affecting mortality rates in patients with abdominal vascular

injuries. J Trauma 2001;they collected data on 470 patients with

abdominal vascular injuries seen at a Level I trauma center which were

then reviewed retrospectively. They found out that Rapid control of

bleeding sites (to keep blood transfusions to < 10 units) and urgent

correction of hypothermia seem to be the main factors improving

survival over which the surgeon has some control.(38)

Cornwell EE, Belzberg H, Hennigan K, Maxson C, Montoya G,

Rosenbluth A, Velmahos GC studied Emergency medical services

(EMS) vs. Non-EMS transport of critically ill patients. Arch Surg

2000, prospectively test the hypothesis, an interview protocol, a

method for combining time estimates, and a screening method to

identify a sample of carefully matched patients, were developed. To

accomplish these tasks, the EMS study group, consisting of members

of the Division of Trauma/Critical Care, trauma registry personnel,

and members of the Social Science Research Institute of USC, was

formed. An interview protocol was developed to determine the time of

injury and the factors affecting decisions to access the EMS system.

Graduate students in the social sciences were trained to apply this tool

to patients, witnesses, and friends, and to use it in conjunction with

data obtained from police and sheriff reports with cooperation from

29
the Los Angeles Police Department and the Los Angeles County

Sheriff's office. Medical examiner reports for no surviving patients

were also used. They found out that severely injured non–EMS-

transported patients arrived at the hospital more quickly than their

EMS-transported counterparts. Also they conclude by saying that

future study will be directed at more severely injured patients where

time and distance differences are confirmed and a trend toward

outcome differences identified. A longer study period is clearly

required to enroll a sufficient number of patients with the more severe

injury inclusion criteria.(39)

30
 AIMS AND OBJECTIVES

AIM-To assess the level of awareness and prehospital care given to

severe trauma patient.

PRIMARY OBJECTIVE-Assess the causes of not availing

advanced trauma care ambulance services in patient with severe

trauma in terms of: -

1) non-availability of EMS services,

2)lack of awareness about potential benefits of EMS services, and

3) financial burden on patient’s family.

SECONDARY OBJECTIVE- Assess the level of prehospital care

given on route by BLS/ACLS ambulance services before arriving at

definitive care Centre.

31
 MATERIAL AND METHODS

STUDY SITE

This study was conducted at Emergency Department of Fortis Hospital,

Noida

STUDY POPULATION

Patients who were >18 and with triage complaints of severe trauma were

taken into this study.

STUDY DESIGN

Our study is a prospective type observational study.

SAMPLE SIZE

This is a pilot study

Prevalence of awareness to use Emergency medical services (EMS) is 50%

(through pilot study on 16 cases). At two sided, 95% confidence interval

and 20% relative error in the given prevalence, sample size came out to be

97.

• Formula: Sample size (n) = Z2pq / d2

32
 • Where n = Sample size,

• Z value at two sided 95% CI (i.e. 1.96)

• p = prevalence in %, q = 100 –p,

• d = margin of error = relative error X prevalence

• =20% of 50% =0.2 X 50% = 10%

• So, n = (1.96)2* (50* 50) / (10*10) = (3.841*2500)/100

• = 96.04 = 97 (approximate).

• Finally, in this study, minimum sample size was targeted at least 100

patients.

TIME FRAME

This research was done from April 2016 to March 2017.

Inclusion criteria

Severe trauma patients

1. Age>18yrs Patient of either sex with age between 18yrs-85 years

were taken

2. Patient with history of RTA

3. Fall from height

4. Assault

33
Exclusion criteria

1. Burns

2. Patient who have received treatment in emergency department

of other hospital for >4hrs

STUDY METHOD

All adults between age 18-85 years presenting as severe trauma patients

(Code1-annexure 4) were included in our study. Demographics in terms of

name, age and sex of all patients were recorded first. Inclusion and

exclusion criteria were applied and study cases were taken further

subdividing into those coming through EMS services and those coming

through Non-EMS services.

Primary outcome was measured in terms of why people did not avail

emergency medical services in cases of severe trauma. This was evaluated

by verbally asking the patient/patient attendant about reason for not

availing EMS services in terms of:

1.non availability of EMS services

2.lack of awareness among people about potential benefits of EMS

services, or

3.patient/patient family not availing EMS services due to financial issue.

34
Secondary outcome was measured in terms intervention done in patients

coming to us via EMS services. Intervention done in

a) BLS services were noted for: -

1)measurement of on route vitals

2)cervical spine immobilization

3)fluid resuscitation on route

4) O2 therapy

b) ACLS services were noted for: -

1)all 3 parameters mentioned above

2)primary survey using ABCD approach and intervention as required in

terms of: -

a) endotracheal intubation

b) spinal immobilization

c) drug administration

d) blood given.

35
36
STATISTICAL METHOD-

• Categorical variables were expressed in frequency and percentages

and continuous variables in mean with standard deviations.

• Associations between two variables / to test the difference in

proportions was analyzed using Chi-square tests (when at least 5

expected frequency in each cell) otherwise fisher exact test was

used.

• Kruskal Wallis H test was used to compare the median score among

three groups.

• SPSS versions 22(SPSS Inc., Chicago, Illinois USA) was used for data

analysis. A P value < 0.05 have been considered as statistically

significant.

ETHICAL CONSIDERATION-

Institutional ethical committee approval for the study was taken on 22nd

Feburary,2016 Written informed consent was taken from all patients.

Those who were unconscious surrogate consent from legal guardian or

other duly authorized representative was taken. Fresh informed consent

37
from each participant was taken after they regain consciousness. As there

is no change in patient management, this study poses no threat to patient

safety.

38
 RESULTS AND OBSERVATIONS

Between 1st April 2016 to 30th March, 2017 total 2100 patients presented

to our emergency department with trauma out of which 180 patients had

severe trauma. After applying inclusion criteria and exclusion criteria 101

patients were taken up for this study. Among 79 excluded patients 10

patients (12.65%) had age <18 years,66 patients (83.54%) stayed in other

hospital for > 4hrs, out of which 5 patients stayed in other hospital for >

4hrs and were of age <18 years (6.3%), only 2 patients (2.53%) came to

our emergency department with severe burns.

The average age of patients was 39.02 (SD=20.8) years in our study. There

was significant association between gender distribution and severe trauma

patients with p value<0.001 and majority among them were males

(85.10%) (table no 1). In our study 89 patients were brought through Non-

EMS services whereas only 12 patients came through EMS services which

was found to be statistically significant with p value <0.001 as seen in table

1.

39
Table 1-Descriptive Statistics of the Patients (n=101)

p value
Age (years) 39.02± 17.28 (Mean ± SD) 18 - 85 (Min-Max) --

Sex Male: Female: <0.001

86 (85.1) 15 (14.9)
Mode of Arrival EMS: 12 (11.9) Non-EMS: <0.001
89 (88.1)
Those coming through EMS services were further categorized into patients

who came via BLS services (3) and patients who came via ACLS services

(9), rest all patients came through Non-EMS services (figure 1).

Fig 1-Mode of arrival

9(8.9%)
3(4%)

89
(88.11%)

Non EMS BLS ACLS

40
In our study mechanism of injury was predominantly RTA/MVA in 72%

followed by fall from height in18% and by assault is only 8% (figure 2).

FIG.2-MECHANISM OF INJURY

101
90.9
total no of patients

80.8
70.7
60.6
50.5
40.4
30.3
20.2
10.1
0
NON EMS BLS ACLS
RTA 67 4 4
FALL 17 1 1
ASSAULT 5 0 4

RTA FALL ASSAULT

We found a significant association (p value <0.05) between patients

coming to hospital via both ACLS and BLS services when compared to

patients who arrived through Non-EMS services (table 2). Kruskal Wallis

H test was used to compare the median arrival time through multiple

comparison and we found that time to door was longer in patients who

came through both BLS and ACLS services in comparison to patients

coming through Non-EMS services.

Table 2-Time To door (Time of Arrival-Time of Incident)

Mode (n=101) Median (IQR) Min-Max *p value

ACLS (9) 180 (130-208) 75-240

41
 BLS (3) 95 (70-210) 70-210 <0.001

Non-EMS (89) 45 (30-88) 5-480

Kruskal Wallis H test*

In our study patients coming through either ACLS and BLS services

received prehospital care when compared to those coming through Non-

EMS services and was statically significant (p<0.05).Patients coming with

Non-EMS services(29.2%) and BLS services (33%) were found to be in

shock when compared to patients who received ACLS care although it was

statistically insignificant (p>0.05).This was primarily because we had

relatively lesser no (smaller sample size) of patients coming through ACLS

services when compared to Non-EMS services(figure 3).

42
 Fig. 3 CARE GIVEN and PATIENTS IN
SHOCK

P 26
N A
O T 9
0 3
I
1 0
E
O N CARE GIVEN
F T SHOCK
S MODE OF ARRIVAL

NON EMS(89) BLS(3) ACLS(9)

Patients coming to us through BLS were given care. All of them had there

vitals checked on route were given iv fluids and two of them had c-spine

immobilized. (Table 3.).

Table 3. Distribution of Intervention done in patients coming via BLS

services.

BLS Care Given (n=3) Yes (%)

Prehospital Vital monitoring 3 (100.0)

Fluid administration 3 (100.0)

C-Spine immobilization 2(66.7)

O therapy
2 2(66.7)

43
Patients coming through ACLS were assessed in terms of ABCD approach

and stabilized accordingly. (Table 4.a and 4.b).

Table 4.a Primary survey in patients coming via ACLS services

ACLS Given(n=9) Yes (%)

Airway 9 (100.0)
(n=9)
Breathing 9 (100.0)

Circulation 9 (100.0)

Disability 9 (100.0)

Table 4.b Distribution of Intervention done in patients coming via

ACLS services.

Endotracheal Intubation 7(77.8)

Spinal immobilization 9(100)

Drug administration 9(100)

Blood administration 1(11.1)

44
To summarize prehospital care in our part of western U.P., India was found

to be inadequate and majority of patients coming to us where through Non-

EMS services. Lack of awareness (72%) among people was noted as the

main reason for not availing prehospital care followed by non-availability

of EMS (27%) as second most common cause followed by financial issue

in 1.1% of total patients (figure4).

Fig.4-REASONS FOR NOT AVAILING EMS

FINANCIAL
1(1.1%)
AVAILBILITY OF
EMS
24(27%)

AWARENESS
ISSUES
64(72%)

45
 DISCUSSION

Our study was a prospective, observational study conducted in the

department of Emergency at Fortis Hospital, a tertiary care Centre in Noida

between 1/4/2015 to 31/3/2016.Hundred and one patients were enrolled in

study who came with severe trauma. Patients were further divided into

those who came after availing EMS services and those who came through

Non-EMS services

Demographics

The mean age was 39 years. There was almost three times more males as

compared to females in the study group; this was in concordance with the

study done by Md Paravar et al (1) whereas a study done by Carr Bg et al

(36) shows almost equal sexual ratio. This might be attributed to the fact

that Carr Bg et al (36) study was done in U.S.A which has more equalized

ratio of female to male drivers when compared to both Iran and India. As

both are developing countries with lesser female drivers as well as males

being more aggressive and impulsive thereby being more prone to injuries.

46
 Fig. 5 SEX DISTRIBUTION ACROSS STUDIES

85.10% 83.10%
% OF PATIENTS

53.40%
46.60%
MALE

FEMALE

14.90% 16.90%

Our study,India Md pervar et carr bg et al,2008(5)

al,2014(1) Iran U.S.A
COMPARISON WITH OTHER STUDIES

EMS VS NON_EMS

When compared to study done by Cornwell EE et al in USA (39) in which

65% people came through ems services while majority of people (88.1%)

in our study came through Non-EMS services (figure 6). This might be

because of the fact that in USA ambulance services are commonly catering

to a locality or a community at all times. In USA, they have self-

dispatching ambulances available in the community as well as a national

emergency number i.e. 9-1-1 which works for all three emergency services

(i.e. police, ambulance and fire brigade). In most cases, a 9-1-1 call will be

answered at a central facility, usually referred to as a Public Safety

47
Answering Point, after which needs of the caller are identified, and the call

is routed to the dispatcher for the emergency service(s) required. (40)

In India EMS services still remain largely fragmented and confined to

larger cities and patients who can pay from their pockets in majority of

cases. India has two different yet overlapping publicly funded ambulance

systems, with both popularly known by their helpline numbers, 108 and

102. Between them, they have more than 17,000 ambulances across the

union of 31 states and union territories. Also, private hospitals in the

country provide different telephone numbers for ambulance services as

opposed to in developed countries. (17)

Fig. 6 Showing Mode of Arrival (EMS vs.

NON EMS)
NON EMS EMS

88.1
100 65
% of patients

38
50 11.9

0
Our study,India Cornwell EE et a,
2000(13)USA

48
In our study the mechanism of injury was predominantly road traffic

accidents/motor vehicle accidents in 72% followed by fall from height in

18% and assault (8%) which is in concordance with study done by Md

Paravar et al (1) (figure 7).

Fig. 7 Showing mechanism of injury

Percentage of patients

100

50

0
RTA/MVA Fall From Assault/ot
height hers
0ur study,India 73 19 9
Md Paravar et al ,Iran 85.4 11.9 2.7

0ur study,India Md Paravar et al ,Iran

The median time to door in our study was seen to be 180 mins in case of

patients arriving through ACLS, 95 mins through BLS and 45 mins through

Non-EMS services whereas in study done by Carr bg et al (36) median

duration in minutes for urban, suburban, and rural ground ambulances for

the total prehospital interval were 30.96, 30.97, and 43.17 mins

respectively. The mean transport and time to door was 11.1 and 12.8 mins

respectively. These differences might be because when compared to

49
developed countries with proper emergency systems in place, there is no

single system which could play a major role in managing emergency

medical services in India. (17) To further classify and study median duration

in terms of urban, suburban and rural as done by Carr bg et al (36) more

resources, better documentation and a more uniform EMS system needs to

be developed before we can actually study this in a larger setting.

Furthermore, in our study people coming via Non-EMS services were more

critically injured and 26 patients were found to be in shock. This might be

due to the fact that most people in severe condition are brought to the

nearest hospital by bystanders through Non-EMS services. Other factors

also delay EMS services such as traffic and delay in receiving and

dispatching ambulances. It also correlates with a study done by Cornwell

EE et al (39) which showed that patients who were critically injured reached

to hospital earlier through Non-EMS services when compared to ems

services. Despite this importance of a reliable EMS cannot be

overemphasized, especially in India where the government has the

responsibility of caring for a majority of the population.

It can be argued that a nation of a billion people has been deprived of a

decent EMS for too long now and it is high time the government takes

definitive action. The success of a few services is evident enough of the

50
need for EMS and what it will take to ensure that it works as expected. In

a healthcare system that is sprouting and experiencing the benefits of

involving private players, a public-private partnership framework could be

the right way forward for policy-makers. At a time when the emphasis on

preventing damage is greater than ever, the provision of pre-hospital care

will be the key to ensure that lives are not lost due to avoidable

circumstances. (17)

The severe trauma patients were assessed in terms of care given on route

or not. Patient who came to us through Non-EMS modality received no

care by the primary responder whatsoever. Those coming to us through

EMS services received primary intervention and although we did not

evaluate the efficiency or the skill of the emergency medical service

provider generally in India ACLS has doctors but at times these doctors

have not been formally been trained in emergency services. We looked for

patients in terms of intervention done and whether they came to us in shock

or not. We found that 26(29.2%) out of 89 patients coming via Non-EMS

and 1(33.3%) out of three patients were in shock who came through BLS

services whereas none of patient were in shock who came through ACLS

services. But we did not get statistically significant numbers to validate this

finding because of small size of BLS and ACLS group.In India we still

51
follow scoop and run philosophy and bystanders will generally bring the

more severely injured patient to hospital by most readily available means

to save time with no proper documentation on route done by

EMTs/paramedics who bring the patient to hospital.

Three patients came via BLS and all of them (100%) received intervention

in terms of prehospital vitals monitoring and fluid administration whereas

in 2(66.7%) patients both C-spine immobilization and O2 therapy was

given. Out of nine patients coming via ACLS services all were assessed

using ABCD approach in primary survey and in addition to BLS care all

were taken onto spinal board and had C-collar applied though only

7(77.8%) had endotracheal intubation done and all received medication

and one patient had received blood on route though we did not assess the

impact of these as done by other studies. For example, in the study done by

Md Paravar et al (1) they have evaluated the patient in terms of intervention

done in both ACLS and BLS sevices. We have only taken severe trauma

patients in our study they took all trauma patients and then found that more

severely injured patients had received ACLS services. Ninety-two patients

(4.6%) were intubated of all trauma patients. Intubation was done in 67.4%

of patients with severe head trauma and on 70.4% of those with respiratory

52
disorders which coincides with our study though we only classified the

patient as severe trauma patients.

In our study the major reason of people not availing EMS services was

found to be awareness issue in 64 patients followed by availability in 24

patients and only 1 patient due to financial issue. These numbers might be

worse and may vary in rural areas were EMS services are almost negligible

and availability might be major reason as compared to our study which was

done in urban settings.

53
LIMITATIONS

1.In our study although we have taken all severe trauma patients coming to

us within 4-hour period through EMS services so as to avoid patients who

have come from other hospitals after taking primary care in in-hospital

settings. We have still included patients coming to us who have been seen

at some primary care Centre and shifted to our hospital within first 4 hours

2. Small sample size-we were not able to get adequate numbers in cases of

patient coming with EMS services. This can be attributed to both lack of

availing EMS services among general population as well our hospital being

a private institution where number of patients coming are less when

compared to number of patients coming to a government institution.

54
 CONCLUSION

Lack of awareness (72%) about potential benefits of EMS services was

found to be major cause of not availing advanced trauma care services in

patients with severe trauma in comparison to non-availability of EMS

(27%) and financial reasons (1.1%) for not availing EMS care.

Intervention in terms of measurement of prehospital vitals (100%) and

fluid resuscitation (100%) was done in majority of patients coming to us

via BLS services but only few patient had been given C-spine

immobilization and O2 therapy (both 66.7%).

Whereas those coming via ACLS services had been assessed following

primary survey and had on route intervention in terms of endotracheal

intubation (77.8%) and spinal immobilization/spine board and drug

administration (100%) and only one was found to be resuscitated with

blood (11.1%).

We thereby conclude that level of awareness and prehospital care given in

severe trauma patient was found to be inadequate in our study

55
 WAY FORWARD
There is need for an awareness creation program across the nation that fills

this gap. Further there is a need of centralized medical authority which

would be responsible for preparing protocols, imparting technical

assistance, training, capacity building and accreditation of emergency

services procedure. We have planned further study with 3 and 6-month

follow-up to see the impact of non-availing prehospital care in terms of

morbidity and mortality in severe trauma.

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EmergencyMedicine.in.2007.www.emergencymedicine.in/nepi/

print.php?type=A&item_id=15 (accessed 1 Apr2017).

24. Department of Accident and Emergency Medicine: Academics.

www.cmch-vellore.edu/sites/ae/Academics.html (accessed 1

Apr2017).

25. Society for Emergency Medicine India (SEMI). Society for

Emergency Medicine India (SEMI). http://www.semi.org.in/

(accessed 1 Apr2017).

26. Garg R. Who killed Rambhor?: The state of emergency medical

services in India. Journal of Emergencies, Trauma, and

Shock.2012; 5: 49.

27. Study on Impediments to Bystander care In India. SaveLIFE

Foundation

http://savelifefoundation.org/wpcontent/uploads/2016/10/Nation

al-Study-on-Impediments-to-Bystander-Care-in-

India.pdf&p=DevEx,5067.1 (accessed 1 Apr2017).

28. ERS/Patient transport service - Government of India.

60
 National Rural Health Mission. http://nhm.gov.in/nrhm-

components/health-systems-strengthening/emri-patient-

transport-service.html (accessed 1 Apr2017).

29. Dandona R, Pandey A, Dandona L. A review of national health

surveys in India. Bulletin of the World Health

Organization.2016; 94. doi:10.2471/blt.15.158493.

30. Demetriades D, Kimbrell B, Salim A, Velmahos G, Rhee P,

Preston C et al. Trauma Deaths in a Mature Urban Trauma

System: Is “Trimodal” Distribution a Valid Concept?. Journal of

the American College of Surgeons. 2005;201(3):343-348.

31. World Health Organization. Developing prehospital trauma care

approach for South-East Asia. Inter-country consultation,

Ahmedabad, India. New Delhi: Regional Office for South-East

Asia; July 2-4, 2003.

32. Ball C, Williams B, Tallah C, Salomone J, Feliciano D. The

impact of shorter prehospital transport times on outcomes in

patients with abdominal vascular injuries. Journal of Trauma

Management & Outcomes. 2013;7(1).

33. Stiell I, Campeau T. The OPALS Major Trauma Study: impact

of advanced life-support on survival and morbidity. Canadian

Medical Association Journal. 2008;178(9):1141-1152.

61
34. Carr B, Brachet T, David G, Duseja R, Branas C. The Time Cost

of Prehospital Intubation andIntravenous Access in Trauma

Patients. Prehospital Emergency Care. 2008;12(3):327-332.

35. Roudsari B, Nathens A, Arreola-Risa C, Cameron P, Civil I,

Grigoriou G et al. Emergency Medical Service (EMS) systems in

developed and developing countries. Injury. 2007;38(9):1001-

1013.

36. Carr B, Caplan J, Pryor J, Branas C. A Meta-Analysis of

Prehospital Care Times for Trauma. Prehospital Emergency

Care. 2006;10(2):198-206.

37. Newgard C et al.: Emergency Medical Services intervals and

survival in trauma: assessment of the ‘‘Golden Hour’’ in a

North American prospective cohort. Ann Emerg Med.

2003;55(3):236-246.

38. Tyburski J, Wilson R, Dente C, Steffes C, Carlin A. Factors

Affecting Mortality Rates in Patients with Abdominal Vascular

Injuries. The Journal of Trauma: Injury, Infection, and Critical

Care. 2001;50(6):1020-1026.

39. Cornwell E. Emergency Medical Services (EMS) vs Non-EMS

Transport of Critically Injured Patients. Archives of Surgery.

2000;135(3):315.

62
40. Kuehl A. Prehospital systems and medical oversight.

Kendall/Hunt Pub.: Dubugue, Iowa, 2002.

63
ANNEXURE-1:

64
 DATA SHEET

1. S.NO
2. DATE
3. NAME
4. AGE
5. SEX
6. UHID/IPID NO.
7. DATE OF INCIDENT
8. APPROXIMATE TIME OF INCIDENT
9. MODE OF ARRIVAL-EMS/NON-EMS
• EMS-BLS/ACLS
10. TIME OF ARRIVAL
11. MECHANISM OF INJURY-RTA/FALL/ASSAULT
12. CARE GIVEN ON SCENE/ON ROUTE: YES/NO- IF YES
IF BLS: -
a) PREHOSPITAL VITALS TAKEN: YES/NO
b) Fluid administered: YES/NO
c) C-spine immobilization: YES/NO
d) O2 administration

IF ACLS following ABCD approach and intervention done in addition to BLS: -

a) Endotracheal Intubation: YES/NO
b) Spinal immobilization: YES/NO
c) Drug administration: YES/NO
d) Blood administration: YES/NO
13.REASONS FOR NOT AVAILING EMS
e) FINANCIAL
f) AWARENESS ISSUE
g) AVAILABILITY OF EMS

65
 ANNEXURE-2:
PATIENT INFORMATION SHEET
& INFORMED CONSENT FORM

PART I: PATIENT INFORMATION SHEET

STUDY NAME: “Prospective Observational Study To Assess The

Awareness And Level Of Prehospital Care Given In Cases Of Severe

Trauma Coming To Tertiary Care Hospital In India ”

Please read this information form carefully. Take time to ask as many

questions as you want. The study personnel will explain any word or

information you do not clearly understand.

INTRODUCTION

You are being invited to take part in an observational study for assessing

level of prehospital care in our part of community in cases of severe

trauma patients. Severe trauma occurs frequently in the community. In

Emergency department, every year we see many patients out of which

20% are severe trauma patients.

66
PURPOSE OF THE STUDY

The purpose of this study is

1. Level of prehospital care given to the patients

2. Intervention done on route or at scene to stabilize the patient

3. Reasons for not availing EMS services

STUDY PROCEDURE AND TREATMENT

In the study, it is planned to recruit severe trauma patients, from the

emergency department of our hospital. This is a single center,

observational, study. Single center means that the study will be conducted

only in one center i.e. Fortis hospital, Noida.

Observational means the study will observe the level of prehospital care

given in patients of severe trauma. Your participation in this study will

have no impact on the treatment decisions made by doctor.

DATA COLLECTED:

If you agree to take part in this study, the following information related to

you will be collected:

67
Demography, that is, age and gender. Level of prehospital care given to

the patients. Intervention done on route or at scene to stabilize the patient.

Reasons for not availing EMS service, time of arrival.

RISKS AND BENEFITS:

This program is only observational and does not involve any special

medication outside of the treatment prescribed by your doctor. As such

there will be no direct risk if you participate in this study. You will not

receive any compensation for your participation in this study. Solely your

doctor determines all treatments prescribed to you.

STUDY PARTICIPATION AND WITHDRAWAL/REMOVAL

FROM STUDY

You can participate in this observational study if you meet the necessary

requirements for this study.

If you decide to take part, you will need to sign this form. You would be

given a copy of the signed completed form. You will be told if any new

information becomes available that could affect your willingness to be in

the study.

68
At any time during your participation in this study if you

1) have any queries regarding the study or

2) need additional information

3) decide to withdraw from the study,

You may contact your study doctor Dr.______________________ (Name

of Investigator) at ______________________________ (Contact no. of

Investigator)

CONFIDENTIALITY

All data will be encoded. Moreover, all measures to protect the

confidentiality of your records and your identity will be taken according to

the applicable laws and/or regulatory, and will not be made publicly

available. If the results of this study are published, your identity will remain

confidential.

The persons and the entities you are authorizing to use or disclose your

individually identifiable health information may include your doctor and

his/her staff, the institution, or members of ethics committee. You may ask

for additional information, at any time during the study, from your doctor

who is conducting this study.

69
ADDITIONAL INFORMATION

If you desire or want any further information on this study, you may

contact:

Dr. ______________________________________ (insert name of

Doctor)

Telephone: _________________________________ (insert emergency

contact number(s).

If you desire or want any further information on your rights, you may

contact the undersigned member of ethical community.

Mr./Mrs./Dr. ______________________________________ (Insert

name of member of ethical committee)

Telephone: _________________________________ (insert emergency

contact number(s).

70
PART2: INFORMED CONSENT FORM

Subject Identification Number of the Trial - ________

Title of the Project- Prospective Observational Study To Assess The Awareness And

Level Of Prehospital Care Given In Cases Of Severe Trauma Coming To Tertiary Care

Hospital In India.

Name of Principal Investigator- Dr. AKASH SINGHAL Mb- ___________

Subject’s name: _____________________________ UHID:_________

Date of birth (dd/mmm/yyyy)/Age: ______________

Subject’s Initials

(short signature)

(i) I confirm that I have read and understood the information sheet for the above study

and have had the opportunity to ask questions. All my questions have been answered in

detail to my total satisfaction clarifying all my doubts and providing me all requested

information in a way that I can understand thoroughly. [ ]

71
(ii) I understand that my participation in the study is voluntary and that I am free to

withdraw at any time, without giving any reason, without my medical care or legal

rights being affected. [ ]

(iii) I have not concealed or distorted any current condition, or any medical history

information, which might impair or affect my health or my participation in this study.

I have answered all questions pertaining to my health accurately and truthfully. [ ]

(iv) I understand that the Sponsor of the observational study, others working on the

Sponsor’s behalf, the Ethics Committee and the regulatory authorities will not need my

permission to look at my health records both in respect of the current study and any

further research that may be conducted in relation to it, even if I withdraw from the

study. I agree to this access. However, I understand that my identity will not be revealed

in any information released to third parties or published. [ ]

(v) I agree not to restrict the use of any data or results that arise from this study provided

such a use is only for scientific purpose(s).[ ]

(vi) I agree to take part in the above study. [ ]

(vii) All of the above has been explained to me in the language I know and

I understand. [ ]

*********************************************************************

*********

Signature (or Thumb impression) of the Subject:

…………………………………………

72
Date: ……. /……/……

Signatory’s Name: ………………………………………………………………….

*********************************************************************

*********

Signature of the Investigator: …………………………………….

Date: ……../……../……

Study Investigator’s Name:

………………………………..………………………………

*********************************************************************

*********

Signature (or Thumb impression) of the Legally Acceptable Representative (if

applicable):

…………………………………….............................................................................

Date: ……../……../……

Acceptable Representative’s Name: ……………………………..………………

*********************************************************************

*********

Signature of the Impartial Witness (if applicable):

………………………………………………….

73
Date: ……../……./………

Name of the Witness: …………………………………………………………

Statement by the researcher/person taking consent

I have accurately read out the information sheet to the potential participant, and to

the best of my ability made sure that the participant understands that the following will

be done:

1. Clinical data shall be collected

2. Investigations as per requirements shall be done

I confirm that the participant was given an opportunity to ask questions about the

study, and all the questions asked by the participant have been answered correctly and

to the best of my ability. I confirm that the individual has not been coerced into giving

consent, and the consent has been given freely and voluntarily.

A copy of this ICF has been provided to the participant.

Name of Researcher/person taking the consent________________________

Signature of Researcher /person taking the consent__________________________

74
Date ___________________________

Day/month/year

ASSENT FORM (UNCONSCIOUS PATIENT)

Attendee has read the foregoing information, or it has been read to me. I

have had the opportunity to ask questions about it and any questions that I

have asked have been answered to my satisfaction. Attendee consent

voluntarily to participate as a participant in this research.

Name of Attendee__________________

Relationship with attendee _________________

Signature of Participant/attendee ___________________

Date ___________________________

Mobile Number: ________________

Email: _______________

75
IF ILLITERATE

A literate witness must sign (if possible, this person should be selected by

the participant and should have no connection to the research team).

Participants who are illiterate should include their thumb-print as well.

I have witnessed the accurate reading of the consent form to the potential

participant, and the individual has had the opportunity to ask questions. I

confirm that the individual has given consent freely.

Name of Witness_____________ Thumb impression of the

Relationship with witness __________ participant___________

Signature of witness ___________________

Date ___________________________

Mobile Number: ________________

Email: _______________

76
STATEMENT BY THE RESEARCHER/

PERSON TAKING CONSENT

I have accurately read out the information sheet to the potential participant,

and to the best of my ability made sure that the participant understands that

the following will be done:

1. Clinical data shall be collected

2. Investigations as per requirements shall be done

I confirm that the participant was given an opportunity to ask questions

about the study, and all the questions asked by the participant have been

answered correctly and to the best of my ability. I confirm that the

individual has not been forced into giving consent, and the consent has

been given freely and voluntarily.

A copy of this Informed consent form has been provided to the participant.

77
Name of Researcher/person taking the consent _________________

Signature of Researcher /person taking the consent ______________

Date___________________

78
 ANNEXURE-3:

रोगी जानकार* शीट और स0ू चत सहम5त 6प8

भाग 1: सच
ू ना शीट

प6रचय-

अ:ययन का नाम:"फो=ट> स अ?पताल मA आने वाले गंभीर आघात के मामलो मA जागHकता और उJहA

Kया 6ेहॉि?पटल सेवा Nमल* हO पर संभाPवत अयलोकन अधयन।”

इस जानकार* 6प8 को :यान से पढ़A ।िजतने भी 6शन आप पछ

ू ना चाहते हO ।उJहA पछ
ू ने के Nलए समय

ले । अ:यन काNम>क दआ
ु रा Xकसी ऐसे शZद या जानकार* को समजाया जाएगा िजससे आप पण
ू > Hप से

नह*ं समजतA हO।

प\रचय

79
आप को गंभीर आघात के मर*ज] के बारे मA हो रह* एक अवलोकनाथमक अ:यन के Nलए आमं`8त Xकया

जा रहा हO। इस अ:यन मA आपकa भागीदार* ?व0चक हO । आमतोर पर आपातकाल*न Pवभाग मA हम बहुत

मर*ज दे खते हO िजन मA से २०% मर*ज गंभीर Hप से अगाथ हुए होते है ।

अ:ययन का उfदे gय

इस अ:ययन का उfदे gय है :-

1. रो0गय] को द* गई 6ेहॉि?पटल दे खभाल के ?तर I

2. रोगी को ि?थर करने के Nलए माग> पर या igय पर Xकया गया ह?तjेप I

3. ईएमएस सेवाओं का लाभ नह*ं उठाने के कारण I

अ:ययन कa 6Xmया और उपचार

इस अ:यन मA हम आपातकाल*न Pवभाग मO आने वाले गंभीर अगाथ के मर*ज़ो को लेना चाहते हO I यह

एक एकल कAo मA होने वाला हO I िजसका मतलब हO कa यह फो=ट> स अ?पताल नॉएडा मA कa जाएगीI

अवलोकनाथमक अ:यन का मतलब हO कa यहाँ आये गंभीर अगाथ के मर*ज] को Kया 6ेहॉि?पटल

दे खबाल Nमले हO इसका अवलोकन Xकय जाएगा I इस अ:यन मA आपकa भागेदार* से 0चXकrसक fवारा

द* गए उपचार संबद* 5नण>य पर कोई 6भाव नह*ं होगा I

संगह
ृ *त डेटा :

80
आप इस अ:यन मA भाग लेने के Nलए सहमत हO, तो आप 5नtनNलuखत से संबं0धत जानकार* एक8 कa

जाएगी :

जनसांिvयकa , यथाथ> उw और Nलंग

गंभीर आघात कैसे हुआ

जोuखम और लाभ :

यह काय>mम केवल पय>वेjणीय है और 0चXकrसक उपचार 5नधा>\रत के बाहर Xकसी Pवशेष दवा को

शाNमल नह*ं करता Iइस अ:यन मA आपकa भागेदार* से 0चXकrसक fवारा द* गए उपचार संबद* 5नण>य

पर कोई 6भाव नह*ं होगा I

अ:ययन मA भागीदार* आहरण / अ:ययन से हटाने-

81
य=द आप इस अ:यन कa ज़Hर* उपेjाओं को परू ा करते है तो आप इस अवकलोकनाथमक अ:यन मA

बहगीदार* ले सकते हO I य=द आप भागदार* करने का 5नण>य करते है तो आपको इस 6प8 पर ह?ताjर

करने होगे Iआपको ह?तारNशत तथा परू े Xकये 6प8 कa एक 65त द* जायेगी I य=द अ:यन मA जार* राyे

कa आपकa इzछा को 6भPवत करने वाल* कोई नई जानकार* 6ा{थ होगी तो उसे आपको बताया जायेगा

इस अ:यन मै आपकa बहगेदार* के दौरान Xकसी भी समय य=द :

1. आपको अ5त\रKत जानकार* कa आवgयकता हो

2. अ:यन के बारे कोई 6शन ,या

3. आप अ:यन को छोड़ने का 5नण>य करे तो आप अ:यन 0चXक?तक से संपक> कर सकते हO

डॉ ______________________ (अJवेषक का नाम) ______________________________ मA

(अJवेषक का संपक>)

इसके इलावा अ:यन 6योजग fवारा Xकसी भी समय इस अ:यन को समा{तः Xकया जा सकता हO I

गोपनीयता I सभी डेटा इनको•डंग कर द* जाएगी इसके अलावा, आपके \रकॉड> कa गोपनीय रखने के

Nलए सभी उपाय] और आपकa पहचान लोगो को साव>ज5नक Hप से उपलZध नह*ं कर* जायगी I इस

अ:ययन के प\रणाम 6काNशत करे जायेगA , तो अपकa पहचान गोपनीय रहे गी I

€यिKतय] और सं?थाओं िजJहA आप €यिKतगत Hप से पहचान यो•य जानकार* का खल

ु ासा या 6कट

82
कर रहे है िजJहे आप अ0धकृत कर रहे हO उनमA आपके डॉKटर और उसके कम>चा\रय] , सं?था, या

नै5तकता सNम5त के सद?य] को शाNमल हो सकते हO I आप Xकसी भी समय अ:ययन के दौरान अपने

डॉKटर ,जो इस अ:ययन का आयोजक है उनसे अ5त\रKत जानकार* के Nलए पछ

ू सकते हO I

अ5त\रKत जानकार*

आप इस अ:ययन पर कोई भी अ0धक जानकार* चाहते हO, तो आप संपक> कर सकते हO :

डॉ ______________________________________ (डॉKटर का नाम )

टे ल*फोन: _________________________________ (आपातकाल*न संपक> नंबर (एस )

आप अपने अ0धकार पर कोई भी अ0धक जानकार* चाहते हO, तो आप नै5तक समद

ु ाय के सद?य

अधोह?ताjर* संपक> कर सकते हO

Mr/Mrs/Dr :- ______________________________________ ( नै5तक सNम5त के सद?य का नाम

Nलखे )

टे ल*फोन: _________________________________ (संपक> नंबर Nल

पय>वेjणीय अ:ययन मA भाग लेने के Nलए स0ू चत सहम5त फाम>

अ:ययन का नाम:"फो=ट> स अ?पताल मA आने वाले गंभीर आघात के मामलो मA जागHकता और उJहA

Kया 6ेहॉि?पटल सेवा Nमल* हO पर संभाPवत अयलोकन अधयन।”

83
मर*ज का नाम: _____________________________ UHID: _________

जJम (डीडी / एम एम एम / YYYY) / उw कa 5त0थ: ______________

65तभागी के ह?ताjर

(लघु ह?ताjर)

(i) मO इस बात कa पिु ‚ट करता हूँ Xक मOने पढ़ा है और ऊपर के अ:ययन के Nलए जानकार* शीट को समझा

है और मझ
ु े सवाल पछ
ू ने का अवसर भी Nमला है I मेरे सभी 6gन] को मेर* संतिु ‚ट अनस
ु ार Pव?तार मA

जवाब =दये गये है मेरे सभी संदेह] को ?प‚ट Hप से दरू कर =दया गया हO िजससे मA ?प‚ट Hप से समझ

गया हूँ I[ ]

(Ii) मO समझता हूँ Xक इस अ:ययन मA मेर* भागीदार* ?वैिzछक है ,`बना कोई कारण और मO अपनी

0चXकrसीय दे खभाल या कानन

ू ी अ0धकारो को 6भाPवत Xकये `बना, अपना नाम वापस लेने के Nलए

?वतं8 हूँ I[ ]

(Iii) मO Xकसी मौजद

ू ा हालत, या Xकसी भी 0चXकrसा के इ5तहास के बारे मA जानकार* को 5छपाऊँगा नह*ं,

जो कa मेरे ?वा?…य को ख़राब या इस अ:ययन मA मेर* भागीदार* को 6भाPवत कर सकता है I मO सह*

ढं ग से और सzचाई से मेरे ?वा?…य से संबं0धत सभी सवाल] का जवाब दं ग

ू ाI[ ]

(Iv) मO समझता हूँ Xक पय>वेjणीय अ:ययन के 6ायोजक, 6ायोजक कa ओर से काम कर रहे अJय लोग],

आचार सNम5त और 5नयामक अ0धका\रय] दोन] वत>मान अ:ययन के संबंध और Xकसी भी आगे

84
अनस
ु ंधान के jे8 मA अपने ?वा?…य के \रकॉड> को दे खने के Nलए मेर* अनम
ु 5त कa जHरत नह*ं होगी ,

भले ह* मO अपना नाम अ:ययन मA से वापस ले लँ ू I मO उनके fवारा डेटा को उपयोग करने के Nलए सहमत

हO I हालांXक, मO समझता हूँ Xक मेर* पहचान तीसरे पj के Nलए जार* या 6काNशत कa कोई भी जानकार*

मA मेर* पहचान का खल
ु ासा नह*ं Xकया जाएगा I[ ]

(V) मO इस अ:ययन से उrपJन होने वाले आकड़ो के उपयोग को 65तबं0धत न करने के Nलए सहमत हूँ

बरशतˆ ऐसी 6योग केवल वै‰ा5नक उfदे gय (ओं) के Nलए Xकया जाये I[ ]

(Vi) मO ऊपर अ:ययन मA भाग लेने के Nलए सहमत हूँ I[ ]

(vii) ऊपर के सभी बाते मझ

ु े उस भाषा मA समझाया गया िजससे मO जानता और समझता हूं I[ ]

**************************************************

****************************

ह?ताjर (या अंगूठे का 5नशान) मर*ज का :

तार*ख: ……/……/……

ह?ताjरकता> का नाम:

**************************************************

****************************

अJवेषक के ह?ताjर:

85
तार*ख: ……/……/……

अ:ययन जांचकता> का नाम:

**************************************************

****************************

कानन
ू ी तौर पर ?वीकाय> 65त5न0ध के ह?ताjर (या अंगूठे का 5नशान) (य=द लागू हो):

……………………………………

तार*ख: ……/……/……

?वीकाय> 65त5न0ध का नाम:

**************************************************

****************************

5न‚पj गवाह के ह?ताjर (य=द लागू हो):

तार*ख: ……/……/………

गवाह का नाम

86
 ANNEXURE-4

Emergency care is one of the most sensitive areas of health care.

Emergency departments across the globe follow a triage system in

order to cope with overcrowding. The intention behind triage is to

improve the emergency care and to prioritize cases in terms of clinical

urgency. The term "triage" is derived from the French word trier (to

sort). Iserson and Moskop describe the requirement of three conditions

for triage in emergency practice:

1. At least modest scarcity of resources exists.

2. A health care worker (often called a "triage officer") assesses each

patient's medical needs based on a brief examination.

87
3. The triage officer uses an established system or plan, usually based

on an algorithm or a set of criteria to determine a specific treatment or

treatment priority for each patient.

In hospitals that apply triage for regular emergency care, triage is the

first point of contact with the ED. Assessment by the triage officers

involves a combination of the chief complaint of the patient, general

appearance and at times, recording of vital signs. Triage guidelines

score emergency patients into several categories and relate it to the

maximum waiting time based on specific criteria of clinical urgency.

Initial versions of triage guidelines had three levels of categorization

mostly termed as emergent, urgent and non-urgent. Studies have

revealed that five-level triage systems are more effective, valid and

reliable. Subsequently, the patient is labeled with a colored tag.

Depending on this tag, the patients are sent to specified areas where

they will be consulted by the physicians. While undergoing treatment,

the patient may improve or worsen and so may need to be re-triaged

and shifted to appropriate area for further treatment.

88