Evolution of Emergency Medicine in India and the Emergence of the MEM Program at Trichy

Jacks of all trades, and Masters of Time!

C.M. Santhosham*

Senior Consultant Intensivist, Programme Director – MEM SEMI CCT, Kauvery Hospital, Trichy, India

Background

Emergency medicine is the medical specialty concerned with treating acute illnesses, (medical and surgical, including trauma), among all age groups, that require immediate attention and redressal.

Emergency medicine, as an independent medical specialty, is relatively young.

History of evolution of Emergency Medicine

Dominique Jean Larrey, a military surgeon is the father of Emergency Medical Services (EMS). He introduced ambulance services, and volunteers to mobilize medical staff, to speed up the transfer of the wounded.

Before the 1960s and 1970s, hospital emergency departments (EDs) were staffed by family physicians, general surgeons, or interns on a rotating basis. In many EDs, nurses would triage the patients and physicians would be called in to manage, based on the type and severity of injury or illness. During this period, groups of physicians left their respective practices to devote their work exclusively to establishing the field of emergency medicine.

In the UK, in 1952, Maurice Ellis was appointed as the first “casualty consultant” at Leeds General Infirmary, and in 1967, the Casualty Surgeons Association was established with Maurice Ellis as its first President. In the US, the association was headed by Dr. James DeWitt Mills in 1961. He, along with his four associate physicians at Virginia, established 24/7 year-round emergency care, which was known as the “Alexandria Plan.” In 1979, the American Board of Medical Specialties declared Emergency Medicine an independent medical specialty in the US. The first emergency medicine residency program in the world was begun in 1970 at the University of Cincinnati, and the first Department of Emergency Medicine was started in 1971 at the University of Southern California.

In 1990, the UK’s Casualty Surgeons Association changed its name to the British Association for Accident and Emergency Medicine and subsequently became the British Association for Emergency Medicine (BAEM) in 2004. In 1993, an intercollegiate Faculty of Accident and Emergency Medicine (FAEM) was formed as a “daughter college” of the six medical royal colleges in England and Scotland to arrange professional examinations and training. In 2005, the BAEM and the FAEM were merged to form the Royal College of Emergency Medicine, which conducts membership (MRCEM) and fellowship (FRCEM) examinations and publishes guidelines and standards for the best practice of emergency medicine.

Emergency Medicine in India

The Republic of India is the seventh largest country in the world and is home to nearly 1.3 billion people. With 28 states and 8 union territories spread over a vast geographic area, with varying economic resources and infrastructure, India is the world’s most populous democracy needing emergency services in both urban and rural areas.

Although emergency physicians and emergency medicine have long been a felt need in the country, the practice of emergency care remained confined to large public hospitals for a very long time, with very few private hospitals admitting emergency cases as they preferred to avoid the medico-legal formalities that invariably arose when dealing with emergencies. This problem was mitigated to some extent when the judicial system mandated the delivery of care by every hospital regardless of a patient’s paying capacity and medico-legal status at the time of the emergency. Failure on the part of any hospital to provide timely medical treatment to a person in need of such treatment is deemed to be a violation of the patient’s “Right to Life,” which is guaranteed by the Constitution of India. This is the closest India has come to enacting laws similar to the EMTALA (Emergency Medical Treatment and Labor Act) and the COBRA (Consolidated Omnibus Budget Reconciliation Act), which are well recognized in the USA.

Most emergency departments in centrally run university and government hospitals do not match up to the “Emergency Department Categorization Standards” proposed by the Society of Academic Emergency Medicine (SAEM). Emergency care is offered in areas designated as ‘casualty’ that are often manned by junior specialty residents with little overview and are mere ‘referral points’ for specialized care. Triage, something that is vital to good emergency care, is rarely practiced. Problems are worse in rural areas, where even the most basic emergency obstetric care has been found to be lacking.

On a completely different level, however, is the defense sector in India, where military hospitals, paramedics, and nurses trained in emergency medicine have long been functioning very efficiently.

The first privatized emergency department (ED), modeled on the American Community Hospital Emergency system, was established in Sundaram Medical Foundation in Chennai, with help and support from emergency physicians from the Long Island Jewish Medical Center, USA, in the late 1990s. This marked a landmark change in the psyche of the private hospitals in the country. Today, well-equipped EDs have cropped up in private medical centers all over the country, and many of these centers are headed by physicians who are formally trained in emergency medicine.

In 2009 July 19, the Medical Council of India recognized the field of emergency medicine as an independent medical specialty.

EMS in India

The EMS system in India is best described as ‘fragmented.’ The fundamental principle behind EMS systems worldwide is to have a common emergency communication number connected to responsive agencies. Although India has an emergency number 102 for calling ambulances, the responsiveness of the system has always been doubted. In 2007, Ramanujam et al. reported that nearly 50% of trauma victims admitted to a premier hospital in an urban Indian city had received no pre-hospital care.

The lack of a uniform EMS access number across the country and the lack of awareness among commuters about the existing numbers make access and egress from emergencies difficult. The lack of trained professionals manning ambulances makes the quality of care heterogeneous. EMS services have remained unaccountable, and this has led to the failure to introduce corrective measures for improving EMS in India.

There is palpable vigor among the bureaucratic brass and political leadership regarding re-initiating the process for allotting a unique emergency response number. How successful this push will remain to be seen.

After the emergence of Emergency Medicine as an independent specialty, the burden on other specialty physicians with regard to the management of patients with acute illness has reduced and the patient care in the emergency has improved drastically.

As the initial management of the patient with acute illness has been streamlined with standard protocols, patients get appropriate treatment in time.

Interested Societies

Several interest groups have been instrumental in the development of emergency medicine. SEMI, the Society of Emergency Medicine in India, was started in 1999 and has served as an important forum not only for national emergency physicians to brainstorm the steps for the development of emergency medicine in the country, but they have also served as an important focal point for contact with other international agencies like the ACEP (American College of Emergency Physicians). AAEMI, the American Academy for Emergency Medicine in India, was established in 2001 and has partnered with SEMI in order to bring attention and recognition to Emergency Medicine in India. The more recent Indo-US Emergency and Trauma Collaborative (INDUS) has furthered the cause of nationalized emergency medicine education in India. NEPI, the Network of Emergency Physicians in India, is a virtual network of emergency physicians and aspirants in the field that provides a venue to engage in academic, administrative, and research-related discussions about emergency medicine in India.

Emergency Medicine in Kauvery Specialty Hospital

Emergency Medical Service in Kauvery Specialty Hospital has a good standard of care, both in infrastructure and services, but the integration between the emergency department and the intensive care unit needed to be improved, especially while taking care of the critically ill.

So, to strengthen the department we started the emergency medicine course, Master in Emergency Medicine (MEM), affiliated to Society of Emergency Medicine of India (SEMI). It is a full-fledged 3years course offered to post- MBBS graduates and foreign medical graduates (FMG) who are MCI-recognized.

It was a single seed that was sown in 2017, but well nurtured by a management and strengthened by all the consultants of the hospital. It was started with single candidate; today we have 20 young doctors working 24/7 on rotatory basis not only in ER and ICU but wherever they called in the hospital, thus learning, serving and growing…

So far three of them successfully completed their courses.

Two of our successful candidates joined back in our hospitals to serve in the department…

Conclusion

A major milestone in the evolution of Emergency Medicine was the change in the term casualty (fatal, death, wounded) to the emergency department (ED) or emergency room (ER). Initially, it was headed by surgeons, orthopedicians took care of the victims of accidents with bone trauma, and in later years anesthesiologists oversaw its function. Today ER’s are staffed by dynamic emergency physicians who are trained in securing the airway, inserting central lines, performing ICD’s and in resuscitation unresponsive patients. Currently, the emergency department is the face of the hospital that is in the closest contact with the public, caring for the acutely ill, severely injured, intoxicated, or overdosed patients in all age groups. It thrives in an atmosphere of high drama, quick reactions, efficient saving of lives and limbs, and occasionally a witness to great tragedy and intense grief.

The modern-day emergency physicians are jack of all trades and masters of time….

Reference

[1] Alagappan K, Cherukuri K, Narang V, et al. Early development of emergency medicine in Chennai (Madras), India. Ann Emerg Med. 1998;32:604-608.

[2] Ramanujam P, Aschkenasy M. Identifying the need for pre-hospital and emergency care in the developing world: a case study in Chennai, India. J Assoc Physicians India. 2007;55:491-495.

Dr. C. M. Sathosam

Senior Consultant Intensivist

Evolution of Emergency Medicine in India and the Emergence of the MEM Program at Trichy