Why it is necessary to increase the availability of emergency services and create clinicians to handle acute care
Heart attacks and breathing difficulties often happen early morning. Accidents too can happen anytime during the day, especially late nights or early mornings. But often, when patients come with such presentations, senior clinicians may not be readily available and they need to be called in. The nearby nursing home or hospital may also not have the required equipment to diagnose the presentation accurately.
According to a report by the Indian Head Injury Foundation, more than 100,000 lives are lost every year and over one million suffer from serious head injuries.
One out of six trauma victims die as compared to one in two hundred in the United States. This seemingly unbreachable gap speaks volumes of the perfected PTC procedures in US and their near absence in India.
While 95 per cent of the victims died due to not receiving optimal care during the ‘golden hour’ period, with proper care, at least 35 per cent of those who died from head injuries could be saved.
“You would be lucky to have clinicians available for one-third of the 24x7 span,” points out Dr Dhavapalani Alagappan, Emergency Medicine, Apollo Hospitals, Chennai.
He stresses on the need for proper emergency clinicians at least in all the bigger hospitals.
In 2009, the Medical Council of India, taking cognisance of this desperate need in the country, has stipulated that all government hospitals, especially the big ones, must provide specialisation in emergency care. Since then emergency seats in the Diplomate National Board Council (DNB) and MD have come up, but not in all states. In Tamil Nadu, for instance, in the government sector, there are no MD emergency seats till now except the National Board seats and in a couple of private colleges.
A point to be noted here is that though most corporate hospitals have an emergency department, the skill set is variable. When a patient presents with a medical emergency, the attending clinician needs a lot of clinical expertise to deal with it.
“The patients are very ill at the time of presentation. They not only need timely care but also expert care. Some conditions like the heart attack or the stroke will need the back up of specialists also. So, a proper emergency department, backed by specialists, ideally working round the clock, would be the best environment to deliver superlative care,” he points out. When the government is revamping the healthcare system, this is something it should keep in mind, he recommends.
In the west, the medical curriculum has been revamped. All medical students are trained in some common emergencies, if not all, and spend four to six months in the emergency department. During their formative years, and in the undergraduate level as well, they cover a significant amount of common emergencies, which is important.
“We have lessons to take. It is the way to go, to provide acute care,” the doctor opines.
An emergency specialist needs to acquire skillsets from a very wide range of specialties. In other words, he is a generalist who focuses on acute care.
“A child could come in with fits. The next person could be elderly, suffering from stroke. The third one could be somebody who is injured badly. So there could be a very varied spectrum of illnesses,” points out Dr Dhavapalani.
To be able to deal with all of that, the physicians need significant amount of training across specialties, which is a challenge and cannot happen in smaller hospitals.
Even in the west, according to the doctor, it is not very developed. In Europe, for instance, emergency medicine is really advanced in the UK and Ireland but not yet established in mainland Europe, where multiple specialists pitch in. The anaesthetist or the physician for internal medicine person plays the role, which isn’t ideal.
Only big government or private institutions can provide training in emergency care. Ever since DNB and MD Emergency Medicine came up, the number of emergency physicians is increasing, though the gap between the need and availability is very wide still.
The clinician needs training in various specialties – intensive care, medicine, paediatrics and so on in addition to being in the emergency department itself. In the west, typically, post internship, it takes them seven years to become a consultant.
In India, PG programme are three years. “They evolve. A clinician does not stop evolving,” assures the doctor.
In the UK, there has been a recent push to provide life support skills like CPR to adolescent children as part of their curriculum. This is a wise move since they are often the first responders. If something happens at home, if their grandparents or parents are having a cardiac arrest, the children are most likely to be the first responders. They may be perplexed, but if they know what to do objectively, they can handle it then and there. There is a lot of thought that has gone in and can be replicated.
“From Apollo, we provide first aid and CPR training in corporates, colleges, schools, etc. But it will work better if it is made part of the curriculum in schools as they have access to adolescents who can imbibe all this knowledge. It’s not all that complex. It just needs to be thought out,” says Dr Dhavapalani.
“The very first DNB batch did not expect it to be so intense or challenging. They couldn’t cope with the acuity of the presentations or the misery of the patients. They were bombarded with sick patient after sick patient,” reminisces Dr. Dhavapalani.
It needs mental toughness and can shake one up. Clinicians who want to take this up as their career path should first attach themselves to an emergency care unit for a week and see if they can handle it. The other downside is that the clinicians cannot enjoy a social life as well.
However, the upside is the adrenalin rush of working under pressure. It can also be gratifying to revive a patient who comes in very sick. With right treatment, if they turn around really quick, the excitement of resuscitating somebody and seeing them get better is very rewarding.
There is much demand for emergency clinicians across the globe, and the good thing is, many youngsters are opting for it.