Jan-Jul 2018

Saving Lives: Emergency Medical Services in India

Saving Lives: Emergency Medical Services in India

BY MILIND SOHONI, WITH ANUBRATA BANERJEE

By the year 2025, road traffic deaths in India are expected to cross 250,000 annually. Providing timely and high-quality emergency health services is a challenge, given supply-side problems, regulatory and policy issues, and lack of awareness about emergency care in the country. A robust national emergency medical service with an interdisciplinary approach is the need of the hour to complement the country’s still evolving healthcare facilities, argued panelists at a First Practice-based Summit on Emergency Medical Services held at the Indian School of Business.

At times, in medicine, you feel you are inside a colossal and impossibly complex machine whose gears will turn for you only according to their own arbitrary rhythm. The notion that human caring, the effort to do better for people, might make a difference can seem hopelessly naive. But it isn’t.
—Atul Gawande (2008: 10)
 

The National Trauma Institute in the United States estimated in 2014 that life years lost due to trauma injury accounted for 30% of all life years.1 In the US, the economic burden of trauma is an estimated $671 billion annually in healthcare costs and loss of productivity.

The high economic costs of trauma injuries are an even greater concern for a transforming economy such as India. Institutional voids in healthcare create a complementary requirement for a robust and efficient national emergency medical service to handle accidents and health shocks. Some studies have pointed out that by 2025, road traffic deaths in India are likely to cross 250,000 (Singh, 2017).

Besides road accidents, World Health Organisation (WHO) statistics from 2004 to 2013 show that cardiac disease and cyanotic vascular disease were the leading causes of death due to a lack of emergency medical services (EMS) at the point of care. In light of this, the need for an effective EMS system based on evidence-based policy making with an interdisciplinary perspective becomes critical. The First Practice-based Summit on Emergency Medical Services was held at the Indian School of Business on March 21, 2017. This Summit brought together researchers not just from the ISB but also the University of Illinois at Urbana-Champaign (UIUC), the University of Toronto, and healthcare practitioners from the state government who presented their findings in this area across disciplines. The keynote speaker, Dr. Prasad Rajhans of the Department of Critical Care and Emergency Medicine at Deenanath Mangeshkar Hospital, captured the essence of the Summit by saying, “Life-saving does not depend on any particular path – in fact, it is not a medicine but a skill.”

The one-day Summit was an extension of a joint research project undertaken by Milind Sohoni, Professor of Operations Management at ISB, and Lavanya Marla, Assistant Professor at University of Illinois – Urbana Champaign, who received the United States India Educational Foundation 21st Century Knowledge Initiative grant for their research on operational and logistical challenges in the efficient management and administration of EMS in emerging economies. There is an urgent need to extend the myopic view of EMS beyond just operations to an interdisciplinary perspective encompassing business models, strategy, process control, policy, and innovation, among other disciplinary competencies and skills, said Sohoni.

The Summit had panels on various themes such as the challenges of managing the logistics of ambulance services, academic research insights with a focus on the Indian setting, the impact of regulation and policy on ambulance service operations, and the role of start-ups, entrepreneurship and venture capital in health and emergency services.

Logistical Challenges

The panel discussion on supply-side challenges in EMS highlighted issues around ambulance fleets and keeping ambulances well-replenished with supplies. Panellists pointed to the need for an effective healthcare system with good facilities and pre-arrival notifications. They argued that in order to augment the productivity of EMS in an emerging economy such as India, it is essential to create general awareness about the EMS ecosystem. Paramedics need to be trained on new life-saving techniques. Further, EMS documents should be standardized so that there can be seamless inter-facility patient transfer. Addressing these gaps will help mitigate the challenges of all the key stakeholders and their capabilities on the EMS supply side, the panel concluded. One of these is the need to increase the number of self-sufficient EMS vehicles equipped with a ventilator, defibrillator, infusion pumps, etc., at critical accident spots. Another is the need to standardize EMS reporting data, which will be useful in the event of disasters such as epidemics. It is essential to study and quantify the improved outcomes of a trauma (a sudden cardiac arrest, for example) due to the intervention of EMS, said the panel. This will serve as a motivating force for all the stakeholders in the EMS ecosystem.

There is an urgent need to extend the myopic view of EMS beyond just operations to an interdisciplinary perspective encompassing business models, strategy, process control, policy, and innovation, among other disciplinary competencies and skills.

Research Insights

In the academic research panel, Sarang Deo, Associate Professor in Operations Management, ISB, examined how EMS in India differed from EMS in developed countries such as the US or the UK. He described a joint project that he had undertaken with Marla to understand ambulance diversions. Ambulance abandonment, where a caller calls an ambulance service but does not use the service despite an ambulance being deployed, is a major problem in developing countries.

Three reasons could explain ambulance abandonment. First, the emergency might have been resolved by the time the ambulance arrived. Second, the emergency was so acute that the caller ended up using his/ her private mode of transportation. And third, it was a nuisance call. The bottlenecks caused by ambulance abandonment result in an ambulance not being dispatched to another or more critical patient.

It is important to study caller behavior before dispatching an ambulance so as to avoid a wasteful deployment, said Deo. Callers need to be segregated based on calls from urban or rural areas, or trauma or non-trauma conditions. Huge investments have led to very little improvement in ambulance diversion behavior. Hence, operational changes require monitoring and outcome measurement, argued Deo.

Marla’s project focussed on ambulance locations and strategies. If an ambulance has gone to serve a patient at one particular point, the other ambulances need to change their positioning such that proper coverage is maintained to serve emergency cases. Marla also contended that both private and public providers of EMS should complement each other. Public ambulance providers may have many ambulances to provide, while private ambulance providers may have vehicles positioned in favorable areas.

Justin Boutilier, a Ph.D. scholar from the University of Toronto, discussed his study on the optimization of EMS response time through technology intervention with a GPS device and an android application. Boutilier and his co-author found that it is important for an ambulance to investigate in advance which routes are safe and efficient to follow with the help of technologies such as spatial positioning. The study also explored the use of drone technology to facilitate the rapid delivery of automated external defibrillators (AEDs) to the site of a cardiac arrest, emergency kits for motor vehicle accidents, and blood and medical supplies in rural areas. As an aside, Boutilier mentioned the Silicon Valley-based robotics firm Zipline, which is using medical drones to supply blood in Rwanda (Rosen, 2017). Such an experiment would be worthy of consideration in congested urban India.

Regulation and Policy

The Summit highlighted important regulatory and policy matters related to EMS services. Dr. Ghanshyam Shirke of the Maharashtra Emergency Services outlined the need for policy around the licensing and career path of paramedics. Standardised certification and training of paramedics coupled with regular reviews will motivate paramedics and encourage enrolment in paramedical training programmes.

Shirke also emphasized the need to urge policymakers to enforce the national ambulance code in India. For example, at the state government’s end, punitive actions should be taken against nuisance EMS callers. He also advocated providing EMS services at high-risk destinations such as the Kumbh Mela in order to avoid mass casualties due to stampedes or other disasters.

It is also worth mentioning here that in recent times, state governments in India have become more proactive on the EMS front. In December 2016, Karnataka adopted and approved the Good Samaritan Law (Doshi, 2016). This law provides legal protection to bystanders who help road accident victims and instructs police and hospitals not to harass people who provide emergency help in times of distress. In another recent development, the Delhi government also announced that it would absorb the medical bills of emergency road accident victims. This is a step that will increase the overall effectiveness and efficiency of EMS in India.

It is important to study caller behavior before dispatching an ambulance so as to avoid wasteful deployment. Huge investments have led to very little improvement in ambulance diversion behavior. Hence, operational changes require monitoring and outcome measurement.

Startups and Entrepreneurship

The problem of EMS is broader than technology, policy-making or supply-side interventions can hope to resolve, even in tandem, Sohoni noted. That is why the Summit highlighted opportunities for entrepreneurs to address existing gaps in EMS.

Jaimon Jose, Founder, Ambee Ltd, spoke of how Ambee is trying to reduce waiting times for emergency vehicles from existing levels of 40 minutes to something closer to cab hailing waiting times. Through their product, Ambee envisions a network of quality hospital and private ambulances so that users can request the nearest ambulance according to their requirements.

Jagdeep Gambhir of Karma Healthcare spoke of telemedicine as a solution for transferring hospital care to primary care at the remote end in rural areas. For example, in an emergency situation where a decision needs to be made at the pre-hospitalisation stage, a video consultation with a trained nurse or a doctor can help save a life. Gambhir’s organization opened private clinics in rural areas with qualified care providers, nurses, and paramedics. These clinics can also facilitate video conversations for follow-ups between patients and doctors.

Speaking of innovation in Bangladesh, Rahat Hossain explained how his organization Critical Link created and trained a team of first responders with knowledge of first aid. They use motorbikes and bicycles to reach accident sites and can assist as divers in coastal areas.

Evidence-based, Future-Focussed Emergency Services

To conclude, all the speakers agreed on the need for evidence-based and future-focussed work in EMS. They called for state government data to be made available to academics, policymakers, and the public.

Three important points were the key takeaways from the Summit: First, a focus on care, and not just transport, at all points in the supply chain; second, unbundling services to increase efficiency, for example, by separating ambulances from first responders and the distribution of defibrillator kits; and third, the need to develop hybrid models that combine public and private EMS to ensure affordability and access along with innovation in the EMS space.

Based on his experience at MD Anderson Cancer Centre in Texas, Rajendra Srivastava, Dean and Novartis Professor of Marketing Strategy and Innovation at ISB, brought in an opportunity cost perspective. He posed the following question: If emergency services could be streamlined, how many millions of dollars would it save in terms of rooms that do not have to be built, operating theatres that do not need to be installed, equipment that does not need to be purchased, or staff that does not need to be hired? As the participants pondered this scenario, Shirke, in his concluding remarks, reinforced what so many of the speakers had been urging throughout the session: “EMS and private hospital systems must interact in such a way that there is a synchronized effort in saving patients’ lives.”

Anubrata Banerjee is a freelance writer with the Centre for Learning and Management Practice at the ISB.

ENDNOTE

  1. Life years are used to measure disease burden, where one life-year is one year in good health, especially when adjusted for quality of living.

FOR FURTHER READING

Doshi, V. (2016). “Karnataka Leads the Way as India’s Good Samaritan Law Takes Aim at Road Deaths”, The Guardian, December 23. Retrieved from https://www.theguardian.com/
global-development/2016/dec/23/karnataka-leads-way-indiagood-
samaritan-law-road-deaths

Gawande, A. (2008). Better: A Surgeon’s Notes on Performance. London: Profile Books.

National Trauma Institute (2014). Trauma Statistics. Retrieved from http://nationaltraumainstitute.net/home/trauma_statistics.html

Rosen, J W (2017). “Zipline’s Ambitious Medical Drone Delivery in Africa”, MIT Technology Review, June 8. Retrieved from https://www.technologyreview.com/s/608034/blood-from-the-skyziplines-ambitious-medical-drone-delivery-in-africa/

Singh, S K (2017). “Road Traffi c Accidents in India: Issues and Challenges”, Transport Research Procedia, 25: 4708-4719.
Retrieved from http://www.sciencedirect.com/science/article/pii/S2352146517307913.

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