Much has been discussed recently about the quality of emergency care available in Kerala, especially in the case of road accidents. The tragic case of a man who suffered head injury and could not find a hospital for treatment has dominated the news headlines for weeks together.
It is worth noting that Murugan's case is only one of 36,000 major road accidents that happen on the roads of Kerala every year—a staggering number for a small state whose population is just 35 million. While there is no denying that what happened to Murugan was tragic and unfortunate, this however is not the case with all road accidents in Kerala. Many of the victims do receive good quality care, thanks to a large network of hospitals throughout the state.
In fact, Murugan’s case represents the tiny tip of a large iceberg—a predictable and expected complication of an imperfect healthcare delivery system. This article is written to illustrate the big picture, and discuss the opportunities and challenges in the field of emergency services and trauma care.
1. More modern hospitals
There is a growing network of high-quality hospitals with state-of-the-art trauma facilities in Kerala, although predominantly in the private sector. Some of these centres also train doctors and paramedical staff in emergency medical care.
Hospitals are showing an active interest in obtaining accreditation with agencies such as NABH, which requires streamlining of all aspects of patient care and governance. From the patients’ standpoint, this means that they can expect a global standard of care at accredited facilities.
In the Government sector, accident black dot mapping using GIS (geographic information system) has recently been completed in Kerala. Based on this, 37 government hospitals will be designated as trauma care centres after upgrading the existing facilities. The government is planning to install a unified emergency response network system which includes ambulances and user-friendly mobile-phone apps that utilise GPS.
2. More specialised doctors now available
Many ER’s (Emergency rooms/Casualty) are now headed by doctors with experience and postgraduate training in emergency medicine. Compared to the past, there are more neurosurgeons and other specialised doctors available now, which means that ability of the healthcare sector in the state to deliver emergency medical care is better than it used to be.
However, not every hospital will be able to employ a full-time neurosurgeon, because the case volume in a small hospital will not be enough to keep him busy. Neurosurgeons therefore tend to cover several small to medium-sized hospitals in a region. The downside is that the neurosurgeon might be tied up at one hospital while an emergency call comes from another hospital.
3. The arrival of unified call numbers
Over the past four years, there has been a welcome trend for emergency ambulance services to form GPS-enabled networks similar to that of Uber, so that the nearest respondent can reach the patient in the quickest possible time. Response times averaging 10 minutes have been achieved in metros like Ernakulam.
A group that deserves special mention in this context is the NGO-run emergency network called ‘ANGELS’, who started an emergency response console in Calicut, followed by Ernakulam. In the event of an emergency, people could dial a common number, “102”, which would be picked up by the central console operator, and directed using GPS to the nearest available ambulance.
From a patient’s standpoint, it is easier to remember and dial just one number, than to try contacting a hundred ambulances one after the other by dialling their individual phone numbers during an emergency.
This project and has received exemplary support from district administration. Of the 650 ambulances registered in Ernakulam district, over 235 have already registered with the network.
4. Greater awareness of warning signs and the ‘Golden Hour’
More people are now aware of the warning signs of a heart attack and stroke, prompting them to call an ambulance early. This shortens the delay in getting to hospital. In both these conditions as well as trauma, treatment during the golden hour is critical in ensuring survival and good outcomes. For instance, a clot busting injection works best when given early in a case of stroke, as it is able to open up blocked blood vessels that supply the brain. Delay in treatment leads to permanent brain damage, hence the usage ‘time is brain’.
5. Patients spend much less, compared to the west
Although the cost of medical equipment is high, the actual healthcare delivery cost remains relatively low in Kerala compared to the west. For example, to undergo a medical procedure such as colonoscopy in Kerala in a state-of-the-art private hospital, a patient spends only about 1/50th of the amount spent by a patient in the US—in spite of using the same equipment and medications, and performed by doctors of equivalent skills and knowledge.
Equipment purchase costs in Kerala being the same as in the west, the main reason for this remarkable difference is lower manpower cost—which consists of healthcare staff salary and per-patient fees of doctors, both of which are comparatively low. However, as manpower cost rises in the private sector, it will eventually get transferred on to the patient—as most patients in Kerala pay out-of-pocket than through insurance.
1. Good Samaritan rule yet to be accepted.
Onlookers are often reluctant to help a trauma victim for fear of being entangled in a police case and its legal consequences. Even though the Supreme Court of India has given a clear direction to protect the good Samaritan from such outcomes, some civilians are still reluctant to come forward and offer help. From the victim’s perspective, this can mean delays in receiving life-saving treatments.
Hospitals can help by recognising good Samaritans. Media can help publicise good deeds by civilians, which will encourage others to follow suit. Law enforcement personnel must ensure that good Samaritans are not harassed. Periodic reassurance by senior police officials would also help reduce anxiety of the general public to assist trauma victims.
2. Faulty transfer of patients: first, do no harm.
Many trauma victims are transported to hospital on three-wheelers or other private vehicles in a manner that destabilises spine fractures. Lay people sometimes treat the human body like a sack of potatoes. Spine trauma victims are lifted by their limbs without spine immobilisation and hauled on to the backseat of an autorickshaw by people who lack basic life support training.
By the time such a patient arrives in the casualty in a crumpled state, any incomplete spinal cord injury would have turned permanent, lifelong paralysis being the result. The general public therefore needs to be made aware of the importance of immobilising neck and spine fractures during transfer of trauma patients.
3. EMT’s (Emergency Medical Technician) not available in most ambulances.
In Kerala, ambulances are frequently operated by a single driver who might not be BLS-certified and therefore will not be able to treat the patient. In most instances, this person is merely transporting the patient from point A to point B after a preliminary assessment, which means that no treatment gets delivered during the golden hour.
In the absence of a qualified emergency medical technician or physician or staff nurse on board who can administer treatment during the transfer, much of the ambulance service that exists now in Kerala therefore is nothing more than a glorified taxi service.
In developed nations, ambulances have the equipment and personnel required to resuscitate and stabilise the patient, deliver emergency medications including thrombolysis for heart attacks, provide ventilator support and manage complex fractures. Only a few of the ambulances operating in Kerala have such personnel and facilities at this time.
Adherence to the National Ambulance Code is expected to standardise and streamline emergency response services across the country. Ambulance drivers can advance their own skills by completing the EVOC (emergency vehicle operators course) and BLS (Basic life support).
4. Ambulances that serve different masters and have different standards
One of the hurdles for creating a unified emergency response system for Kerala is the heterogeneity in the ambulance services available. Unlike developed nations that have an organized nation-wide network of emergency vehicles, the ambulances operating in Kerala come under various categories.
Some are owned by NGO’s (Non-government organizations) and local bodies such as municipalities and grama panchayats, others are owned by private individuals who operate a fleet of vehicles, still others are kept by hospitals for their exclusive use, and a few are maintained by large industrial firms to cater to their own staff healthcare needs. Unsurprisingly, needs, attitudes and priorities vary between these categories.
5. Wrong utilization of ambulances
At this time, ambulances are also commonly used to transport the dead; this is an example of incorrect utilisation of a limited medical resource. Hearse vans are specialised transport vehicles that can be used instead for that purpose; this will free up the ambulances for transferring patients. Hearse vans are increasingly available in Kerala.
6. Irregular payments for ambulances
Ambulance drivers report that a small but significant number of users refuse to pay for the service. While transferring a destitute patient, there must be a user-friendly mechanism to reimburse the ambulance driver. Greater consistency as well as transparency in fees for service are required, as are regulations to ensure that patients are not selectively taken to any particular hospital in return for financial incentives.
7. Traffic snarls and other driver woes
Though most road users move out of the way when they see an ambulance approaching, the congested roads and limited infrastructure make it difficult for ambulances to reach their destinations without delay. Ambulance drivers complain that traffic signals are not adjusted in their favour often enough, leading them to be stuck in traffic for a long time.
Ambulance drivers report harassment by law enforcement and by other road users upon allegations of using the siren while not transporting a patient. Most of these instances however involve an ambulance that is responding to an emergency phone call and is therefore empty.
Accidents involving ambulances are not uncommon. Only those with adequate road experience and suitable mental aptitude must be assigned to driving an ambulance, which is a job involving considerable stress and pressure. Though they are eligible for priority, ambulance drivers must remember that all traffic rules are still applicable to them, and that they must ensure the safety of fellow road users at all times.
A newer concept to beat traffic blocks is the bike ambulance by which an EMT can reach the trauma victim faster. First aid or life-saving treatment can thus be given on the spot, while waiting for the large ambulance to arrive.
8. Communication gaps
Not all patients can be treated at all hospitals, as some specialist services will not be available everywhere. Those who suffer certain types of life-threatening injury can only be revived at centres that have certain equipment and expertise. Unfortunately, an ambulance driver working alone will be no position to match the patient’s needs with locally available expertise. They frequently rely on the bystander’s request, which in itself will not be an informed choice.
Hospitals in the region must be encouraged to publish an updated list of the available facilities and services. Once a centralised console with real-time expert advice becomes available, the ambulance will be able to transport the patient to the nearest possible destination—without losing valuable time by stopping and enquiring at various hospitals.
For instance, once the EMT provides a case summary of the patient being transported, the console can check with nearby hospitals and verify where exactly the equipment, medication and subspecialist required for that specific patient’s condition are available.
9. To stabilise or not to stabilise?
This is a difficult question. While it superficially makes sense that all patients be taken to the nearest hospital and stabilised before transfer to a larger centre if needed, this practice could prove to be dangerous in certain situations. For instance, a patient with a heart attack will need to get to a place where advanced cardiology facilities are available, and any time lost by stopping over elsewhere could prove fatal.
If a hospital without such facilities accepts the treatment responsibility of such a patient and the outcome is not good, the case could be hard to defend in court, especially if there were better equipped centres in the vicinity. In an increasingly litigious environment, doctors and hospitals are reluctant to accept trauma patients whose medical and surgical needs exceed locally available expertise and equipment.
10. Quality of medical education vs. number of doctors
Once the ambulance reaches the casualty (E.R.), the trauma victim should ideally be assessed by a doctor with specialised training and experience, as several decisions and life-saving treatments have to be undertaken without delay. However, in many centres—in private as well as public settings—it is not uncommon for inexperienced doctors to be put in the situation instead.
Whether this doctor is competent to handle a seriously injured trauma victim without supervision, is a question to be addressed by hospital administrators. Equally pertinent is whether the casualty doctor has adequate backup from doctors of concerned specialties.
In the past decades, the majority of the doctors practising in the region had passed out of reputed medical institutions after receiving good-quality training. In addition to academic calibre, a few medical colleges also gave consideration to the applicant’s aptitude while admitting students for the MBBS course.
As demand for seats increased, criteria for admission to the MBBS course became less stringent. In addition, students now have the option to complete the MBBS course outside India. The end result is greater heterogeneity in doctors’ knowledge, skills, experience, outlook and priorities.
On the good side, more people are becoming doctors, which mitigates the shortage experienced in the past. Subspecialisation and placement of doctors in areas that suit their academic interest and capacity is important, as not all doctors can work productively in all settings.
11. Human resource scarcity in the public sector
A major problem in the public sector is the lack of adequate numbers of staff manning the casualty and support services. Doctors employed in Government hospitals have observed that the staffing pattern has not been upgraded for several decades, even as the patient volume has gone up several-fold. Shortage of senior doctors and super-specialists is an ongoing problem even in some government medical colleges.
It is not uncommon for a team of just two doctors being made to see 300-500 patients daily at the medical outpatient clinic in Government hospitals. This is an appalling situation both for the doctor as well as for the patient; no meaningful healthcare can be delivered in such settings. The overall lack of equipment in the public sector is compounded by scarcity of qualified technical support staff, and failure of repair and maintenance.
However, just as a skilled artist can create magic even with a broken paintbrush, these shortcomings of the public sector are compensated to a large extent by the unrelenting individual commitment shown towards patients by dedicated doctors, nurses and support staff.
12. Emergency services misused by the public for routine care
It is a common practice for patients to visit the casualty during odd hours for trivial health problems like a common cold, for the sake of convenience. This takes away the doctor’s time from patients who urgently need medical attention.
13. Unfavourable environment for emergency physicians and staff
Many hospitals have limited number of personnel in their casualty, which can be inadequate to handle a sudden influx of patients with trauma. Lack of security, threats of violence by emotionally charged or drunk bystanders, increasingly litigious climate and scarcity of essential equipment and support facilities can make it a challenging workplace to be in. Hospitals can help by employing their most experienced staff in such areas, where communication and soft skills are of greater use.
14. Lack of a green channel for emergency patients in hospitals
Hospitals provide both emergency as well as routine outpatient and inpatient services. However, delays often occur when services such as radiology are occupied by non-emergency patients. Just as vehicles on the road give way to ambulances, priority must be given to those patients who are acutely ill.
Likewise, special types of billing patterns are needed for those visiting casualty, which minimise the need for bystanders to run around from counter to counter at hospitals. All of these measures together should be aimed at reducing waiting times as well as improving the door to needle time.
15. Private-public divide. Expensive equipment—who will pay the bill?
Although Kerala has made giant strides in the level of quality available to patients, a lot of this has been the effort of private hospitals with state-of-the-art equipment, which in turn happens to be expensive. Unlike a government hospital with comparable facilities, the money spent to purchase such equipment in the private sector unfortunately has to be recovered from the patient. This is a harsh reality in the field of health care in India, where only a minority of patients have medical insurance.
ICU beds, ventilators and paraphernalia cost enormous amounts of money to set up and maintain. Though some hospital bills do get written off in apparently genuine cases, it is unfeasible for a private hospital to routinely admit patients free of cost to such facilities.
A mechanism to pay for the immediate emergency care expenses for trauma victims will need to be established, especially in the private sector. A government-aided insurance program, which will help offset the cost to private hospitals that treat destitute trauma patients will be a welcome first step.
16. Polarisation of healthcare
Over the past 10 years, hundreds of small hospitals and clinics have shut down in Kerala due to increasing overhead costs, proving that running a hospital is not a profitable venture in most cases. Many of the smaller hospitals which are still surviving have had to cut down their bed strengths and staffing, as the revenues are not enough to pay the stipulated staff salaries. With no government aid, private clinics operate solely on income from patient fees.
Government healthcare facilities being already overcrowded for the reasons stated above, patients are increasingly being left with no choice but to flock to large tertiary level hospitals even for routine healthcare.
As the smaller friendly neighbourhood clinics continue to close down, healthcare will eventually get polarised to powerful organisations that own and operate large hospitals. This will not be a good thing for the common man, as small low-cost clinics had traditionally been the mainstay of healthcare delivery to a large section of the population.
In a populous country such as India, healthcare is ideally run in a decentralised hierarchical system, with less serious everyday problems being taken care of at grassroots level clinics, leaving the larger centres to take care of complex illnesses. Polarisation will lead to overcrowding of referral centres by people who do not require tertiary level care, which will compromise the care delivered to all.
17. Inadequate measures for primary prevention
Unfortunately, most of the attention in trauma care seems to be concentrated on what happens after the accident. Perhaps of greater importance is prevention, as it is a major public health problem in Kerala that leads to 36,000 serious injuries including 4200 deaths a year—many of whom are young. Doubtless, it is easier and cheaper to prevent than treat.
Although faulty infrastructure is often blamed for accidents on the road, the vast majority of accidents are directly caused by human error—a still under-recognised entity. Human error can range from over-speeding, irrational hurry, joyrides, underage or drunk driving, refusal to use safety equipment, failure to follow basic traffic rules, and lack of courtesy to other road users.
Eliminating human error during driving needs to be addressed seriously before issuing driver’s license, and also enforced by imposing penalties for all forms of dangerous road behaviour. Road safety must be made an essential part of school curriculum. This topic was discussed in my earlier article titled ‘Staying alive on our roads’. Read more
In summary, although the standards of medical expertise and technology have improved in select centres, overcrowding of emergency rooms, lack of networking between hospitals, congested infrastructure and insufficient manpower are significant barriers in delivering quality healthcare to trauma patients in Kerala.
In spite of such barriers, several individual doctors and healthcare staff remain committed to their patients; it is their extraordinary effort that makes the system seem healthier than it really is.
There is no easy solution; substantial upgrades have to occur at multiple levels to bring about any meaningful improvement. Creating an organised network of trauma centres with efficient communication systems, and upgrading the existing ambulance services to include EMT in each vehicle are urgently required. A government-aided program that provides for emergency care expenses of trauma victims is essential.
(The author is a senior consultant gastroenterologist and deputy medical director, Sunrise group of hospitals)