|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 4 | Page : 298-299
Emergency medicine: The emerging medical field in India
Sasidharan Sameer, Deepak Verma
Resident, Department of Emergency Medicine, Apollo Hospital, Mysore, Karnataka, India
|Date of Web Publication||7-Feb-2014|
No. 2332, Sampige Road, J Block, Kuvempunagar, Mysore - 570 023, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sameer S, Verma D. Emergency medicine: The emerging medical field in India
. Int J Health Allied Sci 2013;2:298-9
"What is the big deal in emergency medicine (EM)?" This seems to be the very question that rattles most orthodox, mainstream, medical practitioners in India. Not surprisingly, many have turned a cold shoulder toward the idea of accepting it as a medical specialty even after it has been officially recognized as a medical specialty by Medical Council of India on July 21, 2009.  The latest development in recognizing emergency medicine as a medical specialty in India came with the announcement of approval for Diplomate National Board (DNB) seats on Nov 14 th 2013, by the National Board of Examinations, India.  With this announcement, the second largest nation with over a billion people passed a major milestone in the development of emergency medicine into a mature specialty.  Is there any meat to this matter or is this going to be just another "hype" that would tide over with time? Let us take a pragmatic approach to analyze the need for emergency medicine in India and to decipher if there is any scope for a future in this field.
In medicine, we always talk about the entity of "time". Take for example the common phrases, "time is brain"-often heard in the management of acute stroke/head injury or "time related ischemic changes in the cardiac muscle"-in relation to Acute Myocardial Ischemia or even trauma, which is now the leading killer of young persons in their productive years.  Our body experiences many irreversible dire changes and if we do not institute immediate effective management; there is no "second chance". The National Health Profile of India 2009 lists injury as the 3 rd leading cause of death in India. Recent calculations by the Planning Commission of India estimate the total societal cost of injury in India to be approximately 3% of India's gross domestic product.  The statistics is endless, but it all points to the same conclusion; there is an indubitable need for professional emergency care in India.
In India, the emergency department (ED) often referred to as "casualty" has traditionally been regarded as a "stop gap vocational avenue" for PG aspirants who often work unsupervised without any formal training in emergency medicine. Prior to the 1960's even countries like United States had emergency rooms similar to many of the current EDs commonly seen in India, which varies between hospitals and usually consists of only a simple casualty or accident ward lacking specialty-specific training and resources.  The United States has progressed over the last four decades, with many of the hospital ED being transformed into a highly effective setting for urgent and lifesaving care, as well as a core provider of ambulatory care with highly trained emergency providers. 
In comparison, a survey done in Chennai revealed that the average ED staff consists of 6 doctors. Of these, only a mean of 20% have completed some form of postgraduate training, 22% are Advanced Cardiac Life Support (ACLS) certified, 10% are Pediatric Advanced Life Support (PALS) certified and 11% are Advanced Trauma Life Support (ATLS) trained.  Furthermore, only under 50% of the surveyed departments had essential emergency resources such as central venous catheters (32% [12/38]), pressure bag (45% [17/38]), triage protocol (24% [9/38]), infusion pump (37% [14/38]) and non-rebreather mask (47% [18/38]).  As nations around the world strive toward providing competent emergency care which "traditionally implies the rapid and appropriate care of victims of traumatic and medical emergencies" - Sikka and Margolis,  a great deal still needs to be done in India.
Even in the area of pre-hospital care, there is much scope for improvement in India as only about 2% of patients are transported to an ED by ambulance.  Because the vast majority of pre hospital care is performed by bystanders in what has been described as the scoop and run approach where patients are dropped off at the closest area hospital, there is a need for hospital ED categorization and standardization that is currently lacking.  These facts point toward obvious gaping holes in the emergency care network in India which must be urgently addressed.
Merely understanding and accepting the need for change alone would not suffice. We also ought to be sure that by investing the time and resources in training emergency staff, a significant difference can be realistically anticipated. A recent study by Gerardo et al.  has yielded the following results: The establishment of a dedicated specialty trauma team incorporating full-time EM presence including EM-trained and board-certified emergency physicians was associated with:
- A reduction in overall non-dead on arrival mortality rate from 6.0% to 4.1% from the time period preceding (1999-2000) to the time period after (2002-2003) this intervention (1.9% absolute reduction in mortality, 95% confidence interval [CI] 0.7%-3.0%)
- Among patients who were most severely injured (injury severity score ≥25), mortality rates decreased from 30.2% to 22.0% (8.3% absolute reduction in mortality, 95% CI 2.1%-14.4%).
The study concluded that an implementation of a dedicated full-time trauma team incorporating both trauma surgeons and EM-trained, board-certified or -eligible emergency physicians was associated with improved mortality rates in trauma patients treated at a Level I academic medical center, including those patients presenting with the most severe injuries. These findings certainly point toward an extensive scope of development for the presently budding field of emergency medicine in India.
As we embark on this paradigm shift in our view of emergency medicine in India and as we make room for the growth of this specialty, let's take a moment to envision the future of a professionally trained emergency physician. He/she would ideally develop the ability to work sensibly under immense time sensitive situations with minimal aid, achieving maximum result-keeping the patient alive. With our increasingly uncertain political, economic and environmental climate, whereby disaster/calamity can take any form and strike at any time, he/she has to be trained rigorously not only to identify the need for immediate management in a patient, but to be able to institute those life-saving measures in "half the time, under double the pressure." In essence an Emergency Physician is our first line of defense against fatality.
| References|| |
|1.||Medical Council of India. Amendment Notification. New Delhi, India, 2009 July 21. |
|2.||National Board of Examinations, Public Notice - DNB EMERGENCY MEDICINE, Thu 21st Nov, 2013. Available from: http://www.natboard.edu.in/matter.php?notice_id=1223 |
|3.||Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med 1999;33:97-103. |
|4.||Gupta SK, Kumar N, Thergaonkar A, Singh AR, Singh KV, Mehta P, Parmar C, Mishra BN. Report of the Working Group on Emergency Care in India, Ministry of Road Transport and Highways, Govt. of India. Available from: http://morth.nic.in/inde×2.asp?slid=771 and sublinkid=432 and lang=1. |
|5.||Subhan I, Jain A. Emergency care in India: The building blocks. Int J Emerg Med 2010;3:207-11. |
|6.||Committee on the Future of Emergency Care in the United States Health System. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press; 2007. |
|7.||Khadpe J, Thangalvadi T, Rajavelu R, Sinert R. Survey of the current state of emergency care in Chennai, India. World J Emerg Med 2011;2:169-74. |
|8.||Sikka N, Margolis G. Understanding diversity among prehospital care delivery systems around the world. Emerg Med Clin North Am 2005;23:99-114. |
|9.||PoSaw LL, Aggarwal P, Bernstein SL. Emergency medicine in the New Delhi area, India. Ann Emerg Med 1998;32:609-15. |
|10.||Das AK, Gupta SB, Joshi SR, Aggarwal P, Murmu LR, Bhoi S, et al. White paper on academic emergency medicine in India: INDO-US Joint Working Group (JWG). J Assoc Physicians India 2008;56:789-98. |
|11.||Gerardo CJ, Glickman SW, Vaslef SN, Chandra A, Pietrobon R, Cairns CB. The rapid impact on mortality rates of a dedicated care team including trauma and emergency physicians at an academic medical center. J Emerg Med 2011;40:586-91. |