February 19, 2019

The Golden Hour – The Ambulance

Continued from last topic ( http://newsnviews.online/nv-awaaz/the-golden-hour-a-central-trauma-care-research-centre-cum-university/ )

  1. The Ambulance

 With trauma centres having been established, the next step would be to ensure that the victim is carried to the trauma centre in as little time as possible – and this requires the ambulance. An ambulance has been defined as a vehicle equipped for transporting the sick or the injured to and from a hospital, especially in emergencies such as an accident, natural disaster, etc. Primarily, ambulances are of two types:

  1. Advanced Life Support Ambulance: – ALS

An ambulance capable of providing treatment of life-threatening medical emergencies through the use of techniques such as endo-tracheal intubations, administration of drugs or intravenous fluids, cardiac monitoring, and electrical therapy by a qualified person.

  1. Basic Life Support Ambulance: – BLS

An ambulance capable of providing basic life support to patients. The most basic can even take the form of being on a smaller chassis.

There is also the ‘Air Ambulance’, which is a small fixed-wing aircraft, or a helicopter, with medical equipment and personnel on board to transfer victims from remote places to a hospital or trauma centre. By reason of the expense involved, it is not further discussed.

  1. Ambulances are built on a light commercial vehicle chassis and carry a siren as also revolving lights that indicate and ask for precedence in traffic. They are costly and require time to build. A fully-equipped ALS ambulance costs in the region of Rs. 35 lakhs. A medium-size BLS ambulance would cost in the region of Rs. 20 lakhs. A small ambulance (primarily patient transport) would cost about Rs. 7 lakhs. The overall cost would also vary, depending on the equipment and the level of professional expertise that is assigned to be on board the ambulance.
  1. An ambulance has to be registered with the Regional Transport Authority and also needs to be cleared by the Regional Health Authority and the police. In Delhi, a vehicle can be registered by the Transport Department as an ‘Ambulance’ only after it has been approved by the Committee for Registration of Ambulances.30   Presently, after the ambulances are ready, it takes time and ‘effort’ to get the required clearances.
  • which comes under the city government’s Health & Family Welfare Department
  1. In a major step towards improving the quality and safety of ambulances on Indian roads, the National Ambulance Code AIS:125 (Automotive Industry Standard) recommended by the Central Motor Vehicles Rules-Technical Standing Committee has been approved by the Ministry of Road Transport & H This Code puts in place minimum standards and guidelines regarding the constructional and functional requirements of road ambulances in India. The Code classifies road ambulances into four types (A, B, C & D) that is First Responder, Patient Transport, Basic Life Support and Advanced Life Support, respectively.
  1. Looking at it in practical terms, a mid-level ambulance, having proper equipment and trained personnel, can even carry out several diagnostic tests on board, so that by the time the patient reaches the trauma centre, the basic tests would have already been carried out, and information relayed in advance for the trauma centre to be ‘ready’. In critical cases, the treatment can start in the ambulance itself.
  1. Ambulances are either owned and operated by the Government, or owned and operated by private hospitals. Sometimes, charitable organisations also operate an ambulance service. A look at the Government hospitals will show many ambulances, lying idle in an unserviceable state.
  1. Availability of capital and operational expenses apart, there is also the utility factor as to how many accident victims an ambulance brings to a trauma centre in one year so as to justify the capital and the operational expenditure.
  1. Presently, if an ambulance owned by a private hospital, even if it is next door, is asked to pick up a patient and carry him not to that hospital, but to a trauma centre, the response generally will be ‘no ambulance is available’. But if an offer is made for payment of the charges, whether they are actually paid or not, they may reluctantly drop the person to the trauma centre.
  1. Where the person does not pay the bill, or is unable to pay the bill, there is, at present, no system of recovery of that money, or even a part of it, by the hospital from the G Practically, the paying out of such bills will be cheaper, and the money spent will be worth it. Allowing private transporters to run basic ambulance services against payment by the Government needs to be explored, and if found feasible, put in place.
  1. A serious problem today is that in many an accident, the injured are trapped inside the vehicle. If a crowd collects (or even when a state-of-the-art ambulance with trained paramedics arrives within minutes), they are helpless, for it needs special equipment and professional rescuers to often cut the vehicle and pull out the injured. In the absence of proper rescue cutters, the paramedics will only be able to look on helplessly as the victim(s) trapped inside the vehicle bleeds to death because they are unable to extricate him from the vehicle.
  1. Till we are able to have rescue teams31 alongside the ambulance, tow vans in each district32 can be taken into the loop, given some training, obligated to carry some equipment, given / issued a training video on ‘How to’ and also paid an annual stipend plus an honorarium per call to cover the costs of attending. The computer at the District Control Room (discussed in sub-topic 9 infra), upon receiving the Lat-Long, should be able to send an SMS to the rescue cutters and others to take instructions on the location of the accident.
  1. While gas cutters are not easy to arrange, by which time it is often too late, a more convenient and simpler, though less effective, substitute would be a 125mm angle-grinder fitted with a high speed reinforced Cut-off wheel (1.2 mm thick). It can run on the battery of the vehicle (12 volts DC), and would be quite effective in cutting out metal pieces so as to rescue those trapped inside the vehicle. Gas cutters require a professional operator, but an angle grinder such as this can be operated by anyone. A crow bar must also be carried.
  1. Considering today’s traffic scenario, we need to use the services of a trained paramedic, who would usually travel on a 250cc motorcycle with his first-aid kits hung on either side of the rear wheel. He will be able to reach the site much earlier than the ambulance, and then start giving the much-needed first aid while waiting for the ambulance to arrive.
  1. It is not just speed; it is also the ability to go through traffic jams where an ambulance may be stuck, while a motorcycle will find its way through.33 He can park his motorcycle at the accident site and accompany the injured in the ambulance to the trauma centre. Being a trained person, he can do more by way of first aid as compared to lay members of the public. He can retrieve the motorcycle later.
  • fully equipped with trained personnel and equipment, including gas cutters, etc.
  • Most of them have a tie-up with the traffic police for removal of vehicles wrongly parked.

For recruitment, a candidate may be required to pass not only an examination on paramedics and first aid, but, hopefully, also a motorcycle speed driving test. It is the situation of traffic on our roads that calls for such (ostensibly) weird solutions.

  1. Looking at it in the overall perspective, in order to bring the injured to the trauma centre in time, we need very many more ambulances. The shortage on this score is acute. Systems for their coordination and control are also required. The question is also what we as a nation can afford to allocate.
  1. It is also proposed that the ambulances be parked at a distance of 50 kms on the highways, and trauma centres be set up every 100 kms.34 While on the highways and in the metros, the cost of a proper ambulance (ALS / BLS), or even less sophisticated or mid-level ones, may be justified, let us look at all those accidents which happen in places other than the metros or the highways, or on roads that are otherwise not well connected. It is here that the autorickshaw ambulance (as advocated in sub-topic 11) becomes necessary.

Next Topic: Harnessing the Public – and the Mobile Telephone