September 21, 2017

The Golden Hour – A Central Trauma Care Research Centre-cum-University

..continued from previous topic http://newsnviews.online/nv-awaaz/the-golden-hour-trauma-centre/

  1. A Central Trauma Care Research Centre-cumUniversity

 

  1. While we need trauma care centres all over the country, to enable them to function efficiently and provide value for money, we also need to establish a Central Trauma Care Research Centre-cum-University – CTRU for short.
  • [25.04.2005] decided by the National Consumer Disputes Redressal Commission; reported as II (2005) CPJ 35 NC. Also noted in the Law

Commission’s Report.

Generally -1

  1. A clarification first. To recapitulate, being time sensitive, trauma care requires a different approach (of course depending on the extent and nature of the injury). Broadly speaking, the stages are:
.1 At the site – the first 10 minutes (or the platinum 10 minutes);
.2 While transporting to the trauma centre – the next 50 minutes;
.3 Attention at the trauma centre – in the first few hours;
.4 Further attention till the patient can be removed from ICU;
.5 Post-ICU care;
.6 Post-recovery care at hospital in order to reduce
the impairment / effects of the injury; and
.7 Back at home, long term care to sustain,

CTRU will help develop systems and guidance that will ensure effective trauma care, at affordable costs and provide quality at each stage.

  1. The University will engage in multi-disciplinary research in the areas of medicine, trauma care, and indigenous, traditional and generic medicines. It will specifically cater to the needs of trauma care, specialising in analysing and developing best treatment methods for road accident victims. To develop qualitative, effective and economical post-accident response techniques, protocols, specifications, etc., it is necessary that research in this field is encouraged and adequate funding for the same is ensured. For its proper functioning, it will require adequate infrastructure. The CTRU will be under the ambit of the Ministry of Health and Family Welfare – with support from the MoRTH.
  1. While trauma care education will be imparted at institutions attached to hospitals, the proposed ‘University’ would be different from a typical medical college. ‘Different’ in the sense that the students here would be those who already have a post-graduate degree and would be pursuing a further specialised course – a second post-graduation, either as a short-term course, or as a long-term course – but attending only a few days in a month while working at a trauma centre somewhere in the country.
  1. Post-graduate continuing education in trauma care also may be introduced. The University will allow doctors to pursue long distance fellowship programmes while remaining at their original employment. They will be conducting research, writing papers and sending their observations to CTRU. CTRU will be a centre for excellence and for dissemination of information and a platform for exchange of new research findings on trauma care and ancillary treatment methods.
  1. The CTRU in contemplation would also function as a repository of all research papers and centre for exchange of ideas and information on critical care and medication. Some doctors will be appointed on regular basis to serve long term with the CTRU, while others will be appointed on contractual or temporary basis to do research or undertake projects relating to emerging issues of trauma care and treatment.
  1. It will prepare teaching material on trauma care for surgeons, doctors, paramedics and nurses for being used at the trauma care centres. It will need to have well-developed infrastructure to do quality research with sufficiently advanced information and communication The University will need to be located where doctors will not hesitate to come on a long-term or short-term basis to do research, attend refresher courses or perform some teaching assignments, etc.

Well-stocked library -2

  1. In the world market today, there is enough literature on trauma care

– books and research papers published in international periodicals, which are well researched and evidence based. However, because of the prohibitive cost, it is not practicable for most hospitals and even medical colleges, let alone individual doctors, to purchase or have access to them.

  1. But an institution of the kind as the proposed – CTRU – can purchase all these books and also subscribe to all these journals and stock them in its reference library. They can be used by those doing research – or by the visiting doctors and surgeons – to update their knowledge.

Repository for research, scholarly work -3

  1. The next step will be to support and encourage our doctors to publish research papers, etc. so that the library becomes gradually populated with Indian research, findings and results. The library will contain not only books and journals, but also observations and reports from trauma centres, doctors (and even the lay people), categorised and sub-categorised – and duly arranged – to make them relevant per topic as also per the audience they address.
  1. It is not so much the medical or trauma-care teaching which is more important. It is the collection and processing of material and discussion on that, and exchange of ideas and sharing of experiences, which are the present day needs. The main focus of CTRU will be preparation of
  1. India has produced, and continues to produce, brilliant doctors. That many have migrated and settled abroad is one issue, but there are many brilliant and well-meaning who are still working here.
  1. Now, if one such person in the course of his daily work devotes a small part of his time to do research and prepare a paper because of the promptings of his inner conscience – or spiritual duty – to serve the society, to whom will he send it ? CTRU will come in handy in such cases and will provide him with that ‘Post Office box’.
  1. It is a basic human instinct that if he knows it will reach a place where it will be kept and be available for the like-minded, he will be willing to work even more on the project. And if he decides to do further research he can take a trip to the CTRU – he can even combine it with a few days holiday for the family – utilise the library and look not only at the foreign publications but also what his like-minded countrymen have written.
  1. Today, in our country, seeing an injured, at times, people – ranging from those in the crowd, to those who transport, and those at the trauma centre (including surgeons and others), and at the aftercare – come up with brilliant ideas which they would be happy to share. Professional publications by the CTRU are addressed in para 128 et seq.
  1. Unless a Centre as proposed here is established, we will only be importing ideas from other countries and not developing those which are needed by our own country, tailored to our needs; nor will we be giving an opportunity to our medical professionals for development at advanced levels.

Receiving and Analysing empirical evidence -4

  1. To ensure affordable trauma care, we need to rely on ‘Evidence-based medicine’, i.e., the process of systematically reviewing, appraising and using clinical research findings to aid the delivery of optimum clinical care to patients – or trauma care in this case, to the injured.
  1. Evidence-based medicine forms part of the multifaceted process of assuring surgical and clinical effectiveness, the main elements being:

Collection of data – of the problems, treatment and the outcome.

The logic is its ability to turn a specified problem into answerable questions by examining: (1) similarly injured; (2) the methods deployed

– diagnostic, surgical and related medicine; and (3) the outcomes achieved.

  1. Evidence-based medicine, to illustrate, includes 100 people with similar injuries being given different interventions and treatments, and then comparing which worked the best. A decision so taken and then dissemi-nated is really its goal. Evidence-based medicine has much to offer. It is being applied not only to pharmaceutical treatments and surgical interventions, but also increasingly to diagnostic tests and even medical devices (equipment). The problem in India today is:

Where can we find the information to help trauma professionals make better decisions ?

  1. Accessing ‘information’ of clinical practice is the first step followed by analysis of such information. Additionally, improved access to resources and integration with medical IT systems means that medical professionals are now, more than ever before, in a position to gather evidence at the initial point, transmit, store, analyse, thus ensuring that evidence is translated into practice. This will include discontinuance (removal) of ineffective or potentially harmful treatments to enhance the quality of trauma care.
  1. Collection of statistics and data will not mean just the number of deaths on the roads or later at trauma centres. There is much more to empirical evidence and analysis than merely statistics. Each injury / death requires study of the care at site, the transit to trauma centre, at the trauma centre and thereafter till recovery / These, if reported in a scientifically designed Form and electronically submitted and analysed, would provide the data needed to develop better systems in trauma care.
  1. CTRU will receive and process reports received from ground level from all over the country in the data processing and analysis unit and then find appropriate methodology for dealing with it. Besides, the CTRU will regularly receive reports from various trauma centres in the country on the problems faced – as also ideas and thoughts for newer forms of procedures and practices for consideration. These can be published as research papers in a simple language suited to our conditions.
  1. Before we can use the ‘evidence’ it is necessary to: (1) Gather (capture) it at the initial stage; (2) Group & classify it; (3) Critically appraise it; (4) Interpret it in context; (5) Implement it; (6) Store and retrieve it; and (7) Ensure it is kept updated. Meta-analysis and systematic review is also Finally, it is the dissemination.
  1. Such grouping and classification will then be available to the surgeons, the doctors, and others, to share their experiences on what are the best as also the affordable – rather qualified according to availability of resources – interventions, treatments, etc. This grouping or classification will help us evolve the best practices and evidence-based medicine.
  1. Stated differently, these 5,00,000 injuries occurring annually in various parts of the country need to be grouped and classified – as injury types

– so that for each on the following three stages:

  1. 1. first aid at site before transportation / removal to trauma centre;
  1. 2. immediate intervention and attention and this includes the first 24 hours and also the next few days; and
  1. 3. recovery stage at the hospital trauma centre;

and if they survive, the recovery at home. See para 188 infra.

  1. All trauma centres in the country can be required to send a monthly report in an electronic form giving the total number of injured, the kind of injuries, the treatment carried out, the waiting period, or shortfall in capacity (of that centre) or the surplus etc.14 For purposes of improvement, the raw data, when received from the trauma centres from all over the country, can then be put together, processed and
  1. With all the data received, classified, analysed and further research carried out, the next step will be preparing a manual for Standardised operating Procedures & P It will also prepare other checklists, Forms for recording observations, and Forms as would be otherwise necessary, not just for legal purposes, but for better treatment.
  1. Guidance manuals on how to fill in these Forms, how to make observations and how to record them in these Forms, will also be developed. So often, we find that these forms and instruction notes are simply copied from the West without adequate redesigning and adaptation to suit our conditions.

14  personnel, equipment, supplies, etc

  1. CTRU will develop methods for advanced proficiency in the care of seriously injured and lay down the qualifications required to supervise surgical critical care units. It will critically evaluate the relationship between evidence based practice and professional development. It will help understand the rationale behind pre-hospital trauma patient care management, and the evaluation and development of practice.
  1. On any particular problem, the CTRU can call for opinions from the practicing professionals and experts. If they are similar, they can be readily accepted and disseminated. But if there are differing views, a seminar can be organised and the concerned persons invited to discuss the issue threadbare and the conclusion that emerges can be published as a paper resolving the matter.
  1. Considering the degree of similarity between a trauma centre for road accident victims and centres to treat soldiers who sustain battlefield injuries, some tie-up between the armed forces institutions, say, the AR&RC, New Delhi; or the AFMC, Pune, on the one hand and the CTRU on the other, would work to mutual advantage and help develop
  1. Re-engineering existing processes will require data processing and More particularly, it will develop those systems and methods as are: (1) suited to our country and our populace; and (2) are affordable. It is better to give a lesser level (or quality grade) of treatment immediately without delay than to tell the injured groaning in pain:
  1. 1. the (sophisticated) equipment is busy, or is not functioning; or 2. the specialist is not available or has gone on some other duty, which is a common ‘answer’ at hospitals.
  1. CTRU will develop systems for trauma care which give best value for money (spent by the State). Also, it will integrate higher spending with those who can afford to pay. Quality, particularly in the context of trauma care, means standard and consistent care, rather than fancy treatments.
  1. In post-hospital care, the objective is to rehabilitate the patients by making the most of resources available, which could make a big difference in the functioning and quality of life the injured will be able to lead thereafter. Emphasis would also be given to developing methods for counselling a patient psychologically both in short term and long term to come out of trauma stress. The objective is to send a person back home, completely fit and functional to work and serve the society.
  1. CTRU will network all regional trauma centres for all aspects of trauma care, including patient care, data collection and establishment of a National Trauma R With modern-day telecommunications, a trauma surgeon who is located anywhere in the country can carry out research work over the Internet, for which the CTRU can have a portal.

He can respond to queries or give his own thoughts or consultation papers.

  1. CRTU will be a referral centre for patients from neighbouring regions who require specialised trauma management and rehabilitation. It will have a control room for effective co-ordination and communication besides having networking linkages with other hospitals and agencies. The control room will monitor the performance of trauma centres across the country.
  1. The reports on performances, difficulties that arise, etc. will be collected.

These will be used to assess the method that has been prescribed. This can be for an overall process, treatment of a particular injury or even more specific as to equipment used.

  1. The CTRU will be on the lookout for trends. Receiving referrals, feedback on administering trauma care and statistics on types of trauma being faced by centres, the CTRU will be able to identify and develop trends and take steps to streamline trauma care for that particular injury. Trend analysis can be shared with other authorities, such as road authorities, informing them of what sort of accidents are taking place and where. It will, in a way, ‘re-run’ the evidence-based medicine programme.

Training courses for surgeons, doctors, nurses and paramedics -7

  1. Continuing, trauma care needs many and diversely trained professionals. Education and training in trauma care is a specialised It is estimated that by the turn of the decade, we would require thousands of trained persons.
  1. While medical colleges abound, there is need for running short term super-specialty courses for trauma care. CTRU could be: (1) setting the curriculum, training the teachers who will train nurses and paramedics; and (2) teaching doctors, nurses on how the new methods work. The students will be those who are already educated and trained in general fields (many of whom may be having post-graduate education), whether as a paramedic, a nurse, a physician, a diagnostic, or a surgeon.
  1. Put differently, it will be a post graduate specialised trauma course – usually part-time, but will consist of 20% education / class room teaching and 80% collection, processing, analysing and rewriting of what are the thoughts and experiences of trauma professionals and others from all over the country.
  1. Trauma care is nurse-centric. Insofar as nursing and trauma care is concerned, it is not that the nurses and paramedics will be trained at the CTRU. But systems for their training will be developed and the teachers at other centres would be trained here so as to teach trauma care nursing and paramedics. It will prepare a training course for nurses in medical care training and one for technicians in emergency medical care.
  1. Such specialised education needs a series of short courses at an Institute like the one contemplated here, so as to give the required expertise in Emergency Medical Care. Trauma surgeons with certain minimum experience can be allowed to pursue long distance fellowships.
  1. There will be – like at the National Judicial Academy at Bhopal for judicial officers – periodic refresher courses and seminars organised where those concerned with trauma care can exchange ideas and receive further education and training. It can also prepare course material for long distance learning through I Hopefully, one day specialists from all over the world will come to our CTRU to learn.

Professional Publications -8

  1. Another area to attend to is publications. Let us look at the offices of

100 top trauma surgeons / doctors in the country – the library they have and the journals they read. It will be sad to note that almost none of them are written or published in India. We need books written in India for use of Indian professionals to treat trauma patients.

  1. CTRU can set-up a research wing to do research and advise on emergency care of this nature and make available PDF files in English and also in regional languages which the doctor on duty at the reception of a trauma centre can look for on its website and download. If this information is available as a few pages of printout specific to the problem being faced, the care at the trauma centre can be improved
  1. The publications of the CTRU can again be of various levels, super-specialised for use by the trauma surgeons on the one end and for the use of the semi-literate common man on the other, and on all fields covering trauma care. The handbook for a Level-4 trauma centre will be different from that for a Level-3 (and so forth). It can also publish manuals for paramedics, nurses, and even surgeons and others for use in rehabilitative recovery of the injured.
  1. What we require today is a government supported programme – a research institute – attached to some premier hospital which publishes manuals, research papers and easy simple explanatory papers with pictorial illustrations and translations into regional languages etc., detailing techniques of treating road accident victims whether at site, or in the ambulance, or at the trauma centre, or at the normal hospital or even thereafter at home are administered. It can run a web portal containing all substantial material (mostly downloadable as PDF file) for the benefit of all concerned with trauma care.
  1. To take a sample, apart from rushing the victim to the trauma centre at the earliest, the trauma centre can be linked by video and computer to a central desk at a specialised accident care body (located anywhere in the country) from which the doctor or the surgeon attending to the victim can take precise expert guidance and even have guidance material roll out of his printer in a minute or two.
  1. The doctor or the surgeon at the trauma centre can simply select and pull out from the already printed material or download from the website of the CTRU and give it to the family of the injured person as a kind of guidance on how to do after-care and follow-up-care.
  1. Lastly, it will be written in India, suited for India, literature (of several levels) for use of those involved in trauma care – from the super-specialists at one end, to the paramedics or even less, on the other. In short, publications of the centre will not only create utility but will also foster trust and credibility. Hopefully, the publications of the CTRU will come to find a place in the libraries of trauma centres all over the world.

Certification and Audit of Trauma Centres -9

As noted earlier, trauma centres need: (1) certification as trauma centres; and (2) grading levels. This would include not only the initial certification, but also regular ‘watch’ as to performance levels. The sign-board outside a trauma centre proclaiming its level should be lived upto.

  1. While the CTRU is not expected to become another bureaucratic department to go and ‘inspect’, but some effective central system can be worked out so that the other medical councils, health departments etc. in the various States can under guidance from those at the CTRU, carry out the certification as also the performance audit of trauma centres in their respective S Unless efforts at developing management and financial audit systems are put in and a design prepared, the headlines ‘Trauma centres in coma’ [The Tribune – 8.11.2014 – page 6] will continue to appear.

Developing design and management systems for trauma centres -10

For each trauma centre that is planned and constructed, there is a tendency to hire a separate architect and design team. The right thing will be team work at CTRU which will prepare a ‘standard design’ (for each of the four levels) of the building, architectural design, the equipment requirement, the personnel requirement and the services, etc. Based on such design, the thousand trauma centres that we need in the country can be built and equipped.

  1. So important is design for the trauma centre that it will call for substantial expenditure. But then, the expense and effort here more than pays for itself by the cost saving when that design is used for hundreds of trauma centres. The working practices for these levels of trauma centres as also the training of personnel and provision of material for them has to be prepared by CTRU.
  1. Next, we assume that one fine day, we are able to establish 1,000 trauma centres (of various levels from Level-1 to Level-3) in the country. Apart from training and skills for the personnel, it will need a Management Manual on how to run and operate that trauma centre – and one that is suited to our conditions. Such manuals (for each level of trauma centre) will be prepared and updated at the CTRU so that each trauma centre can work to maximum efficiency.
  1. Further, though not readily ‘visible’ as equipment, most important is ‘software’ for managing and operating trauma centres. Ironically, much of the hospital management software for countries abroad is actually designed by our young professionals. Hopefully, the CTRU will give them an opportunity, harness their intellect, and encourage them to develop operating software for the trauma centres, and then make it available to all the trauma centres in the country. It can also enter into a technical collaboration with software developers as well.
  1. Both within the trauma centre and as networking to the others, including the CTRU, development and installation of quality software will enable cost reduction by over 50%. Besides, the Forms as are being used by trauma centres all over the country will need specialisation, and effort and expense at design. See discussion on Forms design in Topic 14 infra.
  1. To conclude on this, development of a proper design and management / operation system at the CTRU will double the output (productivity), and at the same time, reduce the cost of trauma care by 50%.

Encouraging Indigenous equipment -11

  1. For trauma care, apart from the skills of the personnel attending, there is also the question of availability of equipment and medicines. Beginning with the equipment, first, we go to a top (or a Level-1) trauma centre in India today and take a look at the equipment – diagnostic, surgical and others – available and also estimate its cost.
  1. Second, we go to a hospital (or trauma centre) where 50% of these injured on the roads in the country are taken and attended to.15 We make a list of the equipment available there and also estimate its cost.
  1. For the third step, we compare the two. We will notice a vast difference: (1) the non-availability of the required equipment with the second as compared to the first; and (2) whatever is there, is of poor quality and is often not even functional.
  1. We then guesstimate that if reasonable equipment, and not necessarily that which is state-of-the-art, had been available at all trauma centres in the country, how many lives could have been saved ?
  1. Fifth, we go back to the Level-1 trauma centre. We prepare a list of the equipment that is available at this trauma centre. We call this the main list. Thereafter (sixth), we segregate the main list of equipment into two parts: (1) that which is ‘made in India’ (List 1); and (2) that which is ‘imported’ (List 2).
  1. List 2 is then further sub-divided into two lists: (1) what can be manufactured in India; and (2) what cannot be manufactured in India16
  • The range is wide from mid-level to bare.
  • The distinction between ‘is’ and ‘can be’ is not as blurred as some might tend to think it is.

We call these lists: List 2.1 and List 2.2. Now, in respect of the List 2.2 (that which cannot be made in India), we ask two questions:

  1. 1. can we make in India similar equipment of a lesser quality, say, 20% less, i.e., 80% of the imported sample before us ? and
  1. 2. if so, at what cost as compared to the imported one ?

An answer of ‘most’ and at very low cost, will not come as a surprise.

  1. Imported medical, diagnostic, surgical and other related equipment can be quite costly. We cannot forget that not every trauma centre will be able to install expensive equipment (and provide the more expensive medicines).
  1. There is no reason why we cannot utilise the ‘less sophisticated’ (and the less costly) ‘made in India’ equipment to better advantage and treat the injured, rather than allow them to die for non-availability of the expensive imported equipment. Practicality demands that rather than ‘not being available’ at all, a ‘less sophisticated’ or even a more ‘primitive’ model may well be used.
  1. The term ‘less sophisticated’ is best explained by an illustration.

When a new model equipment is introduced in the market (of course at a much higher cost), which has improved features over the previous model and also has additional features, we can refer to the previous model as the ‘lesser one’. Even ‘two models behind’ would serve some purpose, rather than not having any equipment at all.

  1. There are also issues of ‘patent protected’ and ‘patent expired’. As long as we are able to provide trauma care (as also healthcare generally) with the not so latest equipment, particularly that which has lived past its patent life and is, therefore, manufacturable locally and thus incurring less cost, it should be encouraged. This is where the proposed CTRU will have a role to play. That is now described.
  1. First, the CTRU will carry out a countrywide survey to catalogue the particulars of the equipment required, the ones presently being imported, those with patent expired and those being made locally.
  1. Second, it will also survey, who all in India could have the technical capability to design and manufacture. The idea is to encourage those who are interested.
  1. Third, the CTRU can help develop systems – in collaboration with IITs, Engineering Colleges, Technical institutes, medical equipment manufacturers, etc. – for the manufacture of ‘previous generation’ equipment for use in our country.
  1. Fourth, it can also have a tie-up with the diagnostic and medical / surgical equipment manufacturers and the pharmaceutical industry so as to develop low cost indigenous equipment for trauma care and then disseminate that information to the trauma centres in the country. Finally, it will also keep a record of how such equipment is functioning at the trauma centres.
  1. Looking at the future, it is time that we encouraged our boys and girls to develop and manufacture the non-patented equipment because doing so will help the industry develop, and at the same time, ensure that most of the injured receive proper trauma care.
  1. Slowly, we can help develop a designing and manufacturing capacity, which, in time, will provide the nation’s trauma centres and hospitals with quality medical equipment at low cost. More importantly, doing so will also give an opportunity to them to think originally, develop and excel, and one day, make not only comparable but even better equipment than those presently being imported.

Encouraging Generic medicines -12

  1. After the discussion on equipment, we come to medicines. Not every trauma centre will be able to provide (expensive equipment apart) the more expensive medicines. Medicines can vary vastly in price, many times with negligible difference in effectiveness.
  1. For trauma care, first at the trauma centre, and thereafter during the operation and recovery, we have therefore to also look for those medicines which we can afford and make them available to the lesser level trauma centres.
  1. Referring more to the post-operative care for patients, generic medicines and others made in India need to be encouraged. Take, for instance, the basic pain reliever – P It is sold under various brand names, such as Crocin, Anacin, etc. Similar is the situation for antibiotics which are in public domain. The chemists, however, tend to push those medicines where they make a larger profit.
  1. The proposal here is simple. Brand names which can be understood by the masses need to be coined by the Government (Ministry of Health) – and with the degree of skills that private players in the market deploy.
  1. The idea is that instead of, say, ‘Paracetamol’, the brand name which the Government coins is made available to the public – whether as distribution from a government hospital or on a prescription by a private doctor. For instance, if for Paracetamol, the Government coins a brand, say, ‘F&P-R’ (Fever and Pain Relief), in a particular lettering (font) and colour combination, there can be a hundred players in the market who can manufacture ‘F&P-R’, sell under that brand name (against a licence), and pay royalty to the Government that will besufficient to cover the cost of inspecting, policing and certifying (their products) for maintenance of requisite standards.
  1. The result will be that even a semi-literate person can go to any chemist, and instead of asking for Paracetamol,17 or any of the many commercial brand names of today, ask for ‘F&P-R’. He will get it, and it may have been manufactured by anybody, but under a licence from the G The private manufacturers can continue producing Paracetamol under their existing or new brand names. This will encourage competitively priced drugs in the market.
  1. It will help develop the Government ‘owned’ simple brand names so that instead of relying on commercial names for generic medicines (and thereby on multi-nationals), these brand names can be popularised for use all over India. These can even have, alongside, regional language equivalents.
  1. Just as there is a rationale behind compulsory licensing, there is a rationale behind the coining and user of a simple standardised brand / trade names as aforesaid. Confining the discussion here to accident victims, about a dozen brands will suffice. Something similar also needs to be done even for the contents of the first-aid kit.
  1. Those at the trauma centre, when discharging a patient, can enquire from the patient his financial status, and prescribe the medicines / drugs accordingly. Encouraging generic medicines made in India will allow these persons to receive treatment at home as well, and that too at a low cost. We have to look for what we can afford and is within our means.
  • which most of the non-educated will not understand or will find it difficult to pronounce

Encourage Traditional (Ayurvedic) medicine and Yoga -13

  1. Reminding ourselves of the timeline drawn earlier, upon discharge from a trauma centre or a civil hospital, an accident victim comes home with a list of medicines prescribed by the doctors for further treatment and recovery. We assume that the minimal cost variety has been prescribed. Many will not be able to afford even that cost. And those who cannot afford even these medicines, should they not turn to our own traditional methods and Ayurvedic herbal treatments, which are good and cost very little ?
  1. It will come as a surprise that many multi-national pharmaceuticals have taken upon the traditional Indian medicine and while indirectly trying to deprecate it, use the same knowledge to obtain patents and make commercial profits.
  1. There are many traditional methods to aid recovery that have been used in India from times immemorial. The range is wide and the cost, very little or even next to nil. This knowledge has been allowed to
  1. To take an example – an oft-used system for healing injuries in the villages is to lay the recovering injured on a string charpoy18 wearing only an underwear. Next to him, in a steel container (tasla) Uplas19 are burnt. When the fire has subsided and they are still red hot, the tasla is shifted and placed under the charpoy over which the person is lying covered by a slightly heavy cotton sheet. Once in place, Chhaachh (butter milk) is sprinkled on these burning Uplas. The resultant steam vapours have a beneficial effect for healing.
  1. Like this, there are said to be many other remedies. All these need to be collated and researched. Those that are found beneficial should be propagated in simple language by CTRU. The object is that those who cannot afford expensive medicines also get their share of traditional and alternative medicine at very little cost. It is knowledge collection and dissemination which is the emphasis here.

Ayurveda – using Natural Plants

  1. Besides traditional methods, we can usefully avail our own Ayurvedic20 herbal treatments, which are effective and cost very little. Nature
  • a wooden frame into which jute strands are woven to become a bed
  • cow dung cakes / manure which ignite to serve as fuel
  • The older Ayurvedic texts are Susruthã Samhiã and the Charakã Samhitã.

has been kind to provide India with a wide variety of herbs and trees. Names of some are noted below:

  1. 1. Harjor (or Hadjor or Hadjod)

(Asthisamharaka)                                                                                Cissus Quadrangularis

  1. 2. Haldi (Turmeric)21                                                                                 Curcuma Aromatica
  2. 3. Harsingar

(Night-flowering Jasmine)                                                                       Nyctanthes arbour-tristi

  1. 4. Tulsi (Basil)                                                                                              Ocimum tenuiflorum
  1. 5. Nirgundi (Sinduka)                                                                                 Vitex negundo
  1. 6. Saijan ki phalli (drum stick)                                                                 Moringa oleifera

All these can together be ground into a paste and then heated with mustard oil. This paste can be applied to the injured portion and bandaged for a month or so. This will help in full recovery of the injury, which apparently looks healed from the outside, but with the pain persisting, it is not healed from inside.

  1. Also, the leaves of Harjor, Nirgundi and Tulsi along with Saijan ke phalli and Haldi can be boiled together for a few minutes and a decoction (Kashayam) made, which, when taken regularly once in the morning and once in the evening for a month, will help the internal injury to heal faster. Not to be missed out are the benefits of Neem (Azarica Indica) with its antiseptic and other properties, and Aloe Vera, both of which are found in plenty in our country.
  1. There is also Fitkari, which is not exactly a herbal product, but a chemical compound (in English Potash alum or Potassium aluminium sulphate). It is widely available all over the country at low cost, and operates as an antiseptic.
  1. Branded Ayurvedic medicines sold in the cities are not cheap. Yet, most of these are available for free in the villages. Farming of these plants needs to be encouraged and so also availability of their products near the proposed TtoT centres.22
  1. To the educated and well-to-do, most of all this may appear humbug, but to those injured who cannot afford allopathic medicines, it will do wonders. The unfortunate part is that development and dissemination of this information has been missing.
  • Also used is Vana Haridra, another variety of turmeric.
  • something of a poor man’s chemist

178. At the same time, not to be forgotten is Homeopathy,23 which is affordable and effective for recovery after discharge from the trauma centre. Homeopathic medicines reduce complications of surgery and enhance healing so that the patient can recover more quickly.

179. For instance, for those who have trouble in recovering from the effects of anaesthesia following surgery like stupor, disorientation, nausea, vomiting, Phosphorus 30 is a good remedy. Similarly, Arnica 30 and Hamamelis 30 can be useful for patients who have undergone long term intra-venous therapy.

180. External application of Calendula and Hypericum can help to prevent infection from surgical wounds. Post-surgical infections can be treated with Pyrogenum 200. For scarring, adhesions and keloid after surgery, one can use Thiosinanum in 30 potency.24 In short, for affordable treatment after discharge from the trauma centre, Homeopathy also deserves its place.

Yoga

  1. Next, we come to our own, and very ancient, Yoga.25 The benefits of Yoga for general well-being, health, and disease prevention, including healthy mind and thinking, are many.
  1. Even for those injured in a road accident, who were fortunate to survive albeit with injury, Yoga can be very helpful. If there are muscular spasms or problems in the nervous system, joints, or flexibility has been affected, to regain the flexibility, to stimulate the body system, to stimulate the nervous system and for better blood circulation, Yoga Asans or stretching exercises are very useful.
  1. Stretching exercises like Urdhvahastottanasan, Konasan, Paadhas-tasan, Uttanpadasan, Naukasan, Vayuyanasan, Katichakrasan, have an effect on the total nervous system, the total muscular system and the circulatory system. They help strengthen them slowly and regain normalcy.
  • Homeopathy, a system of alternative medicine, was developed in 1796 by Samuel Hahnemann, a German Physician.
  • Note: The various ‘remedies’ are only by way of introduction to the subject and are not a ‘prescription’ in any way.
  • Yoga (a Sanskrit term) denotes the physical, mental, and spiritual practices or disciplines that aim to transform body and mind. There are a variety of schools, practices and goals. Its origins date back to pre-vedic Indian traditions. Following the success of Swami Vivekananda in the late 19th and early 20th century, Gurus from India later introduced Yoga to the West, where it has come to be widely respected.
  1. If a victim has gone into depression because of an accident or because of the side effects of medicines, in that case also, Yogic Asans – Pranayam and meditation – will help.26 Of course, the Yoga Asans have to be injury specific. In this manner, different Yogic exercises or Yogasanas, Pranayam, meditation will benefit the victim in different stages.
  1. In our country, there are some brilliant Yoga expounders and Gurus. They could be requested to assist at the CTRU in developing programmes for treating accident victim cases so that they can lead a better life. Yoga is something that even the rich should not miss out on.

At the CTRU

  1. So much for the alternative systems of medicine. Coming back to the CTRU, the discussion here is not on ‘Which is Better?’ The point is: at least for those who cannot afford allopathic medicines, can a desk at the CTRU not be developed to propagate these remedies so that no citizen remains without affordable and effective treatment ?
  1. Despite all this wealth of knowledge being there, it is not made available to the injured poor. This is what the CTRU can do in collaboration with AYUSH.27 It may also help counter negative propaganda.
  1. Para 108 supra had pointed out the need to group and classify as ‘Types’, the 5,00,000 injuries that are reported annually. That was for purposes of immediate trauma care. We need a similar classification of the impairments so as to create systems and remedies, and for improved recovery, i.e., lesser permanent disability. Such classification can be carried out at CTRU whereafter for each injury type, appropriate remedies (as these) can be collated, further researched and developed, and then disseminated.
  1. The point being one of importance is further explained. The CTRU, which will be receiving data of injuries from all over the country, can ask its research scholars, who will be computer savvy, to group / classify the ‘after discharge’ impairments that need care and improvement.
  • The various Yogasanas are only by way of introduction to the subject and are not a ‘prescription’ in any way.
  • AYUSH – is a Government of India Department under the Ministry of Health

& Family Welfare which focuses attention on development of Education & Research in Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homoeopathy systems of medicine. It also lays emphasis on improving the availability of medicinal plant material, research and development and awareness generation about the efficacy of these systems.

  1. Thereafter, for each type of problem, the CTRU can even prepare a ‘query’ about the medical ailments that will be (typically) encountered in the recovery stage after discharge from trauma care, and distribute it to a dozen experts each in Ayurveda, Homeopathy, Yoga, etc. who will give their opinion to the CTRU.
  1. Depending on the replies which the CTRU receives, the researchers can again sort out and seek multi-peer open review or hold a seminar. The most common response, not outside the bounds of reason, will be accepted.
  1. With the consensus arrived at, a paper / book / manual with the right and affordable remedies may be published by the CTRU for each ailment as a separate section. Stated simply, the task for CTRU would be to collect this information / knowledge from all over the country, recheck for its worth and then re-express it in a form that is suited to the poor and the rural India.

Disseminate to the public-14

  1. Knowledge so gained and collated cannot be left on the shelves of the CTRU. Para 128 et seq had referred to professional publications.
  1. Trauma care, beginning with first aid on site, patient stabilisation, transportation and then formal care at the trauma centre, the initial start off diagnostics, stabilisation, etc. are fields where minutes matter and for early responders (as helpers), a degree of familiarisation, if not full education, is essential.
  1. Best trauma care will be achieved only when the awareness amongst the general public is increased through educational pamphlets in regional languages explaining what a trauma centre is; how it works; what are the kinds of injuries being treated there; what are their implications; and what are the prescribed methods for efficient recovery, how the injured are picked up, etc.
  1. CRTU will help develop and disseminate procedures and practices (and literature) that will enable practical and affordable trauma care so that no injured remains without at least some minimum level of trauma care immediately without delay. It is clarified that the suggested dissemination of knowledge should not be considered a substitute for formal training in first aid.
  1. This will help create public awareness and help harness their support and cooperation, especially from drivers of autorickshaws, commercial vehicles, volunteer groups, etc. Those who opt for first aid for road accident victims need to be also educated and familiarised.
  1. The CTRU can also prepare a set of books or DVDs on remedies as aforesaid to help improve the health, reduce impairment and enable full recovery, as part of post-accident injury care and recovery. These can be prepared in simple and colloquial form, multi-lingual and made available at printing cost for distribution. They can have subtitles, animations, and engaging narration. These videos can also highlight the role of traditional medicine in the post-operative recovery stage and reference to such video DVDs advertised on national television.
  1. Leaflets on trauma care can also be distributed to children in schools.

They can be taught from them and be allowed to carry them home to serve as a simple manual (with the proviso that some of the advice contained will change with time and better procedures). Similarly, flyers and pamphlets can be prepared for the use of adults also. In fact, ideally, the CTRU’s publications should be available as a downloadable PDF on its website.

Conclusion

  1. Considering that JPNATC (last sub-topic) is itself an extension of AIIMS, the CTRU proposed in this sub-topic can start functioning from there before it moves to a larger campus of its own, say, a 50 hectare one. We cannot ignore the financial resource limitations that we face as also what we can provide in terms of financial outlay to make sure that the trauma centres are reachable.
  1. In this connection, it may also be mentioned that recently India28 has signed a five-year agreement with the NTRI,29 in collaboration with Monash University.
  • Ministry of Health and Family Welfare
  • The NTRI – ‘National Trauma Research Institute’ is part of The Alfred hospital campus, located at Melbourne [Victoria, Australia]. Their mission and the goals are focussed on reducing death and disability, and improving the quality of life of survivors of traumatic injury. They do this through:

Innovative programs of research and research translation Exchanging knowledge through effective partnerships and dialogue Improving systems of trauma care Building awareness of the personal and community impact of traumatic injury Mentoring the next generation of research leaders.

  1. The aim is that the indigenous trauma care systems and methods developed in our country by our surgeons and doctors are then not only available to our citizens, but come to be copied by those outside, thereby commanding respect from the world over.

Next Topic The Ambulance