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Model for Integrated Services for Evacuation of Casualties
CIDM12th Feb.2009
Dr. G V Ramana Rao MD, DPH, PGDGM,ACLS, ITLS
Executive Partner,
EMRI, Hyderabad
Structure of presentation
• Responding individual emergencies – EMRI Way
• MCI and DM – EMRI efforts• Evacuation of Casualties – NDMA – MPMCE & CIDM
• Model EoC
Changing the World
The experience of EMRI as India’s First and Only Professional Integrated Emergency Response Provider
• 300,000 emergencies occur per day (108 M p.a.)
• 80% are at the bottom of the pyramid
• 80% deaths occur in hospitals in the first hour
• 4 M deaths p.a.
• Absence of 4 As
• Access
• Availability
• Affectionate Care
• Affordability
Emergency Scenario in India Until 2004
• To provide Free emergency response services for Medical, Police and Fire emergencies across India by 2010 in PPP (Public Private Partnership) framework
• To respond to 30 million emergencies and save 1 million lives annually by 2010
• To deliver services at global standards through Leadership, Innovation, Research & Training and Technology
• To be recognized as best-in-class
• With the following architecture of 9 elements
Vision
2. PPP(Public Private Partnership)
• EMRI architecture and performance led to the following PPP (Public Private Partnership) framework • Up to 95% of expenses by Government
(Public)
• EMRI to contribute a minimum of 5% of expenses towards costs of Leadership, Technology (Process, Medical & Research) and provide free IT solutions
• Management by EMRI to sustain long term performance at International quality and speed
Govt. ofA.P.
Govt. ofGujarat
Govt. ofMP
Govt. ofUttarakhand
Govt. of Tamilnadu
Govt. ofRajasthan
Govt. ofGoa
Govt. ofAssam
Govt. ofKarnataka
Govt. ofMeghalaya
Govt. ofPunjab
3. Leadership
• Is not Charisma, Public Relations, Showmanship
• Is performance consistent behaviour and trustworthiness
• Is Thinking, Doing and Communicating
• Is setting Direction, Aligning and Motivating
• Is creating an environment of continuous learning • Learning doesn’t end with school or college • You must learn throughout you life - never cease to be a student
9
3.1 Partnerships
City of AustinUSA
National Emergency
Number Assocoation
911 NENA, USA
Singapore HealthServices
American Assoc of Physicians
Of Indian Origin (AAPI)
Shock Trauma Center,
USA
Stanford University,USA
American Academy for
Emergency Medicine in India
Carnegie Mellon University,
USA
Satyam ComputerServices
Rishmond Ambulance
Authority, USAGeomed Research
Public HealthFoundation of India
• Single toll free number ‘1-0-8’ accessible on land and
mobile phones
• Significance of 1-0-8 in 11 X 22 X 33
Sacred number in Hinduism in many ways (Pillars, Nama Japa, Krishna dances with 108 Gopies, Natraja dances in 108 poses)
Distance of the sun from the earth divided by the diameter of the sun
In Japan, at the end of the year a bell is chimed 108 times to finish the old year and welcome the new one. Each ring represents one of 108 earthly temptations a person must overcome to achieve Nirvana
Number of minutes cosmonaut Yuri Gagerin orbited earth during the first manned space flight
The number of stitches on a base ball
4. 1-0-8
• 24X7 Unique Emergency
Response Center staffed
with trained
Communication, Medical
and Police personnel
5. ERC
• Computer Telephony Integration
• Voice Loggers
• GIS / Maps
• GPS / AVLT
• Mobile Communication
• Application software for Sense,
Reach and Care
• ePCR (Electronic Patient Case
Record) Form
6. Technology
Sense Reach Careprev
entio
n
S T R E T C H E R S
E X T R I C A T I O N T O O L S
AUTOLOADERWHEEL CHAIR
SCOOP
SPIINE BOARD
AIR LIFTING
AMBULANCE EQUIPMENT
• Medical Research • Effectiveness of interventions in
specific emergency conditions
• Integration with hospital care
• Innovations in interventions, capacities and capabilities
• Systems Research - Best-practices in EMS / prevention of emergency• Processes• PCR• Prevention• Education and Training
• Operations research (Analytics)• Predict future state of healthcare,
disease incidence
• Better utilization of resources
• Reconfiguring processes
MR
SR
OR
8. Research
• 12,300 + EMRI Associates
• 6,800 + Private Hospitals / Nursing homes (31% in AP and 15% in Guj - patients admitted in pvt hospitals)
• 2,000 Police / Fire Stations
• 368 M population covered in 9 States
• 91% calls taken in first ring
• 8,950 emergencies handled (3.3 Million annualized)
• 1,582 Ambulances - 6 trips a day
• < 10 minutes (2/3rd of RTA and Cardiac) ambulances reached
• < 15 minutes (73% of urban) and < 25 minutes (68% of rural) Ambulances reached
• 100% virtual handholding (in ambulance) by EMTs and physicians
• 130+ lives were saved (51,000+ till now) and 8,820 victims received timely, high-quality pre-hospital care
a
Andhra Pradesh
Gujarat
Sikkim
Karnataka
Orissa
Haryana
Punjab
Himachal Pradesh
Uttar Pradesh
Chatti
sgar
h
JharkhandWest Bengal
Bihar
Arunachal Pradesh
Meghalaya
Tripura
Manipur
Nagaland
Mizoram
Uttarakhand
Madhya Pradesh
Tamil Nadu
Kerala
Jammu & Kashmir
Maharashtra
RajasthanAssam
Goa
Delhi
Today at EMRI
Medical Emergency % of Total
Rural
%
Female
%
AgeYrs
Pregnancy related 21 82 100 22
Injuries 16 48 19 32
Acute Abdomen 15 78 42 37
Suicide related 5 75 46 28
Cardiac related 5 65 43 44
Respiratory related 4 63 38 45
Medical Emergencies - AP
Medical Emergency % of Total
Rural
%
Female
%
AgeYrs
Pregnancy related 34 91 100 23
Injuries 18 60 21 29
Cardiac related 5 61 39 51
Respiratory related 5 59 37 51
Acute Abdomen 4 78 42 37
Suicide related 1 65 41 26
Medical Emergencies - Gujarat
Follow-up after 48 hours - AP
Discharged 70 %
Stable and still in Hospital 27 %
Critical and still in Hospital 1 %
Expired 2 %
Robbery – Thief requested wife to dial 108 after 10 minutes to take the injured husband to hospital
3 Hour Neonate (Baby Girl) Buried
Firing - Between Army Commanders and Naxalites
Cyclist– Fell on road divider rod
Extraordinary Performance fromOrdinary People
Pre-Hospital Care Process-EMRI
• Pre- Arrival Instructions (PAI)
• Pre-Hospital EMT Care – Standing Orders
• On-Line Medical Direction by ERCP
• PCR Documentation
25
EMERGENCY MANAGEMENT INFRASTRUCTURE CAN ALSO BE LEVERAGED IN DISASTER
MANAGEMENT SITUATIONSMay 18 blasts, HyderabadMay 18 blasts, Hyderabad “EMRI took off a lot of the
burden from our shoulders by arriving on time and taking up the responsibility of getting the injured persons to hospitals.”
- Government of Andhra Pradesh
“I reached the hospital on the 108 ambulance… the person on the ambulance removed a splinter from my arm”
- Victim
• Bomb blasts at Mecca Masjid area in Hyderabad injuring 40 and killing 12
• EMRI deploys ambulances immediately after the first call
• Victims transported by EMRI to local private and government hospitals with treatment on the way
MCI- Important Roles – On site and Transportation
• Ambulance Incidence Officer (AIO)• Triage Officer(TO)• Treatment Area Supervisor (TAS) • Treatment Area Officer (TAO)• Logistic Officer (LO)• Equipment Officer (EO)• Ambulance Parking Officer (APO)• Ambulance Loading Officer (ALO)• Safety Officer (SO)• Public Information Officer (PIO)
Essential elements for IAN
• Strategy partnerships • Strategic support – technology, training and research• Size and scale • SOP• Skills set• Surface ambulances • Site experiences• Simulation• SLA
Evacuation of Casualties – NDMA- MP-MPE-
Major Recommendations – Ambulances Reference NDMA EMRI
Response time
-Maintain minimum ( Golden hour)
Urban 14mts; Rural – 21mts<10mts – 2/3 of RTA & cardiac.
Medical Equipment
For resuscitation, Essential drugs,
Stretchers
2-way communication
Spine board/ CPR skills;106 drugs under medical directions; Collapsible / Scoop /Pediatric / Chair stretchers; Cell phones.
Support Staff
Well versed with equipment usageQuality checks
Yes (training)
Yes (OE wkly visits; Qrtly. Checks by quality teams)
SOPs Maintenance of vehicles Yes including preventive maintenance, repair/accident processes etc.(Fleet managers)
Evacuation of Casualties – NDMA- CIDM-
Medical Emergency Plans Reference CIDM EMRI
District Off-site Plan
Mock drills Yes
Dedicated institutes for CDM
To be identified / established Can be seriously considered for training and research.
Community awareness
Develop mechanism –kits. VoiCE program
SOPs To be laid out – Decontamination; risk and resource inventory, proper casualty chemical treatment kits,
can cascade and provide
Integrated EoC Services -EMRI and NDMA
• Computer – Cellphone Integration (CTI)• Ambulance network• Community Awareness (VoiCE)• Preparedness &Mock Drills (Medical/Police/Fire/ Railways)• First Responders (> 3000 trained and handbook)• Emergency Medical Technicians and Paramedics (PGPEC)• Standard Operating Protocols (SO,MD,CCPs,MCI)• Hospital Network (>6000 MoUs)• Documentation (Pre-hospital Care Record PCR)
Conclusion
• EMRI can significantly contribute in EoC in an in MCE and CIDM with relevant and specialized support from NDMA and thereby model Integrated Services for Evacuation of Casualties.